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10693874-DS-3
| 10,693,874 | 24,419,931 |
DS
| 3 |
2189-09-09 00:00:00
|
2189-09-09 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo F PMHx HTN, afib s/p pacemaker on
Eliquis who presented to ___ ED ___ with acute onset
dizziness. History is obtained with the assistance of a ___
interpreter.
She awoke this morning with dizziness. Dizziness described as
clockwise room spinning. Symptoms worse with any form of head
movement. Symptoms improved when pt turned her head to the left
and looked to the left. It is unclear whether symptoms entirely
resolve when pt turns her head to the left or significantly
improve. She denies having similar symptoms before. She denies
any nausea or vomiting. She has been falling more frequently
over
past month due to loss of balance. No falls on day of
presentation or day prior. She was unable to ambulate this AM
when she awoke so had to call EMS.
Per EMS report: VS at arrival were HR 76, BP 142/90, RR 16. Pt
was found "supine L lateral recumbent". She was "complaining of
dizziness for 1 hour" and "sharp pain on head movement to left".
"Neuro exam asymptomatic". BG 110.
On neurologic review of systems, the patient reports
intermittent
diplopia for months. Pt reports intermittent tinnitus and wax in
ears for month. Pt denies headache, lightheadedness, or
confusion. Denies difficulty with producing or comprehending
speech. Denies loss of vision, blurred vision, hearing
difficulty, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention.
On general review of systems, the patient reports chest pain and
abdominal pain. Both symptoms have been ongoing for one week. Pt
denies fevers, palpitations, cough, nausea, vomiting, diarrhea,
constipation, dysuria or rash.
Past Medical History:
"Tiny" stroke, pt unable to recall associated symptoms, >6
months
ago
HTN
Atrial fibrillation s/p pacemaker
GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PHYSICAL EXAMINATION
Vitals: 97.6 72 131/88 18 98% RA
General: NAD, resting comfortably, frail, chronically
ill-appearing
HEENT: NCAT, no oropharyngeal lesions
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Inattentive and a poor historian. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Normal prosody. No
dysarthria. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI. Eyes conjugate. +nystagmus on R end gaze with fast beating
to the R. V1-V3 without deficits to light touch bilaterally.
Face
activates symmetrically. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 4+ ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Deferred per pt preference.
===================
Discharge physical examination:
===================
CN: Horizontal and torsional nystagmus on right gaze.
Otherwise unchanged.
Pertinent Results:
Imaging:
CTA chest:
1. No pulmonary embolism or acute aortic abnormality.
2. Left adrenal nodule and oartially imaged right exophytic
indeterminate
renal lesion with possible fat attenuation focus suggesting of
possible angiomyolipoma.
3. Sub 4 mm right pulmonary nodules need no follow-up (per
___
guidelines) in low risk patients. For high risk patients,
follow-up is
recommended in 12 months, depending on the patient's clinical
situation.
4. Cardiomegaly with notable for bilateral atrial enlargement.
5. 2 left thyroid lobe hypodensities, for which no follow-up is
recommended per ACR guidelines.
Shoulder view:
1. No acute fracture or dislocation.
2. Severe right AC joint arthropathy with high riding right
humeral head suggesting chronic rotator cuff disease.
CXR:
Cardiomegaly without superimposed acute process. Right AC joint
arthropathy.
CTA head and neck:
1. No aneurysm, stenosis or dissection in the head and neck.
2. Irregularity of the bilateral carotids, suggestive of
fibromuscular dysplasia.
3. Airspace disease in the partially visualized left lung.
Partially
visualized left atrium appears enlarged, with prominent left
pulmonary vein complex. Correlate with CT chest or
echocardiogram if clinically indicated.
LABS:
___ 05:05AM BLOOD WBC-4.3 RBC-3.48* Hgb-11.6 Hct-33.0*
MCV-95 MCH-33.3* MCHC-35.2 RDW-13.2 RDWSD-45.1 Plt ___
___ 09:40AM BLOOD WBC-6.2 RBC-3.85* Hgb-13.0 Hct-36.7
MCV-95 MCH-33.8* MCHC-35.4 RDW-13.1 RDWSD-45.1 Plt ___
___ 05:50AM BLOOD WBC-6.6 RBC-3.77* Hgb-12.5 Hct-35.9
MCV-95 MCH-33.2* MCHC-34.8 RDW-12.9 RDWSD-44.5 Plt ___
___ 05:50AM BLOOD Neuts-78.7* Lymphs-14.5* Monos-5.6
Eos-0.3* Baso-0.6 Im ___ AbsNeut-5.17 AbsLymp-0.95*
AbsMono-0.37 AbsEos-0.02* AbsBaso-0.04
___ 05:05AM BLOOD Plt ___
___ 09:40AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-33.2 ___
___ 09:40AM BLOOD Glucose-180* UreaN-21* Creat-1.0 Na-133
K-3.6 Cl-96 HCO3-22 AnGap-19
___ 05:50AM BLOOD Glucose-119* UreaN-17 Creat-0.9 Na-134
K-4.0 Cl-98 HCO3-24 AnGap-16
___ 05:50AM BLOOD ALT-11 AST-22 AlkPhos-87 TotBili-0.9
___ 06:45PM BLOOD Lipase-57
___ 05:50AM BLOOD Lipase-31
___ 09:30PM BLOOD cTropnT-0.01
___ 11:25AM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD cTropnT-<0.01
___ 05:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.7
___ 09:40AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8
___ 09:30PM BLOOD Cholest-146
___ 05:50AM BLOOD Albumin-3.9
___ 09:30PM BLOOD %HbA1c-5.3 eAG-105
___ 09:30PM BLOOD Triglyc-75 HDL-63 CHOL/HD-2.3 LDLcalc-68
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine:
___ 06:20AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:20AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
Brief Hospital Course:
___ is a ___ yo F PMHx HTN, afib s/p pacemaker on Eliquis who
presented to ___ ED ___ with acute onset dizziness
concerning for stroke. Neurologic examination notable for
horizontal and torsional nystagmus on gaze to the right. CTA
head and neck did not show any acute process. MRI was not
obtained as she has a pacemaker in place. Stroke risk factors
were assessed and found controlled. We have increased her
apixaban to 5mg po bid and her atorvastatin to 40mg po daily.
Transitional issues:
1. CT chest showed multiple subcentimeter nodules in her right
lung, as well as her left adrenal and her thyroid.
2. Found to have rash in her back area likely from sitting in
the same position for a prolonged period.
3. Will need vestibular therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID afib
2. Citalopram 40 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
5. NexIUM (esomeprazole magnesium) 40 mg oral BID
6. Metoprolol Succinate XL 100 mg PO BID
Discharge Medications:
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral TID
2. Citalopram 40 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO BID
4. NexIUM (esomeprazole magnesium) 40 mg ORAL BID
5. Apixaban 5 mg PO BID
6. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Vestibular neuronitis
Secondary:
1. Per pt prior " Tiny" stroke, pt unable to recall associated
symptoms, >6 months ago
2. HTN
3. Atrial fibrillation s/p pacemaker
4. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted to the hospital with symptoms of severe
vertigo which were concerning for a stroke. We have imaged your
brain and vessels with a CT. We found no evidence of an acute
stroke. We assessed your stroke risk factors and found them well
controlled on your current medication regimen. We have
identified the cause of your vertigo as an inner ear process.
You have been evaluated by physical therapy and they recommended
you go to ___ rehab to work on your dizziness.
We scanned your chest and found you to have small nodules in
your lungs, as well as your thyroid. These issues should be
assessed by your primary care doctor.
Instructions:
1. Please continue all your medications as directed by this
document.
2. Please keep all your follow up appointments as below.
3. Please do not hesitate to call with questions.
It has been a pleasure taking care of you,
Your ___ Neurology team
Followup Instructions:
___
|
10694040-DS-17
| 10,694,040 | 25,923,519 |
DS
| 17 |
2151-12-03 00:00:00
|
2151-12-03 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Niacin Preparations / Novocain
Attending: ___.
Chief Complaint:
Lightheadedness/Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH afib, ___, HTN, prior CVA x2, presenting from
___ with dizziness/weakness. Dizziness described as
feeling "lightheaded" on standing and like she is unsteady on
her feet, usually in the morning or after lying in bed for a
long time. Admits to poor appetite and po intake at baseline
which has been stable. Did have an episode of nausea, vomiting
yesterday shortly after eating a muffin. No nausea or vomiting
currently. Denies diarrhea. No fevers, chills, sweats. Has not
noticed any blood in her urine or stool, though she reports she
does not examine her stool. No other bleeding that patient has
noticed. She was sent in for dehydration per NH report. Pt fell
on ___ and ___, no injuries from the fall. No head injury.
Of note, pt was recently seen in ED on ___ also for mechanical
fall - head/neck CT negative. INR 2.5 as of ___. No falls since
___.
.
In the ED, VS 99.7 72 138/78 18 95%. orthostatic BP's
___ on sitting. Lungs CTAB. CV - irregularly
irregular. Abdomen benign. No neurologic deficits. AOx3.
+Several areas of ecchymosis on R thigh/elbow from fall. Guaiac
negative. Labs significant for Hct 33.9 (39.3 on ___, INR
3.7, K 3.5, Mg 1.9. CT head - no acute intracranial process.
EKG: a-flutter. Pt given 500cc NS gently at 100cc/hr. Admitted
for symptomatic anemia
Past Medical History:
1. Atrial fibrillation
2. H/O CVA x2 ___ and ___
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Myeloproliferative disorder, polycythemia ___
7. H/O malignant left parotid tumor now s/p resection and
radiation in ___
8. H/O nonmalignant right parotid mass s/p resection benign
9. GERD with hiatal hernia
10. Scattered non-calcified pulmonary nodules-followed with
yearly CT scans
Social History:
___
Family History:
Perimenopausal daughter with breast CA.
HTN
Hyperlipidemia
DM
Physical Exam:
Admission PE:
VITALS: 98.5, 150/88, 88, 18, 93% RA
GENERAL: elderly female in NAD
HEENT: PERRL, EOMI
LUNGS: CTAB, poor inspiratory effort
HEART: rapid rate, irregularly irregular, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no HSM
EXTREMITIES: No c/c/e
Neuro:CN grossly intact, no focal defecits. A&Ox3
Discharge PE
VITALS: 98.3, 118/66, 75, RR18, 97% RA. Not orthostatic.
GENERAL: elderly female in NAD
HEENT: PERRL, EOMI
LUNGS: fine crackles base of LLL, poor inspiratory effort
HEART: rrr, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no HSM
EXTREMITIES: No c/c/e
Neuro:CN grossly intact, no focal defecits. A&Ox3
Pertinent Results:
Admission Labs:
___ 03:00PM BLOOD WBC-4.9 RBC-3.27* Hgb-11.3* Hct-33.9*
MCV-104* MCH-34.6* MCHC-33.4 RDW-14.8 Plt ___
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-137
K-3.5 Cl-100 HCO3-27 AnGap-14
___ 03:00PM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9 UricAcd-5.2
Discharge Labs
___ 08:30AM BLOOD WBC-4.1 RBC-3.59* Hgb-12.3 Hct-38.0
MCV-106* MCH-34.4* MCHC-32.5 RDW-14.8 Plt ___
___ 08:30AM BLOOD ___ PTT-38.1* ___
___ 08:30AM BLOOD Glucose-140* UreaN-10 Creat-0.9 Na-138
K-4.1 Cl-99 HCO3-28 AnGap-15
___ 08:30AM BLOOD Phos-3.5 Mg-2.1
___ 01:10PM BLOOD TSH-0.77
___ 03:00PM BLOOD VitB12-369 Folate-7.4 Hapto-166
Head CT:
IMPRESSION: No acute intracranial process. No change from ___.
CXR:IMPRESSION: No evidence of acute disease.
Brief Hospital Course:
___ with PMH afib, dCHF, HTN, prior CVA x2, presenting from
___ with dizziness/weakness. Dizziness described as
feeling "lightheaded" on standing usually in the morning
# Orthostasis/dizziness: Patinet came in complaining of
lightheadedness and the sensation of the room tilting when she
was standing up. This unsteadiness resulted in several falls
over the last few days. In the ED, a head CT was negative for
any acute intracranial process. An EKG showed atrial
fibrillation with rvr (~150bpm) and on orthostatic exam the
patients SBP dropped from 135 to 95 upon standing. Pt responded
well to 100mg of metoprolol and soon converted back into sinus
rhythm. Causes of the patient's orthostasis werer thought to be
related to volume depletion as she has had poor PO intake
recently and her afib . Anemia was also considered as etiology
of symptoms as her admission CBC showed a drop of HCT from 39 to
34 over 3 days. This was felt to be less likelty as patient had
no fatigue/weakness and relatively high hct with no signs of
bleeding or hemolysis. The patient remained in SR for the
duration of the admission and orthostatis removed. She received
several liters throughout admission and showed no signs of fluid
overload. On discharge, her dizziness is greatly improved.
# Polycythemia ___: HCT, while below baseline on ED CBC,
trended up on repeat labs to 38. Hemolysis labs were
unremarkable and there was no signs of bleeding (guiac neg in
ED). Patient's CBC has trended lower over the last year with
fluctuance in HCT. Uncertain cause but may be secondary to
progressive fibrosis. However, other cell lines appear normal.
Hydroxyurea was held throughout admission in setting of low HCT
and should be started back as 2x a week medication instead of 3x
per Heme. She will follow up with them as an outpt next month.
She should have a CBC drawn in 2 weeks prior to appointment. TSH
and B12 were wnl.
.
# Afib with RVR: patient converted back to sinus rhythm soon
after admission. She required 100mg metoprolol for RVR to
150bpm. Pt was maintained on daily dose of metroprolol 75mg BID
throughout the admission without complication. Pt's ECG shows
enlarged P waves making conversion back into afib likely in the
future. Pt will follow up with cardiologist as an outpatient.
Warfarin was restarted after being held for several days for
supratheraputic INR. INR is 2.2 on discharge.
# H/o atypical cells on urine cytology: Found ___ hematuria at
last hospitalization. N hematuria since then or during this
admission. It was believed that with a clean UA, this previous
finding was not contributing to current symtoms. Pt was made an
appointment with urology to follow up.
#Family meeting: Prior to discharge, a family meeting was held
with daughter and 2 sons, ___ (___ work), Dr.
___, and Dr. ___. Pts recent falls
were discussed and ___ were made in her medication to
prevent dizziness and lightheadedness. It was decided to
continue pt on warfarin and make changes in living situation and
family was informed that an added level of care would be optimal
at this time. The pros and cons of wafarin therapy were
discussed. Patient's PVC and atypical urine cytology findings
were also discussed and a follow up plan was established.
Transitions of care:
1.Patient instructed to immediately inform staff at rehab and
assisted living if she develops heart palpitations or dizziness
again and to avoid standing up.
2.Pt to continue short term rehab for gait instability prior to
returning home
3.Follow up with heme regarding hydroxyurea dosing
4.Follow up with urology regarding abnormal cytology
5.DNR/DNI
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/Caregiver.
1. Atorvastatin 20 mg PO DAILY
2. Hydroxyurea 500 mg PO 3X/WEEK (___)
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Warfarin 1 mg PO DAILY16
Do not give on ___. Give 2mg instead
8. Omeprazole 20 mg PO DAILY
9. Warfarin 2 mg PO ___
2mg on ___
10. azelastine *NF* 0.05 % ___ BID PRN
1 drop to affected eye
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Loratadine *NF* 10 mg Oral daily
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Metoprolol Tartrate 75 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal BID
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
1 tab under tongue every 5 min as needed for chest pain, up to 3
doses
18. Senna 1 TAB PO BID:PRN constipation
19. tetrahydrozoline *NF* 0.05 % ___ prn conjunctivitis
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. Mirtazapine 30 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 1 mg PO DAILY16
Do not give on ___. Give 2mg instead
11. azelastine *NF* 0.05 % ___ BID PRN
1 drop to affected eye
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Hydroxyurea 500 mg PO 2X/WEEK (___)
___
14. Loratadine *NF* 10 mg Oral daily
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
1 tab under tongue every 5 min as needed for chest pain, up to 3
doses
16. Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal BID
17. tetrahydrozoline *NF* 0.05 % ___ prn conjunctivitis
18. Warfarin 2 mg PO ___
2mg on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Orthostasis secondary Afib and volume depletion
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 during your stay at ___.
You came in due to lightheadedness and dizziness. A CT scan of
your head showed no bleeding or strokes. An EKG showed that you
were in atrial fibrillation, which is a heart arrhythmia you
have a history of. Your blood pressure dropped significantly
when you stood up which is most likely why you felt dizzy. We
also gave you intravenous fluids because we felt you were
dehydrated. Your atrial fibrillation stopped and you now feel
less dizzy and lightheaded.
Please continue to take all of your home medications as
directed.
We also met with you and your family about your care for the
future. Please follow-up with your outpatient providers with
any questions that may come up later regarding medications and
further care.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10694040-DS-19
| 10,694,040 | 23,122,713 |
DS
| 19 |
2152-01-05 00:00:00
|
2152-01-07 22:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Niacin Preparations / Novocain
Attending: ___.
Chief Complaint:
Atrial fibrillation with rapid ventricular response.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: The patient is an ___ year old female
with h/o CVA with residual cognitive deficits, hypothyroidsim,
diastolic heart failure, HTN, hypothyroidism who presents with
SOB and atrial fibrillation.
At ___, she was noted to be in a tachyarrhytmia, and
hypotension to the ___ systolic. She was given 1 L NS in the
ride over from ___ to the ED.
In the ED, initial VS were 150 93/55 24 98% RA. On the flow
sheet she was noted to by hypotension to the ___ systolic at 1
___.
On transfer, 98.1 71 79/46 16 100%.
Labs notable for a normal U/A, Lactate 1.5, Trop 0.01, MCV 101,
Plt 458, INR 2.5.
CXR showed on single frontal view no pleural effusion, PTX, or
focal airspace consolidation. L sided pacemaker terminates in
the R venticle, unchanged from 11 days prior. Unchanged lead
position.
She received 1.5 L NS in total, 5 mg IV Metoprolol, and
Levofloxacin 750 mg IV.
Patient was recently admitted and had a VVI Pacemaker placement
___. Per the ED, she is without chest pain or shortness of
breath, mostly complains of feeling cold and weak. No headache,
no nausea vomiting. No fevers or chills, no abdominal pain, no
diarrhea.
The daughter, who is HCP, suspects that she does not take good
PO and also believed there might have been a metoprolol dosing
error in the past.
On arrival to the MICU, she is AAOx3 and comfortable.
Past Medical History:
1. Atrial fibrillation
2. H/O CVA x2 ___ and ___
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Myeloproliferative disorder, polycythemia ___
7. H/O malignant left parotid tumor now s/p resection and
radiation in ___
8. H/O nonmalignant right parotid mass s/p resection benign
9. GERD with hiatal hernia
10. Scattered non-calcified pulmonary nodules-followed with
yearly CT scans
Social History:
___
Family History:
Perimenopausal daughter with breast CA.
Mother with HTN and died of an MI at age ___. Her father died at
age ___.
Hyperlipidemia
DM
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: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, pacemaker site is C/D/I
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, gait deferred
Discharge Physical Exam
BP 117/103, HR 83 , 96%RA
A+Ox3 in NAD, sitting up in chair in her own clothing
Cardiac: Irregularly irregular, regular rate
Lungs: CTAB
Abd: protuberant, soft, nontender, nondisteended
Extremiteis: No peripheral edema, some thin skin noted, but no
ulcerations or signs of cellulitis on the anterior shins
bilaterally
Pertinent Results:
___ 10:46AM BLOOD WBC-5.5 RBC-3.59* Hgb-11.6* Hct-36.1
MCV-101* MCH-32.4* MCHC-32.2 RDW-15.0 Plt ___
___ 10:46AM BLOOD Neuts-68.2 ___ Monos-7.6 Eos-1.7
Baso-0.9
___ 10:46AM BLOOD ___ PTT-39.1* ___
___ 10:46AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-28 AnGap-13
___ 10:46AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0
___ 10:46AM BLOOD TSH-0.28
___ 10:54AM BLOOD Lactate-1.5
___ 10:46AM BLOOD cTropnT-<0.01
___ 06:15PM BLOOD cTropnT-<0.01
___ 05:04AM BLOOD WBC-5.2 RBC-3.55* Hgb-11.7* Hct-35.2*
MCV-99* MCH-32.9* MCHC-33.1 RDW-15.1 Plt ___
___ 05:04AM BLOOD ___ PTT-39.7* ___
___ 05:04AM BLOOD Glucose-98 UreaN-15 Creat-0.8 Na-140
K-4.0 Cl-105 HCO___ AnGap-11
CXR ___: SINGLE FRONTAL VIEW OF THE CHEST: There is no
pleural effusion, pneumothorax or focal airspace consolidation.
The heart size is top normal. The mediastinal contours are
normal. A left side pacemaker is intact with its wire
terminating in the right ventricle. Its location appears
unchanged from approximately 11 days prior.
IMPRESSION: Unchanged lead position.
Brief Hospital Course:
The patient is an ___ year old female with h/o CVA with residual
cognitive deficits, hypothyroidsim, diastolic heart failure,
HTN, hypothyroidism who presents with atrial flutter and
hypotension.
# Hypotension: Multiple etiolgies are possible, but was felt to
be most likely rapid venticular rate causing poor forward flow
causing hypotension. Other etiologies could include volume
status, or infection. Volume status based on UOP, lytes, and
exam appears to be normal. Infection has been worked up with
normal blood cultures to date, negative U/A, no skin
impairments, no fever, no WBC count, and without CXR findings.
Hypotension was not secondary to a pericardial effusion, given a
bedside ECHO which did not show this. She did not appear
hypovolemic on labsgive mild enlagment of sillhoute on x-ray,
mildly low voltages, and recent instrumentation. She responded
well to 75 mg metoprolol TID, and was discharged on 150 mg XL
metoprolol
# Atrial Flutter: Patient appears to have a ___ atrial
flutter. Etiologies of atrial fibrilation/flutter could include
hyper or hypovolemic states, MI, infection, electrolyte
abnormalities, or thyroid dysfunction. Patient appears euvolemic
as described above. She ruled out for an MI, and did not have
lyte abnormalities. Her TSH was also normal.
# Hypothyroid:
- Continue home synthroid.
# P ___:
- home hydroxyurea.
# Prior CVA:
- Continue home ASA and statin.
# Presumed Emphysemia: No note of this in her recent history,
but given large lung volumes and smoking history would favor
this as the etiology for her medication Fluticasone-Salmeterol
- Continue Fluticasone-Salmeterol
# Insomnia:
- continue mirtazapine QHS
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ Apothocary.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
Hold for SBP <100, HR <60
4. Hydroxyurea 500 mg PO QTUTHSA (MO,TH,SA)
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Metoprolol Tartrate 75 mg PO BID
Hold for SBP <100, HR <60
7. Mirtazapine 30 mg PO HS
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Nitroglycerin SL 0.3 mg SL PRN Q5min up to 3 doses
12. Senna 1 TAB PO DAILY:PRN constipation
13. tetrahydrozoline *NF* 0.05 % ___ PRN conjunctivitis
14. traZODONE 12.5 mg PO HS:PRN insomnia
15. Warfarin 1 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Furosemide 20 mg PO DAILY
Hold for SBP <100, HR <60
4. Hydroxyurea 500 mg PO QTUTHSA (MO,TH,SA)
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Mirtazapine 30 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 20 mg PO DAILY
9. Senna 1 TAB PO DAILY:PRN constipation
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 1 mg PO DAILY16
12. Nitroglycerin SL 0.3 mg SL PRN Q5min up to 3 doses
13. tetrahydrozoline *NF* 0.05 % ___ PRN conjunctivitis
14. traZODONE 12.5 mg PO HS:PRN insomnia
15. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth qday Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial Flutter with Tachyarrythmia
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 in the Intensive Care Unit.
You were admitted to our Unit because you were noted to have a
low blood pressure as well as a fast heart rate at the ___
___, as well as in our emergency department. We looked for
several reasons why this might be; we did not think that you
were dehydrated, we did not find any evidence of infection in
your blood, urine or chest x-ray, we do not think that you had a
heart attack, and we do not think that you have any fluid around
your heart.
Our suspicion is that you may need a longer-acting medication
that slows down your heart rate.
Please make sure to make an appointment with your cardiologist
within a week of your discharge from the ___.
Followup Instructions:
___
|
10694087-DS-10
| 10,694,087 | 21,510,087 |
DS
| 10 |
2129-10-18 00:00:00
|
2129-10-24 07:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
code stroke for headache, left arm numbness and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old ___ man with past medical history of
diabetes, h/o complex migraines with L sided weakness, ? TIA,
depression with prior suicide attempts, presents from his
inpatient psych facility with headache a L sided numbness and
weakness.
The patient reports that he has a history of sea-sickness as a
child, but no migraine headaches until the past ___ years. In
___ he had a 3 day migraine headache and then
collapsed at work (while cooking). He was taken to ___ and was diagnosed with a TIA. In ___ he
presented
to ___ for migraine headache with L arm
weakness and numbness and was diagnosed with a complex migraine.
He had 2 other headaches this year ___ and ___ where
he was admitted to ___ for complex migraine. These
both were also associated with L arm weakness and numbness, L
sided blurry vision, and slowed speech. He says his weakness
typically takes a few days to improve. He says Fiorcet has
worked
the best for him in the past, although he only takes Motrin at
home. He says Demerol has made him feel sick before.
The patient was admitted to an inpatient psych facility around
___ - since his depression worsened around the
___
and he had passive SI with prior suicide attempts. He has been
uptitrated on Prozac while he was there and says he feels much
better now and denies passive or active SI.
The patient had onset of a "mild" headache last night and took
Motrin and went to bed around 8 ___. He awoke at 4 AM with a
throbbing headache and took more motrin, he noted some L arm
numnbess at that time. He went back to bed and woke up again at
7:40 AM and noted that he continued to have L arm numbness and
also some L foot tingling (although he somtimes has foot
tingling
from his diabetes). He sat down to eat breakfast and noted that
he had difficulty cutting his ___ Toast with his left hand
with some L hand weakness. He still had a pounding L sided
headache, originating from his L posterior occiput with
radiation
to his L frontal region. + Throbbing, + Photophobia +
Phonophobia
+ Nausea. Also endorses prior L sided blurry vision similar to
his prior migraine. His psych facility sent him to ___ for
sroke rule out.
In the ___ ED the patient was called as a code stroke. ___
showed no hemorrhage. No TPA was given since the patient was
outside the window and exam and history c/w known histoy of
complex migraine.
Patient is on a ___ and needs a 1:1 sitter while admitted
to the hospital, and needs to be sent back to his psych facility
once improved.
On neuro ROS, the pt endorses headache, loss of vision, blurred
vision.
Denies diplopia, dysarthria, dysphagia, lightheadedness,
vertigo,
tinnitus or hearing difficulty.
Endorses slowed sleep but no word finding difficulty or
difficulty comprehending speech.
Endorses L arm and leg numbness and tingling. 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.
Past Medical History:
- DM2
- obesity
- complex migraines with L sided numbness and weakness
- prior TIA ? ___ collapsed in the setting if headache
___)
- psych hx: bipolar disorder, inpatient
___
for suicidal ideation. ___ attempted to jump off ___, ___ 14 litium pills, 6 advils in attempt
to
OD. Prior psych hospitalizations: ___ ___ psych unit, ___
___
psych unit, ___, ___ psych unit
- compulsive gambling
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Exam:
Vitals: T: 97 HR-89 BP-135/61 15 100% Nasal Cannula
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No nuchal rigidity. There is + extreme tenderness to
palpation of the L occiput and to a lesser extent the L temporal
region.
Neurologic:
-Mental Status: Awake, alert, attentive to examiner. Speech is
slow but fluent with normal intonation. Naming, repetition,
reading intact. No paraphasic errors. No dysarthria. Follows
commands.
-Cranial Nerves:
Photophobic, unable to tolerate fundoscopic exam. VFF to finger
counting, although decreased visual fields to red desaturation
testing on the L hemifield bilaterally. Visual acuity ___
bilaterally. PERRL 5->4 bilterally. Face symmetric with full
strength with smile. EOMI without nystagmus or diplopia in any
direction of gaze. + Tongue protrudes midline and palate
elevates
symetrically.
-Motor:
Normal bulk, tone throughout. L arm pronation and drift, L leg
drift which hits the bed just after 5 seconds.
Delt Bic Tri WrE FFl FE Fflx IP Quad Ham TA Gastroc
L 5 4+* 4+* ___ 5 4+ 5 4+ 4+ 5
R 5 ___ ___ 5 5 5 5 5
* pain limited (aggrevates shoulder pain)
-Sensory: Decreased light touch and pinprick sensation on the L
arm circumferentially up to the level of the shoulder and L leg
up to the level of the hip.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Deferred
Discharge Exam:
Neuro:
Awake, oriented to name, place, date, but depressed. Answers
questions. Speech slow but no aphasia. Visual field complete to
finger counting. 3-beat nystagmus on L gaze. CN V and VII
intact. Sensation intact to touch and cold in legs and arms. L
arm downward drift without pronation, strength 5- in L ECR, IP,
and Quad, otherwise full strength. 2+ reflexes in biceps,
triceps, ___, quad, 1+ Achilles, mute plantar reflex.
Pertinent Results:
___ CT Head
No acute intracranial abnormality.
___ 09:20AM BLOOD WBC-10.5 RBC-4.67 Hgb-15.5 Hct-41.4
MCV-89 MCH-33.2* MCHC-37.6* RDW-13.3 Plt ___
___ 09:45AM BLOOD Neuts-64.5 ___ Monos-4.6 Eos-2.3
Baso-0.6
___ 09:45AM BLOOD ___ PTT-35.2 ___
___ 09:20AM BLOOD Glucose-158* UreaN-10 Creat-0.9 Na-137
K-3.8 Cl-102 HCO3-26 AnGap-13
___ 07:43AM BLOOD ALT-21 AST-17
___ 09:20AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.1 Mg-2.1
___ 09:45AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 12:28PM BLOOD Lactate-3.0*
___ 08:53AM BLOOD Lactate-3.0*
___ 09:57AM BLOOD Glucose-244* Lactate-2.6* Na-137 K-4.1
Cl-100 calHCO3-22
Brief Hospital Course:
Mr. ___ is a ___ year old ___ man with past medical history of
diabetes, h/o complex migraines with L sided weakness, and
possible TIA who presented with one of his typical complex
migraines with left sided hemiparesis. During admission his
hemiparesis resolved. He continued to have a headache and
musculoskeletal neck pain, improved with tizanidine and
scheduled ketorolac, although other medications were tried
during admission. He continues on a steroid taper with a medrol
dose pak upon discharge. He has been started on verapamil for
migraine prophylaxis.
The history of TIA is questionable because this is most likely
his first presentation of complex migraine.
He will be discharged to inpatient psychiatry per ___.
# Neuro
- migraine prophylaxis with verapamil
- s/p fioricet and ketorolac prn and scheduled, tizanidine and
flexeril. Tizanidine and ketorolac were most successful in
treated acute migraine pain. The patient was discharged with
tizanidine prn and ibuprofen prn.
- Prednisone taper during admission and medrol dose pak on
discharge
- cont ASA 81 for possible prior TIA
- zofran prn for nausea (associated with migraines)
- will have outpatient neurology follow up
# Psych: ___
- continue prozac
- discharged to inpatient psych
# DM
- discontinue metformin as the lactic acid is persistently
elevated.
- per ___ consult, glipizide and januvia on discharge
- NPH insulin sliding scale based on steroid taper
***Transitional issues:***
- follow up glycemic control on glipizide and januvia - goal
HgbA1c <7.0%
- follow up migraine control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluoxetine 60 mg PO DAILY
4. Ibuprofen 400-600 mg PO Q8H:PRN acute migraine headache
Do not take more than 2 days per week for headache
5. GlipiZIDE XL 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Verapamil SR 120 mg PO Q24H
8. Januvia (sitaGLIPtin) 100 mg oral Daily
9. MEDrol (Pak) (methylPREDNISolone) 1 pak oral as directed
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Tizanidine 4 mg PO Q8H:PRN neck muscle spasm
12. NPH 10 Units Breakfast
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complex migraine with left hemiparesis and left sided sensory
changes
Musculoskeletal neck pain
Orthostatic hypotension
Diabetes mellitus type 2
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 a complex migraine with
left sided weakness and numbness. Your headache improved with
medications and your left sided symptoms resolved during this
admission.
You have been started on migraine prophylactic medication. You
will be discharged on a steroid taper to help treat the
headache, and you will have ibuprofen as needed if you need to
treat an acute migraine - you should take this medication on no
more than 2 days per week because if you take it more frequently
it could make your headaches worse. You will have tizanidine as
needed for musculoskeletal neck pain. You will have zofran as
needed for nausea.
Since you will be on a steroid taper, you will have insulin for
a short duration to treat the spike in glucose that steroids can
cause.
You developed an increased lactate (blood test abnormality)
while on metformin, so this medication was stopped. You will now
take two new medications to control your diabetes.
You had orthostatic hypotension (low blood pressure on standing)
during admission, likely due to dehydration and a prolonged stay
in bed. This was treated with IV and oral fluids.
You will follow up with Dr. ___ for your migraines.
You will be discharged to inpatient psychiatry to continue to
treat your psychiatric illness.
It was a pleasure taking care of you during this admission.
Followup Instructions:
___
|
10694480-DS-9
| 10,694,480 | 29,468,088 |
DS
| 9 |
2170-07-17 00:00:00
|
2170-07-20 13:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, pneumothorax
Major Surgical or Invasive Procedure:
___: Right pigtail placement (placed at outside hospital)
___: Right 14 ___ chest tube insertion
___: Exploratory laparotomy, ileocecectomy, stapled
side-to-side ileocolic anastomosis.
___: ___ line placement
History of Present Illness:
___ year old gentleman with ___ year smoking history who presented
with sudden onset shortness of breath, found to have R PTX s/p
pigtail placement. Per patient, patient was in usual state of
health on ___ sitting, watching TV when he developed sudden
onset
R sided chest pain and dyspnea. He called EMS and was brought to
___.
At ___, initial vitals were: 98.3 F (36.8 C). Pulse: 117.
Respiratory Rate: 20. Blood-pressure: 159/93. Oxygen Saturation:
100% room air; Normal. Exam was notable for: Uncomfortable,
tachycardic, decreased air movement at R lung field, wheezes in
left lung field.
Labs there notable for: WBC 22.9, Hgb 14.3 Plt 344, lactate 1.6,
troponin < 0.01. CXR demonstrated large R pneumothorax, and
pigtail catheter was placed.
He received solumedrol 125/duoneb for suspected COPD component
and was transferred to ___ for bed availability and further
management.
Past Medical History:
Hypothyroidism
Hyperlipidemia
L4/L5 disk herniation
Sciata
Chronic Back Pain
H/O Fall and TBI from fall with prolonged ICU hospitalization
Social History:
___
Family History:
None reported
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 PO 157/92 HR 74 RR 20 SpO 96% 4L
GENERAL: A&O3x Moderate distress, very diaphoretic
HEENT: Poor detention with no obvious dental carries. MMM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Absent breath sounds right base, decreased breath sounds
per all lung fields, scattered exp wheezes
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: ++ clubbing, or edema, no cyanosis
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
VS: 98.3, 125/80, 60, 16, 95 Ra
Gen: A&O x3. Moving around room comfortably.
CV: HRR
Pulm: LS ctab
Abd: softly distended. Midline incisione with staples, removed
around umbilicus with VAC dressing placed. Faded incisional
erythema, resolving.
Ext: WWP, No edema
Pertinent Results:
Admission Labs:
___ 10:01AM BLOOD WBC-29.9* RBC-4.30* Hgb-13.9 Hct-40.2
MCV-94 MCH-32.3* MCHC-34.6 RDW-13.1 RDWSD-45.0 Plt ___
___ 10:01AM BLOOD ___ PTT-28.3 ___
___ 10:01AM BLOOD Glucose-139* UreaN-24* Creat-1.0 Na-138
K-5.9* Cl-97 HCO3-27 AnGap-14
___ 07:36AM BLOOD LD(LDH)-268*
___ 01:42PM BLOOD ___ pO2-45* pCO2-53* pH-7.36
calTCO2-31* Base XS-2 Comment-GREENTOP
PERTINENT LABS:
IMAGING:
MRI C-Spine ___ (per PCP ___
Shallow disc protrusion in the midline and on the right side at
C5-6 level with moderate narrowing of the superior portion of
the right neural foramen. Mild disc bulging and degenerative
changes at other levels. No evidence of intrinsic spinal cord
signal abnormalities or extrinsic spinal cord compression.
CT Chest w/o contrast ___
-Consolidative masslike density in the periphery of the right
lower lobe containing small cavity is likely responsible for the
right moderate to large right hydropneumothorax which is worse
incomparison to most recent chest x-ray from ___
05:31. The consolidation is possibly infectious in etiology,
although primary lung neoplasia cannot be ruled out,
particularly in the absence of prior studies.
-Mild ___ opacities in the left lung suggest mild
pneumonia.
-Emphysematous changes.
CXR ___
1. Right-sided pigtail catheter is in unchanged position with a
persistent small right apical pneumothorax.
2. 3.2 cm masslike opacity in the right mid lower lung.
Nonurgent chest CT is recommended for further characterization.
Brief Hospital Course:
___ year old gentleman with ___ year smoking history who presented
with sudden onset shortness of breath, found to have spontaneous
right pneumothorax and loculated pleural effusion secondary to
PNA. Chest tube placed at outside hospital and the patient was
transferred to ___. OSH CXR also demonstrated a pulmonary mass
which was concerning for infectious process vs. malignancy and
follow-up Chest CT demonstrated pleural effusion, and a cavitary
lesion. Thoracics was consulted and followed along. He was
started on broad spectrum antibiotics. He was ruled out for TB,
flu, other viruses, and glucan and galactomannon (sent given
immunosuppression on steroids, as below) were negative.
Pleural fluid was drawn from the effusion and demonstrated an
exudative effusion concerning for empyema. Cultures from the
pleural fluid grew GPCs and he was narrowed to Vanc/Unasyn 3g q6
(Unasyn started ___, final course likely ___ course
depending on response). The GPCs speciated to coagulase negative
staph and he was narrowed to Unasyn IV. Given that his effusion
continued to worsen, and imaging suggested the possibility of
loculations, Interventional Pulmonology was consulted and a
second posterior chest tube was placed on ___ and the first
tube removed. This was followed by two infusions of intrapleural
TPA + DNAase on ___ and ___. Repeat imaging on ___
showed the chest tube in good position and improving pleural
effusion. Additionally the patient was treated symptomatically
with duonebs q6, albuterol PRN, and tesslon pearls and
guaifenesin. IP recommended 6-week course of unasyn, with repeat
outpatient imaging and follow-up with Thoracics.
On ___ the patient developed worsening abdominal pain and
distension over the course of several hours. CXR and KUB
demonstrated evidence of pneumoperitoneum. ACS was consulted and
the patient was taken to the OR for exploratory laparotomy,
ileocecectomy, and stapled side-to-side ileocolic anastomosis
(reader referred to the Operative Note for details). The patient
was hemodynamically stable. He received some fluid boluses for
low urine output and soft blood pressure but was ultimately sent
to the general surgical floor from the PACU in good condition.
He remained NPO with IV fluids and a NGT to suction, receiving
supportive care, POD0-POD2. On POD2, the NGT was clamped and
then removed, as the patient was endorsing flatus. After
trialing a clear liquid diet for POD3, the patient became
distended and started to vomit. The NGT was replaced on POD4. On
POD5, WBC was noted to be rising so a CT scan was done which
showed an ileus, no abscess or leak. The patient briefly
required a PICC line with TPN while awaiting full return of
bowel function. POD9, the patient's incision was noted to be
erythematous and indurated. The incision was opened and drained
of pus at the bedside. Wound cultures were growing Enterococcus,
which was sensitive to the Unasyn the patient was getting. A
wound VAC was placed on POD11.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability on POD9/10. The patient voided without
problem. During this hospitalization, the patient ambulated
early and frequently, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay.
Infectious Disease continued to follow the patient and recommend
6 week course of unasyn. CT torso was done which showed the
previous right loculated pocket of fluid along oblique fissure
has almost completely resolved, small right pneumothorax almost
completely resolved, and a new pneumonia in the left lower lobe.
An echocardiogram was also done given the patient's new heart
murmur. It was notable for moderate to severe aortic valve
stenosis and no discrete vegetations or pathologic regurgitation
identfied.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
for wound VAC care and for home infusions of antibiotics, and
PICC line care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He had follow-up arranged
with ID, Thoracics, and in the ___ clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Levothyroxine Sodium 200 mcg PO DAILY
3. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Ampicillin-Sulbactam 3 g IV Q6H
RX *ampicillin-sulbactam [Unasyn] 3 gram 3 g IV every 6 hours
Disp #*44 Vial Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*20 Packet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % ___ mL IV every six (6) hours
Refills:*0
9. Atorvastatin 40 mg PO QPM
10. Levothyroxine Sodium 200 mcg PO DAILY
11.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
[] Right spontaneous pneumothorax
[] Right complicated pleural effusion, empyema
[] Right cavitary lesion
[] Pneumoperitoneum, acute perforation of the anterior cecum (1
cm perforation).
[] Postoperative ileus
[] Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ with acute onset of difficulty
breathing. You were found to have a collapsed lung, and a chest
tube was inserted to help reinflate the lung. You were
transferred to ___ for further care. The Interventional
Pulmonologists were consulted, and your chest tube was replaced
with a new one to try to better drain fluid from the lung. The
Infectious disease team was consulted due to a cavitary lesion
seen in the right lung, which is believed to be the cause of the
pneumothorax. You were treated with IV antibiotics. On ___, you
developed acute onset of abdominal pain and distention. A CT
scan was done, which showed free air concerning for a
perforation of your intestine. You were taken urgently to the
operating room for an exploratory laparotomy and ileocecectomy.
Post-operatively, your course was complicated by an ileus and
you required a nasogastric tube be reinserted to decompress your
stomach. Your abdominal incision was also red and when staples
were removed, pus drained out, indicating infection. You are
being treated with antibiotics for this as well. You are now on
a regular diet and having bowel function. You have a PICC line
in, to go home to complete a course of IV antibiotics. Your
chest tube has been removed and you are breathing comfortably.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10695080-DS-6
| 10,695,080 | 20,952,726 |
DS
| 6 |
2178-03-01 00:00:00
|
2178-03-02 07:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status and Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with metastatic RCC to the bone, lung,
adrenal glands, liver, and brain which has progressed through
multiple chemotherapy regimens who presented to the ED with
lethargy. He was hospitalized from ___ with fevers
and shortness of breath. It was felt that his dyspnea was
multifactorial from tumor burden, anemia, and mild congestive
heart failure and pleural effusions. He was initially treated
for PNA, but since his fevers were thought to be secondary to
malignancy, ABX were discontinued. He was treated with Lasix
for new diagnosis of diastolic heart failure and discharged home
on hospice given his poor preformance status and tumor
progression.
.
His family states that he became drowsy lethargic around 5 ___
the day prior to admission and felt hot. He was brought to ___.
___ where he was found to have a fever to ___, and
diagnosed with pneumonia on chest x-ray. He was transferred to
___ given that he is followed here by oncology. Prior to
transfer CT head was negative, and he was given vancomycin. In
the ER at ___, Vitals were 99.3 98 117/73 19 99% 2L NC; he
was given Ceftazidime 1g, 3.5 liters of fluid.
Past Medical History:
Past Oncologic History:
___ stage IV
- ___ developed left-sided flank pain and reports that during
the workup for his flank pain, he underwent CT abdomen in ___,
which was reportedly entirely negative to his knowledge.
- ___ developed persistent cough and mild increase in
shortness of breath.
- ___ chest x-ray which showed a large left-sided pleural
effusion, which was drained on ___ and was negative for
malignancy based on cell block analysis.
- ___ chest CT with contrast, which revealed an ill-defined
2-cm thyroid nodule, a 2.4 x 2.0 x 2.9 cm right paratracheal
lymph node as well as a 2.9-cm hilar node and enlarged
subcarinal
lymph node, complete atelectasis of the left lower lobe with a 5
mm pulmonary nodule in the lower lobe, multiple pulmonary
nodules
in the right lung with the largest measuring 5 mm. There was no
notable abdominal findings on the limited cuts of this chest CT.
- ___ bronchoscopy, thoracoscopy, mediastinoscopy, pleural
biopsy and pleurodesis by Dr. ___. This was notable for
biopsies of the left pleura and station 4 lymph nodes that
revealed poorly differentiated metastatic carcinoma with focal
clear cell features staining positive for cytokeratin AE1/AE3,
vimentin, RCC and very focally for CK7 and CD10. Tumor cells
were negative for calretinin CK20, CK5, and TTF1 thought to be
overall consistent with metastatic involvement from a renal
primary.
- ___ CT torso revealed similar intrapulmonary and
intrathoracic findings as ___ chest CT. In addition, a
2.6 cm solid lesion in the right kidney enhancing following
contrast administration was seen. No other right renal lesions
or left kidney lesions. There was also a 10.4 mm celiac lymph
node. No filling defects in the IVC or artery were noted on
this
contrast study. head CT, which was negative for intracranial
pathology.
- ___ C1D1 Sunitinib 50mg PO QD. ___ path review
confirmed
poorly differentiated carcinoma with focal clear cell and
papillary features.
- ___ completed 4wks on cycle 1 Sunitinib
- ___ C2D1
- ___ CT with mixed response, slight decrease in
mediastinal
and hilar adenopathy, overall stable disease.
- ___ C3D1
- ___ C4D1--change to 2weeks on 1week off.
- ___ CT Torso with stable bilateral pulmonary nodules.
Loculated pericardial collection 2.6x4.1cm slightly increased in
size since prior study. Unchanged mediastinal, hilar and
retroperitoneal adenopathy. Ill-defined lesion in lower pole of
the right kidney, stable in appearance since prior imaging.
- ___ C5D1 Sunitinib 50mg 2wk on 1wk off
- ___ C5D1 Sunitinib 50mg 2wk on 1wk off
- ___ CT with stable disease
- ___ C6D1 Sunitinib 50mg 2wk on 1wk off
- ___ C7D1 at dose reduced 37.5mg QD, 2wks on 1wk off
- ___ Called in w hematuria, improved with PO hydration
- ___ CT showed progressive disease despite sunitinib, DCed
sunitinib
- ___ Signed consent for DF-HCC ___, a phase II trial of
temsirolimus plus bevacizumab, but enrolled stalled due to new
brain mets noted on ___
- ___ PET CT showed extensive FDG-avid disease in the left
hemithorax, and FDG-avid lymphadenopathy involved essentially
all
major stations in the thorax. Multifocal FDG-avid
lymphadenopathy
in the abdomen and pelvis. FDG-avid osteolytic lesion at the
left
posterior 9th rib, with a large soft tissue component.
Innumerable small FDG-avid foci in the bones, without definite
anatomic correlates, all concerning for osseous metastases.
- ___ MRI head showed multiple bilateral intracranial
metastases and evidence of leptomeningeal carcinomatosis
- ___ Completed whole brain XRT with 3600 cGy
- ___ Seen in clinic w 30 lbs weight loss, DOE, admitted to
___
- ___ Started Temsirolimus 25 mg IV weekly
- ___ W2 Temsirolimus 25 mg IV weekly
- ___ W3 Temsirolimus 25 mg IV weekly, admitted for pain
control, weight loss, poor performance status
- ___ W4 Temsirolimus 25 mg IV weekly. Delayed by 1 day for
IV access. Clinically improved
- ___ Portacath placed for difficult access
- ___ W5 Temsirolimus 25 mg IV weekly
- ___ Held dose of temsirolimus, admit for worsening DOE,
new fever
- ___: discharged home on hospice
.
Other Past Medical History:
- Tinnitus.
- Hypertension, well controlled on atenolol.
- Status post cholecystectomy.
- Status post titanium rod to his left tibia in ___.
- History of positive PPD in the setting of BCG as a child.
Social History:
___
Family History:
No family history of lung disease or kidney cancer.
Physical Exam:
EXAM ON ADMISSION:
VS: T 98, BP 118/82, P ___, RR 18, SpO2 100% on 3L
GEN: intermittently interactive, AOx2, somnolent
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, R sided
crackles pan-inspiratory
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: CN II-XII intact, ___ strength throughout, intact
sensation to light touch
EXAM ON DISCHARGE:
VS: T 96.8, BP 112/70, HR 81, RR 18, SpO2 95% on RA
GEN: A+Ox3, NAD, sitting at edge of bed
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesions
NECK: Supple, no JVD
CV: RRR, normal S1 and S2. No M/R/G.
CHEST: Respiration unlabored. Decreased breath sounds and
crackles at left base and mid lung. Few crackles on right.
Left Port-a-cath accessed without erythema or tenderness.
ABD: Bowel sounds present. Soft, NT, ND, no HSM.
EXT: No ___ edema. Pulses ___ 2+ bilaterally.
SKIN: No rash, warm skin.
NEURO: CN II-XII intact, ___ strength throughout
PSYCH: appropriate
Pertinent Results:
LABS ON ADMISSION:
___ 03:30AM BLOOD WBC-7.2 RBC-3.35* Hgb-8.2* Hct-26.4*
MCV-79* MCH-24.6* MCHC-31.3 RDW-17.3* Plt ___
___ 03:30AM BLOOD Neuts-78.8* Lymphs-12.0* Monos-6.5
Eos-2.6 Baso-0.2
___ 03:30AM BLOOD ___ PTT-32.4 ___
___ 03:30AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-134
K-4.2 Cl-103 HCO3-23 AnGap-12
___ 03:30AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8
___ 03:47AM BLOOD Lactate-1.0
___ 06:00AM BLOOD ALT-22 AST-25 LD(LDH)-576* AlkPhos-117
TotBili-0.4
___ 06:00AM BLOOD Albumin-2.8* Calcium-9.2 Phos-4.4 Mg-2.1
.
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-9.3 RBC-3.54* Hgb-8.6* Hct-29.0*
MCV-82 MCH-24.3* MCHC-29.7* RDW-17.0* Plt ___
___ 06:28AM BLOOD Neuts-81.0* Lymphs-9.7* Monos-6.4 Eos-2.8
Baso-0.2
___ 06:00AM BLOOD Glucose-77 UreaN-11 Creat-0.8 Na-137
K-4.5 Cl-103 HCO3-24 AnGap-15
___ 06:00AM BLOOD ALT-20 AST-26 LD(LDH)-740* AlkPhos-131*
TotBili-0.3
___ 06:00AM BLOOD Albumin-2.8* Calcium-9.2 Phos-4.5 Mg-2.2
___ 03:30AM URINE Color-Straw Appear-Clear Sp ___
___ 03:30AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:30AM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
.
MICROBIOLOGY:
___ 3:30 am URINE CULTURE (Final ___: NO GROWTH.
___ 3:30 am BLOOD CULTURE (Pending): No growth to date.
___ 3:45 am BLOOD CULTURE #___ATH LINE (Pending):
No growth to date.
.
IMAGING / STUDIES:
# CHEST (PA & LAT) ___ at 4:05 AM):
Nodularity throughout both lungs more prominent on the right
lung likely represents disseminated carcinoma as documented by
the CT torso of ___. Opacification of the left lung base
may represent moderate left pleural effusion with compressive
atelectasis, however underlying infectious process or mass
cannot be completely excluded in the correct clinical setting.
In addition to the disseminated carcinoma there appears to be
mild volume overload or worsening neoplastic process within the
right lung. A left Port-A-Cath tip projects at the level of the
cavoatrial junction.
.
# CT HEAD W/O CONTRAST ___ at 4:14 AM):
IMPRESSION: No evidence of acute intracranial hemorrhage or
obvious mass effect. Please note that a non-contrast head CT is
not sensitive for the detection of intracranial masses. If there
is continued clinical concern and need for evaluation of
parenchymal masses noted on the prior MRI, then a repeat MRI of
the brain can be obtained with and without contrast, if not
contra-indicated. The right lateral ventricle is slightly more
concave - ?related to orientation - attention on f/u.
.
Brief Hospital Course:
The patient is a ___ yo with a PMHx of metastatic RCC which has
failed chemotherapy (with Sutent, Temsirolimus, and Bevacizumab)
who presents with altered mental status and fever after going
home ___ on hospice.
.
# Fever: Likely secondary to leptomeningeal disease and extent
of malignancy. Given concern for post-obstructive pneumonia
given CXR, we initially covered for HCAP. Lumbar puncture was
deferred given his prior antibiotic treatment in the ED and low
likelihood of meningitis given the rapid improvement in mental
status and lack of meningeal signs. Vancomycin and ceftriaxone
were initiated for a 7 day course. Urine cultures were no
growth, and blood cultures demonstrated no growth during his
stay, but final results were pending at the time of discharge.
He had no further episodes of fever during his stay. He was
discharged on Levofloxacin for oral coverage of possible
pneumonia since IV antibiotics were not available on hospice.
.
# Encephalopathy: Differential diagnosis on arrival included
cerebral edema vs leptomeningeal spread of disease vs sepsis vs
overuse of narcotics. Cerebral edema was not visualized on
imaging. Upon admission, narcotics were reduced from Oxycontin
40 mg TID to 30 mg BID. By day two of admission, his mental
status had greatly improved. It is likely that the reduction of
Oxycontin resulted in the improvement in mental status.
Antibiotic coverage with Levofloxacin was continued on discharge
since infection could not be completely ruled out. He was
discharged on the reduced dose of Oxycontin with Oxycodone for
breakthrough pain.
.
# Pain Control: He has had difficulty with pain control and
adjustment of his narcotics doses for adequate relief without
over narcotization. His Oxycontin likely contributed to his
altered mental status and lethargy on admission. He was
discharged on the reduced dose of Oxycontin 30 mg PO BID with
Oxycodone 10 mg PO Q4H for breakthrough pain. He was also
started on standing doses of Ibuprofen 400 mg PO Q6H and
Acetaminophen 1000 mg PO Q8H. The addition of these
non-narcotic pain medications appeared to have good effect with
a reduced need for narcotics. His pain was well controlled
without sedation or confusion during his stay, and he was
discharged on this new regimen. He will likely neec close
followup of his pain control regimen after discharge with care
to avoid over escalation of his narcotics doses.
.
# Metastatic RCC: He is status post failure of two regimens, and
per primary oncologist no further anti-neoplastic care is
indicated. He recently went home on hospice on ___.
Palliative care was consulted on admission for further teaching
about the role of hospice and reevaluation for hospice services.
He was discharged home with the same hospice service.
.
# Chronic diastolic CHF: He did not appear fluid overloaded on
exam. His outpatient dose of Furosemide 20 mg PO daily was
continued.
.
# Appetite / Nutrition: Patient was continued on Megestrol
Acetate 400 mg PO BID and Ensure supplements with meals.
.
# DVT Prophylaxis: Heparin 5000 units SC TID
.
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
2. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*2*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose packet PO DAILY (Daily).
Disp:*30 packs* Refills:*2*
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
Disp:*600 mL* Refills:*2*
6. chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for hiccups.
Disp:*120 Tablet(s)* Refills:*0*
7. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO TID (3
times a day).
Disp:*900 ml* Refills:*2*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. krill oil-omega-3-dha-epa 45-45 mg Capsule Sig: One (1)
Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
12. Ensure Liquid Sig: One (1) bottle PO twice a day.
Disp:*60 bottles* Refills:*2*
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO every
six (6) hours as needed for pain.
Disp:*1000 ml* Refills:*0*
15. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. oxycodone 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
3. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
5. chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for hiccups.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
8. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. multivitamin Tablet Sig: ___ Tablets PO DAILY (Daily).
10. Ensure Liquid Sig: One (1) PO twice a day.
11. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
18. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Renal Cell Cancer
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with altered mental status and fever.
Your mental status improved after decreasing your pain
medication doses. You were treated with antibiotics for a
possible pneumonia, and should complete a course of
Levofloxacin. You were discharged home with hospice services to
make you more comfortable at home.
The following medication changes have been made to your regimen:
START: Levofloxacin 750 mg by mouth daily until ___
DECREASE: Oxycontin 30 mg by mouth twice daily
CONTINUE: Oxycodone 10 mg every 4 hours as needed for pain
START: Acetaminophen 1000 mg every 8 hours
START: Ibuprofen 400 mg by mouth every 6 hours
STOP: Krill Oil
Please continue all other medication as prescribed.
Please contact your hospice team or primary oncologist if you
have any medical concerns while at home. It is important that
you take your pain medications as prescribed to avoid future
problems with confusion and lethargy. Your hospice team should
be contacted if your pain worsens and is not well controlled
with the current medication regimen.
Followup Instructions:
___
|
10695591-DS-19
| 10,695,591 | 27,085,800 |
DS
| 19 |
2168-01-17 00:00:00
|
2168-01-17 14:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
adenosine / iodine / Lasix / shellfish derived / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
Removal of left cephalmedullary nail and subsequent left total
hip arthroplasty; ___ ___
History of Present Illness:
History the patient is a pleasant female who sustained a fall
about a month ago and had a TFN done at ___
unfortunately this is cut into the acetabulum and she has been
referred to us for definitive management past medical history
includes history of alcohol abuse COPD coronary artery disease
gastroesophageal
reflux disease high blood pressure nephrolithiasis depression
fibromyalgia pancytopenia liver cirrhosis tobacco abuse lupus
irritable bowel syndrome right upper lobe pulmonary nodules.
Past Medical History:
past medical history includes history of alcohol abuse COPD
coronary artery disease gastroesophageal reflux disease high
blood pressure nephrolithiasis depression fibromyalgia
pancytopenia liver cirrhosis tobacco abuse lupus irritable bowel
syndrome right upper lobe pulmonary nodules.
Social History:
___
Family History:
non-contributory.
Physical Exam:
Exam on Discharge
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Dressing clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Left lower extremity fires ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
negative except per extremity injury addressed during this
hospital stay.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left cephalomedullary nail cutout and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for conversion to left hip total
arthroplasty, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the left lower extremity, and will
be discharged on enoxaparin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 200 mg PO DAILY
2. Mirtazapine 15 mg PO QHS
3. Omeprazole 20 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth 5 times daily Disp #*60 Tablet Refills:*0
2. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 1 syringe daily Disp #*24
Syringe Refills:*0
3. LORazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every 6 hours as needed
Disp #*28 Tablet Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*21 Tablet Refills:*0
5. TraMADol 50 mg PO Q6H:PRN pain
Ok to request partial fill. Wean as tolerated.
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*28 Tablet Refills:*0
6. Atorvastatin 10 mg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO DAILY
10. Mirtazapine 15 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left cephalomedullary nail cut-out.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight-bearing on the left lower extremity.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take enoxaparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
daily physical therapy. Touch down weight bearing on the left
lower extremity, no hip precautions.
Treatments Frequency:
patient has incision over left hip. Ok to leave incision open to
air. No bathing or soaking the incision in water.
Followup Instructions:
___
|
10695678-DS-7
| 10,695,678 | 21,391,669 |
DS
| 7 |
2133-01-22 00:00:00
|
2133-01-22 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
naproxen
Attending: ___
Chief Complaint:
1. Transfer from OSH s/p fall
2. L ___ nondisplaced rib fracture
3. L clavicular fracture
4. L pneumo thorax
Major Surgical or Invasive Procedure:
1. Placement pigtail chest tube catheter
History of Present Illness:
This patient is a ___ year old female who presented to the ER
after a fall last night. She fell down the stairs after
having 1 drink. +head injury, clavical pain and chest wall
pain. Seen at ___ by Dr. ___. CT head and face without
traumatic injury. C spine cleared clinically CXR and
clavicle xrays with L sided pnthx ~20 % and L clavicle
fracture. Dr. ___ was not able to get a pigtail catheter
at ___ and Ms. ___ was hemodynamically stable so
large CT not placed and transferred to ___. +SOB,
+clavicle and CW TTP. No N/V.
Past Medical History:
PMH: diabetes, hypertension, high cholesterol
PSH: none
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 99.3 HR: 86 BP: 144/66 Resp: 18 O(2)Sat: 100 Normal
Constitutional: awake, alert, NAD
HEENT: L periorbital ecchymosis, Extraocular muscles intact
supple
Chest: decreased BS on L
Cardiovascular: Regular Rate and Rhythm. Focal TTP L
clavicle and L chest wall.
Abdominal: Soft, Nontender
Skin: Warm and dry
Neuro: Speech fluent, no focal weakness (though does not
pove L arm as much due to pain)
Psych: Normal mentation
___: No petechiae
Pertinent Results:
___ 10:25AM BLOOD WBC-7.0 RBC-3.64* Hgb-11.9* Hct-35.6*
MCV-98 MCH-32.7* MCHC-33.5 RDW-12.3 Plt ___
___ 10:25AM BLOOD Glucose-135* UreaN-19 Creat-0.7 Na-141
K-4.2 Cl-105 HCO3-28 AnGap-12
___ 10:25AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0
Imaging:
CT Chest ___:
Frontal and lateral views of the chest are obtained. Left-sided
chest tube is again seen, extending into the medial left upper
hemithorax, may be encroaching on the mediastinum, and coils
distally. A moderate left
pneumothorax remains. Extensive subcutaneous edema is seen along
the left
chest wall. Left retrocardiac opacity is seen. Given differences
in
technique, the right paratracheal mediastinum is less prominent
as compared to the prior study. Right base atelectasis. Cardiac
silhouette is top normal. Displaced mid left clavicle fracture
is seen. Left sided rib fractures seen on study earlier today
were better appreciated on that study
CXR:
___
Interval decrease in subcutaneous emphysema involving the left
lateral soft tissues. Left chest tube remains in place with its
tip coiled at the apex, and there is still a moderate left-sided
pneumothorax with persistent collapse of the left lower lobe.
Overall, when compared to the prior study of ___ at 17:38,
there is overall improved aeration in the left upper and mid
lung. Overall, cardiac and mediastinal contours are likely
stable given differences in positioning between studies. Right
lung is grossly clear. No evidence of pulmonary edema
___
IMPRESSION: Interval re-development of large left-sided
pneumothorax with
associated signs of mild rightward mediastinal shift
___
Left apical pleural drain unchanged in position. The medial
component of the small-to-moderate left pneumothorax has
increased the most, apical and lower lateral components less so,
and the anterior and posterior components not appreciably. Left
lower lobe atelectasis is still substantial. Right lung is
grossly clear. Cardiomediastinal silhouette is unremarkable. Dr.
___ I discussed the findings and their clinical significance
by telephone at the time of dictation
Brief Hospital Course:
Ms. ___ was transferred from an OSH for management of a
Left sided pneumothorax, multiple L sided ___ non-displaced rib
fracture and L clavicular fracture s/p fall. Pigtail chest
catheter placement was performed in the ___ ED with interval
improvement. Patient was admitted to the ___ Trauma service for
continued management of pneumothorax and pain control for
multiple rib fracture. Pain was controlled on i. v. pain
medication transitioned to po when tolerated. CXR was followed
for interval change in pneumothorax and IS was encouraged
throughout hospital stay. Chest tube was placed to water seal
on HD3 with interval re accumulation of large pneumothorax.
Chest tube was returned to suction and patient was managed an
additional 3 days on suction before attempted water seal on HD7.
Oxygen was weaned as tolerated. Patient tolerated water seal
without interval change in pneumothorax and pigtail chest
catheter was removed on HD8. Follow up CXR was without increase
in pneumothorax at time of discharge. Patient was tolerating a
regular diet with adequate urine output, ambulating
independently with good po pain control and stable vital signs
at time of discharge. Orthopaedics was consulted for management
of left clavicular fracture and recommended sling for comfort.
Medications on Admission:
___: lisinopril 10', simvastatin 20', metformin 500', aspirin
81', calcium+D 650', multivitamin
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left pneumothorax
2. Left clavicular fracture
3. Left ___ non-displaced rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen and evaluated in the ED as a transfer from an
outside hospital for a left clavicular fracture, multiple left
sided rib fractures and a left sided pneumothorax. A chest tube
was placed in the ED and you were admitted to the ACS service
for continued management. Attempted water-seal of you chest
tube resulted in interval increase in pneumothorax and an
additional 3 days were required at which time your physical
examination and CXR were consistent with removal of chest tube
which was well tolerated. Your repeat CXR did not show any
increase in pneumothorax at time of discharge.
-___ not drive while taking narctoic pain medication
-You may shower in the next ___ hours if you leave the occlusive
dressin in place
-Please call or return to the ED for increased work of
breathing, increased chest pain, irregular heart beat, nausea,
vomiting or temperature greater than 101.4.
Followup Instructions:
___
|
10696430-DS-12
| 10,696,430 | 26,383,796 |
DS
| 12 |
2152-11-08 00:00:00
|
2152-11-08 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Humira / Humira / Penicillins / erythromycin base / codeine /
doxycycline / Keflex / clindamycin / Influenza Virus Vaccines
Attending: ___.
Chief Complaint:
Diffuse joint pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a ___ year-old with the history below who presented
to the ED yesterday complaining of diffuse myalgias and
arthralgias worsening over 9 days, ultimately with pain and
inflammation of the shoulders, elbows, and hands/fingers so
severe as to limit her walking (hip pain) and use of her arms
and
hands. Additionally she reports low grade fever (99-100.2) over
6 days and over the past ___ hours, has had a sore throat
without cough, that is improved but present today. She
presented
to the ED where she was given plaquenil, fluids, toradol IV,
multiple doses of IV morphine and admitted for "RA flare" for
ongoing management.
Past Medical History:
RA
Depression
Asthma
Seasonal allergy
Social History:
___
Family History:
Her maternal niece and maternal uncle have rheumatoid arthritis.
Physical Exam:
VS: 97,8 PO 122 / 75 96 16 98 RA
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions (cannot see any tonsilar exudates or coating), no
supraclavicular or cervical lymphadenopathy, no JVD, no carotid
bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing. there is some notable edema
of the ___ MCP joint, rt greater than left, and UEs with pain
with active motion throughout, cannot fully extend either elbow
due to pain
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
No
sensory deficits to light touch appreciated. No pass-pointing
on
finger to nose. 2+DTR's-patellar and biceps. No asterixis, no
pronator drift, fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
___ 09:00AM URINE HOURS-RANDOM
___ 09:00AM URINE HOURS-RANDOM
___ 09:00AM URINE HOURS-RANDOM
___ 09:00AM URINE UCG-NEGATIVE
___ 09:00AM URINE GR HOLD-HOLD
___ 09:00AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 09:00AM URINE RBC-4* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-4
___ 09:00AM URINE HYALINE-1*
___ 09:00AM URINE MUCOUS-MOD
___ 09:00AM URINE RBC-4* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-4
___ 09:00AM URINE HYALINE-1*
___ 09:00AM URINE MUCOUS-MOD
___ 02:50AM GLUCOSE-91 UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
___ 02:50AM ALT(SGPT)-18 AST(SGOT)-15 LD(LDH)-219 ALK
PHOS-67 TOT BILI-0.4
___ 02:50AM CALCIUM-9.3 PHOSPHATE-4.7* MAGNESIUM-2.1
___ 02:50AM CRP-27.1*
___ 02:50AM WBC-13.7* RBC-4.09 HGB-13.2 HCT-38.8 MCV-95
MCH-32.3* MCHC-34.0 RDW-11.7 RDWSD-40.8
___ 02:50AM NEUTS-70.0 LYMPHS-15.7* MONOS-11.2 EOS-2.3
BASOS-0.4 IM ___ AbsNeut-9.60*# AbsLymp-2.15 AbsMono-1.53*
AbsEos-0.31 AbsBaso-0.05
___ 02:50AM PLT COUNT-265
___ 01:45AM GLUCOSE-94 UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21*
___ 01:45AM WBC-ERROR DISR RBC-ERROR DISR HGB-ERROR DISR
HCT-ERROR DISR MCV-ERROR DISR MCH-ERROR DISR MCHC-ERROR DISR
RDW-ERROR DISR RDWSD-ERROR DISR
___ 01:45AM NEUTS-UNABLE TO LYMPHS-UNABLE TO
MONOS-UNABLE TO EOS-UNABLE TO BASOS-UNABLE TO AbsNeut-UNABLE
TO AbsLymp-UNABLE TO AbsMono-UNABLE TO AbsEos-UNABLE TO
AbsBaso-UNABLE TO
___ 01:45AM PLT COUNT-UNABLE TO
============================
ADMISSION CHEST X RAY
No evidence of pneumonia
Brief Hospital Course:
___ y/o F with a history of seropositive RA (+RF and +CCP) who
presents with polyarticular pain and swelling, in addition to
low grade fevers and sore
throat. Rheumatology was consulted for the question of an RA
flare.
Given the polyarticular pain, synovitis on exam, in the setting
of a lack of regular treatment for her RA and possibly a viral
infection (sore throat and low grade fever), her presentation
was thought to be consistent with a Rheumatoid Arthritis flare.
They thought that she would benefit
from initiation of steroids now to decrease pain and
inflammation. Long term, she would benefit from a DMARD such as
Methotrexate, and the plan was to discuss this at her follow up
visit with Dr. ___ on ___.
Their recommendations were:
"- Initiate Prednisone 30mg daily x1 week, then taper down to
20mg
daily, further downtitration to be determined at outpatient
Rheumatology visit
- We have provided the patient with information about
Methotrexate so she can have a more informed discussion about it
at her next clinic visit. Additionally, we will attempt to move
this appointment with Dr. ___ on ___ to sooner, if
possible.
- Check ___, Anti-dsDNA, Ro, La, and Complement
levels, to evaluate for SLE"
.
The patient requested to leave since it was her birthday and she
and her husband felt that she could care for herself at home.
Her hospital course was reviewed. She was receiving oxycodone 5
mg three times a day here. Her PMP was reviewed and it was not
concerning. She was given a prescription for 15 tablets at 5 mg
tid PRN pain. She understood that by receiving this short
prescription it might make it harder for her to get a longer
course from another provider. She demonstrated understanding of
this. Pt counseled to avoid using heavy machinery or taking it
with ambien which she also received a ppx for in the last month
based on PMP review. She also demonstrating understanding of
this. I reviewed with her that rheumatology wanted the
aforementioned labs checked but that she could have them drawn
when she sees Dr. ___ in f/u. Her care was d/w Dr. ___
rheumatology attending who agreed with discharging her tonight.
She was continued on her home medications and given only two
prescriptions, one for prednisone 20 mg daily for 1 week and one
for oxycodone as described above.
[X]Time spent on discharge related activities: > 30 minutes.
above completed by Dr. ___ discharge orders and plan
completed by Dr. ___. I was attending of record when pt
was admitted, and so am signing this document to finalize it.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Diclofenac Sodium ___ 75 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Cetirizine 20 mg PO DAILY
5. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Cetirizine 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Please do not take with ambien or other sedatives. No
driving/heavy machinery use
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth three times a
day Disp #*15 Tablet Refills:*0
4. Diclofenac Sodium ___ 75 mg PO BID
Pt takes this at home.
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Venlafaxine XR 75 mg PO DAILY
Pt has been on this regimen for years w/o side effect
7. PredniSONE 30 mg PO DAILY Duration: 7 Days
Please contact Dr. ___ re a prescription for the rest of
your prednisone taper.
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Rheumatoid Arthritis
Secondary
1. Multiple food allergies, with a chronic rash.
2. Well controlled asthma,
3. H/o Thyroid disease in past, treated with PTU previously,
euthyroid since
4. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___:
You were admitted with a flare of your rheumatoid arthritis. You
were seen by the rheumatology consult service and attending Dr.
___. It was decided to start you on a prednisone taper starting
with prednisone 30 mg daily for a week. Today is day 1 of 7 and
you have already taken 30 mg for today. Please contact Dr. ___
___ the rest of your prednisone taper. You were a short course of
oxycodone for pain control. Please do not take while driving or
operating other dangerous equipment or when taking ambien. This
medication causes sedation..
Followup Instructions:
___
|
10696480-DS-19
| 10,696,480 | 20,914,399 |
DS
| 19 |
2156-05-13 00:00:00
|
2156-08-11 10:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Multiple stab wounds
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male with PMHx of HIV
presents to the ED via EMS with stab wounds. Patient states
that he was involved in an altercation erlier tonight and he
did not note being stabbed at the time. Patient sustained
stab wounds to left chest, left arm, right sided abdomen and
right thigh. He does report pleuritic CP, but ___ head
strike or LOC.
Past Medical History:
hx of HIV
Social History:
___
Family History:
non contributory
Physical Exam:
Vitals: WNL
HEENT: No scleral icterus
Cardiac: WNL
Respiratory: Breathing comfortably: Chest wall incision site
clean,dry, intact.
Abdomen: Soft, non-tender to rebound or tenderness
Extremity: Stab wounds well heeled.
Pertinent Results:
___ 09:22AM WBC-6.0 RBC-3.84* HGB-12.1* HCT-34.5* MCV-90
MCH-31.6 MCHC-35.2* RDW-14.4
___ 10:05PM VoidSpec-SPECIMENS
___ 10:05PM VoidSpec-MISLABELED
___ 10:05PM VoidSpec-MISLABELED
___ 10:05PM VoidSpec-MISLABELED
___ 10:05PM VoidSpec-MISLABELED
___ 10:47PM PLT COUNT-105*
___ 10:47PM NEUTS-78.8* LYMPHS-13.0* MONOS-7.1 EOS-0.8
BASOS-0.3
___ 10:47PM WBC-5.2 RBC-3.73* HGB-11.8* HCT-33.4* MCV-90
MCH-31.7 MCHC-35.4* RDW-14.1
___ 10:47PM GLUCOSE-95 NA+-137 K+-3.6 CL--104 TCO2-22
___ 10:47PM GLUCOSE-101* CREAT-1.1 SODIUM-137
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
___ 11:35PM ___ PTT-26.5 ___
___ 09:22AM WBC-6.0 RBC-3.84* HGB-12.1* HCT-34.5* MCV-90
MCH-31.6 MCHC-35.2* RDW-14.4
Brief Hospital Course:
MR. ___ was admitted following multiple stab wounds. He was
admitted to the ICU secondary to finding 1 abdominal stab wound,
which did not violate the facia, and 1 stab wound near the chest
well. He did not develop any symptoms, and his CT was did not
show any signs of inta abdominal injuries. He was transferred to
the floor on and was discharged from the hospital with a course
of antibiotics and was continued on his home medications. At the
time of discharge he was doing well. HE was ambulating and
tolerating PO.
Medications on Admission:
2. Atovaquone Suspension 750 mg PO BID
3. Citalopram 40 mg PO DAILY
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY RX *omeprazole [Prilosec] 20 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
7. PALIperidone ER 6 mg PO QHS
8. QUEtiapine extended-release 300 mg PO QHS
9. RiTONAvir 100 mg PO BID
10. Xanax XR (ALPRAZolam) 2 mg oral Qhs
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Doses
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
2. Atovaquone Suspension 750 mg PO BID
3. Citalopram 40 mg PO DAILY
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
RX *omeprazole [Prilosec] 20 mg 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
7. PALIperidone ER 6 mg PO QHS
8. QUEtiapine extended-release 300 mg PO QHS
9. RiTONAvir 100 mg PO BID
10. Xanax XR (ALPRAZolam) 2 mg oral Qhs
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple stab wounds
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to ___ following admission for multiple stab
wounds. A CT scan was obtained which showed some fluid around
the lower portion of your lung and a small defect in the
abdominal wall. These injuries were carefully watched while ___
were admitted in the ICU.
___ were started on antibiotics, which ___ will continue to take
for 2 weeks. ___ will need to follow up in the ___ clinic in 2
weeks.
Followup Instructions:
___
|
10696506-DS-7
| 10,696,506 | 22,787,701 |
DS
| 7 |
2172-12-12 00:00:00
|
2172-12-23 22:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
alcohol withdrawal and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of etoh abuse who presents w/ report of etoh
withdrawal and cough. Says he has had 2 weeks of cough that is
occasionally productive of green phlegm. Patient states he has
mild dyspnea on exertion after walking a few blocks. No chest
pain/fever/hemoptysis. Also drinks about a 1L of vodka per day.
Last drink was 2 days ago. States that he is currently tremulous
and saw "faces on the wall" yesterday morning in the ED. Patient
states that he has also been vomiting for several days, and has
difficulty keeping any PO down.
Patient has complicated history of alcohol abuse with multiple
hospitalizations for detox and previous rehab stints most
recently 2 months ago. He denies history of withdrawal seizures
or ICU stays due to withdrawals. (+) Hallucinations in the past
most recently ___.
No abdominal pain, headache, diarrhea, fevers/chills
(+) 15lb weight loss in ~2 weeks but states he has not been
eating regular meals.
In the ED, initial vital signs were 0 97.6 92 121/95 16 99% 6L
nc . He didn't appear to be withdrawaing overnight, but was
intoxicated and vomiting on admission. He was persistently
vomiting throughout morning, unable to control with zofran,
ativan and IV D51/2NS. He was also given 40meq K with folate,
thiamine, and MVI, and one amp d50 due to FSGS of 70
87 118/76 20 96% RA
On the floor, patient is NAD, but tremulous. Vitals were: 98.3
113/64 83 18 98%RA
Past Medical History:
-perforated sigmoid diverticulitis: Sigmoid colectomy/End
Colostomy, ___ pouch, revision ___
-etoh abuse with withdrawl (+ hallucinations, no
seizures/intubation) last detox ___, last drink ___ at 0400
-polysubstance abuse: last use of intranasal cocaine/heroin in
early ___
-fulminant hepatic failure / HRS ___ EtOH/Tylenol intoxication
in ___
-bipolar disorder
Social History:
___
Family History:
Father, uncles and paternal grandmother with significant
alcoholism. Mother and cousins with depression. Brother with
___
Physical Exam:
ADMISSION:
Vitals- 98.3 113/64 83 18 98%RA
General: NAD, heavily tattooed, somewhat disheveled male
HEENT: sclera injected, no icterus, clear oropharynx
Neck: supple, no jvd
CV: RRR, no m/r/g
Lungs: CTA b/l, good air movement, no wheezes/rales, rhonchi,
clear to percussion b/l
Abdomen: well healed midline scar, soft, nontender, no
hepatomegaly
GU: no foley
Ext: no edema, ___ strength
Neuro: CNII-XII intact, but tremulousness in bilateral UE.
Skin: no jaundice
DISCHARGE:
Vitals- 97.5 98 (61-98) 122/91 (110-128/89-93) 18 99%
General: NAD, heavily tattooed, somewhat disheveled pleasant
male
HEENT: no sclera icterus, clear oropharynx
Neck: supple,
CV: RRR, no m/r/g
Lungs: CTA b/l, good air movement,
Abdomen: well healed midline scar, soft, nontender, no
hepatomegaly
GU: no foley
Ext: no edema, ___ strength
Neuro: AAOx3, but tremulousness in bilateral UE, improved. no
tongue fasciculations
Skin: no jaundice
Pertinent Results:
==============
LABS
==============
ADMISSION:
___ 11:28PM WBC-4.8 RBC-4.72 HGB-15.6 HCT-45.3 MCV-96
MCH-33.0* MCHC-34.4 RDW-14.0
___ 11:28PM NEUTS-42.6* LYMPHS-46.7* MONOS-6.6 EOS-0.8
BASOS-3.4*
___ 11:28PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:28PM GLUCOSE-90 UREA N-8 CREAT-0.7 SODIUM-134
POTASSIUM-3.1* CHLORIDE-93* TOTAL CO2-19* ANION GAP-25*
___ 11:37PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG
___ 11:37PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:37PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:10AM LIPASE-32
___ 10:10AM ALT(SGPT)-161* AST(SGOT)-264* ALK PHOS-81 TOT
BILI-1.7*
___ 10:10AM GLUCOSE-158* UREA N-6 CREAT-0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
DISCHARGE:
___ 06:00AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-132*
K-3.7 Cl-99 HCO3-21* AnGap-16
___ 06:00AM BLOOD Na-134 K-4.5 Cl-100
___:00AM BLOOD ALT-146* AST-154* AlkPhos-110 TotBili-1.2
___ 06:00AM BLOOD ALT-164* AST-221* AlkPhos-90 TotBili-2.1*
DirBili-0.7* IndBili-1.4
___ 11:28PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:00AM BLOOD HCV Ab-NEGATIVE
================
IMAGING:
================
RUQ ___
The liver is again noted to be diffusely echogenic consistent
with fatty
infiltration. No focal liver lesion is identified. No biliary
dilatation is
seen and the common duct measures 0.2 cm. The portal vein is
patent with
hepatopetal flow. There is sludge partially filling the
gallbladder. No
gallstones are visualized. The pancreas is unremarkable however
the distal
pancreatic tail is obscured from view by overlying bowel gas.
No ascites is
seen in the right upper quadrant.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No biliary dilatation.
3. The gallbladder is partially filled with sludge.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a past medical history of
alcohol abuse with multiple hospitalizations for withdrawals
presents for alcohol withdrawal and persistent nausea and
vomiting.
#Alcohol withdrawal- Patient has long history of Alcohol abuse
with multiple hospitalizations for detoxification, previously
complicated by hallucinations, but no history of seizures or
intensive care unit stays. He presented with intoxication with
an alcohol level of 241 and an initial anion gap of 22 which
improved to 12 with adequate hydration in the ED. He was placed
on CIWA with Valium prn. Additional Valium 10mg TID was given to
ameliorate the detox and minimize the patient's anxiety. He was
started on thiamine, folate, and a multivitamin. He was
successfully detoxed without complications. He declined rehab
and decided to return to ___ and restart work. He was
strongly encouraged to seek out additional help in ___
for his sobriety.
#Nausea/Vomiting- Patient had persistent nausea and vomiting on
admission likely secondary to withdrawal with resolving element
of alcoholic ketoacidosis as patient had an initial elevated gap
of 22 which improved to 12. Lipase was 32, making pancreatitis
unlikely. His nausea was controlled with zofran and he was
transitioned to oral intake.
#Acute Liver Injury- Patient had elevated Tbili to 1.7 with a
peak of 2.1 from previous baseline of ~0.4. Patient also had
transaminitis, with his ALT/AST 161/264. His previous ALT were
in the ~200s and AST ~100s. A RUQ ultrasound was performed that
showed fatty infiltration with biliary sludge. Elevations were
attributed to acute alcohol injury. His LFTs downtrended and on
discharge were: ALT 146, AST 154, T. Bili of 1.2.
#Cough- Patient presented with several week history of dry
cough. Chest Xray in the ED showed no acute process. The patient
was afebrile and had no leukocytosis. The cough was determined
to be post-viral and he was given tessalon pearls.
# Code: Full
# Emergency Contact: ___ (mom) ___
**Transitional Issues:**
-___ liver function
-continue monitoring and support of sobriety
-patient found to be thrombocytopenic, please recheck and workup
as appropriate
Medications on Admission:
none
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Alcohol withdrawal
-Transaminitis/Alcoholic hepatitis
-Post-viral cough
-Anxiety
Secondary Diagnosis:
-Alcohol Abuse
-Polysubstance Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You presented to the hospital for alcohol
detoxification. We gave you a medication called valium to
prevent withdrawal and monitored your symptoms. You successfully
completed detoxification and we encourage you to continue with
your sobriety. We strongly encourage you to seek additional help
in ___, including finding a new primary care doctor and
attending AA meetings.
During your admission you were found to have elevated liver
enzymes (a marker for injury to your liver). We performed an
ultrasound of your liver which showed changes due to your
alcohol use. Your liver tests improved during the admission, but
are still elevated. You should have your primary doctor
___ these in ___ months.
Followup Instructions:
___
|
10696541-DS-9
| 10,696,541 | 28,102,876 |
DS
| 9 |
2173-01-23 00:00:00
|
2173-01-23 19:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
History of Present Illness:
Mr. ___ is an ___ gentleman with a past medical history
of coronary artery disease, hypertension, dyslipidemia,
gastroesophageal reflux disease and BPH, with a recent diagnosis
of metastatic anorectal mucosal melanoma (BRAF ___
mutated) who is presenting today because of ongoing rectal
bleeding. He has had diarrhea for many months but has had
progressively worse BRBPR since starting a new medication,
Pembrolizumab, last week.
With regard to his onc history, he was started on ipilimumab on
___ and completed on ___. Unfortunately, his
re-staging CT scans showed signs of disease progression.
Additionally, his symptoms of fatigue, weight loss, small
caliber stools and rectal bleeding did not improve so he was
initiated on Pembrolizumab on ___.
In the ED, his initial VS were: 98 76 113/69 30 100%. His labs
were notable for: WBC 11, Hgb 9.5, Hct 29.9, Plt 464, LFTs wnl,
BMP whl, D-Dimer 667, UA negative. Lactate 3.2. He reported
tachypnea so imaging included a normal CXR and a CTA which
showed pulmonary emboli seen in the subsegmental branches of the
posterior segment of the left lower lobe. He received 1L NS and
was sent to the OMED service for a further work-up.
Past Medical History:
PAST ONCOLOGIC HISTORY
- ___: Presents to PCP with complaint of rectal bleeding for
2.5 weeks. Hemoglobin 12.6 at that time.
- ___: Evaluated by Dr. ___ GI at ___, who
recommends EGD and colonoscopy.
- ___: Colonoscopy reveals a large dark mass in the distal
rectum. Biopsy of the rectum demonstrates malignant melanoma.
BRAF is wildtype.
- ___: CT torso shows the bulky lower rectal intraluminal
mass, with two large retrorectal lymph nodes (3 x 1.5 cm and 1.8
x 1.5 cm) and multiple borderline-enlarged para-aortic lymph
nodes.
- ___: PET reveals markedly FDG-avid circumferential wall
thickening of the rectum corresponding to the primary tumor,
with
multiple FDG-avid regional lymph nodes. MRI brain shows no
evidence of intracranial metastatic disease.
- ___: C1D1 ipilimumab 3 mg/kg.
- ___: C2D1 ipilimumab 3 mg/kg.
- ___: C3D1 ipilimumab 3 mg/kg.
- ___: C4D1 ipilimumab 3 mg/kg.
- ___: Restaging CT demonstrated pulmonary nodes and
persistent mediastinal lymphadenopathy
- ___: Started Pembrolizumab q3weeks
PAST MEDICAL HISTORY:
- CAD s/p CABG ___ ___, SVG->RCA). Had
recurrence in ___ and underwent balloon angioplasty of left
circ.
- HL
- HTN
- GERD
Social History:
___
Family History:
Brother had leukemia. Another brother had ___ dementia.
Father died of heart disease
Physical Exam:
====================
ADMISSION EXAM
====================
VS: 122/50 75 22 100% RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: Grossly wnl
SKIN: Warm and dry
====================
DISCHARGE EXAM
====================
VS: 98.8 98.9 60-70s 100-130/40-70s 18 99% on RA
GEN: elderly cachetic man in no distress, AOx3
HEENT: PERRLA. MMM. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: breathing comfortably on room air, CTAB no crackles or
wheezes
Abd: BS+, soft, NT, no rebound/guarding
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. Normal gait. No focal deficits.
Pertinent Results:
==================
ADMISSION LABS
==================
___ 11:35AM BLOOD WBC-11.0 RBC-3.53* Hgb-9.5* Hct-29.9*
MCV-85 MCH-26.8* MCHC-31.6 RDW-13.7 Plt ___
___ 11:35AM BLOOD Glucose-105* UreaN-19 Creat-1.1 Na-138
K-4.4 Cl-101 HCO3-24 AnGap-17
___ 11:35AM BLOOD ALT-11 AST-19 AlkPhos-98 TotBili-0.3
___ 11:35AM BLOOD Lipase-13
___ 11:35AM BLOOD Albumin-3.5 Calcium-9.4 Phos-2.7 Mg-2.1
___ 11:35AM BLOOD D-Dimer-667*
___ 07:28AM BLOOD CRP-46.3*
====================
IMAGING
====================
___ LENIs: IMPRESSION: No evidence of deep venous
thrombosis in the bilateral lower extremity veins.
___: IMPRESSION: 1. Pulmonary emboli seen in the
subsegmental branches of the posterior segment of the left lower
lobe. Eccentric appearance suggests a subacute or chronic PE.
2. Multiple pulmonary nodules (stable to marginally increased
in size) and stable prominent mediastinal lymph nodes in this
patient with known metastatic melanoma.
___ Flexible Sigmoidoscopy: Very poor prep. However, there
was a friable distal rectal mass, covered with stool, with
contact bleeding. No fresh blood proximal to the lesion. We
inserted scope to 20 cm, but could not pass further due to the
poor prep. Mucosa appeared normal.
Otherwise normal sigmoidoscopy to 20 cm
==================
DISCHARGE LABS
==================
___ 06:50AM BLOOD WBC-8.3 RBC-3.23* Hgb-8.5* Hct-26.6*
MCV-82 MCH-26.3* MCHC-32.0 RDW-14.3 Plt ___
___ 06:50AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-135
K-4.4 Cl-103 HCO3-26 AnGap-10
___ 06:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ gentleman with a past medical history
of CAD, HTN, HL, GERD and BPH, with a recent diagnosis of
metastatic anorectal mucosal melanoma (BRAF ___
mutated) who presented because of ongoing rectal bleeding. He
had a flex sig on ___ which demonstrated a bleeding rectal
mass without mucousal involvment or concern for autoimmune
colitis. It is suspected that his symptoms are likely related to
his rectal mass. He was discharged on lomotil and immodium with
plans to follow up with Dr. ___ on ___.
===================
ACUTE Issues:
===================
# Rectal Bleeding: Pt with progressively worsening diarrhea and
BRBPR after starting pembrolizumab on ___. Initially
thought to possibly represent infectious colitis, autoimmune
colitis triggered by pembrolizumab or ipilimumab esp given his
many BMs per day (up to 17). Flex sig showed bleeding from the
mass itself with no bleeding proximal to the lesion and normal
appearing mucosa. His many BMs were thought to represent urgency
from the sensation of mass in rectum. He was treated with
imodium, lomotil, and sucralfate enemas. His H/H was
downtrending initially but then stable.
#Subsegmental PE: Pt with PE in subsegmental branches of the
posterior segment of the left lower lobe. Did not require
oxygen. Given his ongoing bleeding and subsegmental location of
the PE, and subacute/chronic appearance per radiology, with no
oxygen requirement, deferred anticoagulation as the risks of
more significant GI bleeding outweigh the risk from PE at this
time. LENIs were without clot so no benefit to SVC filter at
this time.
#Metastatic anorectal mucosal melanoma: S/P course of ipilimumab
with disease progression. Started on Pembrolizumab on ___.
===================
CHRONIC Issues:
===================
#CAD s/p CABG ___ ___, SVG->RCA). Had
recurrence in ___ and underwent balloon angioplasty of left
circ. Cont atorvastatin 40mg daily, nitroglycerin, metoprolol.
Aspirin was initially held due to concern for LGIB but was
restarted prior to discharge.
#HTN: continued amlodipine 2.5 mg tablet daily
===================
Transitional Issues:
===================
- Continue lomotil, immodium and sucralfate enemas for bowel
relief
- F/u with Dr. ___: ongoing treatment with Pembrolizumab.
Patient will also f/u regarding possibility of palliative
surgery
- Pt code status was DNR/DNI this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. Metoprolol Tartrate 12.5 mg PO BID
5. Nitroglycerin SR 2.5 mg PO Q8H:PRN chest pain
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
5. Aspirin 81 mg PO DAILY
6. Nitroglycerin SR 2.5 mg PO Q8H:PRN chest pain
7. Sucralfate Enema ___ID
RX *sucralfate 1 gram/10 mL ___ID:PRN Refills:*0
8. LOPERamide 4 mg PO QID diarrhea
RX *loperamide [Anti-Diarrhea] 2 mg 2 tabs by mouth four times a
day Disp #*100 Tablet Refills:*0
9. Diphenoxylate-Atropine 1 TAB PO QID diarrhea
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
four times a day Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
anorectal mucosal melanoma
pulmonary embolus
diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___
due to worsening diarrhea. You underwent a flexible
sigmoidoscopy that showed the bleeding is due your rectal mass.
There was no evidence of colitis. We are treating your symptoms
with imodium and lomotil.
You were also found to have a small pulmonary embolus (blood
clot in the lung). This is most likely not of clinical
significance. Because of your ongoing rectal bleeding, we did
not treat the pulmonary embolus. If you develop shortness of
breath, lightheadedness, chest pain, or leg swelling, you should
call your doctor immediately.
Please attend your follow-up appointments as listed below.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10696644-DS-24
| 10,696,644 | 29,389,445 |
DS
| 24 |
2129-08-12 00:00:00
|
2129-08-16 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ilosone / Dicloxacillin / Ace Inhibitors
Attending: ___
Chief Complaint:
acute kidney injury
rhabdomyolysis
pulmonary hypertension
congestive heart failure
Major Surgical or Invasive Procedure:
left internal jugular CVC placement
History of Present Illness:
In the ED, initial VS were:T-97.8 ___ BP-112/70 R-18 O2%-90%
RA
___ man with a history of HIV on HAART, hepatitis C, CAD
status post CABG in ___, CHF with an EF of 50%, hypertension,
hyperlipidemia, and a severe stroke in ___ with residual
dysarthria and left greater than right-sided weakness who
presents after falling from his wheelchair and hitting his
head. On ground for around an hr. Pt recently d/c'd ___ with
desats to ___ PNA. Pt denies any CP, SOB, dizziness before
the fall or after.
IN the ED:
___ triggered for hypoxia to ___. ___ up and did well and came
back up to 100% w/ a NRB. hypoT, never tachy . Got labs from art
stick. Had no access for peripheral and given L-IJ central line.
Pt received 1.5 l NS. Elevated trop with normal CK index. Had
negative CT head and neck.
On arrival to the MICU:
Pt had foley placed with 300CC of tea colored urine produced and
received 1.5 L of NS bolus. ABG was drawn.
Past Medical History:
-HIV: dx ___, likely through IVDU (last CD4 count 438/30% vl
128 on ___
-HCV: no therapy, stage I to II fibrosis on liver biopsy in
___, genotype 1A
-CAD: CABB x 1 Lima to LAD ___ s/p MI ___
-Diastolic CHF, EF 50-55%
-CVA: ___ intercerebral hemorrhage in medial/superior
cerebellar peduncle, wheelchair bound w/ residual L paresis
-HTN
-hypercholesterolemia
Social History:
___
Family History:
There is a significant family history of premature coronary
artery disease of the father who had an MI at age ___ and uncles
who have had heart attacks in the past. Otherwise, there is no
other history of unexplained heart failure or sudden death.
Physical Exam:
Admission physical exam:
Vitals: T:afeb BP:113/72 P:82 R:18 O2:96
General: Alert, oriented,
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Wheezing and crackles in all lung fields
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Hypospadias foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Baseline left facial droop with markedlydysarthric
speech,LUE and LLE with ___ strength, RUE and RLE ___. Sensation
grossly intact
Discharge Physical Exam:
VS - 98.7 118/54 70 20 93% on shovel face mask 10L
GEN: Awake, alert and oriented. No acute cardiopulmonary
distress
HEENT: Sclera anicteric, MMM, OP clear
NECK: Supple, elevated JVP
PULM: Good aeration, CTAB, without w/r/r.
CV: RRR normal S1/S2, no mrg/
ABD: Soft, non-tender, obese, nondistended, no rebound or
guarding.
EXT: WWP. 2+ right radial pulse. left radial pulse not palpable,
but left hand is well perfused. ___ pulses difficult to
palpate ___ edema. 2+ pitting edema b/l LEs to knee, improved
from yesterday.
NEURO: awake, A&Ox3, dysarthric. left facial droop. left upper
and lower extremities ___ strength. Right extremities ___
strength.
SKIN: no ulcers or lesions. venous stasis/chronic edema changes
in b/l lower extremities
Pertinent Results:
Admission labs:
___ 06:30PM BLOOD WBC-11.8* RBC-4.81 Hgb-15.5 Hct-47.7
MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt ___
___ 06:30PM BLOOD ___ PTT-33.7 ___
___ 06:30PM BLOOD Glucose-115* UreaN-42* Creat-3.6*# Na-141
K-3.5 Cl-95* HCO3-32 AnGap-18
___ 06:30PM BLOOD ___
___ 06:30PM BLOOD CK-MB-34* MB Indx-0.2 cTropnT-1.67*
___ 06:37PM BLOOD ___ pO2-49* pCO2-53* pH-7.41
calTCO2-35* Base XS-6
___ 06:37PM BLOOD Lactate-2.6*
Pertinent labs:
___ 04:13AM BLOOD CK-MB-26* MB Indx-0.2 cTropnT-1.69*
___ 04:13AM BLOOD ALT-42* AST-316* ___
AlkPhos-52
___ 04:13AM BLOOD Glucose-154* UreaN-41* Creat-2.9* Na-140
K-3.5 Cl-100 HCO3-33* AnGap-11
___ 01:14AM BLOOD WBC-11.3* RBC-3.79* Hgb-12.2* Hct-38.7*
MCV-102* MCH-32.1* MCHC-31.4 RDW-17.8* Plt ___
___ 01:35AM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-41.0
MCV-99* MCH-31.8 MCHC-32.0 RDW-17.5* Plt ___ 03:43AM
BLOOD WBC-7.4 RBC-4.16* Hgb-13.0* Hct-41.7 MCV-100* MCH-31.3
MCHC-31.2 RDW-16.5* Plt ___
___ 05:11AM BLOOD WBC-7.1 RBC-3.90* Hgb-12.4* Hct-38.5*
MCV-99* MCH-31.8 MCHC-32.2 RDW-16.4* Plt ___
___ 04:54AM BLOOD Glucose-90 UreaN-64* Creat-3.0* Na-143
K-3.9 Cl-108 HCO3-23 AnGap-16
___ 01:14AM BLOOD Glucose-84 UreaN-67* Creat-2.7* Na-149*
K-3.3 Cl-110* HCO3-27 AnGap-15
___ 01:30AM BLOOD Glucose-93 UreaN-59* Creat-2.2* Na-150*
K-3.3 Cl-109* HCO3-32 AnGap-12
___ 04:32AM BLOOD Glucose-110* UreaN-50* Creat-1.7* Na-150*
K-3.3 Cl-107 HCO3-39* AnGap-7*
___ 03:43AM BLOOD Glucose-116* UreaN-37* Creat-1.6* Na-143
K-3.7 Cl-97 HCO3-39* AnGap-11
___ 05:11AM BLOOD Glucose-108* UreaN-36* Creat-1.7* Na-140
K-4.0 Cl-94* HCO3-40* AnGap-10
___ 06:30PM BLOOD ___
___ 04:13AM BLOOD ALT-42* AST-316* ___
AlkPhos-52
___ 04:45PM BLOOD CK(CPK)-724*
___ 05:05AM BLOOD Type-ART Temp-38.6 pO2-89 pCO2-74*
pH-7.17* calTCO2-28 Base XS--3 Intubat-NOT INTUBA
___ 01:34PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.40
calTCO2-38* Base XS-8
___ 11:21AM BLOOD ___ pO2-40* pCO2-71* pH-7.40
calTCO2-46* Base XS-14
___ 05:31AM BLOOD ___ pO2-57* pCO2-72* pH-7.39
calTCO2-45* Base XS-14
___ 01:28AM BLOOD Lactate-2.2*
___ 01:34PM BLOOD Lactate-1.0
Imaging
___ CXR
PORTABLE CHEST: ___.
HISTORY: ___ man with shortness of breath and acute
hypoxia.
FINDINGS: Single portable view of the chest is compared to
previous exam from
___. Compared to prior, there has been interval
improvement of
aeration at the lung bases. There are some persistent bibasilar
opacities,
right greater than left. Cardiomediastinal silhouette is stable
as are the
osseous and soft tissue structures.
IMPRESSION: Mild interval improvement in the previously seen
bibasilar
opacities which persist. These could be due to resolving
infiltrates or
atelectasis or potentially aspiration.
___ CT head
FINDINGS: There is no acute intra-axial or extra-axial
hemorrhage, mass,
midline shift, or territorial infarct. Right occipital lobe
encephalomalacia
as well as regions of encephalomalacia centered in the right
middle cerebellar
peduncle are again seen. Global volume loss of the cerebellum
is again noted.
Elsewhere, gray-white matter differentiation is preserved.
There is partial opacification of the inferior right mastoid air
cells.
Mucous retention cyst seen in the right maxillary sinus. Other
paranasal
sinuses and left mastoids are clear. The skull and extracranial
soft tissues
are unremarkable.
IMPRESSION:
No acute intracranial process. Encephalomalacia within the
right occipital
lobe and right middle cerebellar peduncle, unchanged from prior
___
TTE: Poor image quality.The left atrium is normal in size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. No late
contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). 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
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. 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. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The tricuspid regurgitation
jet is eccentric and may be underestimated. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
due to poor image quality on prior study, a direct comparison of
RV size nad function is not possible. The current study suggests
a more dilated/dysfunctional RV though.
___ lower-extremity venous u/s
IMPRESSION: No deep vein thrombosis.
___ CXR
1. Nasogastric tube is seen coursing below the diaphragm with
the tip not identified. Left internal jugular central line has
its tip in the proximal SVC. There continues to be diffuse
bilateral airspace process with probable associated layering
effusions. This may reflect worsening pulmonary edema, although
superimposed bilateral pneumonia cannot be entirely excluded.
Clinical correlation is advised. No pneumothorax is seen.
Overall, cardiac and mediastinal contours are likely stable, but
somewhat difficult to assess due to diffuse airspace process.
___ Head CT
IMPRESSION: No acute intracranial process identified to explain
patient's neurologic decline.
___ EEG (from neurology note)
EEG was done and showed spikes of 3Hz with right hemispheric
predominance.
___ Video Swallow
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There was evidence of
intermittent penetration of thin, as well as intermittent
aspiration of nectar consistency. For further details, please
refer to speech and swallow division note in OMR.
Preliminary Report IMPRESSION:
Penetration of thin consistency and aspiration of nectar
consistency, both intermittently.
Brief Hospital Course:
Active Problems
#rhabdomyolysis- Pt found on the ground for an extended period
of time which could be the cause for his rhabdo. ___ received
aggressive IV fluid to try to maintaine a 200CC urine output
while not compromissing his respiratory status. His CK
eventually came down but CR was still elevated. Renal was
consulted and recommended no HD. ___ still producing urine and CR
was stable. Creatinine stabilized at 1.6-1.7. This likely
represents his new baseline. He continued to have good urine
output throughtout rest of admission.
#elevated trop- Pt has signigicant elevation of trop. EKG
similar to previous. Pt received 325 ASA. His CK-MB index was
never elevated and trop was not raising so a cards consult was
not obtained.
#ATN: Muddy brown cast found in urine ___. Most likely ___ to
rhabdo. Improving toward baseline. Most likely CKD at this
point. Cr remains stable at 1.7. Good urine output maintained
throughout admission. Pt. to follow-up with renal as outpatient
#Hypoxemia- Chronic O2 requirment likely multifactorial related
to pulmonary HTN, COPD, OSA, OHS. Current increase in O2
requirement likely ___ PE vs heart failure. Unable to obtain CTA
at this time due to pt ___. Has been improving with diuresis and
thus it is most likely ___ CHF/pulmonary edema, less likely PE,
heparin was switched to subcut. As patient continues to improve
with diuresis, did not pursue further PE work-up. Treated with
vanco and cefipime after 8 day HCAP coverage. Currently no
clinical evidence of pneumonia. Pt. responded well to IV Lasix
40mg BID. Upon discharge, pt. likely at his baseline hypoxemia.
No evidence of significant pulmonary edema on most recent CXR
and only mild bibasilar crackles on exam. Still 5 liters net
positive for length of stay ___ aggressive fulid resuscitation
for severe rhabdo upon initial presentation. Would recommend
continued diuresis to achieve euvolemia and optimize respiratory
status. Renal function slowly improving, so patient likely able
to autodiurese soon. Though not confirmed, pt. likely has
significant pulmonary HTN based on old TTE, recent chest CT with
enlarged PA, and multiple pulmonary HTN risk factors as outlined
above. Pt. scheduled to follow in pulmonary clinic with Dr.
___ further w/u and treatment of this presumed pulmonary
HTN. At time of discharge, pt. saturating in low ___ on nasal
canula, which is likely around his baseline oxygenation. No
pulmonary symptoms.
#new onset seizure activity- ___ experienced change in mental
status while in the ICU with echolalia, confusion, and leftward
gaze deviation with random leftward saccadic eye movements.. A
CT head was ordered which showed NAP and EEG which showed
epileptiform discharges. Neurology was called and pt was placed
on Keppra. His mental status improved significantly back to
baseline without any further evidence of seizure activity or
changes in mental status. Pt. to be discharged on Keppra 500mg
BID. Pt. will f/u in epilepsy clinic in ___ weeks time after
discharge for furthur management.
#Nutrition - video swallow. Speech therapy recommend ground
solids with nectar thickened liquids. Likely chronic aspirator
___ to prior CVA. Pt. to be discharged on this diet.
Chronic Problems
#HTN - antihypertensives were held throughout admission,
particularly in setting of agressive diuresis following
resolution of rhabdo. Metoprolol and triamterene-HCTZ can be
restarted once pt. back to euvolemia.
#HIV - pt. was maintained on his regimen of Saquinavir and
Ritonavir
Transitional Issues
#Volume overload - upon discharge, pt. net positive 5 liters for
length of stay. has been getting IV lasix 40mg BID. Would
recommend continuing diuresis with goal of euvolemia. Diuresis
was associated with significant improvement of pt.'s respiratory
status. Discharged on 5L nc, with saturations in low ___.
Probably will only require a couple more days of diuresis, as
renal function continues to improve toward his baseline. Would
recommend checking daily electrolytes while actively diuresing
and while Cr continuing to normalize.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 50 mg PO TID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO DAILY
5. Saquinavir (Invirase) Cap 400 mg PO BID
6. RiTONAvir 400 mg PO BID
7. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
8. Levofloxacin 750 mg PO DAILY
Day 1= ___, finishes on ___
9. Tiotropium Bromide 1 CAP IH DAILY
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of
breath
11. oxygen
416.8 Other chronic pulmonary heart diseases
Home oxygen @ 5 LPM continuous via shovel mask, conserving
device for portablity
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. RiTONAvir 400 mg PO BID
3. Saquinavir (Invirase) Cap 400 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB
5. Furosemide 40 mg IV BID
6. LeVETiracetam 500 mg PO BID
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
8. Docusate Sodium 50 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO DAILY (being held for
continued diuresis)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rhabdomyolysis
Acute Kidney Injury
Acute on chronic diastolic congestive heart failure
Non-convulsive seizure activity
Discharge Condition:
Mental status: clear, oriented
Ambulatory status: requires wheelchair. Full assist for
transfers
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___
___. You were admitted for muscle breakdown
known as rhabdomyolysis caused by your fall. This muscle
breakdown caused damage to your kidneys, which was treated with
IV fluids. Your kidneys and the muscle breakdown improved with
IV fluids. You also developed a pneumonia, which was treated
with IV antibiotics and your breathing improved. You continued
to require more oxygen than normal. This was likely due to some
of the fluid that you received backing up into your lungs. We
treated this with a medicine called Lasix, which helped to
remove fluid, and your breathing improved. You also had a period
during which you were very confused. We performed a brain
activity test called an EEG which showed some seizure activity.
We treated this with an anti-seizure medication called Keppra.
Your mental status improved significantly and is now back to
normal. You are being transferred to a rehabilitation facility
where they will continue to remove fluid to help improve your
breathing. They will also work on regaining your strength
through physical therapy.
It is likely that you have a lung disease known as pulmonary
hypertension. This is likely why your oxygen levels are always
low. It will be very important that you follow-up with your
pulmonologist (lung doctor) Dr. ___.
Followup Instructions:
___
|
10696668-DS-3
| 10,696,668 | 28,820,729 |
DS
| 3 |
2163-11-26 00:00:00
|
2163-11-26 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Facial cellulitis and abscess
Major Surgical or Invasive Procedure:
Bedside expression of pus. Incision and Drainage at ___.
History of Present Illness:
___ yo f, pmh of tonsillectomy, acne, presenting with left sided
facial swelling x 3 days. Started on Bactrim yesterday.
Worsening pain and swelling last 24 hours. No fevers, no resp
distress, no diplopia, no difficulty swallowing, no decreased
hearing, and no sore throat. No traumatic incident. ___ be
remembers some picking at acne. Went to ___
attempt, anesthesia with lido w/epi, small pus sent for wound
culture but minimal return. WBC 11.8 at OSH. On OCPs.
Past Medical History:
tonsillectomy, acne
Social History:
___
Family History:
non contributory
Physical Exam:
General Evaluation Exam at discharge
Gen: NAD, AAO x3
HEENT: NC/AT, PERRL, EOMI, Improved swelling and erythema to
left cheek, minimal fluid drainage from I&D site on left cheek,
tender, Cervical lymphadenopathy, Full painless ROM of neck, OP
WNL
Resp: no respiratory distress
MSK: moves all extremities
Pertinent Results:
___ 05:01PM GLUCOSE-98 UREA N-9 CREAT-0.7 SODIUM-137
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-18* ANION GAP-20
___ 05:01PM estGFR-Using this
___ 05:01PM WBC-14.2* RBC-3.95 HGB-12.2 HCT-36.6 MCV-93
MCH-30.9 MCHC-33.3 RDW-11.9 RDWSD-40.8
___ 05:01PM NEUTS-82.8* LYMPHS-10.7* MONOS-5.6 EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-11.80* AbsLymp-1.52 AbsMono-0.79
AbsEos-0.00* AbsBaso-0.05
___ 05:01PM PLT COUNT-259
___ 04:45PM URINE HOURS-RANDOM
___ 04:45PM URINE UCG-NEGATIVE
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ and
had a Facial Abscess and cellulitis. The patient received IV
Clindamycin and had further drainage. She tolerated the
treatment well, improved clinically, and was ready for DC.
.
Neuro: Received pain control with morphine, Toradol, and Tylenol
to good effect. Was switched of narcotics on HD1.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs
were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs
were routinely monitored.
.
GI/GU: No GI complaints. Tolerated PO intake.
.
ID: Pt was given Clindamycin 900 mg Q8 hours. Wound cultures
were taken from ___ and ___. They were followed and
showed MRSA. Was sensitive to clindamycin and she was continued
on Clindamycin PO 300mg QID. Wick was replaced daily. The
patient's temperature was closely watched for signs of worsening
infection. She did not spike a temperature while in the
hospital.
.
At the time of discharge on HD3, the patient was doing well,
afebrile with stable vital signs, improved facial swelling,
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. She is being
discharged on 300 mg QID Clindamycin x 10 days, daily wick
changes at home, and follow up in clinic with Dr. ___ on
___
Medications on Admission:
Oral Contraceptives
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Clindamycin 300 mg PO QID x 10 days
4. Oral contraceptives
Discharge Disposition:
Home
Discharge Diagnosis:
Facial Abscess and Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Continue taking your antibiotics as prescribed. Take 300 mg of
Clindamycin every 6 hours. Keep wick in place and change it
every day. Manually message the area, use warm compresses, and
try to express any pus/drainage from the area. Important to
allow site to drain. For pain you can take Ibuprofen 600 mg
every 8 hours and Tylenol ___ mg every 6 hours.
Followup Instructions:
___
|
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2173-07-08 00:00:00
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2173-07-09 16:44:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
Mr. ___ is a ___ with a history of hepatitis C, HTN, CAD, prior
MI, DM, HLD, cirrhosis, CKD stage III, hepatocellular carcinoma,
esophageal varices, portal vein thrombosis, anemia in CKD who
presents for left-sided flank pain and loose stools for 5 days.
5
days ago patient had hepatic ablation and paracentesis. Reports
pain in left flank began while laying in bed. Reports feels
sharp
and can take his breath away is so severe. Reports waves of
sharp
pain. No hx of similar pain. Reports at ___ c/f blood in urine
but
he did not notice any blood in it. Denies fever but has been
feeling hot and cold. Reports has had a cough for a few days.
Denies chest pain, SOB. Denies weakness in ___ arms. Denies
n/v but reports diarrhea for 5 days - loose stools. Reports
scant blood occasionally from hemorrhoids though not in the
stool.
In the ED initial vitals: 98.3 72 149/96 15 96% RA
- Exam notable for: not documented
- Imaging notable for:
CT A/P w/o contrast
1. Multiple dilated and fecalized loops of small bowel without
definite caliber change, which may represent enteritis.
2. Status post radiofrequency ablation of known segment V
hepatic
lesion.
3. Cirrhotic liver with multiple hepatic masses, better
evaluated
on the MRI from ___.
4. New moderate pleural effusion, possibly reactive from the
ablation.
- Labs notable for
UA at ___ with positive nitrates, +_blood
wbc 5.8, hb 13.8, cr 2.1 -> 2.0, 134 -> 137
baseline cr 1.74
- Patient was given:
___ 01:04 IVF NS
___ 08:05 IV Ciprofloxacin
___ 08:38 PO/NG Atorvastatin 80 mg
___ 08:38 PO Metoprolol Succinate XL 100 mg
___ 08:38 PO/NG Furosemide 20 mg
___ 08:38 PO/NG Lisinopril 20 mg
___ 08:38 PO/NG Hydrochlorothiazide
___ 10:07 SC Insulin 4 Units
___ 10:07 IV MetroNIDAZOLE
___ 10:07 PO Aspirin 81 mg
___ 11:58 IV MetroNIDAZOLE 500 mg
___ 14:47 SC Insulin 8 Units
- Vitals prior to transfer: 71 139/81 15 96% RA
Patient reports that after ablation on ___ he developed profuse
diarrhea >10 bowel movements per day which have slowed down over
the past few days because he has stopped eating and drinking in
attempt to stop diarrhea. He has had poor PO intake for the past
three days and he believes he has lost ___ lbs over the last
week. He has had significant R sided flank pain s/p ablation and
he then developed left sided flank pain that was also severe. He
has had one episode of nausea without vomiting. He has had nasal
congestion, cough, and sore throat.
REVIEW OF SYSTEMS: Per HPI, denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
hypertension
hyperlipidemia
IDDM2
Myocardial infarction in ___ and underwent PTCA of his coronary
arteries
Cirrhosis c/b HCC s/p ablation
Social History:
___
Family History:
Notable for myocardial infarction in his mother
and brother, leukemia in his brother who died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Temp: 97.7 PO BP: 144/94 L Sitting HR: 82 RR: 18 O2 sat: 95%
O2 delivery: Ra
General: Thin, alert and cooperative, and appears to be in no
acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting. EOMI in all
cardinal directions of gaze without nystagmus. Vision is grossly
intact, hearing grossly intact. Nares patent with no nasal
discharge. Oral cavity and pharynx are without inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. II/VI holosystolic murmur at RUSB.
Rhythm is regular. There is no peripheral edema, cyanosis or
pallor. Extremities are warm and well perfused.
Pulmonary: Diminished breath sounds in R lung base.
Abdomen: Normoactive bowel sounds. Soft, mildly distended,
nontender. No guarding or rebound. No masses.
Musculoskeletal: ROM intact in spine and extremities. Right
flank
with tenderness to palpation and soft tissue swelling, nor
warmth
or erythema. No joint erythema or tenderness. Muscle bulk and
tone appropriate for age and habitus.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type V. Hyperpigmented macules on pre-tibial legs. No
other lesions or eruptions.
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 353)
Temp: 98.4 (Tm 100.1), BP: 143/86 (134-170/84-89), HR: 70
(70-75), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: ra,
Wt: 140.2 lb/63.59 kg
General: Thin, alert and cooperative, and appears to
be in no
acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting. EOMI in all
cardinal directions of gaze without nystagmus. Vision is grossly
intact, hearing grossly intact. Nares patent with no nasal
discharge. Oral cavity and pharynx are without inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. II/VI holosystolic murmur at RUSB.
Rhythm is regular. There is no peripheral edema, cyanosis or
pallor. Extremities are warm and well perfused.
Pulmonary: Diminished breath sounds in R lung base. Breathing
comfortably.
Abdomen: Normoactive bowel sounds. Soft, mildly distended,
nontender. No guarding or rebound. No masses.
Musculoskeletal: ROM intact in spine and extremities. Right
flank
with tenderness to palpation and soft tissue swelling, nor
warmth
or erythema. No joint erythema or tenderness. Muscle bulk and
tone appropriate for age and habitus.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type V. Hyperpigmented macules on pre-tibial legs. No
other lesions or eruptions.
Pertinent Results:
ADMISSION LABS:
================
___ 10:19PM BLOOD WBC-4.2 RBC-3.82* Hgb-12.5* Hct-36.0*
MCV-94 MCH-32.7* MCHC-34.7 RDW-12.6 RDWSD-42.8 Plt ___
___ 10:19PM BLOOD Glucose-245* UreaN-33* Creat-2.0* Na-134*
K-4.6 Cl-95* HCO3-23 AnGap-16
___ 10:19PM BLOOD ALT-54* AST-93* AlkPhos-208* TotBili-1.6*
___ 10:19PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.2 Mg-1.9
MICROBIOLOGY:
=============
___ 2:28 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ 13:25 ON
___.
Positive for toxigenic C difficile by the Cepheid nucleic
amplification assay.
(Reference Range-Negative).
IMAGING AND STUDIES:
====================
CTU W/O CONTRAST ___:
1. Multiple dilated and fecalized loops of small bowel without
definite caliber change, which may represent enteritis.
2. Status post radiofrequency ablation of known segment V
hepatic
lesion.
3. Cirrhotic liver with multiple hepatic masses, better
evaluated
on the MRI
from ___.
4. New moderate pleural effusion, possibly reactive from the
ablation.
CXR ___:
New moderate right pleural effusion with associated relaxation
atelectasis.
However, consider superimposed infection if clinically relevant.
US ABDOMEN ___:
IMPRESSION:
Moderate ascites and right pleural effusion, no focal fluid
collection.
DISCHARGE LABS:
================
___ 04:49AM BLOOD WBC-2.9* RBC-3.04* Hgb-10.1* Hct-28.8*
MCV-95 MCH-33.2* MCHC-35.1 RDW-12.8 RDWSD-43.7 Plt Ct-52*
___ 04:49AM BLOOD Glucose-121* UreaN-31* Creat-1.9* Na-136
K-4.2 Cl-102 HCO3-25 AnGap-9*
___ 04:49AM BLOOD ALT-32 AST-73* LD(LDH)-303* AlkPhos-208*
TotBili-1.4
___ 04:49AM BLOOD Calcium-7.4* Phos-2.9 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of HCV Cirrhosis s/p
Harvoni (completed ___ complicated by ___ s/p
TACE to segment IV/VIII ___, y90-radioembolization and RFA
on ___, with failure of Sorafenib who presented with diarrhea
and bilateral flank pain found to be C. difficile positive and
was found to have new R pleural effusion.
# R Pleural effusion
# Hepatic hydrothorax
New R pleural effusion appeared to be simple effusion on CT.
Thoracentesis performed on ___ with 800ml of serosanguinous
fluid removed that was transudative on pleural fluid analysis
and thought to be reactive in setting of recent RFA and
consistent with hepatic hydrothorax in setting of ascites.
Patient will need repeat Chest x-ray with IP in 2 weeks.
#Diarrhea
#C. difficile colitis
Patient with profuse watery diarrhea x5 days on presentation
with improvement in diarrhea by time of admission. Prior to
admission he was having poor PO intake. Upon admission was found
to be c. diff positive. Was started on PO vancomycin 125 mg QID
to complete 14 day course ___, last day ___.
#Flank pain and soft tissue swelling
R flank tenderness, w/ edema of right flank at site of recent
ablation probe for RFA. No evidence of hydronephrosis or
nephrolithiasis on CT. He was also experiencing left flank pain
in setting of hepatic hydrothorax and ascites. Pain controlled
with Tylenol and oxycodone.
#HCV Cirrhosis c/b Hepatocellular carcinoma, ascites
Patient with history of cirrhosis secondary to HCV. MELD 17,
MELD-Na 19 on admission. Child class B. Without prior evidence
of decompensation, presented with ascites. He is s/p Harvoni (12
weeks ___. ___ s/p TACE to segment IV/VIII ___,
y90-radioembolization and RFA on ___, with intolerance to
Sorafenib. On admission was found to have small volume
perihepatic and perisplenic ascites that was stable. He was
found to have new R pleural effusion consistent with hepatic
hydrothorax (see above). He was continued on Spironolactone
100mg and Lasix 20 mg. He was discharged with plan for para 10
days after discharge and liver clinic followup ___.
#Proteinuria
Patient with elevated protein on UA. Hypoalbuminemia. Should
have outpatient follow up.
CHRONIC ISSUES:
================
# IDDM2: Continued home regimen lantus 35u qHS. ISS.
# HTN: Continued home metoprolol and home ACEI.
# CKD stage III: Stable at baseline Cr 1.8-2.
# Hx of CAD: Continued home ASA 81, Atorvastatin
# Iron deficiency anemia: Continued home iron supplement.
TRANSITIONAL ISSUES:
=======================
[ ] Interventional pulmonology will ___ patient with
appointment for repeat CXR 2 weeks after discharge, ensure
patient follows up with IP after discharge.
[ ] Should be scheduled for paracentesis 10 days after discharge
and clinic ___ (to be scheduled by ___.
[ ] Patient must continue PO vancomycin to complete ___nd date ___. for treatment of C. diff. PO vancomycin
course should be extended if he is started on any other
antibiotics.
[ ] Pleural fluid and stool cultures pending on discharge.
[ ] Proteninuria on UA, should continue to be monitored as
outpatient.
# CODE: FULL confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times per day
Disp #*50 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Spironolactone 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Clostridium difficile colitis
Right transudative pleural effusion
HCV cirrhosis
R flank soft tissue swelling
SECONDARY:
___ s/p RFA
IDDM
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
diarrhea and you were having pain on your side.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given an antibiotic medicine to treat your diarrhea
caused by C. difficile
- You had a procedure called a thoracentesis to remove fluid
from your R chest that was causing you pain.
- You received diuretic medicine to remove the extra fluid.
WHAT SHOULD I DO WHEN I GO HOME?
-Please weigh yourself every morning, before you eat or take
your medications. ___ your MD if your weight changes by more
than 3 pounds
-Please stick to a low salt diet and monitor your fluid intake
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors.
-___ will need a chest x-ray in 2 weeks. The Interventional
Pulmonary doctors ___ to set this up.
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
|
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| 22 |
2173-11-22 00:00:00
|
2173-11-23 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with HCV cirrhosis c/b HCC (Child A, MELD 20)
with presumed right lung metastasis, hepatic hydrothorax,
esophageal varices, and hepatic encephalopathy, also with CAD
and
CKD p/w altered mental status and hypoglycemia.
Patient was recently admitted to ET service for ___ and
hyperkalemia. For his ___, his admission cr was 2.7 (baseline
2),
thought to be prerenal and improved to 2.3 on discharge after
receiving albumin. He was discharged on sodium bicarb 650 mg TID
for metabolic acidosis. For his hyperkalemia, he required
several
rounds of calcium/insulin/dextrose and Lasix, and his lisinopril
and spironolactone were stopped. He was discharged on ___. A few
other important points from this most recent hospitalization
-- EGD on ___ showed three cords of grade III varices s/p 3
bands. Discharged on omeprazole 20 BID, Carafate 1g QID x2
weeks,
and cipro x7 days (last day ___. Plan repeat EGD in 1 month
-- Propranolol held while inpatient, but restarted on discharge
-- IVC filter placed given DVTs. Lovenox stopped
-- Lasix held in setting of recovering kidney function
He returned home on ___. On the morning of ___ (the morning
of admission), the patient's wife found him slumped against the
wall near the bathtub, conscious but lethargic and very
diaphoretic. EMS was called and his blood sugar was 20, so he
received 25g of D10, which improved his blood sugar to 268. He
does not have much memory of these events. He reports that he
took his normal dose of insulin and that he had normal PO intake
the night before.
Past Medical History:
HTN
HLD
IDDM2
CAD
Cirrhosis c/b HCC s/p ablation, now with recurrence and c/f
metastatic disease to R lung
Esophageal varices
Social History:
___
Family History:
Notable for myocardial infarction in his mother
and brother, leukemia in his brother who died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 BP 125 / 69, HR 60, RR 18, O2 97 RA
GENERAL: Malnourished, NAD, pleasant
HEENT: AT/NC, EOMI, anicteric sclera
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB
ABDOMEN: nondistended, nontender, no fluid wave
EXTREMITIES: no cyanosis, clubbing. 1+ RLE edema to the knees
NEURO: A&Ox3, no asterixis, no focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1019)
Temp: 98.5 (Tm 98.8), BP: 146/82 (131-165/74-90), HR: 81
(66-88), RR: 18, O2 sat: 96% (96-100), O2 delivery: Ra, Wt:
141.8
lb/64.32 kg
GENERAL: NAD, pleasant, laying back in bed
HEENT: AT/NC, EOMI, anicteric sclera
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no m/g/r appreciated
LUNGS: CTAB
ABDOMEN: nondistended, nontender, no fluid wave
EXTREMITIES: no cyanosis, clubbing, trace edema
NEURO: A&Ox3, no asterixis, no focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
=================
___ 04:47AM BLOOD WBC-2.2* RBC-2.31* Hgb-7.8* Hct-23.8*
MCV-103* MCH-33.8* MCHC-32.8 RDW-14.1 RDWSD-52.9* Plt Ct-38*
___ 04:47AM BLOOD ___ PTT-39.3* ___
___ 04:47AM BLOOD Plt Ct-38*
___ 04:47AM BLOOD Glucose-107* UreaN-26* Creat-2.3* Na-140
K-4.9 Cl-110* HCO3-20* AnGap-10
___ 04:47AM BLOOD ALT-17 AST-27 LD(LDH)-233 AlkPhos-113
TotBili-0.7
___ 04:47AM BLOOD Albumin-3.5 Calcium-8.2* Phos-3.0 Mg-1.6
DISCHARGE LABS
=================
___ 04:45AM BLOOD WBC-1.9* RBC-2.35* Hgb-7.9* Hct-23.4*
MCV-100* MCH-33.6* MCHC-33.8 RDW-13.7 RDWSD-49.4* Plt Ct-37*
___ 04:45AM BLOOD Neuts-63.9 Lymphs-12.9* Monos-16.0*
Eos-6.2 Baso-0.5 Im ___ AbsNeut-1.24* AbsLymp-0.25*
AbsMono-0.31 AbsEos-0.12 AbsBaso-0.01
___ 04:45AM BLOOD ___ PTT-34.4 ___
___ 04:45AM BLOOD Plt Ct-37*
___ 04:45AM BLOOD Glucose-273* UreaN-30* Creat-2.0* Na-139
K-4.7 Cl-108 HCO3-20* AnGap-11
___ 04:45AM BLOOD ALT-29 AST-49* AlkPhos-154* TotBili-0.6
___ 04:45AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.0*
Mg-1.8
___ 04:51AM BLOOD %HbA1c-6.0 eAG-126
___ 07:23AM BLOOD TSH-0.28
___ 07:23AM BLOOD Free T4-0.9*
___ 03:43AM BLOOD Glucose-307* K-4.3
IMAGING
=================
___ LENIS
FINDINGS:
There is extensive, nearly completely occlusive thrombus in the
right common femoral, femoral, popliteal, posterior tibial, and
peroneal veins, not significantly changed since ___.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Extensive deep venous thrombosis throughout the right lower
extemity veins, not significantly changed since ___.
MICROBIOLOGY
==================
___ 11:06 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
BRIEF SUMMARY:
==============
___ male with HCV cirrhosis c/b HCC with presumed right
lung metastasis, hepatic hydrothorax, esophageal varices, and
hepatic encephalopathy, also with CAD and CKD p/w altered mental
status and hypoglycemia. His insulin regimen was lower and he
was discharged at baseline mental status.
TRANSITIONAL ISSUES:
====================
[] patient admitted for hypoglycemia. a1c 6% in house. Given
multiple co-morbidities and episode of hypoglycemia to ___,
risk/benefit likely favors more liberal glucose control,
targeting a1c 8%.
[] discharge insulin regimen: 24 units lantus qAM, holding for
blood sugar <100.
[] held propranolol upon discharge given admission for
hypoglycemia to ___ and concern that beta-blockade masked
sympathetic symptoms of hypoglycemia for the patient
[] holding lisinopril and spironolactone given initial
presentation of hyperkalemia requiring multiple rounds of
insulin/dextrose/calcium. Will need outpatient evaluation
regarding risk/benefit of restarting these medications
[] given known variceal bleed and new hemoglobin drop, decision
was made to place IVC filter. Will need to coordinate between
hematology and interventional radiology regarding timing of IVC
removal and need for ongoing anticoagulation. Holding lovenox
upon discharge
[] reevaluate for need for lactulose, patient discontinued in
setting of recent c diff colitis infection
[x] will need follow up on pleural effusion cytology results per
hematology team - on ___, negative for malignant cells
[] lasix held upon discharge given recovering renal function,
minimal abdominal distension, minimal lower extremity edema.
Will likely need to be restarted on outpatient basis after
repeat CMP
[] will need repeat EGD in one month s/p banding on ___
[] started on omeprazole 20mg BID after banding, Carafate 1g QID
(only recommended for 2 weeks - finish on ___ Omeprazole
titration per GI team on outpatient basis
[] will need follow up with nephrology within the month to
titrate sodium bicarbonate and to trend kidney function
recovery. Sent home on sodium bicarbonate 650mg TID
ACUTE ISSUES:
=============
# Bradycardia:
Resolved. Patient presented with normal HR and then became
bradycardic to ___. Of note, he has had HR in ___ even during
most recent admission. Causes of sinus bradycardia in him
include medication induced (propranolol) vs hypoglycemia vs
hyperkalemia vs hypothyroid. HR improved in ED to ___ and on
floor to ___. His BB was held while in house and his HRs
remained in the 60-80s. His hypoglycemia was managed as below
# DM2
# Hypoglycemia:
# Altered mental status:
BG 20 on ___ AM, and received dextrose in the field. Unclear
cause of hypoglycemia, may be from too much insulin or decreased
PO intake in setting of excessive exercise and physical
activity.Furthermore, beta blockers may have precluded symptoms
of hypoglycemia from arising and triggering a corrective
response. Also could have been further exacerbated by ___ with
accumulation of long acting insulin. Blood sugars improved in ED
to 200+ and mental status cleared. He was slowly reinitiated on
Lantus and was discharged home on 24 units. Also was shifted to
AM to avoid nocturnal hypoglycemia. Due to risk of masking
hypoglycemia, his propranolol was discontinued. Was continued on
lactulose and rifaximin for possible HE.
# Hyperkalemia:
Likely secondary to CKD and perhaps beta-blocker ?overdose.
Required insulin/dextrose/Lasix last admission for hyperkalemia.
Resolved following insulin/dextrose tx in ED.
# Metabolic acidosis
# CKD: Baseline cr 2.0 with admission cr 2.2. On last admission,
nephrology was consulted and felt ___ was due to diuretics,
lisinopril, and partially ATN as granular casts were seen. Home
Lasix, lisinopril, and spironolactone were held. She was
continued on home sodium bicarb 650 mg TID.
# Anemia: Multifactorial anemia likely from liver failure,
nutritional deficiencies, and slow bleed. Admission hgb is above
recent baseline. He did not require transfusions while in house
and was continued on home ferrous sulfate.
# HCV Cirrhosis c/b recurrent HCC with c/f metastasis to RUL:
Child A, MELD-Na 20. HCV treated with Harvoni with SVR. HCC
treated with TACE and Y90 x2 most recently ___ and RFA on
___, now with newly diagnosed recurrence. Discussed at ___
Board ___ and plan for oncology visit on ___ to discuss
possible initiation of nivolumab. Did miss this appointment
while in house. Not transplant candidate due to metastatic HCC.
-HE: No current encephalopathy. Continued home rifaximin. Did
give Lactulose while in house for AMS, however, suspected to be
more ___ to hypoglycemia.
-Varices: Grade III varices noted on recent EGD (___) s/p
banding. Continued PPI and Carafate. Propranolol was held in
setting of bradycardia/hypoglycemia
-Volume: Holding home Lasix/spironolactone due to ___, with
ultimate plan per outpatient hepatologist
-SBP: no prior history
-Nutrition: 2g, low k diet
# R Pleural effusion: s/p thoracentesis x 4 ___,
___, all transudative with cytology negative for malignant
cells. Likely hepatic hydrothorax rather than malignant
effusion. No hypoxia while in house
# RLE DVT: Diagnosed ___ and started on lovenox at that
time. During most recent hospitalization, lovenox was stopped in
setting of known varices. IVC filter was placed on ___.
# Elevated troponin: 0.10 I/s/o CKD, now downtrending to 0.07.
EKG without signs of ischemia
CHRONIC ISSUES:
===============
# CAD: Continue home ASA/atorva 80
# HTN: Hold home lisinopril, propranolol I/s/o ___ and
bradycardia
Transitional issues:
====================
#CODE: Full (confirmed)
#CONTACT: Next of Kin: ___
Relationship: WIFE
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Rifaximin 550 mg PO BID
4. Propranolol LA 80 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Sucralfate 1 gm PO QID
7. Ferrous Sulfate 325 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Sodium Bicarbonate 650 mg PO TID
Discharge Medications:
1. Glargine 24 Units Breakfast
2. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Disp #*60 Packet Refills:*1
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Ferrous Sulfate 325 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Rifaximin 550 mg PO BID
8. Sodium Bicarbonate 650 mg PO TID
9. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
==========
Hypoglycemia
Bradycardia
Hyperkalemia
Secondary
==========
Diabetes mellitus type 2
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
You were here because your blood sugar was found to be very low
and your heart was beating very slow.
While your were here, your insulin was decreased so your sugars
would not get too low. We also stopped one of your medications
(propranolol/metoprolol) which can prevent you from feeling the
signs of low blood sugar.
When you leave, it is important to take your medications as
prescribed. Make sure to check your sugar at least 4 times
daily, with a value first thing in the morning and before every
meal. If you have any feelings of dizziness, feeling "foggy," or
shaky, check your blood sugar immediately.
****Before you give yourself insulin in the morning, please
check your sugar levels. If your sugar is below 100 in the
morning, please eat something and check again. If your sugar is
above 100 at that time, you may give yourself the long acting
insulin (lantus) that we prescribed you. If your sugar is above
350, please contact your primary care physician about your
insulin regimen****
Also, make sure to look for any signs of bleeding, including
bright red blood in your stool or dark, tarry stools. Come bake
to the ER immediately if you notice this.
We wish you the best of luck!
Your ___ Care Team
Followup Instructions:
___
|
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2174-04-07 00:00:00
|
2174-04-07 22:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Anterior chest tube placement and removal
History of Present Illness:
___ is a ___ year old man with history of HCV cirrhosis,
c/b hepatocellular carcinoma and recurrent right sided hepatic
hydrothorax who presented with chest pain following outpatient
thoracentesis found to have pneumothorax.
Over the last week patient developed symtpoms typical of his
recurrent hydrothorax includine dyspnea on exertion, hoarse
voice, and fatigue. He was seen in ___ clinic on ___ had 3L
thoracentesis of his known right-sided effusion drained. At the
time he developed right sided chest pain. CXR showed small PTX
and he was sent home with plan to repeat CXR today. His chest
pain persisted throughout the night, up to ___, worse with
coughing, and radiating into his back. He presented to the
hospital for repeat CXR this morning which showed increasing
PTX,
and he was referred into the ED. Otherwise, no fevers, reports
chronic rhinitis. No N/V/D. No dysuria. No new leg pain or
swelling. He presented to the ED. No fevers, no headache, no
visual change, no sore throat, no difficulty breathing, no
palpitations, no cough, no vomiting, no abdominal pain, no
diarrhea, no hematochezia, no melena, no dysuria, no
arthralgias,
no rash, no back pain.
In the ED, initial VS were pain 8, T 97.0, HR 70, BP 133/92, RR
18, O2 96%RA. Initial labs notable for Na 134, K 4.4, HCO3 20,
Cr
2.0, Ca 8.5, Mg 1.7, P 3.1, ALT 35, AST 66, ALP 414, TBili 1.7,
Alb 2.8, trop 0.20 with CK-MB of 4. Lactate 1.1. CXR showed
large
right pleural effusion and enlargement of right apical moderate
sized pneumothorax from prior day. IP was consulted and placed a
right sided pigtail catheter was placed with improvement in
pneumothorax. Patient was given 1mg IV dialduid x2, ASA, insulin
1L NS. Patient reported immediate resolution of his chest pain
and cough with placement of the pigtail catheter. VS prior to
transfer were pain 0, T 97.7, HR 61, BP 124/71, RR 15, O2 94%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- HTN
- HLD
- IDDM2
- CAD (s/p stent in ___
- HCV Cirrhosis (sp SVR with Harvoni) c/b HCC s/p ablation, now
with recurrence and c/f metastatic disease to R lung
- Recurrent right hydrothorax
- Esophageal varices
- CDiff infection
- RLE DVT sp IVC filter
- Hx of GIB
- CKD (baseline Cr ~2)
Social History:
___
Family History:
Notable for myocardial infarction in his mother
and brother, leukemia in his brother who died at age ___.
Physical Exam:
ADMISSION:
==========
ADMISSION PHYSICAL EXAM:
VS: T 97.4 HR 64 BP 135/91 RR 20 SAT 95% O2 on RA
GENERAL: Pleasant and well appearing but thin man, standing up
next to his bed in no distress.
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops;
RESPIRATORY: Appears in no respiratory distress. Decreased
breath
sounds ___ way up right lung. Left lung with crackles at the
bases. Right sided chest tube at ___ ICS mid clavicular line
with
some surrounding subcutaneous swelling with crepitus. Current
attached to clamped vac.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: Firm 1cm right suprclacvicular node. No abdnormal
bruising
DISCHARGE:
==========
VITALS: 97.3 Axillary15___ / 96 ___
GENERAL: Pleasant and well appearing but thin man, seated
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops;
RESPIRATORY: Appears in no respiratory distress. Decreased
breath
sounds ___ way up right lung posterior field. L lung clear. R
chest tube previously in anterior chest now removed, minimal
subQ emphysema, nontender to palpation
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities with RLE edema
(chronic per patient from DVT), no LLE edema; Normal bulk
NEURO: Alert, oriented, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: Firm 1cm right suprclacvicular node. No abdnormal
bruising
Pertinent Results:
PERTINENT LABS:
===============
___ 11:55AM BLOOD WBC-5.1 RBC-3.75* Hgb-12.8* Hct-36.7*
MCV-98 MCH-34.1* MCHC-34.9 RDW-13.8 RDWSD-49.8* Plt Ct-71*
___ 11:55AM BLOOD Neuts-70.2 Lymphs-10.4* Monos-16.6*
Eos-2.0 Baso-0.4 Im ___ AbsNeut-3.59 AbsLymp-0.53*
AbsMono-0.85* AbsEos-0.10 AbsBaso-0.02
___ 05:06AM BLOOD WBC-3.4* RBC-3.10* Hgb-10.4* Hct-30.3*
MCV-98 MCH-33.5* MCHC-34.3 RDW-13.6 RDWSD-48.0* Plt Ct-46*
___ 05:06AM BLOOD Neuts-57.9 Lymphs-13.1* Monos-20.0*
Eos-7.8* Baso-0.6 Im ___ AbsNeut-1.94 AbsLymp-0.44*
AbsMono-0.67 AbsEos-0.26 AbsBaso-0.02
___ 11:55AM BLOOD ___ PTT-46.7* ___
___ 11:55AM BLOOD Glucose-291* UreaN-33* Creat-2.0* Na-134*
K-4.4 Cl-99 HCO3-20* AnGap-15
___ 11:55AM BLOOD Albumin-2.8* Calcium-8.5 Phos-3.1 Mg-1.7
___ 05:06AM BLOOD Glucose-176* UreaN-36* Creat-1.8* Na-135
K-4.0 Cl-102 HCO3-22 AnGap-11
___ 05:06AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.6
___ 11:55AM BLOOD ALT-35 AST-66* AlkPhos-414* TotBili-1.7*
___ 05:06AM BLOOD ALT-28 AST-49* LD(LDH)-306* AlkPhos-318*
TotBili-1.6*
___ 11:55AM BLOOD cTropnT-0.20*
___ 11:55AM BLOOD CK-MB-4 cTropnT-0.18*
___ 06:30PM BLOOD cTropnT-0.20*
___ 05:06AM BLOOD CK-MB-5 cTropnT-0.18*
___ 11:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:07PM BLOOD ___ pO2-28* pCO2-44 pH-7.36
calTCO2-26 Base XS--1
___ 03:11PM BLOOD Lactate-1.1
PERTINENT MICRO:
================
___ CULTURE-PENDING
___ CULTURE-PENDING
___ FLUIDGRAM STAIN-negative;
CULTURE-PENDING;
ANAEROBIC CULTURE-PENDING
___ pleural fluid cytology:
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS
- Mesothelial cells, histiocytes, and lymphocytes.
PERTINENT IMAGING:
==================
___ XR 1:
IMPRESSION:
In comparison with the study of ___, there is increase in
the degree of hepatic hydrothorax on the right. The fluid line
is just below the level of the carina at this time. The left
lung remains clear.
___ XR 2:
IMPRESSION:
Interval decrease in right-sided hepatic hydrothorax after
thoracocentesis. There is a tiny apical right-sided
pneumothorax.
___ XR 1:
IMPRESSION:
Enlargement of right-sided apical moderately sized pneumothorax.
No evidence of tension.
___ XR 2:
IMPRESSION:
1. Interval placement right-sided pigtail catheter with interval
decrease in right apical pneumothorax. There is minimal
residual pneumothorax on the current exam.
2. Large right pleural effusion is similar compared to prior
with improvement of adjacent compressive atelectasis.
___ XR:
IMPRESSION:
1. Stable moderately sized right-sided pleural effusion with
associated
volume loss.
2. There is no pneumothorax.
Brief Hospital Course:
___ year old man with HCV cirrhosis c/b HCC and recurrent R-sided
hepatic hydrothorax, HTN/HLD, DM2, CAD, RLE DVT s/p IVC filter
with thrombosis of the filter, CKD (baseline Cr ~2.0) and other
issues admitted with chest pain and an iatrogenic pneumothorax
after undergoing an outpatient therapeutic thoracentesis. ~3L of
fluid was removed, and immediately after he noted development of
chest pain and was sent to the ED. CXR revealed pneumothorax. He
was admitted, IP placed a pigtail chest tube, with immediate
resolution of his pain. The following morning, the chest tube
was pulled, and a repeat chest film showed complete resolution
of the pneumothorax. He was discharged home with IP follow-up.
___ is clinically stable for discharge today. On the
day of discharge, greater than 30 minutes were spent on the
planning, coordination, and communication of the discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Ferrous Sulfate 325 mg PO BID
3. Furosemide 40 mg PO BID
4. Glargine 26 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
8. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Glargine 26 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Atorvastatin 80 mg PO QPM
3. Ferrous Sulfate 325 mg PO BID
4. Furosemide 40 mg PO BID
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
8. Spironolactone 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Pneumothorax, iatrogenic
SECONDARY: Hepatocellular carcinoma, recurrent hepatic
hydrothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital for
monitoring and pain control after developing a pneumothorax (air
around your lung), a complication of the procedure you had to
drain some of the fluid around your lung (a thoracentesis). Our
interventional pulmonary doctors placed ___ in your chest to
remove the air around your lung, and your symptoms improved. We
were able to remove the tube the next day, and a repeat X-ray
showed that the pneumothorax was fully resolved. You were
discharged home.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10697025-DS-19
| 10,697,025 | 21,037,088 |
DS
| 19 |
2147-03-26 00:00:00
|
2147-04-07 15:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided abdominal pain
Major Surgical or Invasive Procedure:
___: Excisional debridement of complex abdominal wall
abscess involving the lower abdomen into the groin.
___: Debridement of lower abdominal wall and both groins.
___: Incisional debridement of a necrotizing soft tissue
infection of the right groin and placement of a VAC drain.
___: Sharp debridement of skin, fat and fascia from right
lower quadrant necrotizing soft tissue infection site followed
by placement of VAC sponge 10 x 20 cm.
___: Wound washout, partial closure and placement of VAC.
History of Present Illness:
This patient is a ___ year old female who complains of Right
sided abdominal pain, Transfer. ___ female with past
medical history significant for diabetes, hypertension,
transferred with concern for necrotizing fasciitis. Patient
reports that over the past 3 days, she is felt infection on
her right lower abdomen. She reports inability to see or access
that area. She reports it is painful to wipe after urination.
She reports chills, no fevers. Denies nausea, vomiting, chest
pain, shortness of breath. She was seen ___
outside hospital, where CT scan of the abdomen demonstrates
concern for necrotizing soft tissue infection. She was given 900
mg clindamycin at 2130 and transferred. Reports that blood
sugars have been poorly controlled over the past few days.
Past Medical History:
Past Medical History:
HTN, DM, obesity
Past Surgical History:
tubal ligation
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 98 HR: 108 BP: 91/67 Resp: 18 O(2)Sat: 94 Normal
Constitutional: Heavyset, nontoxic
Chest: Normal
Cardiovascular: Normal
Abdominal: Normal
Skin: Inferior aspect of the patient's abdominal wall pannus
to the right of midline with increased induration and
erythema extending into the right labia majora which is also
enlarged and erythematous. No crepitus appreciated
Neuro: Speech fluent
Psych: Normal mentation
DISCHARGE PHYSICAL EXAM:
VS: 98.3 PO 137 / 75 L Sitting 68 18 96 Ra
GEN: Awake, alert, sitting up ___ bed. Pleasant and interactive.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, obese. Wound to Right groin, base bright
pink, moist, serousanginous drainage.
EXT: Warm and dry, no edema.
Neuro: A&Ox3. follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 11:45PM BLOOD WBC-38.0* RBC-4.84 Hgb-13.4 Hct-41.0
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.1 RDWSD-40.3 Plt ___
___ 06:55AM BLOOD WBC-43.8* RBC-4.38 Hgb-12.2 Hct-37.5
MCV-86 MCH-27.9 MCHC-32.5 RDW-13.2 RDWSD-41.3 Plt ___
___ 03:46PM BLOOD WBC-39.4* RBC-4.25 Hgb-11.9 Hct-35.7
MCV-84 MCH-28.0 MCHC-33.3 RDW-13.4 RDWSD-41.1 Plt ___
___ 02:25AM BLOOD WBC-29.5* RBC-4.03 Hgb-11.2 Hct-33.5*
MCV-83 MCH-27.8 MCHC-33.4 RDW-13.3 RDWSD-40.3 Plt ___
___ 12:14PM BLOOD WBC-26.6* RBC-4.14 Hgb-11.3 Hct-34.9
MCV-84 MCH-27.3 MCHC-32.4 RDW-13.7 RDWSD-42.5 Plt ___
___ 01:56AM BLOOD WBC-26.8* RBC-4.05 Hgb-11.0* Hct-34.5
MCV-85 MCH-27.2 MCHC-31.9* RDW-13.8 RDWSD-43.2 Plt ___
___ 02:21AM BLOOD WBC-13.8* RBC-3.83* Hgb-10.4* Hct-32.8*
MCV-86 MCH-27.2 MCHC-31.7* RDW-14.0 RDWSD-44.0 Plt ___
___ 05:08AM BLOOD WBC-10.8* RBC-3.64* Hgb-10.0* Hct-32.0*
MCV-88 MCH-27.5 MCHC-31.3* RDW-13.3 RDWSD-41.8 Plt ___
___ 04:49AM BLOOD WBC-12.8* RBC-3.72* Hgb-10.2* Hct-32.8*
MCV-88 MCH-27.4 MCHC-31.1* RDW-13.5 RDWSD-42.9 Plt ___
___ 04:50AM BLOOD WBC-8.4 RBC-3.55* Hgb-9.8* Hct-31.7*
MCV-89 MCH-27.6 MCHC-30.9* RDW-14.6 RDWSD-46.5* Plt ___
___ 04:43AM BLOOD WBC-7.0 RBC-3.85* Hgb-10.6* Hct-33.9*
MCV-88 MCH-27.5 MCHC-31.3* RDW-14.8 RDWSD-46.3 Plt ___
___ 05:15AM BLOOD WBC-6.5 RBC-3.94 Hgb-10.9* Hct-34.6
MCV-88 MCH-27.7 MCHC-31.5* RDW-14.8 RDWSD-46.5* Plt ___
___ 05:35AM BLOOD WBC-6.6 RBC-3.92 Hgb-10.9* Hct-34.5
MCV-88 MCH-27.8 MCHC-31.6* RDW-15.2 RDWSD-47.5* Plt ___
___ 04:53AM BLOOD ___ PTT-28.8 ___
___ 02:21AM BLOOD ___ PTT-33.6 ___
___ 01:56AM BLOOD ___ PTT-28.7 ___
___ 12:14PM BLOOD ___ PTT-24.8* ___
___ 02:25AM BLOOD ___ PTT-25.7 ___
___ 11:45PM BLOOD ___ PTT-25.3 ___
___ 11:45PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.5*
___ 06:55AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.5*
___ 03:46PM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1
___ 12:14PM BLOOD Calcium-7.8* Phos-3.2 Mg-2.0
___ 01:56AM BLOOD Calcium-7.6* Phos-4.0 Mg-1.8
___ 05:13PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.8
___ 02:21AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.9
___ 04:53AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.9
___ 05:08AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
___ 04:49AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
___ 11:44AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9
___ 03:53PM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0
___ 04:53AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
___ 02:37AM BLOOD %HbA1c-8.5* eAG-197*
___ 12:04AM BLOOD Lactate-2.7*
___ 08:55AM BLOOD Glucose-304* Lactate-1.9 K-3.5
___ 08:45PM URINE Color-Straw Appear-Clear Sp ___
___ 01:39PM URINE Color-Straw Appear-Clear Sp ___
___ 08:45PM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 01:39PM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM*
___ 11:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:48 am ABSCESS Site: ABDOMEN
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
WOUND CULTURE (Final ___:
VIRIDANS STREPTOCOCCI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 4 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringenes, and C.septicum.
None of
these species was found.
___ 11:00 am TISSUE NECROTIC FAT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ (___),
___ @ 16:45.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:14 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 1:38 pm TISSUE RIGHT GROIN WOUND.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
Reported to and read back by ___ @ ___ ON ___ -
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
___ ALBICANS. RARE GROWTH.
Yeast Susceptibility:.
Fluconazole MIC 0.5 MCG/ML= SUSCEPTIBLE.
Results were read after 24 hours of incubation.
Sensitivity testing performed by Sensititre.
ANAEROBIC CULTURE (Final ___:
DUE TO LABORATORY ERROR, UNABLE TO PROCESS.
ANAEROBES ARE SCREENED FOR ___ THE THIO BROTH MEDIA.
TEST CANCELLED, PATIENT CREDITED.
___ 9:16 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Imaging:
CT A/P (OSH): Subcutaneous gas c/f NSTI involving lower
abdominal
pannus to R of midline with 2 small fluid collection towards the
posterior aspect of the air collection
___ CXR:
1. Right internal jugular line terminates ___ the right atrium.
2. NG tube terminates with side port at the GE junction.
Consider advancing 3 cm.
3. Right hilar fullness may be due to patient rotation.
Recommend correlation with prior exams if available and
attention on follow-up if not
___ CXR:
___ comparison with the study ___, the cardiomediastinal
silhouette is stable. There is increased engorgement of central
pulmonary vessels as well as peripherally, consistent with
elevated pulmonary venous pressure. More focal areas of
opacification at both bases raises the possibility of
aspiration/pneumonia ___ the appropriate clinical setting. Mild
atelectatic changes are again seen at the bases.
___ US unilateral upper extremity: Right arm
1. No evidence of deep vein thrombosis ___ the right upper
extremity.
2. Superficial thrombus of the distal right cephalic vein.
3. Right internal jugular vein cannot be evaluated overlying
bandage.
Brief Hospital Course:
The patient presented to Emergency Department on ___. Pt
was evaluated upon arrival to ED by the ___ team due to a marked
leukocytosis and erythematous area ___ her pannus. Given
findings, the patient was taken to the operating room for
surgical debridement of her necrotizing soft tissue infection.
There were no adverse events ___ the operating room; please see
the operative note for details. Pt remained intubated to
facilitate future evaluation of necrotic tissue ___ the operating
room, and then transferred to the SICU for observation. On POD
#1 the patient was taken back to the operating room for further
evaluation of surgical debridement, the debridement was found
adequate and the patient was taken back to the ICU intubated. On
POD #2 the patient was extubated by the ICU team without any
issues. Patient was adequately controlled with IV pain
medications and she was hemodinamically stable at this point
with a down trending leukocytosis. On POD #3 the patient was
taken back to the operating room for surgical debridement of
pannus and vac placement, with no intraoperative complications.
Subsequently after extubation the patient was taken back to the
PACU and transferred to the surgical floor to continue her care.
Neuro: The patient was alert and awake upon initial evaluation.
The patient was kept intubated and sedated after her first
surgical intervention. After extubation the patient had
adequate pain control with an combination of IV and PO pain
medication regimen.
CV: The patient had pressor-dependent hypotension likely
secondary to sepsis. Subsequently after extubation the pressor
requirement diminished and the patient had no other acute
cardiovascular issue. She remained hemodinamically stable up to
her transfer to the surgical ward.
Pulmonary: The patient had ventilator dependent respiratory
insufficiency ___ the post-operative period. On POD #2 the
patient had minimal ventilator requirements and subsequently was
extubated. The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube ___ place for decompression during her ICU
course. Patient had adequate stress ulcer prophylaxis with
famotidine while intubated. Once tolerating adequate oral
intake, nasogastric feeding tube removed, and she continued to
take adequate POs. Patient's intake and output were closely
monitored. Blood glucose was closely monitored and controlled
with insulin.
ID: The patient's fever curves were closely watched for signs of
infection. Upon admission the patient was started on Vanco,
Zosyn and Clindamycin to manage her necrotizing soft tissue
infection. Multiple surgical debridement of the infected area
was performed until no infection was grossly visible. Her
leukocytosis was trended since her admission and upon discharge
from the ICU had trended from 43.8 -> 13.8. On ___,
developed pruritic red rash starting on her back and spreading
over neck, trunk & proximal limbs. At this time vancomycin was
recently discontinued and she remained on zosyn antibiotics.
Infectious disease was consulted and recommended switching
antibioitic classes. Due to timing of rash, unable to
differentiate which antibiotic was most likely cause.
Antibiotics therapy was switched to metronidazole and
ceftriaxone. A two week course after local/surgical infection
source control was administered. On ___ wound vac dressing was
changed at the bedside.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
The patient worked with Physical therapy who agreed to discharge
to rehab.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. glimepiride 4 mg oral daily
4. Gabapentin 100 mg PO TID
5. Atorvastatin 10 mg PO QPM
6. Naproxen 500 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. DiphenhydrAMINE 25 mg PO Q6H:PRN itch
3. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
4. Glucose Gel 15 g PO PRN hypoglycemia protocol
5. Heparin 7500 UNIT SC TID
6. Glargine 10 Units Dinner
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Sarna Lotion 1 Appl TP QID:PRN itchy/rash
8. Atorvastatin 10 mg PO QPM
9. Gabapentin 100 mg PO TID
10. Lisinopril 40 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. HELD- Naproxen 500 mg PO Q8H:PRN Pain - Moderate This
medication was held. Do not restart Naproxen until you talk to
your primary care.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Necrotizing soft tissue infection
Diabetes Mellitus type II
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 ___
with a necrotizing soft tissue infection of the lower abdomen.
You were taken to the operating room and had the infected tissue
removed and given IV antibiotics. After several operations, the
infected tissue was all removed. A wound vac dressing was placed
to help the wound heal and prevent further infection. This
dressing will continue to be changed approximately every 3 days.
You are now doing better, your wound is healing, and there are
no further signs of infection. You are now ready to be
discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood ___ your
urine, or experience a discharge.
*Your pain ___ 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 ___ your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10697073-DS-8
| 10,697,073 | 21,610,639 |
DS
| 8 |
2185-11-13 00:00:00
|
2185-11-19 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo male with PMH of liver mass stable since ___
who presents with epigastric pain. His pain began around
midnight the night prior to admission. He ate steak for dinner
that evening. He had difficulty sleeping ___ the pain. He went
to urgent care clinic and he was referred in for further
evaluation. He denies vomiting, fevers, chills, diarrhea, bloody
or black stools.
In the ED, initial VS were: 5 99.8 93 103/54 18 98%. Exam was
significant for guaic negative stool. EKG showed no changes.
Labs were significant ALT 310, AST 288, T Bili 3.3, normal
lipase. He was given GI cocktail. RUQ showed known calcified
mass. VS prior to transfer were 98.9 84 107/68 16 96%.
On arrival to the floor, patient is pain free and states the
medicine he received in the ED helped his pain.
Past Medical History:
psoriasis
GERD
BPH
Anemia
DM (diabetes mellitus), type 2
Hypertension
Ulner nerve lesion
Microalbuminuria
Early stage glaucoma
Vitreous floaters
Cataract incipient, senile
Cholelithiasis s/p cholecystectomy
Liver lesion
Colonic adenoma
+ Hepatitis B core Ab ___ at ___ with positive Hep B
surface Ab and negative hepatitis surface antigen
Social History:
___
Family History:
Patient does not know
Physical Exam:
EXAM ON ADMISSION:
VS: T: 98.3, P: 70, BP: 103/61, RR: 16, 97% on RA
GENERAL: well appearing male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, no JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, minimal TTP in epigastrium,
non-distended, no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
LABS ON ADMISSION:
___ 05:00PM BLOOD WBC-11.8*# RBC-3.54* Hgb-11.1* Hct-33.6*
MCV-95 MCH-31.4 MCHC-33.1 RDW-12.9 Plt ___
___ 05:00PM BLOOD Neuts-91.5* Lymphs-4.6* Monos-3.1 Eos-0.3
Baso-0.4
___ 05:00PM BLOOD ___ PTT-31.7 ___
___ 05:00PM BLOOD Glucose-139* UreaN-14 Creat-0.6 Na-135
K-3.7 Cl-102 HCO3-24 AnGap-13
___ 05:00PM BLOOD ALT-310* AST-288* AlkPhos-106
TotBili-3.3*
___ 05:00PM BLOOD Lipase-24
___ 05:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-BORDERLINE HAV Ab-POSITIVE IgM HAV-NEGATIVE
___ 05:00PM BLOOD HCV Ab-NEGATIVE
___ 05:08PM BLOOD Lactate-1.8
LABS ON DISCHARGE:
___ 08:33AM BLOOD WBC-3.7* RBC-3.88* Hgb-12.1* Hct-35.5*
MCV-92 MCH-31.3 MCHC-34.2 RDW-12.8 Plt ___
___ 08:33AM BLOOD Glucose-177* UreaN-12 Creat-0.6 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
___ 09:00AM BLOOD ALT-131* AST-36 AlkPhos-135* TotBili-1.2
___ 08:33AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0
IMAGING:
RUQ Ultrasound:
1. Known calcified mass in the posterior right lobe of the
liver, thought to represent prior infection as per clinical
notes although not well visualized on this study due to
anticipated shadowing of chunky calcifications.
2. No intrahepatic biliary dilatation.
3. Prominent common bile duct, likely appropriate given the
patient's age and cholecystectomy, not significantly changed.
MRCP:
1. Linear appearing the filling defects seen on multiple
sequences within the lower common duct, appear to be some
debris, possibly stones versus blood products. As the patient
has been discharged at the time of dictation, this has been
entered into the radiology critical reporting database for
communication to the requesting physician.
2. No intrahepatic biliary dilation. Common duct measures 7 mm,
within
acceptable limits for age an in a patient post cholecystectomy.
3. No overt malignancy in the liver or biliary tree; this
examination is
limited by motion.
4. Calcified masses as seen on the prior CT examination of ___ and the subsequent MRI examination performed at
___ on ___ has decreased in size.
Brief Hospital Course:
The patient is a ___ year-old male with history of liver mass
(stable since ___, thought secondary to infection) and hisotry
of cholecystectomy/cholangitis in ___ who presents with
epigastric pain, transaminitis, and elevated total bilirubin.
# Transaminitis / hyperbilirubinemia: At presentation, ALT 310,
AST 288, and t.bili 3.3. Transaminases downtrended without
intervention on serial blod draws. T.bili ultimately trended
downward to normal range. RUQ ultrasound showed known calcified
mass in the posterior right lobe of the liver (thought to
represent prior infection), no intrahepatic biliary dilatation,
and prominent common bile duct. Differential diagnosis included
passed gallstone, impacted stone (too small to be detected on
ultrasound), and malignancy. No evidence of chloangitis
clinically. MRCP was obtained to evaluate biliary tree. MRCP
(read pending at the time of discharge) showed linear appearing
filling defects on multiple sequences within the lower common
duct, appear to be some debris, possibly stones versus blood
products, Nn intrahepatic biliary dilation or malignancy.
Following discharge, the patient was scheduled for outpatient
ERCP and follow-up with Dr. ___.
# Epigastric pain: Unclear etiology, but resolved on day of
presentation. ___ have been related to passed stone or MRCP
findings as described above. Lipase within normal limits. The
patient was continued on home PPI. His diet was advanced to
regular before discharge.
#DMII: Metformin was held during inpatient stay. He was
maintained on ISS.
#HTN: Normotensive during hospital stay.
Transitional Issues:
- ERCP to be performed on ___ to evaluated MRCP findings.
- Follow-up with Dr. ___ in clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Aspirin 81 mg PO DAILY
6. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN GI upset
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Omeprazole 20 mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN GI upset
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal Pain
Elevated Transaminases
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital with abdominal pain and abnormal liver function
tests. You underwent imaging of your liver and bile ducts. A
final interpretation of this imaging study was pending at the
time of discharge. By the time of discharge, your abdominal pain
had improved and you were tolerating a normal diet.
Please follow-up with Dr. ___. You will hear from his
office regarding a scheduled appointment. Please contaqct his
office at ___ if you have not heard from them by the
end of the day on ___.
Addendum:
Your MRCP showed evidence of small stones in the common bile
duct. We will schedule you for an outpatient ERCP. ___
___, MD
Followup Instructions:
___
|
10697731-DS-11
| 10,697,731 | 23,501,895 |
DS
| 11 |
2148-12-22 00:00:00
|
2148-12-22 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Toradol / Ceftriaxone / Nitroimidazole Derivatives
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ doesn't have a past history presenting with abdominal pain
and back pain x24 hours. Patient states that his symptoms
started last night after eating a fatty ___ meal and a piña
colada. He states that he had diffuse abdominal pain for 2
hours. He states that the pain continued this morning, but moved
to his back. The pain is in the right CVA area. No nausea,
vomiting, diarrhea. No fevers. No urinary symptoms. Patient does
endorse SOB. ROS otherwise negative.
In the ED, initial vitals were: T 98, HR 92, BP 164/92, RR 18,
SPO2 98% on RA. BP subsequently improved to 128/77 while in the
ED.
Exam notable for tense abdomen without rebound, guarding, or
tenderness. He had right CVA tenderness.
Labs notable for:
--Na 141, K 4.0, Creat 0.9, Glucose 105, eGFR>75
--WBC 10.1, Hgb 12.6, Hct 38.2, Plt 204
--Lymphs: 17.9, AbsNeut: 7.02, AbsMono: 1.06
--___: 13.5 PTT: 150 INR: 1.2
--unremarkable LFTs and lipase
--elevated DDimer at 1465
--lactate 1.8
--UA with trace leuk esterase, trace protein, otherwise
negative.
Past Medical History:
- Abdominal pain (negative H.Pylori ___
- Depression
- Constipation, lifelong
- Hepatitis A
- Intractable fungal balanitis
- Elevated amylase
- Inguinal hernia
- GERD
- Chylamydia
- Globus
- Rectal pain
- Knee pain
- Motor vehicle accident
Social History:
___
Family History:
NO family history of cancers or clotting disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Height: ___ Weight: 77.9kgs
VS: T 99.6, BP 126/75, HR 71, RR 18, 96% on RA
Gen: Alert and oriented, in some distress.
HEENT: PERRLA. EOMI. moist mucus membranes
CV: Normal S1/S2, no murmurs, gallops, or rubs.
Pulm: Good airflow bilaterally. No wheezes, rhonchi, or
crackles.
Abd: mid-epigastric ttp, negative ___ sign. Hypoactive
bowel sounds present.
GU: Not examined.
Ext: ___ - No calf pain/ttp during active/passive
flexion/extension. No erythema, edema, or warmth.
Neuro: UE strength ___ and ___ ___ strength and sensation grossly
normal. Cranial nerves intact.
DISCHARGE PHYSICAL EXAM:
========================
Vital signs: T 97.2, BP 109/66, HR 69, RR 18, 98% room air
Gen: Alert and oriented, lying comfortably in bed
HEENT: PERRLA. EOMI. moist mucus membranes
CV: Normal S1/S2, no murmurs, gallops, or rubs.
Pulm: Clear to auscultation bilaterally. No wheezes, rhonchi, or
crackles.
Abd: NTTP, normal bowel sounds.
GU: Not examined.
Ext: No swelling and 2+ peripheral distal pulses bilaterally
Neuro: UE strength ___ and ___ ___ strength and sensation grossly
normal. CN II-XII intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:30PM ___ PTT-150* ___
___ 02:10AM LACTATE-1.8
___ 01:55AM GLUCOSE-105* UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
___ 01:55AM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-75 TOT
BILI-1.0
___ 01:55AM LIPASE-47
___ 01:55AM ALBUMIN-4.4
___ 01:55AM D-DIMER-1465*
___ 01:55AM WBC-10.1*# RBC-4.07* HGB-12.6* HCT-38.2*
MCV-94 MCH-31.0 MCHC-33.0 RDW-12.6 RDWSD-43.7
___ 01:55AM NEUTS-69.3 LYMPHS-17.9* MONOS-10.5 EOS-1.5
BASOS-0.5 IM ___ AbsNeut-7.02* AbsLymp-1.81 AbsMono-1.06*
AbsEos-0.15 AbsBaso-0.05
___ 01:55AM PLT COUNT-204
___ 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 01:55AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
DISCHARGE LABS:
===============
___ 07:44AM BLOOD WBC-11.1* RBC-3.87* Hgb-12.0* Hct-36.8*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.0 RDWSD-44.8 Plt ___
___ 07:44AM BLOOD Plt ___
___ 07:44AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-139
K-4.0 Cl-99 HCO3-30 AnGap-14
___ 07:44AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0
IMAGING:
========
CTA Chest (___): multiple filling defects in the right and left
lower lobe segmental and subsegmental pulmonary arteries,
compatible with acute PE's. No evidence of right heart strain.
Bibasilar atelectasis, no focal consolidations. 8mm right upper
lobe nodule, which should be followed up with a CT in ___ months
if patient has lung cancer risk factors; if low risk for lung
cancer, recommend follow-up CT in ___bdomen and pelvis (___): Moderately distended distal small
bowel loops with fecal contents without definite transition
point, may reflect early or partial SBO. Extensive stool burden
throughout the entire colon with no free air free fluid. No
evidence of hydronephrosis or nephrolithiasis.
RUQ ultrasound (___): Normal findings with no evidence of
stones or gallbladder wall thickening. The hepatic parenchyma
appears within normal limits. The contour of the liver is
smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites. There is no
intrahepatic biliary dilation. The CHD measures 4 mm. The imaged
portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the
pancreatic tail obscured by overlying bowel gas. Limited views
of the right kidney show no hydronephrosis. There is a small
cyst in the right kidney. The visualized portions of aorta and
IVC are within normal limits.
CXR (___): The cardiomediastinal and hilar contours are within
normal limits. The lungs are clear without focal consolidation,
pleural effusion or pneumothorax. No acute cardiopulmonary
process.
Brief Hospital Course:
___ man who presents with epigastric and right flank pain with
radiation to the back subsequently found on CTA to have
bilateral pulmonary emboli.
ACTIVE ISSUES:
==========================
#Pulmonary embolism: Patient had recent long trip to ___ this
___, subsequently had pleuritic pain, SOB, went to the ED
and found to have elevated D-Dimer and submassive bilateral
pulmonary emboli on CTA with ground glass opacities concerning
for pulmonary infarction. He was hemodynamically stable,
saturating well on room air. Very low PESI score of 75. He was
started on a heparin drip on admission. The following day
(___) he was transitioned to rivaroxaban 15mg. He will
take 15mg of rivaroxaban BID for 21 days, and then will take
20mg once daily until told to stop by his PCP. He will follow up
at ___ on ___. No hypercoagulability workup
was performed.
#Pain: He complained of pleuritic pain on admission, thought to
be due to his PE given changes c/f infarction on CT scan. He
remained hemodynamically stable throughout his hospital stay. He
was given IV morphine and Dilaudid in the ED. The following
morning (___), he required only 0.5mg IV Dilaudid. His
pain was well controlled throughout the day with standing
Tylenol. He will go home with Tylenol as well as 5mg Oxycodone
(8 tablets) and a bowel regimen. Pt counseled on side effects
and addiction potential with opiates.
CHRONIC ISSUES:
==========================
#Constipation: Patient has a history of constipation. He had a
BM on the day prior to discharge. He was given a prescription
for senna, dulcolax, miralax, and Colace. He will follow up with
his PCP for further management of his constipation.
TRANSITIONAL ISSUES
==========================
-5mm right upper lobe nodule, which should be followed up with a
CT in ___ months if patient has lung cancer risk factors; if low
risk for lung cancer, recommend follow-up CT in ___ months
-He has an appointment ___ with ___ for follow-up
for his pain and anticoagulation care.
-He was started on Rivaroxaban. He will take 15mg BID for 21
days, and then take 20mg daily, with the course to be determined
by his PCP.
-No hypercoagulability studies were performed. Consider doing
this as an outpatient.
-Patient advised to consider outpatient colonoscopy for
screening.
-He was given 5mg Oxycodone (8 tablets) for pain. Make sure his
patient is well controlled as an outpatient.
-___ need further constipation management with pain medication.
-Code status: Full
-Emergency contact: No healthcare proxy in system. Consider
talking with patient in this regard.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day as
needed Disp #*30 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours as
needed Disp #*8 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g powder(s) by
mouth Daily as needed Refills:*0
6. Rivaroxaban 15 mg PO BID
with food
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
7. Rivaroxaban 20 mg PO DAILY
with food
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
8. Senna 8.6 mg PO BID Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day as
needed Disp #*30 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pulmonary embolism
Secondary diagnosis:
Pain
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for a blood clot in your lungs
(pulmonary embolism). You were given blood thinners and you got
better. Initially, you were on an intravenous blood thinner.
Then, we transitioned you to an oral medication, which you will
go home with. This medication is called Xerelto (or rivaroxaban)
and you will take 1 tablet of 15 mg twice a day for 3 weeks.
Then, you will take one tablet of 20 mg (higher than the
previous tablets) until Dr. ___ you to stop. You will
follow up with Health Care Associates at ___ on ___ at 2:30
pm. Dr. ___ is out of town so you will see one of her
associates. You will also go home with a lot of bowel movement
medications as well as Tylenol and oxycodone for pain.
Best wishes,
-Your ___ medicine team
Followup Instructions:
___
|
10697746-DS-14
| 10,697,746 | 23,225,680 |
DS
| 14 |
2183-02-16 00:00:00
|
2183-02-16 19:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tradjenta / gabapentin / Tylenol
Attending: ___.
Chief Complaint:
Altered mental status, TBI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical (AKA ___, DOB ___ is a ___
female who presents to ___ on ___ with a
moderate TBI. Patient transferred from OSH intubated. History
obtained from chart review and per EMS. Patient was reportedly
found down at the bottom of stairs earlier this evenings, with
presumed fall down stairs. Per report GCS prior to intubation
was 5. Patient taken to OSH where she was intubated, received
hypertonic bolus and Keppra. NCHCT with bifrontal tSAH, right
acute SDH with minimal MLS, right occipital bone fracture and
right cerebellar hemorrhage with compression on the ___
ventricle. Patient was ___ transferred to ___ and
Neurosurgery was consulted.
Past Medical History:
HTN
HLD
DM
Diabetic peripheral neuropathy
GERD
Seborrheic keratosis
Hypothyroidism
Frequent UTIs
Anxiety/Depression
Osteoarthritis of left knee s/p arthroplasty (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
-------------
GCS upon Neurosurgery Evaluation: 10T
Time of evaluation: 20:15
Airway: [x]Intubated [ ]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[x]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, intubated, sedated
HEENT: PERRL, normocephalic with posterior superficial hematoma
Neck: c-collar
Extrem: warm and well perfused
Neuro:
Mental Status: Intubated, sedation held for exam. Eyes open to
voice and follows simple commands.
Orientation: None, intubated
Language: UTA
If Intubated:
[x]Cough [x]Gag [ ]Over breathing the vent
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally.
III, IV, VI: UTA
V, VII: UTA yet appears symmetric at rest
VIII: Hearing intact to voice.
IX, X: Not tested
XI: UTA
XII: UTA
Motor:
Patient moves all four extremities spontaneously and
purposefully. BUE moves antigravity, she used both upper
extremities to pull the blanket over her. BLE moves
spontaneously, crosses one leg over the other in plane of bed.
Shows two fingers to command with RUE
Sensation: UTA
-------------
ON DISCHARGE:
-------------
24 HR Data (last updated ___ @ 420)
Temp: 98.7 (Tm 98.7), BP: 145/68 (93-145/55-70), HR: 72
(65-78), RR: 16 (___), O2 sat: 95% (94-97), O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Eyes open to voice, tracks; able to answer one-word
questions, able to move left and antigravity but not right,
Pupils are 4-3mm, reactive symmetrically, able to move left foot
and complaint of bed
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 07:53PM BLOOD WBC-17.7* RBC-4.14 Hgb-13.3 Hct-41.8
MCV-101* MCH-32.1* MCHC-31.8* RDW-12.6 RDWSD-46.7* Plt ___
___ 07:53PM BLOOD Neuts-82.0* Lymphs-12.5* Monos-4.6*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.49* AbsLymp-2.20
AbsMono-0.82* AbsEos-0.04 AbsBaso-0.03
___ 07:53PM BLOOD ___ PTT-29.2 ___
___ 07:53PM BLOOD UreaN-21*
___ 07:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:37PM BLOOD Type-ART Rates-/___ Tidal V-400 PEEP-8
FiO2-70 pO2-183* pCO2-40 pH-7.28* calTCO2-20* Base XS--7
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 08:03PM BLOOD Glucose-235* Lactate-3.1* Creat-1.1
Na-144 K-3.9 Cl-112* calHCO3-19*
PERTINENT LABS
==============
___ 08:57AM BLOOD CK(CPK)-125
___ 02:50PM BLOOD ALT-14 AST-18 LD(LDH)-281* AlkPhos-106*
TotBili-0.2
___ 04:07AM BLOOD ALT-12 AST-21 LD(LDH)-411* AlkPhos-85
TotBili-0.2
___ 07:53PM BLOOD Lipase-30
___ 04:07AM BLOOD proBNP-1430*
___ 04:07AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.7
Mg-2.7*
___ 12:01AM BLOOD Osmolal-305
___ 05:39PM URINE Color-Straw Appear-Clear Sp ___
___ 05:39PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:39PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 11:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 08:07AM STOOL CDIFPCR-NEG
MICRO
=====
__________________________________________________________
___ 5:30 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 4:30 pm BLOOD CULTURE Source: Line-LUE PICC 1 OF
2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:50 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:42 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:31 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 3:54 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
=======
CT Abd/Pelvis ___
Patchy new ground-glass in the right middle lobe suggest a mild
infectious or inflammatory process. Equivocal finding of mild
proctitis. No short-term change in right adnexal cyst;
follow-up ultrasound of the pelvis is
recommended when clinically appropriate, as mentioned
previously.
CXR ___
Enteric tube traverses the expected course of the esophagus and
exits the
field of view below the diaphragm. The left PICC terminates in
the proximal right atrium. The cardiomediastinal silhouette is
unchanged. Moderate pulmonary edema is improved from ___
and approximately equal in severity to that of ___.
CXR ___
In comparison with the study of ___, there is little
change in the
diffuse bilateral pulmonary opacifications, more prominent on
the right.
Although this most likely represents pulmonary edema, in the
appropriate
clinical setting it would be impossible to exclude superimposed
aspiration/pneumonia. Bibasilar opacification is consistent
with layering
pleural effusions and volume loss in the lower lobe.
Monitoring and support devices are stable.
MR ___ ___. Taking into account the difference in technique, there is
stable
multicompartmental hemorrhages as described above.
2. Nonspecific focus of diffusion restriction with T2/FLAIR
hyperintensity in the body of the corpus callosum, which may
represent a nonhemorrhagic diffuse axonal injury.
3. Diffusion abnormality in the right sylvian region could be
due to
subarachnoid blood products and less likely due to parenchymal
diffusion
abnormality.
4. No large vascular distribution infarct.
5. Paranasal sinus disease as described above.
6. Additional findings as described above.
CT ___ ___. Interval increase in size of right subdural hematoma,
measuring 8 mm.
Stable subdural hematomas along the falx cerebri and cerebellar
tentorium.
2. Stable bifrontal hemorrhagic contusions and adjacent
bifrontal subarachnoid hemorrhage.
3. Stable right cerebellar intraparenchymal hemorrhage, with
stable mass
effect on the right pons and midbrain.
4. Stable extra-axial blood within the right greater than left
posterior
fossa.
5. Stable moderate to severe effacement of the fourth ventricle
without
supratentorial hydrocephalus. Stable small intraventricular
hemorrhages
bilaterally.
6. Re demonstrated nondisplaced right calvarial and skull base
fracture.
CXR ___
Interstitial abnormality is unchanged. Left-sided PICC line
projects over the cavoatrial junction. The NG tube projects
below the left hemidiaphragm. No pneumothorax is seen. There
are small bilateral effusions.
CXR ___
NG tube tip passes below the diaphragm terminating in the
stomach. Left PICC line tip is at the cavoatrial junction.
Heart size and mediastinum are stable. Right lung opacification
and left mid lung consolidations appear to be similar to
previous examination concerning for infectious process that does
not demonstrate substantial improvement and overall appears
substantially progressed as compared to ___.
Vascular congestion is present, mild but no overt pulmonary
edema is currently demonstrated.
CT ___ ___. Right cerebellar intraparenchymal hematoma appears unchanged.
2. Increase in posterior fossa mass effect with deformity of the
fourth
ventricle.
3. Evolution of bifrontal hemorrhagic contusions. Stable small
intraventricular hemorrhage.
4. Unchanged small right frontal subdural hematoma.
5. Re-demonstrated predominantly nondisplaced, comminuted
fracture of the
right skull base is better appreciated on the study from ___.
CT ___ ___. Stable right cerebellar intraparenchymal hematoma and
mass-effect,
including partial effacement of the fourth ventricle and basal
cisterns
without current evidence of obstructive hydrocephalus.
2. Although evaluation is limited due to residual contrast
enhancement from
prior study, there is probable increased bilateral cerebral
subarachnoid
hemorrhage. Right frontal convexity subdural hemorrhage and
right posterior fossa extra-axial hemorrhage are stable.
3. Predominantly nondisplaced, comminuted fracture involving the
right
calvarium and skull base, including the foramen magnum, right
foramen ovale, and right occipital condyle, as above.
4. Partial opacification of the right mastoid air cells without
definite
fracture through the mastoid portion of the right temporal bone.
When
appropriate, dedicated temporal bone CT may be obtained for
better evaluation.
CTA ___ ___. Evolving large right cerebellar intraparenchymal hematoma
with significant regional edema and mass effect including
partial effacement of the fourth ventricle and mild soft tissue
crowding at the foramen magnum, not significantly changed since
the prior study. Similar ventricular size.
2. Bilateral counter coup frontal lobe contusions with scattered
subarachnoid hemorrhage and subdural hematoma overlying the
right frontal lobe. Similar regional edema and mass effect
including 1 mm leftward midline shift.
3. Patent circle of ___ without evidence of high-grade
stenosis,occlusion,or aneurysm.
4. Atherosclerotic plaque at the bilateral common carotid
bifurcations and
proximal ICA resulting in 50% stenosis of the left ICA and 40%
stenosis of the right ICA. Severe atherosclerotic stenosis of
the left vertebral artery origin.
5. Otherwise patent bilateral cervical carotid and vertebral
arteries without evidence of occlusion, or definite intimal
flap to suggest dissection.
6. Extensive skull base fractures involving the right occipital
bone and
extending into the right occipital condyle, foramen magnum and
petrous portion of the right temporal bone with questionable
extension into the carotid canal involving the petrous segment
of the right ICA.
7. Slightly decreased size of large occipital scalp hematoma and
right frontal scalp contusion.
8. Ground-glass airspace disease in the visualized right lung
apex concerning for aspiration and/or contusion.
9. Nonspecific enlarged right cervical level 3 lymph node.
CT Torso ___. Centrilobular ground-glass opacities within the right upper
and lower lobes is concerning for aspiration or less likely
atypical infection.
2. The patient is status post intubation with endotracheal tube
terminating at the level the carina.
3. No acute abdominopelvic injury.
4. 2 cm cystic lesion within the right adnexa in postmenopausal
patient,
incompletely characterized and would be better evaluated by
outpatient pelvic ultrasound.
CXR ___
Endotracheal tube terminates at the level of the carina.
Recommend withdrawal by approximately 3 cm for more optimal
positioning. Enteric tube terminates in the proximal stomach,
with side port in the distal esophagus. Suggest advancement so
that it is well within the stomach.
DISCHARGE LABS
==============
___ AGap=13
4.5260.8
Comments:Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 8.3 Mg: 2.6 P: 4.1
Source: Line-PICC
100
12.___.___
28.5
N:73.7 L:11.7 M:10.6 E:1.5 Bas:0.2 ___: 2.3 Absneut: 8.___
Abslymp: 1.43 Absmono: 1.29 Abseos: 0.18 Absbaso: 0.03
Comments:
___: Includes Metas, Myelos, And Pros.
Brief Hospital Course:
___ female with PMHx of HTN, HTN, T2DM, OA who presented
with bifrontal tSAH, right SDH, cerebellar IPH in setting of a
fall deemed not to be surgical candidate by neurosurgery with
hospital course complicated by aspiration pneumonia and
hypoxemic
respiratory failure that resolved with antibiotics and IV
diuresis. She demonstrated significant neurologic recovery,
underwent PEG placement, and then was discharged to rehab in
stable condition.
ACTIVE ISSUES:
==============
# TBI
# Bilateral tSAH
# Right SDH
# Right cerebellar IPH
# Concern for ___
Admitted to neuro ICU after being found to have bifrontal
traumatic SAH, right SDH, right cerebellat IPH with compression
of fourth ventricle on ___ imaging. Patient initially found
down on concrete garage floor (thought to have fallen backwards
while
trying to navigate 3 steps to reach house from garage) covered
in emesis by husband, 15 minutes after arriving home. Per
husband, she had been in usual state of health prior to this.
Transferred from neuro ICU to ___ on ___. No surgical
intervention was deemed to be necessary by the neurosurgical
team. MRI ___ with concern for diffuse axonal injury. The
patient completed a 7-day course of levetiracetam during this
hospitalization for seizure prophylaxis after her brain injury.
Patient demonstrated improvement in neurological status and
underwent PEG placement with general surgery on ___. She
tolerated tube feeds after this point with some diarrhea as
described below. She was reevaluated by the speech and swallow
team. Recommended n.p.o. except ice chips and continuation of
tube feeds. They recommended that she undergo video swallow
study at her rehabilitation facility. CODE STATUS discussion
with the family during this hospitalization confirmed DNR/DNI
status. Her neurologic prognosis was discussed in detail by the
neurology team as well as neurosurgery team that were following
her for most of her hospitalization. She will need to follow-up
in ___ clinic in 6 weeks after discharge with repeat CT
___ without contrast. TTE report pending at time of discharge.
# Acute Hypoxemic Respiratory Failure
# Aspiration PNA (completed course ___
# OSA
Patient completed a 7-day course of aspiration pneumonia with
vancomycin and cefepime (vancomycin discontinued after MRSA swab
negative) from ___. The patient was also diuresed with IV
Lasix ___ mg IV and was converted to p.o. Lasix on ___ in
the setting of volume overload and elevated BNP. Patient was
completely weaned to room air during the daytime but was noted
to require nocturnal oxygen. Upon review of records, she had
recently completed a sleep study and a CPAP was recommended. She
was started on the settings overnight. TTE did not demonstrate
any major abnormalities. CT on ___ demonstrated right middle
lobe groundglass opacities. However, patient was afebrile with
no cough and hence this was not treated. If fevers or productive
cough develop, patient should be empirically treated for
aspiration pneumonia or another 7 days. Consideration should be
given for p.o. Augmentin versus IV antibiotics for this course.
# Diarrhea
# Leukocytosis
Patient's infectious work-up was unremarkable. Patient has also
just completed a 7-day course of antibiotics for aspiration
pneumonia. MRSA screen was negative. C. difficile negative. CT
abdomen pelvis with evidence of mild proctitis and new right
middle lobe groundglass opacity. Given lack of fevers, cough and
recent completion of treatment for aspiration pneumonia, right
middle lobe groundglass opacity was not treated and patient's
leukocytosis was downtrending on discharge. Per family, she
would take Imodium as needed on as outpatient quite often. Her
outpatient cholestyramine was reinitiated.
# HTN
Discontinued HCTZ, started chlorthalidone. Increased amlodipine
to 10mg, continued 6 labetalol 100 mg 3 times daily, and
continue losartan 100 mg daily.
# Oral HSV
Completed 5 day treatment of acyclovir q8h on ___.
CHRONIC/STABLE ISSUES:
======================
# T2DM
Held home metformin and glipizide. Initiated on glargine daily
and regular insulin q6h while on continuous tube feeds.
# Hypothyroidism
Continued home levothyroxine.
# HLD
Continued home atorvastatin.
# Depression
Continued home sertraline.
TRANSITIONAL ISSUES
===================
CONTACT: ___ (husband) ___
CODE: DNR/DNI
[] Follow-up final TTE report
[] Recommend repeat CBC, chemistry 10 panel 1 day after
discharge and continue to trend leukocytosis and consider
Augmentin x 7 days for aspiration pneumonia in the appropriate
clinical context
[] Monitor electrolytes (chem/ca/mg/phos) while on tube feeds
[] Ensure the patient is up-to-date with all health screenings
and preventative vaccinations
[] 2 cm cystic lesion within the right adnexa in postmenopausal
patient,
incompletely characterized and would be better evaluated by
outpatient pelvic ultrasound
[] Ensure the patient using CPAP at nighttime once cycled off
tube feeds at night to avoid aspiration, would ensure that
patient can physically remove mask if nauseous (Autoset CPAP:
Minimum 5, Maximum 15)
[] Trend blood pressures, adjust antihypertensive regimen as
needed
Greater than 40 mins spent in discharge planning and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. LORazepam 0.5 mg PO BID:PRN anxeity
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Cholestyramine Dose is Unknown PO DAILY
5. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. GlipiZIDE XL 20 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Famotidine 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Glargine 32 Units Bedtime<br> Regular 12 Units Q6H
Insulin SC Sliding Scale using REG Insulin
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
8. Labetalol 100 mg PO TID
9. Ramelteon 8 mg PO QPM:PRN insomnia
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. amLODIPine 10 mg PO DAILY
12. Cholestyramine 12 gm PO DAILY
13. Sertraline 100 mg PO DAILY
14. Atorvastatin 10 mg PO QPM
15. Famotidine 20 mg PO BID
16. Levothyroxine Sodium 88 mcg PO DAILY
17. Losartan Potassium 100 mg PO DAILY
18. HELD- GlipiZIDE XL 20 mg PO DAILY This medication was held.
Do not restart GlipiZIDE XL until you speak to your PCP
19. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you speak to
your PCP
20. HELD- LORazepam 0.5 mg PO BID:PRN anxeity This medication
was held. Do not restart LORazepam until you speak to your PCP
21. HELD- MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until you speak to your PCP
22.CPAP
CPAP machine and kit, use all night once safe from aspiration
perspective
Dx: Severe OSA
ICD-10: G47.33
Autoset 5-15cm H20
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
# TBI
# Bilateral tSAH
# Right SDH
# Right cerebellar IPH
# Concern for ___
# Acute Hypoxemic Respiratory Failure
# Aspiration PNA (completed course ___
# OSA
# Diarrhea
# Leukocytosis
# HTN
# Oral HSV
Secondary Diagnoses
===================
# T2DM
# Hypothyroidism
# HLD
# Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
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 a traumatic fall were
found to have bleeding in your brain
What happened while I was admitted to the hospital?
-You were admitted to the neurologic ICU where you spent a
majority of your hospital stay recovering from your injury
-You are evaluated by the neurosurgeons who determined that you
did not require an operation
-You were cleared from the trauma surgery perspective as well
-You were then transferred to the medicine team where you were
evaluated for diarrhea, and completed a course of antibiotics
for pneumonia
-You are evaluated by physical therapy, occupational therapy,
and speech and swallow who recommended further recovery in a
rehabilitation facility after discharge
-Your lab numbers were closely monitored and you were given
medications to treat your medical conditions
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
****Please see below for recommendations from the neurosurgery
team******
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10698368-DS-7
| 10,698,368 | 28,226,681 |
DS
| 7 |
2148-03-31 00:00:00
|
2148-03-31 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
morphine / Shellfish
Attending: ___
Chief Complaint:
Transfer after left MCA stroke and traumatic left ICA dissection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no significant PMH but FH of stroke at young age in
her mother presents after high speed MVC 10 days ago with sudden
onset this morning fluctuating aphasia and initially fleeting
left hemisensory disturbance followed by a persistent right
hemiparesis and word-finding difficulties. MRI/MRA head and neck
at OSH revealed a left ICA occlusion and a small left MCA
distribution acute embolic infarct and neurology were consulted
for further assessment.
Patient had a high-speed MVC 10 days prior to presentation
(___). Per the patient, she was traveling at ___ MPH, being a
restrained passenger in a car that malfunctioned. The car hit a
telegraph pole on the passenger side, spun 180 degrees, then hit
a tree, on the driver's side. She was propelled forward into the
passenger's side, hitting her head on the dashboard. She
sustained a bruise on the left temple but did not lose
consciousness. She experienced a feeling of heaviness around her
left eye but had no visual symptoms. She was assessed by EMS,
they found her to be awake, without loss of consciousness, per
the patient and without any other significant injuries. There
was
no neck pain at the time of accident and she did not recall
vigorous movements of the neck or a clear jerk of the neck. She
then returned home, catching a flight to ___ from ___ two hours later.
The following morning she noted anterior bilateral neck
discomfort, thus presenting to ___ with
unremarkable head and thorax CT, per the patient. She returned
home with a diagnosis of a neck sprain. Neck pain persisted for
four to five days. She took naproxen, once twice daily, then
once
daily for this. She then developed pain when looking up and to
the right in her left eye, being a dull ache. On ___, she
called
her PCP about this, with ophthalmology evaluation on ___ which
was unremarkable per the patient.
This morning she awoke at 9 AM today (___) and felt that her
voice sounded strange and could not say her cat's name. She then
continued to have word-finding difficulties, but this slowly
improved. She felt that her speech was "thick" with some
difficulty articulating but without any significant slurring.
She
then developed an odd feeling in the left side of her body,
without weakness per the patient although she felt her left leg
was almost dragging and was difficult for her to describe
(denied
frank numbness, tingling). All symptoms had greatly improved by
10:30 or 10:45 AM. She returned to ___, where, at
around
noon, she noted right-sided weakness. She has first noticed
weakness when attempting to write her name ___, not
graphically); word-finding difficulties returned. CT head, then
MRI head and MRA head and neck were performed. A left ICA
occlusion was found with a small left sided MCA infarct. She was
transferred to ___ for further care.
On arrival to ___, she had persistent subtle word-finding
difficulties with slightly hesitant speech with mild right-sided
weakness. Neurology and the patient's nurse noted ___ worsening in
her examination at around 18:30 where both word-finding and
right-sided weakness had worsened whilst in the ED and this was
conveyed to the appropriate covering neurology residents.
Currently, patient denies dysarthria but feels her speech is
slow. Has not walked since initial ED assessment but had some
gait fdifficulty before this. She denies any visual symptoms.
Past Medical History:
PMH:
OA
PSHx:
Hysterectomy and unilateral SO
Tubal ligation priorto this
Wisdom teeth extraction
Social History:
___
Family History:
Mother - strokes in early ___, HTN
Maternal grandmother died age ___ possible due to a massive sroke
Father - HLD
___ - 2 brothers HTN, HLD
Children - 1 son died car accident and 1 son with ___
disability and another with dyslexia
There is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.
Physical Exam:
At admission:
Vitals: T: Not recorded P:77 R:18 BP:118/68 SaO2:100% RA
General: Awake, cooperative right hemiparesis and word-finding
difficulty.
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: Bruises left lateral shin and two tiny bruises on left
posterior chest.
Neurologic:
___ Stroke Scale score was 4
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language was slightly hesitant with subtle expressive aphasia
initially and more hesitant with worse aphasia and some
paraphasic errors latterly (comparing initial assessment at 1600
with repeat at ___ with intact repetition and comprehension.
Normal prosody.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall 3/ 3 at 5
minutes.
CALCULATION Patient was able to do simple arithmetic and
calculate number of quarters in $1.75.
Unable to assess for agraphaesthesia on the right hand due to
being unable to feel the instrument although this was intact on
the leg.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch but slightly reduced
sensation on right face to pinprick.
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. Mild right pronator drift
initially and by repeat assessment at ___ significant right
drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Initial examination.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 4+ 4+ ___ ___ 5 4+ 5 5 5
On final asessment right UE was ___ worse proximally with
decreased dexterity in right hand. Right leg was still strong
and
less affected but had slightly more drift.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on left. On right, UE
affected more so than ___ with decreased temperature in UE and
slightly to mid shin in ___, decreased pinprick in whole right UE
without defecit in ___, intact vibration but decreased light
touch
in RLE/RUE and decresaed proprioception in RUE to rightMCP
joint.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Reflexes brisker on right throughout.
Plantar response was flexor on left and extensor on right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred.
NEURO EXAM AT DISCHARGE:
.
Neuro Exam Prior to Discharge:
Mental Status: Speech fluent ___ words together) with
occasional pauses, oriented to person, place, time, date, able
to repeat complex phrase "if he were here, she would go", able
to read without paraphasic errors, able to follow 3-step cross
body command, no apraxia, able to write full sentence about the
weather
Cranial Nerves: L pupil slightly enlarged, no ptosis, 5->3mm on
the Left pupil reactivity, 4.5->3mm on the Right, EOMI without
nystagmus,
symmetric palate elevation, slowed excursion of R face with
showing of teeth (UMN pattern), tongue midline
Motor: full strength ___ in left upper and left lower extremity,
notable for 4+ delt, 4+ tri, breakable finger extensors in RUE,
and 4 IP, 4 Ham in the right lower extremity Patient has Right
hand postural change with pronator drift testing, and finger tap
is slow on the Right
Sensation: Proprioception intact bilaterally in upper and lower
extremities, decreased pinprick sensation in the right upper
extremity when compared to the left (appears normal in face and
legs), patient has intact vibratory sense in right lower and
left lower extremity
Gait: Good initiation, gait is slow, limited arm swing, turns en
bloc, patient has small steps and appears unsteady but did not
sway in one direction or another
Pertinent Results:
LABS ON ADMISSION:
___ 04:20PM BLOOD WBC-6.4 RBC-4.46 Hgb-13.8 Hct-43.0 MCV-96
MCH-30.9 MCHC-32.1 RDW-12.3 Plt ___
___ 04:20PM BLOOD Neuts-57.2 ___ Monos-3.8 Eos-1.5
Baso-0.5
___ 04:20PM BLOOD ___ PTT-24.1* ___
___ 04:20PM BLOOD Plt ___
___ 04:20PM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
___:45PM BLOOD ALT-15 AST-20 AlkPhos-44 TotBili-0.5
___ 04:20PM BLOOD Calcium-9.5 Phos-3.4 Mg-2.3
___ 02:30PM BLOOD Osmolal-291
___ 11:45PM BLOOD TSH-5.0*
___ 07:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:30PM URINE Hours-RANDOM Creat-27 Na-130 K-20 Cl-141
___ 07:05PM URINE UCG-NEGATIVE
.
STROKE RISK FACTOR ASSESSMENT:
___ 11:45PM BLOOD %HbA1c-5.5 eAG-111
___ 11:45PM BLOOD Triglyc-45 HDL-65 CHOL/HD-1.8 LDLcalc-45
.
ECG:.
Sinus rhythm. Otherwise, normal tracing. No previous tracing
available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 174 88 378/400 29 44 25
.
CXR:
FINDINGS: AP portable view of the chest was obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen. Cardiac
and mediastinal silhouettes are unremarkable. Hilar contours are
also within
normal limits.
IMPRESSION: No acute cardiopulmonary process.
.
MRI brain/MRA head and neck:
MR OF THE HEAD WITHOUT CONTRAST: There are areas of slightly
increased DWI
signal in the left MCA territory in the left frontal and
parietal lobes and in the left temporal lobe, including the
Broca's and Wernicke's areas
representing multiple small acute infarcts. There is no
significant
surrounding edema or mass effect at this point.
.
The ventricles and extra-axial CSF spaces are normal. There is
increased
signal intensity in the left distal cervical internal carotid
artery and the intracranial portions, related to the known
dissection and occlusion.
.
Minimal mucosal thickening is noted in the ethmoid air cells.
The mastoid air cells are clear.
.
MR ANGIOGRAM OF THE NECK: There is increased signal intensity in
the left
cervical internal carotid artery, in the mid and distal cervical
internal
carotid arteries, with extension into the intracranial segments
representing dissection/thrombosis within. There is eccentric
hyperintense signal, suggesting dissection to be a more
favorable diagnosis.
.
The origins of the arch vessels, the common carotid and the
cervical internal carotid artery on the right side are patent.
The left vertebral artery arises directly from the left
vertebral artery is dominant and patent. The right vertebral
artery has a slightly heterogeneous signal intensity, in the
distal cervical and the V3 segments with a narrow V4 segment.
However, there is no definite increased signal within to suggest
a flow-related abnormality.
.
MR ANGIOGRAM OF THE HEAD: There is nonvisualization of the left
intracranial internal carotid artery, to the termination.
Anterior and middle cerebral arteries are patent, with a
slightly prominent appearance of the anterior communicating
artery complex. Contour irregularity of the left A1 segment.
Prominent posterior communicating arteries are noted on both
sides. The right vertebral, the right intracranial internal
carotid artery, the anterior and the middle cerebral arteries
are patent without focal flow-limiting stenosis or occlusion. No
obvious aneurysm more than 3 mm within the resolution of MR
angiogram is noted.
.
IMPRESSION:
1. Multiple small acute infarcts in the left MCA territory as
mentioned
above, no surrounding edema or significant mass effect.
2. Occlusion of the left cervical internal carotid artery,
except for a short segment beyond the origin. Reformation of the
anterior and the middle cerebral arteries. Possibilities include
dissection/thrombotic occlusion. Dissection is more favored,
given the eccentric hyperintense signal on the fat sat
sequences.
3. Patent major other arteries as described above.
.
MR ___ without contrast:
FINDINGS:
There is reversal of cervical lordosis. The cervical vertebral
bodies are
normal in height and alignment. The signal intensity is slightly
heterogeneous, related to scattered fat deposition.
.
Multilevel small anterior and posterior osteophytes are noted.
Disc
desiccation is noted at all levels.
.
On the sagittal STIR sequence, allowing for the artifacts, there
is no
definite increased signal intensity in the cervical vertebrae to
suggest
mass-like lesion. Evaluation of the cord is limited on the STIR
sequence due to artifacts.
.
At C2-C3: No disc herniation, canal or foraminal stenosis.
.
At C3-4: Disc desiccation, mild bulge with a small protrusion
without
significant canal or foraminal stenosis.
.
At C4-5: Narrowing of the disc space, disc desiccation and
diffuse disc bulge with a focal central protrusion/disc
osteophyte complex indenting the ventral thecal sac and the
ventral aspect of the cord. Moderate-to-severe foraminal
narrowing is noted on the right side with deformity on the C5
nerve.
.
At C5-6: Disc desiccation, diffuse disc bulge with a broad-based
disc
osteophyte shallow complex, without significant canal stenosis;
mild foraminal narrowing on both sides.
.
At C6-7: Disc desiccation, diffuse disc bulge and protrusion
indenting the
thecal sac. Evaluation for foraminal narrowing is limited at
this level due to artifacts.
.
At C7-T1: No disc herniation, canal or foraminal stenosis.
.
A few tiny T2 hyperintense foci are noted in the thyroid, which
can be better assessed with ultrasound.
.
Left ICA dissection/occlusion better assessed on the concurrent
MR angiogram of the neck study.
.
IMPRESSION:
1. Multilevel, multifactorial degenerative changes, with most
prominent
changes noted at C4-5 and C5-6 levels, with moderate foraminal
narrowing and mild canal stenosis with indentation on the
ventral cord at C4-5 level.
2. Left ICA dissection better assessed on the concurrent MR
angiogram of the neck study.
3. Small T2 hyperintense foci in the thyroid, correlate with
nonurgent
ultrasound.
.
No obvious cord lesions noted (evaluation is somewhat limited
due to motion and technical artifacts).
.
LABS AT TIME OF DISCHARGE:
___ 05:55AM BLOOD ___ PTT-82.2* ___
Brief Hospital Course:
Mrs. ___ is a ___ RHF with no significant PMH but FH of
stroke at young age in her mother who presented 10 days after a
high speed MVC with sudden onset of fluctuating aphasia
(word-finding difficulties, non-fluent production of speech,
paraphasic errors), fleeting left hemisensory disturbance, and
persistent right hemiparesis. She was admitted to the stroke
service from ___ to ___. Patient was initially admitted
to the NeuroICU for close clinical monitoring and was then
transferred to the floor when stable.
#Left Internal Carotid Artery Dissection with occlusion and Left
MCA distribution acute embolic infarcts. Patient initially had
neurological exam demonstrating primarily R proximal arm/leg
deficits but soon after had right upper extremity motor deficits
in upper motor neuron distribution (with extensors weaker than
flexors and distal extremity weaker than deltoid) and right
lower extremity deficits in an upper motor neuron pattern (with
flexors weaker than extensors and more pronounced weakness
proximally), as well as decreased proprioception in the right
arm. An MRI/MRA head and neck at OSH revealed a left ICA
occlusion after the bifurcation and reconsitution intracranially
thought likely secondary to dissection. The MRI also showed
small left middle cerebral artery distribution acute embolic
infarct in the left corona radiata and ___ areas.
.
An MR ___ was performed ___ given the history of neck pain
and trauma - in addition to left-sided sensory changes. The
imaging showed minimal ventral thecal sac impingement at C4/5
due to disc disease, which may have accounted for initial
bilateral sensory findings. Patient had an MRI/MRA (see full
report above) with multiple small acute infarcts in the left MCA
territory, occlusion of the left cervical ICA except for short
segment beyond the origin, there is reformation of the anterior
and the middle cerebral arteries thought to most likely reflect
dissection. It is suspected that the dissection is
trauma-related.
.
She was started on an IV heparin infusion with goal PTT 50-70,
and eventually started to bridge with Coumadin with goal INR
___. Patient had goal SBP>120 to maintain cerebral perfusion
given the fixed deficit (ie the left ICA thrombosis). Midodrine
5mg TID was started to help achieve this BP goal along with PRN
IVF boluses as well. (Of note, at a regimen of 10mg/10mg/5mg
daily, Ms. ___ had side effects from the midodrine
including feeling "busy inside.") Orthostatics were negative
prior to discharge. The midodrine can be discontinued around
___.
.
Patient's stroke risk factors were assessed, and noted to have
LDL 45 and HBA1c 5.5, which did not require any interventions.
She was monitored on telemetry continuously without any adverse
events or evidence of contributory arrhythmias. The patient was
evaluated by speech and swallow who cleared her for a regular
diet. In addition, Physical and Occupational Therapy saw the
patient and recommended ___ rehab. Patient will have f/u
with Dr. ___ Neurology.
.
#Anticoagulation: Patient was on heparin gtt with goal PTT
50-70. She became therapeutic on her coumadin on day of
discharge with INR 2.1 (goal is ___. She will need to continue
her heparin gtt one day post discharge for overlap with the
coumadin. Please see anticoagulation worksheet associated with
this discharge.
.
TRANSITIONAL ISSUES:
1) Incidental finding of hyperintensity on thyroid which should
be followed by PCP with ___
2) Midodrine likely to be dc'ed 1 week following discharge
3) F/u with Dr. ___ Neurology
4) Anticoagulation: Patient with INR 2.1, will need overlap with
heparin gtt goal 50-70 PTT one more day after her discharge.
Please see anticoagulation worksheet.
Medications on Admission:
Omeprazole unclear dose
Naproxen PRN was taking bid for neck pain and latterly qd
Discharge Medications:
1. omeprazole Oral
2. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six Hundred Fifty (650) units/hr Intravenous ASDIR
(AS DIRECTED): Goal PTT 50-70. Can be stopped 24 hours after
patient thereapeutic INR ___.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
5. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six Hundred ___ (625) units/hr Intravenous
ASDIR (AS DIRECTED) for 1 days: goal PTT 50-70, this can be
discontinued on ___ as patient will be thereaputic on INR ___
(goal PTT is 50-70).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Left Middle Cerebral Artery Distribution
Embolic Infarcts in the setting of traumatic Left Internal
Carotid Artery Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Patient able to ambulate by herself, but will
likely need assistance and monitoring initially
.
Neuro Exam Prior to Discharge:
Mental Status: Speech fluent ___ words together) with
occasional pauses, oriented to person, place, time, date, able
to repeat complex phrase 'if he were here, she would go', able
to read without paraphasic errors, able to follow 3-step cross
body command, no apraxia, able to write full sentence about the
weather
Cranial Nerves: L pupil slightly enlarged, no ptosis, 5->3mm on
the Left pupil reactivity, 4.5->3mm on the Right, EOMI without
nystagmus,
symmetric palate elevation, slowed excursion of R face with
showing of teeth (UMN pattern), tongue midline
Motor: full strength ___ in left upper and left lower extremity,
notable for 4+ delt, 4+ tri, breakable finger extensors in RUE,
and 4 IP, 4 Ham in the right lower extremity Patient has Right
hand postural change with pronator drift testing, and finger tap
is slow on the Right
Sensation: Proprioception intact bilaterally in upper and lower
extremities, decreased pinprick sensation in the right upper
extremity when compared to the left (appears normal in face and
legs), patient has intact vibratory sense in right lower and
left lower extremity
Gait: Good initiation, gait is slow, limited arm swing, turns en
bloc, patient has small steps and appears unsteady but did not
sway in one direction or another
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure to care for you at the ___. You
initially presented to the hospital with complaints of word
finding difficulties and weakness on the right side of your
body. Imaging was obtained of your head and neck, and you were
found to have a dissection (a tear in the vessel wall) in one of
your arteries that supplies the left side of the brain (left
internal carotid artery) with resulting small strokes in the
left side of the brain. We believe the most likely cause of your
stroke was due to your previous car accident and injury to the
blood vessel serving your brain.
.
You were seen by occupational therapy who has recommended that
you go to rehab. Your stroke risk factors were evaluated and
your cholesterol and blood sugars were under good control.
.
Incidintally we found on your imaging that there a small density
in your thyroid gland. This can be evaluated at a later time by
your primary care physician, with the recommendation that you
have an ultrasound of your thyroid.
.
We made the following changes to your medications:
START Midodrine 5mg tablet take one tablet by mouth three times
a day (this can likely be discontinued 1 week after your
discharge - around ___.
START Coumadin (Warfarin) take on 5mg tablet daily at 4pm (your
blood will be checked to see how thin it is on your coumadin by
an INR check with a goal of ___ on INR.
START Heparin drip 625units/hr (this needs to be continued for
one more day, it can stop on ___ as your blood will be thin
with the coumadin, your blood should be checked PTT with a goal
PTT of 50-70)
.
We have made you a follow-up appointment with Dr. ___
(___), please see below.
We wish you all the best!
Followup Instructions:
___
|
10698920-DS-5
| 10,698,920 | 21,487,758 |
DS
| 5 |
2136-10-19 00:00:00
|
2136-10-19 11:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
Lung nodule biopsy
History of Present Illness:
___ man w/PMHx IVUD w/heroin, last used 1wk ago, now presenting
with low back pain. The pain began 5d ago, was in his USOH
until getting out of bed to walk to the bathroom, left leg went
out because of pain. Tried to hold out but the pain got too
bad, so went to ___, given Motrin, referred back to PCP. So
then came here. The pain is L>R, sharp, radiating to the R but
not down the leg, constant, worse w/movement, not sure what
makes it better. Usually uses a cane because he likes them, not
because he has previously needed them. No fevers, chills, no
night sweats. Occ cough for a couple days, non-productive.
Some orange urine for a year, but no other urinary changes. Has
a distant h/o gonorrhea, not sexually active for ___ now.
Currently uses heroin, injects in his arms only, doesn't share
needles. Has been using as a teenager, then stopped for ___,
then after mother died he restarted, then stopped, restarted
after uncle died. No complications to date. Last used 1 week
prior to admission, doesn't use daily. Is interested in
stopping -- ___ is the nurse there, at the ___
(behind ___, ___).
In the ED: good rectal tone, neuro exam unremark, CT spine
w/contrast done, showed possible disciitis, seen by Spine,
ordered inflammatory markers and BCx, admitted for pain control.
VS unremark.
Past Medical History:
Brain aneurysm ___, "they cut it out" (but it may have been
coiled) -- presented with a headache, no stroke
GSW to chest/leg -- bullet fragments remain in the chest
Hypertension
Possible prolonged bereavement, ?depression -- denies any
anti-depressants or therapy
IVDU as per HPI -- ___ house is at ___
Dominant right gynecomastia
Cirrhosis suspected due to Hep C (genotype 1b) and EtOH with
portal hypertension, h/o grade 2 varices (denies bleeding
complications), mild normocytic anemia and thrombocytopenia,
mild coagulopathy
Asymptomatic L sided nephrolithiasis
Possible new diagnosis COPD
H/o seizure disorder
Social History:
___
Family History:
Mother, died of EtOH
No other drug use or other diseases, no cancers
Physical Exam:
Admission physical exam:
T 98.5, BP 137/84, HR 61, RR 18, sat 100% on RA
Gen: middle aged man lying in bed, alert, cooperative, slightly
uncomfortable ___ pain
HEENT: anicteric, PERRL, MMM
Chest: equal chest rise, CTAB posteriorly, no WOB or cough,
upper R chest wall near shoulder with well healed bullet wound
scar
Heart: RRR, no m/r/g
Abd: NABS, soft, NTND
Back: exquisite TTP in the midline of the lumbo-sacral region,
out of proportion to what I would expect
GU: no penile lesions, no inguinal ___, testicles w/o obvious
masses, he does have some subcutaneous pustules on his scrotum
that are not open, they appear to be folliculitis, during the
exam, one bursts and produces a small amount of pus -- he states
this is what has been happening previously
Extr: WWP, no edema
Neuro: CN intact and symmetric, speaking easily, strength ___
bilat, sensation to light touch intact, reflexes symmetric,
oriented x 3
Psych: crying in pain after the exam
Discharge physical exam
Pertinent Results:
___: WBC: 5.9
___: HGB: 12.7*
___: HCT: 39.5*
___: Plt Count: 149*
___: ___: 14.5*
___: INR: 1.3*
___: PTT: 36.2
___: Na: 135
___: K: 4.3
___: Cl: 106
___: CO2: 21*
___: BUN: 20
___: Creat: 1.0
___: eGFR: 93
___: Glucose: 86
___: ALT: 25
___: AST: 40
___: Alk Phos: 145*
___: Total Bili: 4.9*
___: Alb: 2.9*
BCx x ___-spine w/contrast -- IMPRESSION: 1. No clear epidural
abscess is seen. 2. Increased atlas-dens interval (predental
space), which measures 7 mm. Otherwise, no acute fracture or
vertebral malalignment.
CT T-spine w/contrast -- IMPRESSION: 1. No clear epidural
abscess is seen. 2. No acute fracture or vertebral
malalignment. 3. A rounded and possibly spiculated mass is
seen in the periphery of the visualized right lung (3:47).
Dedicated chest CT is recommended.
CT L-spine w/contrast -- IMPRESSION: 1. Disc bulges are seen at
L4/5 and L5/S1, but there is appears to be a connection between
these two areas, which could be due to extruded disc but cannot
completely exclude an epidural abscess on this exam. 2. No
acute fracture vertebra malalignment.
CT Chest -- IMPRESSION: 1. 15mm spiculated solid nodule in the
right upper lobe, should be evaluated as possible lung cancer.
The spiculations reach a minimally thickened pleural surface.
The
adjacent rib is intact. No associated lymphadenopathy or other
nodules identified. 2. Upper lobe predominant centrilobular
emphysema and large apical bulla. 3. Dominant right
gynecomastia
or mass. Mammographic evaluation is recommended. 4. 2 mm
non-obstructing left kidney stone.
Bone scan -- IMPRESSION: Non-specific increased uptake along the
left aspect of the L5 vertebral body with corresponding
decreased uptake along the right L5 and right hemisacrum.
Findings will be correlated with subsequent gallium scan to
assess for the presence of infection.
Gallium scan -- INTERPRETATION: Following intravenous injection
of tracer, whole body planar images were obtained at 3 days.
SPECT images of the lumbar spine were performed, and
reconstructed in the axial, coronal, and sagittal planes. There
is increased tracer uptake at the left L5-S1 level, which
corresponds to
an area of spurring and degenerative changes on the SPECT/CT.
The ratio of tracer uptake to normal bone does not appear to be
increased when compared to the same ratio on bone scan performed
on ___. Overall findings are likely due to inflammatory
process secondary to degenerative changes, and less likely
infection. Physiologic excretion is seen in the colon.
IMPRESSION:
Focal tracer uptake in the left L5-S1 vertebral body with
corresponding spurring and degenerative changes on SPECT/CT.
Overall findings suggest inflammatory process secondary to
degenerative changes, and less likely from infection.
Brief Hospital Course:
___ with medical history including IVDA who presents with low
back pain, incidentally found to have spiculated lung lesion on
imaging s/p biopsy.
.
#LOW BACK PAIN: A CT C/T/L spine with contrast was obtained that
demonstrated disc buldges at L4/L5 and L5/S1 but could not
exlude possibility of epidural abscess. We are not able to
obtain an MRI due to retained bullet fragments. Given history
of IVDA, we decided to further evaluate for possible infection
with bone scan and gallium scan after discussion with Nuclear
Medicine. This demonstrated findings suggestive of an
inflammatory process secondary to degenerative changes and less
likely from infection. He remained afebrile during his hospital
stay with a normal WBC count and blood cultures x2 no growth to
date. Pain service was consulted and he was started on tylenol
(low dose given cirrhosis), gabapentin, lidocaine patch, and
oral hydromorphone. We stopped tizanidine (and cyclobenzaprine)
as he refused to use it saying he got shooting pains from it
down his legs. Severe pain limiting movement continued so he
was started on MS contin. While there is some increased risk of
GI bleed given his liver disease - due to continued limited pain
control, he was also started on low dose NSAIDS and an H2
blocker. Physical therapy saw the patient several times during
the hospital stay.
.
#NON-SMALL CELL LUNG CANCER: He was incidentally found to have a
right lung nodule on CT T spine. A follow-up dedicated CT chest
with contrast demonstrated a 1.5cm right upper lobe spiculated
solid nodule. We discussed with the patient that this was
concerning for possible malignancy and recommended biopsy. On
___ he underwent ___ guided biopsy. This demonstrated
non-small cell lung cancer.
.
#GYNECOMASTIA: He was found to have right dominant glynecomastia
on CT chest imaging. Most likely this is due to hx of cirrhosis.
There is no prior in our system for comparison. Radiology
recommending mammographic evaluation.
.
#CIRRHOSIS: Cirrhosis ___ Hep C (genotype 1b) and EtOH with
portal hypertension, h/o grade 2 varices (denies bleeding
complications), mild normocytic anemia and thrombocytopenia,
mild coagulopathy. He was previously on nadolol as an outpatient
but not recently and we defer this to his PCP. We gave
phytonadione once to try to improve the coagulopathy in case he
needs an invasive procedure (e.g. lung bx) -- it helped a bit.
HIV test negative.
#IVDA: Patient reported that he would like to restart ___
therapy. He will follow up with PCP to discuss this further.
#History of seizure Disorder:
- phenytoin level was subtherapeutic -- admits he wasn't
actually taking it -- have continued it here but in the long run
defer to outpatient providers if could consider stopping this.
Possible new diagnosis COPD
- based on CT chest -- could consider PFTs as an outpatient --
no obvious need for COPD medications at this time
Asymptomatic L sided nephrolithiasis: noted on imaging
Transitional issues:
[ ] mammogram recommedned for evaluation of asymmetric
gynecomastia
[ ] f/up with PCP for referral for ___
PCP ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenytoin Sodium Extended 300 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Phenytoin Sodium Extended 300 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H
3. Gabapentin 600 mg PO Q8H
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply to back QAM Disp #*5
Patch Refills:*0
5. Hydrochlorothiazide 25 mg PO DAILY
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*12 Tablet Refills:*0
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Ibuprofen 400 mg PO Q8H
10. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth every twelve (12) hours
Disp #*2 Capsule Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth Daily Refills:*0
12. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe low back pain
Recent intravenous heroin use
Spiculated lung nodule concerning for cancer
Dominant right gynecomastia
Cirrhosis likely due to hepatitis C (genotype 1b) and alcohol
with portal hypertension, history grade 2 varices (denies
bleeding
complications), mild normocytic anemia and thrombocytopenia,
mild
coagulopathy
Asymptomatic L sided nephrolithiasis
Possible new diagnosis COPD
H/o seizure d/o
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with severe low back pain. We treated your
pain with different medications and with help from the Pain
Service.
We also found that you have a nodule in your lung. A biopsy was
obtained. Unfortunately, this showed lung cancer.
We also found that your right chest wall near the nipple is
somewhat larger than your right left side -- this is called
gynecomastia -- this can happen as a result of liver disease,
but it's unusual for it to be more on one side than another.
Our radiologists recommend you have some special x-rays taken of
that side (mammogram). Please follow up with your primary care
physician to have this scheduled.
It's important that you follow up with a primary care doctor for
all of your medical problems.
Followup Instructions:
___
|
10698984-DS-21
| 10,698,984 | 28,947,835 |
DS
| 21 |
2153-02-27 00:00:00
|
2153-02-27 18:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transient aphasia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ with PMH of cardiac cath s/p 2 stents, NSTEMI, HTN, NIDDM
who
presented to the ED as a transfer from ___ after 2 episodes
of aphasia.
Patient states that she was in her usual state of health until
day of presentation. She states that around 12:30 ___, she had
an
episode where she was having word finding difficulties. She
states that she was able to think of the words; however the
words
just will not come out properly. For example, instead of saying
"because", she was a "broccoli". This first episode lasted
about
15 minutes. She states that during this time, she was having
difficulty writing email, because she just could not spell her
words. She was also having trouble typing on the keyboard. She
also cannot figure out how to print something. These are
typically tasks that she would not have any trouble with. She
denied other symptoms, no new weakness, numbness or tingling,
changes in vision. However, around 3:15 ___, she had another
episode of word finding difficulty. She thinks that the second
episode lasted longer, about 20 minutes or so. This was when
she
went to the hospital in ___. Patient states that she had
run
out of her home aspirin several days ago, and not been taking
aspirin during this time.
Per report, at ___, she had trouble naming, and her
speech was not fluent. NIHSS 2, for language. Labs showed INR
1.1, troponin 0.07. CTA head and neck was read as 'no
occlusion, significant stenosis, or dissection. No significant
stenosis right or left internal carotid arteries. Mild calcific
plaque formation in both carotid bulbs. Patent vertebral
arteries bilaterally.' Per report from outside hospital, her
episode of aphasia lasted about 25 minutes, and then afterwards
had been stuttering and intermittent. She was given aspirin 325
prior to transfer. She was then transferred here for further
management.
Past Medical History:
PMH:
Cardiac cath with 2 stents
NSTEMI
HTN
Laminectomy L4/L5
Cholecystectomy ___
Triple arthrodesis left foot
Lumpectomy right breast
Bilateral carpal tunnel release
Bilateral cataract surgery
Social History:
___
Family History:
FAMILY HISTORY:
Mother had ___
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: 98.6 BP: 130/80 HR: 81 RR: 17 SaO2: 95%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, Able to relate history without
difficulty.
Attentive, Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects on ___ stroke
card. Able to describe cookie picture. Able to read without
difficulty. No dysarthria. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: L pupil 4->2 R pupil 3->2 both postsurgical.
EOMI without nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: R NLFF, present at bedside, her face looks her baseline
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift. No adventitious movements, such as
tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 4+ 5 5 5 5
R 5 5 5 5 5- 5- 4+ 5 5 5 5
Patient states that she has bilateral leg weakness at baseline.
She states that she has had mild right hand weakness ever since
her carpal tunnel surgery earlier ___.
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 3 2 3 3 1
R 3 2 3 3 1
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: Deferred
Discharge EXAM
=================
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, Able to relate history without
difficulty.
Attentive, Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects on ___ stroke
card. Able to describe cookie picture. Able to read without
difficulty. No dysarthria. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: L pupil 4->2 R pupil 3->2 both postsurgical.
EOMI without nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: R NLFF, present at bedside, her face looks her baseline
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift. No adventitious movements, such as
tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 4+ 5 5 5 5
R 5 5 5 5 5 5 4+ 5 5 5 5
-Sensory: No deficits to light touch
-Reflexes:
Not tested
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: Deferred
Pertinent Results:
Admission Labs
===============
___ 07:43PM BLOOD WBC-6.2 RBC-3.63* Hgb-9.8* Hct-32.3*
MCV-89 MCH-27.0 MCHC-30.3* RDW-14.6 RDWSD-46.7* Plt ___
___ 07:43PM BLOOD Neuts-64.6 ___ Monos-7.4 Eos-3.7
Baso-0.5 Im ___ AbsNeut-4.00 AbsLymp-1.46 AbsMono-0.46
AbsEos-0.23 AbsBaso-0.03
___ 07:43PM BLOOD ___ PTT-30.4 ___
___ 07:43PM BLOOD Plt ___
___ 07:43PM BLOOD Glucose-108* UreaN-22* Creat-0.8 Na-140
K-4.4 Cl-106 HCO3-23 AnGap-11
___ 08:30PM BLOOD ALT-26 AST-22 AlkPhos-84 TotBili-0.3
___ 08:30PM BLOOD cTropnT-0.01
___ 08:30PM BLOOD Lipase-43
___ 08:30PM BLOOD Albumin-3.5 Calcium-9.0 Phos-4.2 Mg-1.5*
___ 07:04AM BLOOD %HbA1c-5.2 eAG-103
___ 07:04AM BLOOD Triglyc-173* HDL-46 CHOL/HD-2.4
LDLcalc-31
___ 07:04AM BLOOD TSH-<0.01*
___ 07:04AM BLOOD Free T4-1.7
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING
============
Radiology ReportMR HEAD W & W/O CONTRASTStudy Date of
___ 9:58 AM
FINDINGS:
There are several punctate foci of increased signal intensity on
DWI
bilaterally, in the left posterior and superior frontal lobe,
right superior
frontal lobe, and left parietal lobe (5; 19, 23, 24, 27). The
foci at the
left parietal lobe and right superior frontal lobe correspond
with low signal
on ADC and high signal on FLAIR, indicating that these lesions
are acute to
early subacute infarcts. In addition, there is a
periventricular chronic
lacunar infarct in the left posterior frontal lobe (11; 17).
There are also
multiple foci of decreased signal intensity on GRE in bilateral
parietal lobes
and left posterior frontal lobe that are hypointense on T1, T2,
and FLAIR
which could indicate chronic microhemorrhages or calcium
deposits (10; 19).
There is no evidence of mass, mass effect, or midline shift.
There are multiple foci of subcortical and periventricular
hyperintensities
on T2 and FLAIR which are nonspecific and likely represent
chronic small
vessel ischemic disease. Prominent ventricles and sulci are
associated with
age related involutional change. Major flow voids are
preserved.
The patient is status post bilateral lens replacements.
There is no abnormal enhancement after contrast administration.
IMPRESSION:
1. Multiple scattered foci of acute to early subacute infarcts
in the left
posterior and superior frontal lobe, right superior frontal
lobe, and left
parietal lobe. This pattern suggests a proximal embolic source.
2. There is no evidence of intracranial mass.
3. Possible chronic microhemorrhages in the bilateral parietal
lobes and left
posterior frontal lobe.
4. Chronic infarct in the left posterior frontal lobe. Chronic
small vessel
ischemic disease.
Transthoracic Echocardiogram ___
___ 11:18
IMPRESSION: No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septaldefect, intracardiac thrombus, or
vegetation) seen. Normal left ventricular wall thickness
andcavity size with mild regional systolic dysfunction c/w CAD
in an LAD distribution vs. Takotsubocardiomyopathy. Restrictive
filling pattern. Increased PCWP. Normal right ventricular cavity
sizeand systolic function. Mild mitral regurgitation. Mild
tricuspid regurgitation. Trace aorticregurgitation. Moderate
pulmonary artery systolic hypertension.
Brief Hospital Course:
This is a ___ year old female with a pmhx of CAD w/ cardiac cath
s/p 2 stents, NSTEMI, HTN, NIDDM who presented to the ED as a
transfer from ___ after 2 episodes of aphasia. The episodes
were transient, but on exam she was noted to have some mild
paraphasic errors. She underwent MRI revealing miniscule
punctate scattered foci of acute to early subacute infarcts in
the left posterior and superior frontal lobe, right superior
frontal lobe, and left parietal lobe. This pattern suggests a
proximal embolic source. She had a TTE revealing EF of 49% RWMA
in the LAD territory without evidence of thrombus. A1c was 5.3.
LDL was 25. TSH was less that 0.01 and T4 was 1.7. This should
be followed up. No evidence of afib on telemetry. The patient
will be discharged on ziopatch for rhythm monitoring and will be
continued on her DAPT with asa/brilinta. She will continue on
her atorvastatin.
TI
----
[] recommend repeating thyroid function studies (TSH <0.01, free
T4 1.7 on admission)
[] ziopatch
[] anemia workup
[] f/u with patient's cardiologist to review echo findings
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes
2. DVT Prophylaxis administered? (x) Yes
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes Aspirin, Brillanta
4. LDL documented? (x) Yes (LDL = 25)
5. Intensive statin therapy administered? On atorvastatin 20,
LDL 25
6. Smoking cessation counseling given? (x) non-smoker
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes
8. Assessment for rehabilitation or rehab services considered?
(x) Yes
9. Discharged on statin therapy? (x) Yes
10. Discharged on antithrombotic therapy? (x) Yes Aspirin,
Brillanta indefinitely
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) No
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. TiCAGRELOR 90 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Tolterodine 4 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. TiCAGRELOR 90 mg PO DAILY
7. Tolterodine 4 mg PO DAILY
8. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
ACUTE ISCHEMIC STROKE
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 trouble finding the
right words resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
Hyperlipidemia
Diabetes
We are changing your medications as follows:
You will continue on aspirin and brilinta (You must take them
daily!!)
You will continue on atorvastatin
You will have a ziopatch
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:
___
|
10699016-DS-10
| 10,699,016 | 22,542,301 |
DS
| 10 |
2166-04-17 00:00:00
|
2166-04-18 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with autism and
longstanding history of generalized epilepsy with history of
intubation and treatment for status epilepticus last year. She
is followed in ___ Epilepsy clinic by Dr. ___
Dr.
___. She presents after a cluster of seizures this morning,
transferred from ___.
She was in her USOH until this past month. About three weeks
ago,
she had a "super-cold" as her mother puts it. She had fevers and
sinus symptoms. She says she has been taking her baseline
allergy
medication for this (Flonase and Claritin). Her mother also
noted
some abdominal discomfort, which she was treating with Zantac
last week. Her first ?seizure was an episode with a fall last
___, unwitnessed by her mother, but causing a skinned Right
knee. Then, ___ of last week, she had several staring
spells
the mother thinks may have been seizures. ___ morning around
4:30am, she awoke with several (5?) GTC seizures, accompanied by
vomiting and diarrhea. She was BIBA to ___, where
they found WBC of 18k, ALT slight elevation (59) and AlkPhos
189.
A RUQ U/S showed gallstones (no mention of wall thickening or
not). A HIDA scan was performed, with results uncertain.
Ultimately, she underwent a laproscopic cholecystectomy the
following day (___). The procedure was per her mother
uncomplicated, and she was discharged home ___.
At home, she was walking, speaking at her baseline, and eating
"light" (consisting of mac&cheese, fries, and ice cream). No
bowel movements yet, but urinating OK and passing some flatus.
No
more vomiting and no fevers/chills/sweats. No c/o pain as far as
her mother can tell. Her behavior was normal yesterday (___) with the exception that she was a bit tired and took and
afternoon nap. She looked "fine" in the evening and played on
the
computer as usual.
Then, this morning around 12:30am (___), she awoke her
mother (sleeps in the same bed) with arm-extension up and head
turn (unclear which side, which direction) and leg stiffening
and
jerking, all of which resolved in under 15 seconds. She fell
asleep, but awoke again with a second episode around 2am, this
time with "more severe shaking" and lasting close to a minute.
Her mother gave PO clorazepate 3.75mg after the second episode.
Next, around 4am, she awoke with another one minute episode, GTC
followed by what sounds like a tonic component ("whole body
stiff, with eyes open, not breathing"), followed by return to
baseline within minutes later. Her mother repeated the 3.75mg
clorazepate PO dose and also gave 1000mg (typical dose 1750) of
Keppra. She does not use Diastat due to difficulty administering
it when pt is stiff (?). She called ___ at that point. When EMS
arrived (?5 o'clock hour), the patient seized again, for about a
minute. EMS temp was 99.2F and HR at that time was 120-130s,
sinus. She was BIBA to ___. Their workup was
unrevealing as to a medical or post-op/abdominal abnormality
that
might have triggered today's seizure cluster (see Labs/imaging,
below), so she was transferred here to ___, where she is
followed in Epilepsy clinic by Dr. ___. She arrived
in
NAD with normal VS.
Review of Systems:
<< via mother, and limited answers from pt>>
Denies pain in head, chest. Endorses pain in belly when I press
there, but otherwise not. No recent fevers/chills/sweats. No
recent change in gait or obvious limb weakness. No change in
minimal speech/language or comprehension per mother. No vomiting
or diarrhea since ___. No cough. No rash.
Past Medical History:
1. Generalized, refractory epilepsy with catamenial component
(per OMR --) Had ?staring spells at age ___, treated with Tegretol
for few years then stopped because no seizures. Had febrile
seizure age ___, untreated. Age ___ began having GTCs, associated
with menses (mid-cycle). Treated with increasing doses of
Trileptal, then Depakote, then Keppra, and then Lamictal was
added to the Keppra. No recent changes in these doses.
2. autism
3. apraxic/dyspraxic
4. seasonal allergies (on Flonase, Claritin)
Social History:
___
Family History:
- Cousins with BPD, ___ and Aspergers.
- Father had seizures (developed later in life).
- Maternal grandmother and mother had emergent cholecystectomies
in their early twenties.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.2F (99.2F at EMS ___ ; 98.6F @OSH)
HR 92 (120-130 at OSH)
BP 136/76
RR 16
SaO2 99% RA
General: Awake, cooperative, NAD. Lying in ED stretcher in
hospital johhny and fleece pants, looking around, somewhat
interactive with me and with her mother.
___ and atraumatic. Mild strabismus (Right
exotropia). ANicteric. Mucous membranes are moist. No lesions
noted in oropharynx. No sneezing or coughing or rhinorrhea
witnessed on exam.
Neck: Supple, with full range of motion, no nuchal rigidity. No
bruits. No lymphadenopathy. No goiter.
Pulmonary: Lungs CTA. Non-labored breathing.
Cardiac: RRR, normal S1/S2, no M/R/G appreciated.
Abdomen: Soft, non-tender (on repeated questioning, pt does
endorse mother's question "pain?" when I press in the RUQ, but
she does not exhibit any behavioral/emotional/objective evidence
of this otherwise), and non-distended, +normoactive bowel
sounds.
Four small, unbandaged laproscopy incisions, healing well with
no
exudate/pus/bleeding.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Awake, alert. Says something resembling "KEL - SSSEEE" after
repeated requests to state name. Whenever her mother said the
word "home," she made a high-pitched whooping noise that her
mother says means, "no" and at one point said the letters,
"CEE... VVV... ESSS." Her mother said she does not want to be
here in the hospital and would rather go shopping at ___ and
___. She says "YESSSSS" when asked if mother is her mom,
but also when asked if it is her grandma. Does not reliably
follow verbal commands. Does mimic some simple movements (raise
arms).
-Cranial Nerves:
II: PERRL, 4 to 2mm and brisk. No RAPD. Blinks to threat from
both sides, not as consistently from above or below.
III, IV, VI: Exotropic (Right out slightly) as noted previously.
EOMs full and conjugate; no nystagmus. No saccadic intrusions.
V: Facial sensation intact to pinprick bilaterally (grimaces).
Eyelash-blink reflex intact bilaterally.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Eye closure (resisting
exam) is strong and symmetric.
VIII: Hearing grossly intact.
IX, X: Palate elevates symmetrically with phonation.
XI: cannot assess.
XII: Tongue protrusion is midline.
-Motor:
Spontaneous trunk/neck/arm/hand/leg movements appear grossly
normal and symmetric. Lifts and holds arms against gravity, also
legs, with no apparent assymetry. Tone is normal/loose in all
extremities, with the exception of Right leg, which she hold in
extension unless repeatedly moved and asked to relax, at which
time tone becomes normal. No spasticity. No tremor. No gross
asterixis.
-Sensory:
Grimaces/yelps to mild pinprick in both hands and both feet
(pulls covers over legs to stop exam).
-Reflexes (left; right): diffusely and symmetrically brisk
Pec/delt (+++;+++)
Biceps (+++;+++)
Triceps (++;++) brisk bilaterally
Brachioradialis (+++;+++)
Quadriceps / patellar (+++;+++) w/crossed adductors, more L->R
Gastroc-soleus / achilles (+++;+++) no clonus
Plantar response was flexor on the Left vs. ?extensor (with
tickle response) on the RIGHT.
-Coordination:
No gross titubation or dysmetria was apparent.
-Gait: deferred.
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, NAD.
___ and atraumatic. Mild strabismus (Right
exotropia). Mucous membranes are moist. No lesions noted in
oropharynx.
Neck: Supple, with full range of motion, no nuchal rigidity. No
bruits. No lymphadenopathy. No goiter.
Pulmonary: Lungs CTA. Non-labored breathing.
Cardiac: RRR, normal S1/S2, no M/R/G appreciated.
Abdomen: Soft, non-tender and non-distended, +normoactive bowel
sounds.
Four small, unbandaged laproscopy incisions, healing well with
no exudate/pus/bleeding.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Awake, alert. Whenever her mother said the word "home," she made
a high-pitched whooping Does not reliably follow verbal
commands. Does mimic some simple movements (raise arms).
-Cranial Nerves:
II: PERRL, 4 to 2mm and brisk. No RAPD. Blinks to threat from
both sides, not as consistently from above or below.
III, IV, VI: Exotropic (Right out slightly) as noted previously.
EOMs full and conjugate; no nystagmus. No saccadic intrusions.
V: Facial sensation intact to pinprick bilaterally (grimaces).
Eyelash-blink reflex intact bilaterally.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Eye closure (resisting
exam) is strong and symmetric.
VIII: Hearing grossly intact.
IX, X: Palate elevates symmetrically with phonation.
XI: cannot assess.
XII: Tongue protrusion is midline.
-Motor:
Spontaneous trunk/neck/arm/hand/leg movements appear grossly
normal and symmetric. Lifts and holds arms against gravity, also
legs, with no apparent assymetry. Tone is normal/loose in all
extremities, with the exception of Right leg, which she hold in
extension unless repeatedly moved and asked to relax, at which
time tone becomes normal. No spasticity. No tremor. No gross
asterixis.
-Sensory:
Laughs to tickle on feet and hands.
-Reflexes: Symmetrically brisk throughout
-Coordination:
No dysmetria was apparent.
-Gait: deferred.
Pertinent Results:
ADMISSION LABS:
___ 12:40PM BLOOD WBC-6.5 RBC-4.01* Hgb-12.1 Hct-37.8#
MCV-94 MCH-30.1 MCHC-32.0 RDW-11.9 Plt ___
___ 12:40PM BLOOD Neuts-54.7 ___ Monos-3.8 Eos-2.0
Baso-1.1
___ 12:40PM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-141 K-3.7
Cl-105 HCO3-25 AnGap-15
___ 12:40PM BLOOD ALT-40 AST-28 AlkPhos-163* TotBili-0.4
___ 12:40PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
___ 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:52PM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 08:00PM BLOOD WBC-8.4 RBC-4.02* Hgb-12.1 Hct-38.2
MCV-95 MCH-30.1 MCHC-31.7 RDW-12.0 Plt ___
___ 08:00PM BLOOD Glucose-118* UreaN-13 Creat-0.8 Na-142
K-3.7 Cl-105 HCO3-28 AnGap-13
___ 08:00PM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
REPORTS:
EEG ___: IMPRESSION: This is an abnormal video EEG due to the
presence of four electrographic seizures that began with low
amplitude rhythmic 3 Hz
delta frequency activity in the bilateral frontal regions that
evolved
into high amplitude discharges, lasting between 35 seconds to a
minute
in duration. One of the seizures had a slight left frontal lead
at
onset, suggesting that the left frontal region may have been the
seizure
onset zone. Three of the four seizures occurred during sleep and
had no
clear clinical change, but one occurred while she was awake and
the
patient appeared to have behavior arrest, staring, followed by
downward
gaze. Frequent interictal epileptiform discharges were seen with
a
generalized distribution but a frontal predominance. These
discharges
ocurred frequently at ___ Hz and range from two to eight minutes
in
duration. At other times, low amplitude rhythmic bifrontal ___
Hz
activity could be seen as well without any associated clinical
change.
Overall, these findings indicate a possible frontal seizure
focus, and
the left frontal lead suggests a possible left frontal seizure
focus.
The waking background was slow and disorganized at 5.5 Hz
indicative of
a diffuse encephalopathy.
CXR ___: IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ is a ___ F with autism (dyspraxia/dysarthria)
and catamenial epilepsy who p/w a seizure cluster in the setting
of being post-op from a cholecystectomy.
.
# NEURO: patient was put on LTM, and her EEGs showed many
subclinical seizures. We increased lamictal to 150mg BID (from
150/100mg BID). We checked a lamictal level prior to increasing
the dose. The pt will then have a level checked 1 week from
discharge on the higher medication dose, with the plan to
possibly increase it further if tolerated, depending on
follow-up ambulatory EEG findings. She was continued on her
home dose of keppra 1750mg BID.
.
# CARDS: patient was put on telemetry while here, with no noted
events.
.
# ID: patient's WBC remained WNL and she remained afebrile. Her
CCY site remained clean without exudates or erythema.
.
# CODE/CONTACT: Presumed Full; Mother (___) -
___
PENDING LABS:
Lamictal level
TRANSITIONAL CARE ISSUES:
Patient will need her lamictal level checked 1 week from
discharge to ensure that her level is appropriate on her higher
medication dosing.
Medications on Admission:
1. levetiracitam 1750mg q7am/7pm
2. lamotragine 150/100mg q7am/7pm
3. clorazepate 3.75mg PRN for seizures/clusters
4. Diastat (pt's mother says generally can't use ___ stiff)
5. progesterone cream daily
6. OCP - Triavora(28) daily
7. multivitamin qhs
8. Claritin 10mg qhs
9. Flonase i.n. bid
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levetiracetam 500 mg Tablet Sig: 3.5 Tablets PO BID (2 times
a day).
3. Trivora (28) 50-30 (6)/75-40 (5)/125-30(10) Tablet Sig: One
(1) Tablet PO daily ().
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
5. progesterone (bulk) Miscellaneous
6. clorazepate dipotassium 3.75 mg Tablet Sig: One (1) Tablet PO
once a day as needed for seizure.
7. Diastat 2.5 mg Kit Sig: One (1) dose Rectal once a day as
needed for seizure.
8. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lamictal 25 mg Tablet Sig: Two (2) Tablet PO twice a day:
Total daily dose is 150mg BID;
NO SUBSTITUTIONS.
Disp:*120 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please check a lamictal level on ___ and call the result in to
Dr. ___ at ___.
11. Lamictal 100 mg Tablet Sig: One (1) Tablet PO twice a day:
total daily dose is 150mg BID; NO SUBSTITUTIONS.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for seizures.
We made the following changes to your medications:
1) We INCREASED your LAMICTAL to 150mg twice a day
You will need to get your lamictal level checked 7 days from
discharge. You were sent home with an Rx to get this drawn.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Please follow all of your previously given seizure safety
guidelines.
Followup Instructions:
___
|
10699166-DS-2
| 10,699,166 | 22,785,442 |
DS
| 2 |
2167-08-23 00:00:00
|
2167-08-24 04:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cavotricuspid isthmus ablation
History of Present Illness:
Mr. ___ is a pleasant ___ y/o man with PMH notable for HTN on
losartan presenting as referral from urgent care with two weeks
of shortness of breath.
Per patient, he was in his usual state of health, without any
limitations in his activity, until about 2 weeks ago. At that
point, he began having increasing cough with clear production of
sputum. He denies any fevers or chills, but states that this was
quite bothersome. Over the period of about a week, his cough
improved, but his shortness of breath worsened. He was having
increasing difficulty walking around. He denies orthopnea,
states
he sleeps on 2 pillows at baseline, but has had several episodes
of PND. He has increased ___ swelling, which is new. Endorses
some
weight gain but no specific abdominal fullness or decreased
appetite. Denies any palpitations or chest pain/pressure. Denies
N/V, abdominal discomfort. Has had some difficulty urinating in
the setting of scrotal edema.
On day of presentation, he initially went to urgent care, where
he was found to have pulmonary edema on CXR with O2 sat in low
___ and with HR at 150, regular in possible aflutter. As such,
he
was transferred to ___ for further care.
In the ED, cardiology was consulted for assistance in management
of possible CHF and atrial arrhythmia. He was given 40mg IV
Lasix. ED course is notable for stable vitals (BP
110-150's/80-90s), HR at 150, and O2 sat 95% on 2L. Initial
rhythm consistent with 2:1 aflutter vs. atach. He was given 5mg
metoprolol IV boluses x3 followed by diltiazem 10mg IV x1 with
improvement in HR to 70-90's (AFl with variable block).
He was started on diltiazem PO 30mg TID but continued to require
boluses of 5mg IV diltiazem approximately 1x/hour to rate
control.
On the floor, patient states he feels fine. Denies any chest
pain, palpitations, shortness of breath at rest.
Past Medical History:
-R inguinal hernia
-HTN
Social History:
___
Family History:
Denies any significant history of cardiac disease, arrhythmias,
or cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: HR 140s, BP 115/80, RR 20, O2 Sat 96% 2L
HEENT: NC/AT, EOMI, PERRL, MMM
NECK: supple, symmetric, JVP ~15cmH2O
HEART: rapid rate, regular rhythm with occasional irregular
beats, normal S1, S2; no m/r/g
LUNGS: good air movement with decreased sounds in lung bases
bilaterally, no significant crackles
ABD: Distended, non-rigid, NTTP, no r/g, BS+
EXTR: WWP, +1 pitting edema to shins bilaterally
NEURO: alert, appropriately interactive on exam; no focal
deficits
SKIN: intact, warm, dry
PULSES: distal pulses and radial pulses symmetric, 2+ intact
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 723)
Temp: 98.1 (Tm 100.2), BP: 123/86 (108-132/61-86), HR: 92
(62-120), RR: 20 (___), O2 sat: 91% (91-94), O2 delivery: Ra,
Wt: 216.6 lb/98.25 kg
Fluid Balance (last updated ___ @ 723)
Last 8 hours Total cumulative -900ml
IN: Total 0ml
OUT: Total 900ml, Urine Amt 900ml
Last 24 hours Total cumulative -760ml
IN: Total 640ml, PO Amt 640ml
OUT: Total 1400ml, Urine Amt 1400ml
GENERAL: Elderly white man lying in bed wearing BiPAP mask.
Appears comfortable.
HEENT: Normocephalic, atraumatic. Sclera anicteric.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Crackles at left lung
base, decreased breath sounds at right lung base.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. 2+ pitting edema to the knees
bilaterally
NEURO: awake, alert, grossly oriented
Pertinent Results:
ADMISSION LABS:
===============
___ 10:25AM BLOOD WBC-13.4* RBC-4.22* Hgb-13.1* Hct-40.8
MCV-97 MCH-31.0 MCHC-32.1 RDW-12.8 RDWSD-44.8 Plt ___
___ 11:50AM BLOOD WBC-14.6* RBC-4.21* Hgb-12.9* Hct-39.8*
MCV-95 MCH-30.6 MCHC-32.4 RDW-13.0 RDWSD-43.8 Plt ___
___ 10:25AM BLOOD Neuts-85.2* Lymphs-6.1* Monos-7.1
Eos-0.2* Baso-0.3 Im ___ AbsNeut-11.40* AbsLymp-0.81*
AbsMono-0.95* AbsEos-0.03* AbsBaso-0.04
___ 10:25AM BLOOD ___ PTT-30.8 ___
___ 10:25AM BLOOD Plt ___
___ 10:25AM BLOOD Glucose-169* UreaN-18 Creat-0.9 Na-144
K-4.6 Cl-101 HCO3-31 AnGap-12
___ 11:50AM BLOOD Glucose-137* UreaN-20 Creat-0.7 Na-147
K-4.7 Cl-103 HCO3-32 AnGap-12
___ 10:25AM BLOOD LD(LDH)-231
___ 10:25AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD proBNP-1421*
___ 11:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
___ 06:51PM BLOOD TotProt-7.0 Calcium-9.0 Phos-4.7* Mg-2.2
Iron-58
___ 06:51PM BLOOD calTIBC-251* Ferritn-341 TRF-193*
___ 06:51PM BLOOD TSH-0.96
___ 06:51PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:51PM BLOOD ___
___ 06:51PM BLOOD PEP-NO SPECIFI FreeKap-69.0* FreeLam-18.8
Fr K/L-3.67* IgG-1234 IgA-516* IgM-102 IFE-NO MONOCLO
___ 06:51PM BLOOD HCV Ab-NEG
___ 11:23AM BLOOD Lactate-2.1*
DISCHARGE LABS:
================
___ 08:08AM BLOOD WBC-9.8 RBC-4.16* Hgb-12.8* Hct-40.3
MCV-97 MCH-30.8 MCHC-31.8* RDW-13.4 RDWSD-46.5* Plt ___
___ 04:20AM BLOOD Neuts-79.8* Lymphs-8.6* Monos-10.0
Eos-0.6* Baso-0.2 Im ___ AbsNeut-9.60* AbsLymp-1.04*
AbsMono-1.21* AbsEos-0.07 AbsBaso-0.03
___ 08:08AM BLOOD Plt ___
___ 08:08AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-140
K-4.5 Cl-94* HCO3-39* AnGap-7*
___ 08:08AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
IMAGING:
========
___ Imaging CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Right lower lobe consolidation suggestive of pneumonia.
Additional areas of ground-glass opacification in bilateral
lower lobes may represent additional sites of infection.
3. Ectatic ascending thoracic aorta measuring up to 4.4 cm.
4. Small to moderate bilateral pleural effusions.
5. Enlarged main pulmonary artery, which can be seen with
pulmonary artery
hypertension.
___ Cardiovascular Transthoracic Echo Report
Globally preserved biventricular systolic function in the
setting of hypokinesis of (at least) the distal septum. Mildly
dilated right ventricle with preserved systolic function.
Increased left ventricular filling pressure. Mildly dilated
ascending aorta. Mild mitral and tricuspid regurgitation.
Borderline hypertension.
___ Cardiovascular Transesophageal Echo Final Report
No spontaneous echo contrast or thrombus in the left atrium/left
atrial appendage/right atrium/right atrial appendage. TEE
complication - hypoxia post procedure from upper airway
obstruction. Anesthesia came to bedside after the procedure with
plan for DCCV instead of cavotricuspid isthmus ablation.
___ Cardiovascular EP Procedure Report
Successful cardioversion from atrial flutter to sinus rhythm
Microbiology Results(last 7 days) ___
__________________________________________________________
___ 8:08 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:36 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 11:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with ___ notable for HTN on losartan
presenting as referral from urgent care with shortness of breath
suggestive of new CHF exacerbation in setting of newly diagnosed
atrial flutter resolved with DCCV. His hospital course was
complicated by airway obstruction and desaturations during a
conscious sedation TEE. He was then transferred to the CCU for
BiPAP now s/p ablation, currently in sinus rhythm.
#CORONARIES: unknown
#PUMP: LVEF 60% (TTE ___
#RHYTHM: Atrial slutter s/p CTI ablation normal sinus rhyhtm
ACUTE ISSUES:
=============
#Atrial flutter:
#Atrial fibrillation
The patient was diagnosed with new onset atrial flutter on this
admission with 2:1 conduction and ventricular rates of 150s. In
the ED, he was given pushes of IV Diltiazem followed by doses of
PO Diltiazem with a short period of 4:1 conduction, however he
quickly reverted to 2:1 block at rates of 150. EP was consulted
and given that his EKG appeared to be typical cavotricuspid
isthmus dependent, he was taken for an Atrial Flutter ablation.
This procedure was successful and his repeat EKGs showed sinus
rhythm. A TEE was done prior to this procedure which showed no
left atrial clot. On the day of discharge, the patient converted
to atrial fibrillation with rates in the low 100s. He was
started on Amiodarone 400mg PO BID for one week, followed by
200mg PO BID for 11 days to complete a 10g load at which point
he will change to 200mg PO daily. His metoprolol was increased
to 75mg PO daily, and he will follow up in ___ clinic.
#New HF exacerbation:
The patient has no history of heart failure, and his volume
overload was likely secondary to new atrial flutter. TTE showed
preserved ejection fraction, and heart failure workup was
negative apart from elevation of Free Kappa and IGA. UPEP
unremarkable. Low suspicion for clonal plasma cell disorder but
this should be followed up by primary care with a possible
referral to Heme/Onc.
#CAP, s/p Abx:
The patient was also thought to have a pneumonia on presentation
given shortness of breath and a consolidation on CXR.
CTX/azithro was completed for a 5 day course from ___ to ___.
He remained slightly hypoxic during night time, and likely has
some degree of sleep apnea. He should have a referral for a
sleep study as an outpatient.
#HTN: Continued on home losartan 50mg QD
TRANSITIONAL ISSUES:
=====================
[] The patient should have a Hep B vaccine: HBsAb negative
[] Please follow up the patient's final SPEP/UPEP and M spike
labs: Refer to Heme/Onc if concern for monoclonal gammopathy
[] Repeat EKG at first follow up
[] Please refer for outpatient sleep study for concern for
obstructive sleep apnea
[] Please continue anticoagulation indefinitely with no changes
until follow up with EP
[] Amiodarone load: 400mg PO BID for 7 days, 200mg PO BID for 11
days, 200mg PO daily ongoing thereafter
#CONTACT/HCP: ___ (wife) ___
#CODE: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
RX *amiodarone 200 mg 2 tablet(s) by mouth Twice daily Disp #*28
Tablet Refills:*0
2. Amiodarone 200 mg PO BID Duration: 11 Days
Please start after you have taken 400mg by mouth twice daily for
one week
RX *amiodarone 200 mg 1 tablet(s) by mouth Twice daily Disp #*22
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
Please take 200mg by mouth daily when you are finished with your
11 days of 200mg twice daily (___)
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*0
5. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*0
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- atrial flutter with 2:1 AV nodal block
- atrial fibrillation
SECONDARY DIAGNOSIS:
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because:
- You were found to have a fast irregular heart beat (atrial
flutter)
While you were here:
- You were given medications to slow down your heart rate
- Your heart beat remained fast and irregular despite these
medications
- You were seen by out heart rhythm specialists
(electrophysiologists)
- They recommended a procedure called an ablation where they fix
this irregular rhythm
- You were taken for this procedure and it was successful
- Your heart went back into an abnormal rhythm (atrial
fibrillation)
When you leave:
- Please take all of your medications as prescribed
- Please go to all of your follow up appointments as arranged
for you
- Please return to the ED if you develop any rapid heart rates,
chest pain, dizziness or lightheadedness
It was a pleasure to care for you during your hospitalization!
- Your ___ care team
Followup Instructions:
___
|
10699300-DS-3
| 10,699,300 | 29,573,602 |
DS
| 3 |
2152-04-14 00:00:00
|
2152-04-14 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / valproic acid
Attending: ___.
Chief Complaint:
facial droop
Major Surgical or Invasive Procedure:
TPA at outside hospital
History of Present Illness:
Ms. ___ is a ___ woman with a
complex PMHx including NIDDM, bipolar disorder, HL, HTN,
hypothyroidism, osteonecrosis of right knee who presents today
after having gone to an OSH with acute onset of aphasia and
right-sided weakness and transferred to ___ ED for post-tPA
care. She had been in her USOH until the day of presentation
when she had eaten lunch at her assisted living facility and
appeared to be at her baseline when she returned to her room.
However, when she emerged from her room at approximately 1:30pm
today, she was noted to have drooling, appeared confused, was
unable to say her RN's name and then was completely mute per RN
report from assisted living facility. Per ED notes, a right
facial droop was also noted. This part of the history is
somewhat unclear, as no one who witnessed this is available to
discuss this with. It is unclear if 1:30pm is the time she
presented with symptoms or the time she was last seen well.
Concerned, she was taken to an OSH ED (___) for urgent
evaluation.
Upon arrival, her vital signs were all within normal
limits.
Her ___ stroke scale was scored at 13
(0/1/0/0/0/1/1/1/3/3/0/0/1/1/1, especially significant for
reported b/l ___ plegia). She underwent three NCHCTs that were
read as negative. Of note, she required significant sedation
(haldol, ativan, ketamine) in order to obtain the CTs.
Telestroke was called and an NIHSS of 15 (unknown breakdown) was
scored and tPA was given at 1620. She was then transferred to
the ___ ED for further management post-tPA. Upon arrival, a
code STROKE was called and neurology was invited to urgently
consult.
Past Medical History:
Past Medical History:
1. NIDDM
2. bipolar d/o
3. GERD
4. hypothyroidism
5. HL
6. chronic renal insufficiency
7. osteonecrosis of right knee
Past Surgical History
1. ?oopherectomy
Social History:
___
Family History:
no strokes, father died at ___ of MI. older
brother s/p quadruple bypass at 57. No neurological disorders
in
family.
Physical Exam:
At admission:
VS: 96.3 112 110/63 20 100% 2L Nasal Cannula
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: soft, obese, NTND, NABS, unclear if ascites present on
examination. +well healed scar in RUQ
Ext: 2+ pitting edema bilaterally to knees
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect for most part, though would get agitated at times during
examination. Oriented to person, place, and date (month =
___). Somewhat inattentive during examination, with having
to repeat simple one-step commands several times. Speech very
dysarthric, but fluent with normal comprehension and repetition,
but does have times when she is fluently aphasic, with
non-sensical speech and with abnormal content of speech (talking
about events from ___ years ago); +perseveration. naming intact.
Reading intact. No evidence of apraxia or neglect.
Cranial Nerves: Pupils equally round but minimally reactive to
light, 2mm bilaterally. Unable to assess visual fields fully,
but
generally seem to be intact. Extraocular movements intact
bilaterally, but with sustained left-beating nystagmus on left
gaze. Sensation intact V1-V3. Facial movement symmetric. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift.
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch and pinprick throughout. No
extinction to DSS.
Reflexes: 2+ on right UE and 1+ on left UE. UTO on b/l patellar
or achilles. Upgoing toes b/l.
Coordination: finger-nose-finger normal without dysmetria or
termor.
Gait: deferred.
At discharge:
No deficits
Pertinent Results:
___ 06:40PM WBC-8.3 RBC-3.14* HGB-9.2* HCT-28.0* MCV-89
MCH-29.4 MCHC-33.0 RDW-15.1
___ 06:40PM PLT COUNT-317
___ 06:40PM ___ PTT-19.8* ___
___ 06:40PM CREAT-1.4*
___ 06:40PM UREA N-44*
___ 07:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 07:10PM URINE COLOR-Straw APPEAR-Clear SP ___
ECG:
Sinus tachycardia. Normal tracing. No previous tracing available
for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 184 90 322/409 57 -5 42
MRI Brain - limited study:
IMPRESSION: Limited study. The resolution oN DWI is somewhat
suboptimal. No
alrge area of decreased diffusion is noted. Slightly increased
increased DWI signal in the left aprietal lobe is liekly
artifactual. Consider complete study when appropriate.
Chest Xray - 1 view:
IMPRESSION:
Widened mediastinum of unknown chronicity, possibly due to
lymphadenopathy. No hilar lymphadenopathy identified. A chest
CT would be definitive in establishing the cause of this
abnormality.
Electroencephalogram:
IMPRESSION: This EEG done portably is considered borderline
normal.
There is a small amount of theta slowing which could represent
either
excessive drowsiness or medication effect or part of a mild
encephalopathy. There were no clear epileptiform features and,
while
there were some subtle asymmetries suggesting slightly greater
theta
slowing in the right hemisphere, it was not very prominently
noted.
Brief Hospital Course:
___ woman with a complex PMHx including NIDDM, bipolar
disorder, HL, HTN, hypothyroidism, osteonecrosis of right knee
who presented after having gone to an OSH with acute onset of
apparent confusion/aphasia with right facial droop and drooling
and possible right-sided weakness and transferred to ___ ED on
___ for post-tPA care and latterly admitted to the ICU for
monitoring. The telestroke scoring does mentioned NIHSS of 15
and was given IV tPA - however, there was bilateral arm and leg
weakness noted on the telestroke examination which may be more
suggestive of weakness in the post-ictal phase after a seizure.
On examination on ___ she had no obvious deficits and instead
was felt to be manic, hallucinating with pressured speech,
flight of ideas and very tangential. Her lithium and risperidone
were continued at her home doses. Repeat CT scans requiring
significant sedation were unrevealing. Due to her agitation, the
only MRI sequence that could be obtained was the restricted
diffusion sequence. There was no area of diffusion restriction
to indicate a stroke(an area posteriorly on left is likely
artifactual) or obvious hemorrhage. She underwent a routine EEG,
which did not show any seizures or epileptiform abnormalities.
She remained clinically stable. All her home medications were
continued.
Her transient aphasia and right sided facial droop may have been
the result of a transient ischemic attack. She was diagnosed
with a TIA. It is also possible that her psychiatric disorder
may have played a role in her presentation. She remained
clinically stable and her mood returned to baseline as well. She
was transferred to the floor ___. Physical therapy saw and
evaluated her and recommended that she be sent back to her home
without need for acute rehabilitation.
.
Code Status: DNR/DNI -- confirmed by accompanying paperwork and
mother ___: ___
.
===============================
Medications on Admission:
1. Crestor 40 mg Tab Oral 1 Tablet(s) , at bedtime
2. Lisinopril 10 mg Tab Oral 1 Tablet(s) , at bedtime
3. Risperdal 4 mg Tab Oral 1 Tablet(s) , at bedtime
4. senna 8.6 mg Cap Oral 1 Capsule(s) , at bedtime
5. trazodone 100 mg Tab Oral 2 Tablet(s) , at bedtime
6. Synthroid ___ mcg Tab Oral 1 Tablet(s) Once Daily
7. Miralax 17 gram/dose Oral Powder Oral 1 Powder(s) Once Daily
8. Claritin 10 mg Tab Oral 1 Tablet(s) Once Daily
9. Byetta 10 mcg/0.04 mL per dose Sub-Q Pen Injector
Subcutaneous
10. Lantus 100 unit/mL Sub-Q Subcutaneous 50 Solution(s) Twice
Daily
11. Humalog 100 unit/mL SubQ Cartridge Subcutaneous sliding
scale Cartridge(s) Four times daily
12. ___ Aspirin 325 mg Tab Oral 1 Tablet(s) Once Daily
13. omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
14. Neurontin 100 mg Cap Oral 1 Capsule(s) Once Daily
15. lithium carbonate 300 mg Tab Oral 1 Tablet(s) Twice Daily
16. Lovaza 1 gram Cap Oral 2 Capsule(s) Twice Daily
17. Lasix 40mg qDay
18. procrit (epogen) 40,000 units q2weeks last received on
___. vicodin 7.5/500 BID
20. cogentin (bentropine) 2mg PO BID
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H PRN ()
as needed for pain.
5. omega-3 fatty acids Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
6. benztropine 1 mg Tablet Sig: Two (2) Tablet PO once a day.
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily).
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
13. trazodone 100 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) pen
Subcutaneous once a day.
16. Lantus 100 unit/mL Solution Sig: see below units
Subcutaneous twice a day: 50 unit twice daily.
17. Humalog 100 unit/mL Solution Sig: see below unit
Subcutaneous four times a day: sliding scale insulin based on ___
qid.
18. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Epogen 20,000 unit/mL Solution Sig: Two (2) ml Injection
q2weeks: last dose ___.
20. Vicodin ___ mg Tablet Sig: One (1) Tablet PO twice a day.
21. lithium carbonate 150 mg Capsule Sig: ___ Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
transient neurological event
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: no deficits
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay. You were
transferred to ___ from ___ for concern of stroke.
You received TPA at ___ for suspected stroke. Upon
arrival to ___, we found no evidence of stroke on your exam.
You had a limited MRI scan of your brain done that showed no
strokes.
Please resume taking all your home medications.
Followup Instructions:
___
|
10699336-DS-7
| 10,699,336 | 25,777,608 |
DS
| 7 |
2158-04-17 00:00:00
|
2158-04-17 09:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Bactrim
Attending: ___
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
___ C3-T4 posterior fusion
___ Percutaneous tracheostomy
___ PEG
___ craniotomy for ___ evacuation
History of Present Illness:
___ presenting after MCC. Patient was found in the median of the
highway. No skid marks. Patient lost pulses on scene, received
chest compressions by police with ROSC. EMS was unable to
intubate on scene and placed ___ LT. Transported by Medflight
to ___. While en route, patient became agitated and self
extubated. Another attempt at intubation was unsuccessful and a
second ___ LT was placed. ROSC was obtained. While in the ED,
intubation was attempted but unsuccessful and cricothyrotomy was
performed. Bilateral chest tubes were placed with return of
blood. Patient was hypotensive with negative FAST exam x 3.
Received 3U PRBCs, 1U FFP and was admitted to the TICU
Past Medical History:
PMH: Hypertension, Bipolar Disorder
PSH: Unknown. Has midline and left inguinal surgical scars
Social History:
___
Family History:
NC
Physical Exam:
Discharge PE:
Gen: NAD, lying comfortably in bed; not moving any extremities
CV: rrr, no m/r/g
P: on trach vent, mostly volume control, but intermittently on
pressure support, bilateral chest rise; trachea midline
Abd: soft, NT, ND; G-tube without any surrounding erythema or
tenderness or drainage around the tube
Ext: WWP, some edema; residual faint rash over distal shins
bilaterally, groin bilaterally, axilla bilaterally; pneumoboots
on
TLD: tracheostomy, G-tube
Pertinent Results:
LABS:
============
___ 04:50PM BLOOD WBC-17.2* RBC-4.62 Hgb-13.2* Hct-43.6
MCV-94 MCH-28.6 MCHC-30.3* RDW-16.0* RDWSD-55.8* Plt ___
___ 02:26AM BLOOD WBC-20.4* RBC-4.10* Hgb-12.0* Hct-38.3*
MCV-93 MCH-29.3 MCHC-31.3* RDW-16.7* RDWSD-57.1* Plt ___
___ 07:56PM BLOOD WBC-12.7* RBC-3.18* Hgb-9.3* Hct-29.3*
MCV-92 MCH-29.2 MCHC-31.7* RDW-15.9* RDWSD-52.6* Plt ___
___ 02:21AM BLOOD WBC-8.7 RBC-2.31* Hgb-6.7* Hct-21.2*
MCV-92 MCH-29.0 MCHC-31.6* RDW-16.3* RDWSD-53.1* Plt ___
___ 01:16AM BLOOD WBC-15.8* RBC-3.01* Hgb-8.3* Hct-28.1*
MCV-93 MCH-27.6 MCHC-29.5* RDW-17.5* RDWSD-59.8* Plt ___
___ 01:25AM BLOOD WBC-9.6 RBC-3.08* Hgb-8.5* Hct-27.7*
MCV-90 MCH-27.6 MCHC-30.7* RDW-19.5* RDWSD-62.3* Plt ___
___ 02:26AM BLOOD WBC-8.6 RBC-2.54* Hgb-6.9* Hct-23.4*
MCV-92 MCH-27.2 MCHC-29.5* RDW-19.3* RDWSD-64.6* Plt Ct-81*
___ 04:50PM BLOOD ___ PTT-23.2* ___
___ 01:25AM BLOOD ___
___ 01:54AM BLOOD ___ PTT-36.1 ___
___ 04:50PM BLOOD UreaN-20 Creat-1.3*
___ 01:56PM BLOOD Glucose-135* UreaN-26* Creat-0.6 Na-147*
K-3.9 Cl-113* HCO3-27 AnGap-11
___ 01:30AM BLOOD UreaN-57* Creat-1.8* Na-138 K-4.7 Cl-99
HCO3-25 AnGap-19
___ 02:14AM BLOOD Glucose-103* UreaN-99* Creat-3.1* Na-138
K-5.0 Cl-99 HCO3-24 AnGap-20
___ 02:04AM BLOOD Glucose-114* UreaN-116* Creat-3.3* Na-136
K-4.9 Cl-97 HCO3-26 AnGap-18
___ 02:08AM BLOOD Glucose-100 UreaN-112* Creat-3.0* Na-142
K-4.8 Cl-102 HCO3-26 AnGap-19
___ 06:30PM BLOOD Glucose-110* UreaN-114* Creat-2.2* Na-143
K-3.6 Cl-103 HCO3-30 AnGap-14
___ 02:26AM BLOOD Glucose-89 UreaN-97* Creat-1.6* Na-141
K-4.0 Cl-102 HCO3-25 AnGap-18
___ 09:42PM BLOOD cTropnT-<0.01
___ 03:18AM BLOOD cTropnT-<0.01
___ 09:32PM BLOOD cTropnT-<0.01
___ 06:17AM BLOOD cTropnT-<0.01
___ 02:31AM BLOOD ALT-34 AST-116* AlkPhos-41 TotBili-0.9
___ 04:04AM BLOOD Amkacin-6.6*
___ 02:52PM BLOOD Amkacin-36.7*
___ 05:53PM BLOOD Amkacin-34.5*
MICROBIOLOGY
============
___ 6:46 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
___ 8:30 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~6OOO/ML Commensal Respiratory Flora.
___ 8:14 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
NOCARDIA ASTEROIDES COMPLEX . 10,000-100,000
ORGANISMS/ML..
THIN BRANCHING GRAM POSITIVE ROD(S).
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
___ 10:03 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
NOCARDIA ASTEROIDES COMPLEX . 10,000-100,000
ORGANISMS/ML..
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
SALMONELLA TYPHIMURIUM. ~5000/ML.
IDENTIFICATION PERFORMED BY ___ LABORATORY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SALMONELLA TYPHIMURIUM
|
AMPICILLIN------------ <=2 S
CEFTRIAXONE----------- <=1 S
LEVOFLOXACIN---------- 1 I
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:45 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
NOCARDIA ASTEROIDES COMPLEX . 10,000-100,000
ORGANISMS/ML..
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
___ 8:56 am BLOOD CULTURE RIGHT PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:16 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 12:04 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
SPECIMEN UNACCEPTABLE FOR ANAEROBES.
Test performed only on suprapubic and kidney aspirates
received in a
syringe.
FUNGAL CULTURE (Final ___: NO YEAST ISOLATED.
RADIOLOGY
=========
TRAUMA #2 (AP CXR & PELVIS PORT) Study Date of ___ 4:48
___
1. Tracheostomy tube and bilateral chest tubes in standard
positions.
2. Low lung volumes with mild pulmonary edema and bibasilar
airspace
opacities, potentially atelectasis but contusion is not
excluded.
3. Probable small bilateral pneumothoraces.
4. Widening of the superior mediastinum for which chest CT is
recommended.
5. No acute fracture or dislocation within the pelvis.
6. Multiple bilateral rib fractures.
7. Findings suspicious for fracture of the T3 vertebral body.
CT C-SPINE W/O CONTRAST Study Date of ___ 5:21 ___
1. Severely comminuted fracture-dislocation of C5 and C6
vertebral bodies with involvement of the transverse foramina of
C5 and C6. CTA of the head and neck has been obtained to assess
for vertebral artery injury.
2. Bone fragments in the spinal canal at C5-6.
3. Extensive prevertebral hematoma extending into the upper
mediastinum.
More focal hematoma noted adjacent to the right lateral
esophagus.
4. Fracture of the spinous process of C4 and of the right first
and second ribs medially.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
5:22 ___
1. Multiple comminuted right-sided rib fractures as noted above
including segmental fractures of the ___ ribs on the right.
Left ___ rib fractures.
2. Fracture through the inferior aspect of the T3 vertebral
body surfacing at the inferior endplate. This represents an
unstable 2 column injury.
3. Bilateral hemopneumothoraces, right greater than left.
4. Opacities of the posterior aspects of the lower lobes
bilaterally, right greater than left, likely combination of
atelectasis and contusion.
5. Bilateral chest tubes appear to be close to or in the
mediastinum, with the right chest tube kinked and abutting the
right atrium.
6. Moderate right paraesophageal hematoma.
7. No evidence of aortic injury or solid organ injury in the
abdomen or
pelvis.
8. Right T7 transverse process fracture.
CTA HEAD W&W/O C & RECONS Study Date of ___ 6:21 ___
1. Traumatic injury to the vertebral arteries with occlusion of
the right
vertebral artery from C4-C7 and occlusion of the left vertebral
artery from C2 to just distal to its origin with short segments
of reconstitution.
2. Focus of contrast in the right temporal convexity, which may
represent
arterial extravasation or a pseudoaneurysm.
3. Slight interval increase in the size of an acute right
hemispheric subdural hematoma with unchanged right to left
midline shift and effacement of the basal cisterns.
4. Unchanged, comminuted fracture dislocation of C5-C6, spinous
fracture of C4, nondisplaced fractures of the right zygomatic
arch and right lateral orbital wall, and fracture of T3.
5. Right supraclavicular and prevertebral/paraesophageal
hematomas.
6. Multiple right-sided rib fractures with small bilateral
hemopneumothoraces.
7. Peribronchovascular solid and ground-glass nodules in the
left upper lobe, which may represent aspiration or pulmonary
contusions.
CT HEAD W/O CONTRAST Study Date of ___ 6:19 AM
1. Relatively stable right-sided subdural hematoma, resulting in
cerebral
hemispheric sulcal effacement and 4 mm leftward shift of midline
structures, which appears improved since prior.
2. Persistent effacement of the suprasellar cistern, indicative
of uncal
herniation.
3. Subtle hyperdensities in the left temporal lobe likely
reflects
subarachnoid blood with probable left inferior frontal
parenchymal hemorrhagic contusion.
CT T-SPINE W/O CONTRAST Study Date of ___ 10:45 AM
1. Status post cervical thoracic spine stabilization from C2
through T4 level as described in detail above, using rods locked
with screws, there is no evidence of hardware loosening, the the
screw identified at C7/T1 level on the right crosses through the
superior endplate of T1.
2. Unchanged fracture involving the inferior endplate of T3
vertebral body. Unchanged fractures of the right ___ to 12 ribs.
Unchanged paraesophageal hematoma.
3. Unchanged lung opacities, likely consistent with a
combination of
consideration, atelectasis and pleural effusion as well as
pulmonary
contusions.
CT C-SPINE W/O CONTRAST Study Date of ___ 10:45 AM
1. The patient is status post posterior cervical/thoracic
spinal
stabilization, with rods locked with screws and bone graft
material from C2 through T4 levels as described in detail above.
There is no evidence of hardware complications throughout the
cervical spine.
2. Unchanged comminuted fracture dislocation at C5/C6 level
with bone
fragments in the spinal canal.
3. Multilevel, multifactorial degenerative changes throughout
the cervical spine appear unchanged.
4. Unchanged fracture at the inferior endplate of T3 level.
BILAT LOWER EXT VEINS PORT Study Date of ___ 11:41 AM
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
1:47 ___
1. Limited evaluation due to respiratory motion. There is no
central
pulmonary embolism. The segmental and subsegmental branches are
not well
evaluated due to motion artifact.
2. Complete left lower lobe collapse is new from prior study.
3. Small bilateral pleural effusions.
4. Status post posterior fusion of the cervical and upper
thoracic vertebral bodies, to T4, incompletely imaged.
5. Multiple fractures, as described above, are unchanged in
comparison to the ___ examination.
CT head ___: IMPRESSION:
1. Stable appearance of postsurgical changes related to right
frontal subdural evacuation and craniotomy.
2. No new hemorrhage is identified.
CT chest ___: IMPRESSION:
1. Opacity in the right lower lobe likely reflecting
atelectasis, however the there is adjacent predominantly
perihilar ground-glass opacity, which suggests that this could
also represent the sequela of aspiration in the right clinical
setting.
2. Bilateral pleural effusions, slightly decreased from prior
exam.
3. New area of ground-glass opacity anterior right upper lobe,
which could
reflect inflammation or possibly infection in the right clinical
setting.
4. 7 mm nodule in the left lateral left upper lobe, slightly
increased from prior exam.
CT abdomen and pelvis ___: IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. No evidence of intra-abdominal or pelvic infection.
3. Thickening of the sacral soft tissues, mildly progressed from
___, correlate with physical exam.
4. Please refer to separate dictation for details on
intrathoracic findings.
EEG ___: IMPRESSION: This is an abnormal continuous ICU
monitoring study due to the presence of frequent medium to high
amplitude epileptiform discharges in the right frontal region,
phase reversing at F4 which, at times, may have a field
extending into the left frontal region. The discharges may
appear, at times, in a quasiperiodic fashion at one every four
to five seconds. These findings indicate an area of highly
epileptogenic cortex in the right frontal region. The background
activity is slow and disorganized at ___ Hz with brief bursts of
generalized background attenuation, consistent with a moderate
to severe encephalopathy, which is etiologically non-specific.
There are no clear electrographic seizures.
Renal ultrasound ___ IMPRESSION:
1. New mild fullness of the left collecting system with interval
resolution of the fullness of the right collecting system.
2. Small echogenic foci again seen in the left kidney possibly
representing stones.
3. Foley catheter seen within the bladder which is decompressed
though not
completely empty.
4. No evidence of renal abscess.
___ CXR: IMPRESSION: As compared to the previous
radiograph, there is a subtotal atelectasis of the left lung,
likely caused by a mucous plug, with near complete opacification
of the left hemi thorax and shift of the mediastinal and cardiac
structures to the left. The tracheostomy tube is in unchanged
position. Unchanged normal appearance of the right lung.
Unchanged position of the right PICC line.
Blood transfusions: ___ 9:34A PC ___ E0336V00
O-NEG VOL: 350 (LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE -
COOMBS
___ 7:05A PC ___ ___ O-NEG VOL: 280
(LEUKOREDUCED AT COLLECTION - RC) (IRRADIATED) COMPATIBLE -
COOMBS
___ 11:19A PC ___ ___ O-NEG VOL: 277
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 4:26P PC ___ E___ O-NEG VOL: 350
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 10:30A PC ___ ___ O-NEG VOL: 350
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 4:46P PC ___ ___ O-NEG VOL: 281
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 4:26P PC ___ E0___ O-NEG VOL: 279
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 4:26P PC ___ E0336V00 O-NEG VOL: 350
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 11:52A PC ___ ___ O-NEG VOL: 350
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 11:52A PC ___ E0686V00 O-NEG VOL: 275
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 11:52A PC ___ E0686V00 O-NEG VOL: 276
(LEUKOREDUCED AT COLLECTION - RC) COMPATIBLE - COOMBS
___ 5:30P PC ___ E0___ O-NEG VOL: 279
(LEUKOREDUCED AT COLLECTION - RC) (EMERGENCY ROOM INVENTORY)
ISSUED BY EMERGENCY RELEASE
___ 5:25P PC ___ E0686V00 O-POS VOL: 283
(LEUKOREDUCED AT COLLECTION - RC) ISSUED BY EMERGENCY RELEASE
___ 5:25P PC ___ E0___ O-POS VOL: 280
(LEUKOREDUCED AT COLLECTION - RC) ISSUED BY EMERGENCY RELEASE
___ 5:23P PC ___ E___ O-NEG VOL: 350
(LEUKOREDUCED AT COLLECTION - RC) (EMERGENCY ROOM INVENTORY)
ISSUED BY EMERGENCY RELEASE
Brief Hospital Course:
___ presenting after MCC, was found in the median of the
highway, no skid marks found. He lost pulses on scene, received
chest compressions by police and had ROSC. EMS was unable to
intubate on scene and placed ___ LT. He was transported by
Medflight to ___. While en route, patient became agitated and
self extubated. Another attempt at intubation was unsuccessful
and a second ___ LT was placed. While in the ED, intubation was
attempted but unsuccessful, an emergent surgical cricothyrotomy
was performed. Bilateral chest tubes were placed with return of
blood. He was hypotensive with a negative FAST exam x 3. Because
he was hemodynamically unstable, he received 3U PRBCs, 1U FFP
and was admitted to the ___ for further management.
Injuries identified were as follows:
Right SDH with 9mm midline shift
Severely comminuted fracture-dislocation of C5 and C6 vertebral
bodies
with involvement of the transverse foramina of C5 and C6
C4 spinous process fracture
T3 vertebral body fracture
T7 transverse process fracture
Bilateral vertebral artery dissection
Right zygomatic arch and orbital wall fractures
Bilateral hemopneumothoraces
The sequelae of his injuries was quadriplegia and respiratory
failure. He had a prolonged ICU course complicated by seizures
secondary to development of a chronic SDH requiring
decompression and VAPx2.
Neuro: A severe fracture-dislocation of the C5 and C6 verbetral
bodies was noted on admission. Fusion was delayed on HD1 given
that his airway was secured with only a crichothyroidotomy. On
___, he was taken to the OR for C4-T4 posterior spinal fusion.
Prior to positioning, he desaturated, and required significant
suctioning during the case. Intraoperatively, his EBL was 3.5L
and he received 6U pRBC, 3U FFP, 1U platelets and 7L of IVF were
given. Post-operatively, he had no movement in his upper or
lower extremities though a repeat c-spine and thoracic spine CT
were stable. He wore a C-collar with thoracic extension for 6
weeks for spine stabilization.
He completed a 1 week course of prophylactic Keppra. About ___
weeks into his hospitalization, he was noted to have seizure
activity that was captured on EEG. Due to his worsening mental
status, a head CT was done that showed chronically evolving SDH
with early signs of herniation and emergent decompression was
done. Post-op he was maintained on an anti-seizure regimen of
Keppra, lacosimide, and Dilantin. This regimen was weaned to
only keppra/lacosamide post-operatively which he was maintained
on. During his post-operative recovery there were periods of
concern for altered mental status he underwent subsequent CTs
and EEG monitoring that did not demonstrate further bleeding or
seizure activity and his mental status returned to baseline
however there were peaks and valleys. His normal mental status
is arousable and reactive to questions with cranial nerves
grossly intact.
Transitional plans: Patient should be maintained on
keppra/lacosamide post-operatively. His pain has been controlled
with gabapentin and oxycodone. Recommendations for his
positioning for his spine fractures include Activity: maintain
45 degrees HOB (no less) or reverse Tberg at all times. No HOB
flat.
He will need to make a follow up appointment with Dr. ___
___ spine surgery sometime during mid ___. His office
can be reached at ___. We leave it up to you to
schedule the follow up as coordinating with other appointments
may be easier.
Psych: Patient has history of bipolar disorder and suicidal
ideations; Psychiatry was consulted. He was on and off of
antidepressants. Given his acute insults he was taken off all
anti-depressants. At time the patient reported no desire to
continue on, however, it was determined that he did not have
capacity and even if he did his son had pre-existing
guardianship prior to the accident. He was started on remeron
which was uptitrated with good effect. It was later stopped
while he was on linezolid. He was mostly verbalizing his desire
to stop all care, but would intermittenly say he was in better
spirits and wanted to continue living. However, given his
capacity issues and his son's, who is his ___ to
continue all care, he continued getting full care.
Transitional plans: the patient should continue on his remeron
30mg QHS.
Resp: He was intubated above his cricothyroidotomy on ___ and
his crich was removed. On ___, there was concern that his ETT
had an unintentional cuff leak, so a tracheostomy was placed at
the bedside on ___, and a PEG was placed (also at the bedside)
on ___. His chest tubes were placed to water seal, then removed
on ___ (left) and ___ (right). His ___ CXR showed left lower
lobe collapse with opacification, so he underwent a bronch on
___ with removal of mucous plug and significant improvement of
his CXR. Throughout the rest of the course of his
hospitalization his respiratory status waxed and waned. He
underwent multiple bronchoscopies which helpded with secretion
clearance. On one such bronchoscopy norcardia was cultured from
the lavage and in conjuction with Ct findinds suspicous for
norcardia pneumonia he was started on amikacin and bactrim for
this. Additionally on ___ the patient had a
desaturdation and a chest x-ray showed a small pneumothorax. A
pigtail was inserted and the lung re-inflated. This combined
with increased suctioning led to adequate ventilation and
oxygenation however the patient was originally unable to
tolerate pressure support, but eventually pressure support
periods were used towards the end of his stay to improve his
chest wall strength. He was bronched multiple times and BAL's
were checked. A trach exchange was done on ___ to a Blue line
#8.0 cuffed Portex.
Transitional plans: Continue vent magagement/suctioning per your
facility's direction. Patient will continue on imipenem and
minocycline at this point until follow up with infectious
disease doctor's.
-he also has a 7 mm lung nodule in the left upper lobe which
will need follow up with his primary care doctor
CV: He continued to be intermittently hypotensive and
bradycardic in the TSICU, likely from spinal shock, for which
dopamine and levophed were started. Dopamine was stopped on
___. He continued to be persistently bradycardic, so EP was
consulted. No intervention was deemed necessary. He continued to
require low dose levophed until ___, when his blood pressure
was stable on midodrine only. His blood pressure has been
maintained on midodrine and has been stable. The patient has had
anemia. This is likely anemia of chronic disease and has not
required transfusion in over a month. We recommend transfusing
only for clinically significant anemia or if hgb<7. On ___ he
went into asystole for 5 min, got epinephrine and atropine, and
had return of spontaneous circulation after 5min of CPR. He had
desatted before and it's possible the cause of his asystole was
a mucous plug.
Transitional plans: Continue midodrine 5mg TID. Anemia to be
monitored.
GI: After his PEG was placed, tube feeds were started on ___.
An aggressive bowel regimen was started on ___. The patient did
require several manual disimpactions. The patient was given
ulcer prophylaxis throughout his course.
Transitional plans: Continue tube feeds. Current regimen is
promote at 50ml/hr. Recommend continuining aggresive bowel
regimen and ulcer prophylaxis.
Renal/Gu: The patient has a neurogenic bladder and required
q6-q8 straight catheterization following the removal of his
indwelling catheter. Additionally the patient developed
hyponatremia due to SIADH which briefly required hypertonic
saline however this was substituted for salt tabs. These were
slowly weaned off. On ___ he creatinine started risinig, and
the nephrology team attributed it to intermittent episodes of
hypotension and an elevated amikacin level, so amikacin was
discontinued. Over the ensuing days, his creatinine continued to
rise until it peaked later that week and eventually came back
down from over 3 to 1.3. In the following weak, he also had a
rising creatinine attributed to acute interstitial nephritis by
the nephrology team, but again the creatinine stabilized and
came back down. Throughout multiple times during his blood
clotted off in the foley and required continuous irrigation.
Urology deferred a suprapubic catheter and urodynamic testing
until he is an outpatient. He was also intermittently diuresed
during his stay for volume overload. The nephrology team
monitored him during the stay, and he required intermittent free
water boluses for hypernatremia. Started kayexalate for high K,
sevelamer/amphojel for high phosphate on ___.
Transitional plan: Continue q6-q8 straight cathing. Recommend
against indwelling catheter. Recommend monitoring of
electrolytes per routine of facility. Follow up with Dr. ___
office ___, or outpt closer to rehab, for urodynamic
studies.
Heme: He was initially in spinal shock with 3.5L of blood loss
during his orthopedic case, and was transfused as needed. His
INR was elevated after arrival, so he was given vitamin k and
FFP. He has remained hemodynamically stable since his evacuation
by neurosurgery, though sometimes requiring midodrine. He
developed a left axillary vein DVT and this was found on
Septmeber 1. He was placed on coumadin however his INR became
difficult to manage and was transitioned to lovenox dosing.
Lovenox was ultimately discontinued on ___ and he was just
placed on prophylactic heparin, as the PICC was removed and he
had some transient hematuria, so the risks were felt to outweigh
the benefits. He was started on epoetin before discharge for his
anemia that required intermittent pRBCs.
We recommend against NOACs and if he is put on coumadin again we
recommend close monitoring of his INR given it's history of
variability.
ID:As expected with such a hospitalization and ICU course the
patient has had several infections. Initially he was treated
with levaquin for presumed community acquired pneumonia. He was
also given a 7day course of Vanc/Cefepime for MRSA positive
pulmonary cultures. Finally on ___ his BAL cultures grew out
branching rods which were later identified as norcardia. He
underwent a chest CT that was consistent with norcardia
pneumonia and a head MRI that was negative. He was started on
bactrim and amikacin which he should be continued on at least
until follow up with ID specialist here. The plan originally
from ___ start date of amikacin and Bactrim was for 6 weeks of
antibiotics. Amikacin was d/c'ed on ___ due to rising
creatinnine, and Bactrim was stopped on ___ due to a rash. He
was then placed on Imipenem and minocycline based on ID
recommendations, likely to continue the same 6 week course from
___ start date. A couple of days later he developed a
morbiliform rash and acute interstitial nephritis, thought to be
possibly related to his Imipenem. It was decided to keep him on
it given that nocardia infection would otherwise potentially end
his life, but symptoms worsened, so he was switched to
linezolid. He was also started on a course of fluconazole for
concern from the dermatology team that his rash in the
intertrigenous zones was related to a fungal infection. He
completed his linezolid/minocycline course through ___. He was
then transitioned to clarithromucyn, which will be left on
indefinitely. He was also tested for HIV and was negative.
Transitional issues: Please continue clarithromycin
indefinitely. If questions regarding dosing or management of
antibiotics please contact the ___ ___ office of the
infectious disease division.
Endo: The patient's glucose was monitored and he was maintatined
on an insulin sliding scale while in the ICU. He was continued
on his home dosing of levothyroxine.
Transitional issues: Recommend glucose management per your
institution's policy. Continue levothyroxine 75mcg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lorazepam 2 mg PO TID
4. Simvastatin 40 mg PO QPM
5. Lisinopril 5 mg PO DAILY
6. Sildenafil 50 mg PO ONCE:PRN impotence
7. ASENapine 5 mg SL BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing, SOB
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Milk of Magnesia 30 mL PO Q8H:PRN constipation
7. Sodium Chloride 3% Inhalation Soln 5 mL NEB TID
8. Senna 8.6 mg PO BID constipation
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Nystatin Oral Suspension 5 mL PO QID:PRN prn thrush
11. Mirtazapine 15 mg PO QHS
12. Midodrine 10 mg PO TID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
15. Bisacodyl 10 mg PR QHS
16. Famotidine 20 mg PO DAILY
17. NPH 5 Units Breakfast
NPH 5 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
18. Miconazole Powder 2% 1 Appl TP QID:PRN prn skin irritation
19. LACOSamide 100 mg PO BID
20. LeVETiracetam 500 mg PO BID
21. Docusate Sodium 100 mg PO BID constipation
22. Fleet Enema ___AILY:PRN constipation
23. Gabapentin 300 mg PO QHS
24. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
25. Glucose Gel 15 g PO PRN hypoglycemia protocol
26. Heparin 5000 UNIT SC TID
27. Clarithromycin 500 mg PO Q12H
28. Aquaphor Ointment 1 Appl TP TID:PRN rash or itchiness
29. Epoetin Alfa 5000 UNIT SC 3X/WEEK (___)
30. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID
31. Lorazepam 0.5-2 mg IV Q6H:PRN anxiety
32. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID itching
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right SDH with 9mm midline shift
Severely comminuted fracture-dislocation of C5 and C6 vertebral
bodies
with involvement of the transverse foramina of C5 and C6
C4 spinous process fracture
T3 vertebral body fracture
T7 transverse process fracture
Bilateral vertebral artery dissection
Right zygomatic arch and orbital wall fractures
Bilateral hemopneumothoraces
Community acquire pneumonia
Ventilator acquire pneumonia
Pulmonary norcardia
SIADH/hyponatremia
Axillary vein DVT
Acute Kidney Injury
Discharge Condition:
Mental Status: Confused - sometimes. Clear sometimes, able to
follow commands, nods yes or not to most basic questions. Opens
eyes spontaneously.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital following a traumatic
accident. You sustained a spinal fracture with subsequent
paralysis. You also had a bleed in your head requiring surgery
to relieve the pressure. You have had an extended hospital
course with several infections that are inevitable with these
types of injury and length of hospitalization however you are
now stable and ready to be discharged from the hospital to
rehab.
Please continue to follow the recommendations we have sent your
rehabilitation facility regarding your ongoing care. You will
need follow up with your infectious disease specialists and your
other doctors.
Followup Instructions:
___
|
10699400-DS-10
| 10,699,400 | 27,895,813 |
DS
| 10 |
2184-02-19 00:00:00
|
2184-02-20 10:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hidradenitis Suppuritiva
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of asthma, dvt on coumadin, hidradenitis suppurativa and
multiple hospitalizations for cellulitis who presents at the
request of his PCP's coverage for evaluation of right axillary
wound. Pt notes that he was recently discharged from the
hospital for scrotal cellulitis, taking doxycycline and
moxicillin orally. Over the past week, the patient has developed
an ulceration within his right axillary fold, starting off very
minimally visible to now being approximately 1x2.5cm with
erythematous base, weeping with puruluent drainage, exquisitely
tender to touch or movement of right arm. Also associated with
sharp right arm pain and subjective weakness. Pt denies fever or
chills but notes he never as such even with severe infections in
the past. Denies local trauma, SOB, DOE, chest pain, diarrhea or
constipation, coughing or sneezing. Has mild migraine at this
time. Pt spoke to Dr. ___ who recommended that the pt come
to the ED for evaluation and possible IV medication.
In ED, initial vital signs were 99.2 109 147/85 16 98%RA.
Physical exam notable for reduced ROM of right arm with
elevation ___ to pain. 1x2.5cm erythematous ulcer with purulent
drainage, very tender to palpation. Pt also has multiple other
areas of hidradenitis at various stages of healing, including
along left inguinal fold and medial aspect of left thigh. The
patient was given Zofran, morphine, APAP, and vancomycin.
On arrival to the floor, the patient confirms story as above. In
just days, an area under his right axilla, which has been
quiescent in terms of his hidradenitis lately, began to become
painful and ulcerated in short order. Over the last day, the
area has become exquisitely tender and begun to express a
pus-like fluid. He continues to have drainage of some
hidradenitis lesions in the groin, but those remain unchanged
since his last PCP ___. He does endorse continuing to feel
fatigue and some flu-like symptoms. He had a headache in the
morning. Because I am the patient's PCP and familiar with his
other symptoms, we also discussed his abdominal discomfort,
which has many of the hallmarks or irritable bowel syndrome. The
patient had been taking ___ tablespoons of psyllium daily,
which made him more consistently regular. He was continuing to
have abdominal pain with the first meal of the day and
significant and uncomfortable gas.
Past Medical History:
# Hidradenitis suppurtiva, ___ years, has received multiple
treatments in past including oral abx (clindamycin, rifampin,
cefpodoxime), topical clinda gel, retinoids, topical magnesium
chloride, oral zinc; has required surgical removal of sinus
tract in past. Also complicated by pilonidal cyst.
-s/p L axillary eccrine gland excision ___
-s/p R axillary excision ___
#Post-surgical rhabdomyolysis ___: likely a
succinylcholine-induced, requiring readmission
#Prior rhabdomyolysis (not post-op, per last dc summary)
# OSA, s/p surgery, does not wear CPAP
# Tobacco use
# Asthma, uses inhaler prn
# LUE DVT temporally associated with L axillary surgery
# RUE DVT temporally associated with R axiillary surgery
Social History:
___
Family History:
Mother died in her ___ from brain tumor, history of CVA; Father
died in ___ from a fall, subsequent blood clot, history of DM;
Has 3 sibs, none with hidradentitis.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 97.6 BP 125/84 HR 76 RR 18 100% RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT, MMM, EOMI, sclerae anicteric, OP clear and without
erythema, fixed subcutaneous tumor of right maxilla (consistent
with sebaceous cyst)
NECK: Supple, no LAD
PULM: Good aeration, CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1/S2, no murmurs auscultated
ABD: Soft, NT, ND, normoactive bowel soundsBACK: Subcutaneous
cystic structure on right back medical to shoulder back
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs ___ intact, motor function grossly normal
SKIN: 1 cm x 2.5 cm ulceration with pus under right axilla,
draining lesions of left groin
DISCHARGE PHYSICAL EXAM
VS - Tc 98.2 Tm 98.4 HR ___ BP 114/73 (110s-130s/70s-100s) 20
SpO2 99% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e.
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions. Rt axilla with 1x2.5cm erythematous
ulceration with active purulent drainage, decreased from
yesterday. Lt axilla with healed surgical scars, no active
drainage. Bilateral inguinal folds with multiple lesions in
various stages of healing.
Pertinent Results:
ADMISSION LABS
___ 10:10PM BLOOD WBC-10.7 RBC-5.39 Hgb-14.1 Hct-43.3
MCV-80* MCH-26.3* MCHC-32.7 RDW-15.7* Plt ___
___ 10:30PM BLOOD ___ PTT-47.2* ___
___ 10:10PM BLOOD Glucose-156* UreaN-15 Creat-1.5* Na-139
K-3.7 Cl-103 HCO3-26 AnGap-14
___ 10:19PM BLOOD Lactate-1.3
___ 08:27AM BLOOD Vanco-3.9*
___ 07:50AM BLOOD Vanco-9.4*
US AXILLA, SOFT TISSUE: Irregular lesion in the area of clinical
concern. No fluid pocket. Follow-up
imaging upon resolution of acute findings is suggested.
DISCHARGE LABS
___ 07:50AM BLOOD WBC-6.7 RBC-4.88 Hgb-13.4* Hct-39.3*
MCV-81* MCH-27.4 MCHC-34.0 RDW-15.7* Plt ___
___ 07:50AM BLOOD ___ PTT-45.5* ___
___ 07:50AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-140
K-3.9 Cl-104 HCO___-27 AnGap-13
Brief Hospital Course:
The patient is a ___ man with a history of hidradenitis
suppurativa who is presenting with a likely superimposed
infection in his right axilla.
ACTIVE ISSUES
#SOFT TISSUE INFECTION IN AREA OF HIDRADENITIS SUPPURATIVA: On
admission the patient had an evident flare and infection despite
being on oral doxycycline and moxifloxacin as an outpatient. In
an attempt to control the superimposing infection IV antibiotics
were initiated with vancomycin and Unasyn for gram positive and
gram negative and anaerobic coverage given that these infections
can be polymicrobial in nature. Plastic surgery was consulted
given that their service has previously operated on the patient.
They suggested obtaining a soft tissue ultrasound to evaluate if
any drainable abscess pocket existed. Ultrasound showed a
heterogenous lesion, though no fluid collection. Plastics felt
there was nothing needing operative interventions and would like
to transition the patient to oral Augmentin and Bactrim with
follow up with Dr. ___ in 1 week. Initially during the ___
hospital course his pain was controlled with IV morphine. On
HD#2 he was transitioned back to his at home regimen of
oxycodone which was well tolerated and provided adequate
analgesia. By HD#3, his purulence had decreased and the patient
was tolerating his oral antibiotic and analgesia regimen, and he
was discharged to follow up with Dr. ___ and his PCP as
an outpatient.
ACUTE KIDNEY INJURY: Creatinine at admission was 1.5, increased
from baseline of 1.0. This was felt to be likely pre-renal in
nature due to poor PO intake in the setting of acute illness.
The patient received IVF in Emergency Department as well as a
fluid bolus when arriving on the floor. PO hydration was
encouraged. His creatinine returned to baseline levels on HD#2
and remained there during the rest of his hospital course.
CHRONIC ISSUES
HISTORY OF UPPER EXTREMITY DVT: Patient has had two upper
extremity DVTs, and is thus on lifelong anticoagulation with
warfarin with a INR goal of 2.0-3.0. The patient was maintained
on his home regimen of warfarin, with daily INR checks to
observe for any fluctuations in warfarin activity due to
antibiotic use. He remained therapeutic during his hospital
course.
TRANSITIONAL ISSUES
The patient is to follow up with Dr. ___ for possible
operative intervention in the future, and with his PCP for
ongoing medical management of his hiradenitis and chronic
medical issues.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Clindamycin 1 Appl TP BID
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
4. Ranitidine 150 mg PO BID Start: In am
5. Warfarin 10 mg PO DAILY16 Start: In am
6. Nicotine Patch 21 mg TD DAILY Start: In am
7. Psyllium 1 PKT PO DAILY Start: In am
8. Doxycycline Hyclate 100 mg PO Q12H
9. moxifloxacin *NF* 400 mg Oral Daily
Discharge Medications:
1. Clindamycin 1 Appl TP BID
2. Nicotine Patch 21 mg TD DAILY
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
4. Psyllium 1 PKT PO DAILY
5. Ranitidine 150 mg PO BID
6. Warfarin 10 mg PO DAILY16
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth Twice a day Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hidradenitis suppuritiva
Acute kidney injury
History of DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. As you know, you were hospitalized with an acute
flare of your hidradenitis suppuritiva. We gave you intravenous
antibiotics which helped to control your flare. You had an
ultrasound which showed no deep pocket of drainable infection.
We controlled your pain at first with IV medication, but then
successfully transitioned you back to an oral regimen.
We made the following changes to your medications:
START augmentin and bactrim
Followup Instructions:
___
|
10699400-DS-17
| 10,699,400 | 24,981,153 |
DS
| 17 |
2186-03-11 00:00:00
|
2186-03-14 15:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abscess
Major Surgical or Invasive Procedure:
I&D of right axilla abscess by plastic surgery on ___
History of Present Illness:
___ patient stage III/IV hidradenitis suppurativa with
recurrent infections who is referred from PCP office for HS
flare that began 4 days ago. He initially noted right axillary
pain that progressed to ___ on day of admission, with
associated limitation of ROM, RUE swelling and warmth. He denies
any fevers, chills. His flares are typically managed ___ the
outpatient setting with increased doses of oxycodone, though he
has required prior hospitalizations for this. ___ the office, he
was barely able to undress, and the area was exquisitely tender
to palpation.
___ the ED, initial vitals were: 10 99.9 100 141/80 20 100%RA.
Labs were notable for Lactate:2.1, WBC 15.6. Patient was given
ondansetron 4 mg IV x1, lorazepam 1 mg IV x1, HYDROmorphone 1 mg
IV x1, Vancomycin 1000 mg IV x1, 1000 mL NS.
On the floor, he also complains of "muscle cramps" that have
started ___ his abdominal wall. Today is the first time he has
experienced these symptoms.
Past Medical History:
- Hidradenitis suppurtiva with recurrent skin and soft tissue
infections.
- Post-operative rhabdomyolysis of etiology unclear, malignant
hyperthermia evaluation not completed (see OMR note by Dr.
___ ___
- Exercise/heat induced rhabdomyolysis.
- Pilonidal cyst.
- Obstructive sleep apnea
- Tobacco use
- Asthma, uses inhaler prn
- Provoked LUE DVT ___ setting of axillary surgery x 2
- Multiple I&D of hidradenitis pupurtiva
- Tonsillectomy/adenoidectomy
- Uvulectomy
- Hernia repair
Social History:
___
Family History:
Mother died ___ her ___ from brain tumor, history of CVA; Father
died ___ ___ from a fall, subsequent blood clot, history of DM;
Has 3 sibs, none with hidradentitis.
Physical Exam:
EXAM ON ADMISSION:
===================
Vitals: 98.2 140/81 113 20 97% RA
General: ___ moderate-severe distress especially upon movement
HEENT: AT, NC
CV: rrr, no m/r/g
Lungs: ctab, no w/r/r
Abdomen: bs+, soft, obese, nontender
GU: left-sided pilonidal cyst near anus, bilateral inguinal
lesions (indurated on right)
Ext: three indurated lesions ___ left axilla all tender to touch,
right axilla severely tender to touch with vertical lesion
through middle; posterior right arm erythematous and very tender
Neuro: gross motor function intact
EXAM ON DISCHARGE:
===================
Vitals: 97.7 137/87 79 16 100% RA
VS Range: ___ ___ 98-100% RA
General: ___ moderate distress especially upon movement of right
arm
CV: rrr, no m/r/g
Lungs: ctab, no w/r/r
Abdomen: bs+, soft, obese, nontender
GU: left-sided pilonidal cyst near anus, open lesion on left
gluteus, tender to palpation, bilateral inguinal lesions
(indurated on right)
Ext: indurated tender pocket ___ inferior surface of right arm
under right axilla, tender to touch, s/p drainage by Plastics
now packed, erythema on posterior right arm improved
Neuro: gross motor function intact
Pertinent Results:
PERTINENT RESULTS ON ADMISSION:
==================================
___ 03:50PM BLOOD WBC-15.6* RBC-5.06 Hgb-14.4 Hct-43.1
MCV-85 MCH-28.4 MCHC-33.3 RDW-16.1* Plt ___
___ 03:50PM BLOOD Neuts-77.7* Lymphs-14.7* Monos-6.8
Eos-0.6 Baso-0.3
___ 03:50PM BLOOD Glucose-88 UreaN-11 Creat-1.1 Na-138
K-3.9 Cl-99 HCO3-27 AnGap-16
___ 04:02PM BLOOD Lactate-2.1*
PERTINENT RESULTS ON DISCHARGE:
==================================
___ 05:45AM BLOOD WBC-9.4 RBC-4.68 Hgb-13.3* Hct-39.8*
MCV-85 MCH-28.4 MCHC-33.4 RDW-15.9* Plt ___
___ 05:45AM BLOOD Glucose-123* UreaN-12 Creat-1.0 Na-139
K-4.5 Cl-99 HCO3-30 AnGap-15
___ 05:45AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
RADIOLOGY:
==================================
SHOULDER ___ VIEWS NON TRAUMA RIGHT (___):
No fracture or dislocation. No subcutaneous gas seen.
US AXILLA, SOFT TISSUE RIGHT (___):
5.0 x 4.1 x 2.8 cm complex heterogeneous cystic structure within
the right axilla which ___ the correct clinical setting is
concerning for an abscess.
US BUTTOCKS, SOFT TISSUE LEFT (___):
No sonographic abnormality identified ___ the region of concern
___ the left gluteal area.
MICROBIOLOGY:
==================================
- Blood culture x 2 (___): no growth
- Blood culture (___): no growth
- GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary):
ENTEROCOCCUS FAECALIS. 1 COLONY ON 1 PLATE.
AMPICILLIN sensitivity testing performed by ___
___.
Penicillin Sensitivity testing performed by Etest.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ S
PENICILLIN G---------- 1 S
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). SPARSE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
___ patient with stage III/IV hidradenitis suppurativa
with recurrent infections requiring IV antibiotics presenting
with HS flare.
# Stage III/IV Hidradenitis suppurativa flare with enterococcal
abscess: patient was found to have a fluctuant abscess ___ the
right axilla accompanied by an adjacent erythematous area ___ the
upper posterior arm. US of right axilla showed an abscess that
was drained by plastic surgery on ___. Abscess drainage was
sent for culture and grew ENTEROCOCCUS FAECALIS. Pt was treated
with vancomycin while hospitalized (1000 mg IV q8h on ___,
changed to 1250 mg IV q8h on ___ and discharged on linezolid
for total of 10 days, last dose on ___. On day of discharge,
the cellulitis ___ the right arm had improved and patient was
able to more easily move his right arm. For pain control,
patient was given oxycodone and dilaudid, as well as
ativan/dilaudid qAM for dressing changes.
# Pilonidal cyst: possibly connected to new indurated lesion ___
left gluteus. Ultrasound did not reveal any focal fluid
collection that is drainable.
TRANSITIONAL ISSUES:
[] cont. linezolid for total of 10 days (last dose on ___
[] monitor left glutea pilonidal cyst
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
2. Clindamycin 1 Appl TP BID
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
5. Psyllium 1 PKT PO TID:PRN constipation
6. Ranitidine 150 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
2. Clindamycin 1 Appl TP BID
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
6. Psyllium 1 PKT PO TID:PRN constipation
7. Ranitidine 150 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Linezolid ___ mg PO Q12H
RX *linezolid [Zyvox] 600 mg one tablet(s) by mouth q12hr Disp
#*13 Tablet Refills:*0
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg one tablet(s) by mouth Q12hr-prn Disp #*12
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. hidradenitis suppurativa stage III
2. cellulitis
3. pilonidal cyst
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
presented to us with recurrent abscess of your right axilla. You
underwent incision and drainage by our plastic surgeons. You
were treated with antibiotics for total of 10 days. Please
continue taking your antibiotics as instructed below until ___.
Please go to clinic every other day for dressing changes of your
wound ___ the right axilla.
Please attend all your follow up appointments.
We wish you the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10699400-DS-23
| 10,699,400 | 21,742,275 |
DS
| 23 |
2187-11-08 00:00:00
|
2187-11-08 22:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / rifampin
Attending: ___
Chief Complaint:
L arm swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time:736 ___
_
________________________________________________________________
PCP: Dr. ___
.
CC: L arm swelling
_
________________________________________________________________
HPI:
___ with PMHx of Hidradenitis suppuritiva (dx ___ sp multiple
I+Ds), OSA, asthma, tobacco abuse, diverticulosis, NAFLD, DM2
(previously on metformin), h/o deep vein thrombophlebitis, GERD,
and eczema, who presents with left arm swelling. The patient
reports he developed left upper extremity pain two days ago and
a stinging feeling inside of his arm. He then noticed the next
day. Feels exactly like prior episodes of cellulitis. He has
associated pain and swelling of the arm. No fevers. Denies CP or
SOB. No N/V/D.
.
He thinks that his HS is in better control as long as he
maintains his diet, monitors his stress level and uses the
topical treatments. He did not notice an outbreak of his HS at
the site pre-ceding this episode of cellulitis.
LUE TTP over proximal arm, mild erythema, 2+ pulses
He was seen in the ED in ___ where he had an I and D of a
L buttock abscess.
ADmit for IV abx
In ER: (Triage Vitals: 10
98.9
110
145/83
16
99% RA)
Meds Given:
___ 02:41PO/NGOxyCODONE (Immediate Release) 15
___
___ 05:03IVMorphine Sulfate 4 ___
___ 05:12IVClindamycin 600 ___
___ 09:13PO/NGOxyCODONE (Immediate Release) 15
___
___ 09:13IVCeFAZolin 1 ___
___ 10:44IVDoxycycline Hyclate 100 ___
___ 12:00SCInsulin___ Given
___ 12:31PO/NGOxyCODONE (Immediate Release) 15
___
___ 14:35PO/NGOxyCODONE (Immediate Release) 15
___
Fluids given: Radiology Studies:, consults called.
.
PAIN SCALE: ___ pain in L arm
Worse with slight touch and its very warm.
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI and an intentional twenty pound
weight loss
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [+] flare in R underarm
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
# Hidradenitis Suppuritiva; ___ stage III
# Asthma (controlled)
# OSA (sp tonsillectomy, not on CPAP)
# Diverticulosis
# NAFLD
# DM2
# h/o deep vein thrombophlebitis
# Eczema
# pilonidal cyst sp excision ___
# Hyperplastic colonic polyp
# possible hx of malignant hyperthermia in ___
Social History:
___
Family History:
Mother died in her ___ from brain tumor, history of CVA
Father died in ___ from a fall, subsequent blood clot, history
of DM
PGM - DM
Uncle - ___ I
Physical Exam:
Admission Exam:
Vitals: T 97.5 P 99 BP 126/87 RR 18 SaO2 99% RA
CONS: NAD, comfortable appearing
HEENT: anicteric MMM
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
MSK:no c/c/e 2+pulses
R axilla with tender possible fluid collection
Well healed surgical scars also present
L axilla with very tender pustule with drainage, very tender. ?
Fluctuance
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
Discharge exam:
VS: 97.5, 116/77, 78, 16, 98%RA
GEN: NAD
HEENT/Neck: Anicteric sclera, MMM, OP clear, neck supple
HEART: RRR; no m/r/g
LUNGS: CTAB no wheezes, rales, or crackles.
ABD: Soft NT/ND; no rebound or guarding
EXT: L axillary induration with raised nodular area, painful to
touch, with trace drainage from sinus tract. Erythema has
resolved within marked region on posterior proximal arm.
NEURO: CNII-XII intact. No focal strength deficits
Pertinent Results:
Admission Labs:
___ 12:49AM BLOOD WBC-13.3*# RBC-4.76 Hgb-13.1* Hct-40.9
MCV-86 MCH-27.5 MCHC-32.0 RDW-16.4* RDWSD-52.1* Plt ___
___ 12:49AM BLOOD Neuts-74.1* Lymphs-17.2* Monos-6.8
Eos-0.8* Baso-0.2 Im ___ AbsNeut-9.88*# AbsLymp-2.29
AbsMono-0.91* AbsEos-0.10 AbsBaso-0.02
___ 12:49AM BLOOD ___ PTT-32.4 ___
___ 12:49AM BLOOD Glucose-156* UreaN-15 Creat-0.9 Na-136
K-4.0 Cl-99 HCO3-25 AnGap-16
___ 12:54AM BLOOD Lactate-1.6
Discharge Labs:
___ 06:13AM BLOOD WBC-9.9 RBC-4.88 Hgb-13.1* Hct-41.9
MCV-86 MCH-26.8 MCHC-31.3* RDW-15.9* RDWSD-50.0* Plt ___
___ 06:13AM BLOOD Neuts-63.0 ___ Monos-11.0 Eos-1.2
Baso-0.3 Im ___ AbsNeut-6.22* AbsLymp-2.32 AbsMono-1.09*
AbsEos-0.12 AbsBaso-0.03
___ 05:51AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-135
K-4.2 Cl-98 HCO3-29 AnGap-12
___ 05:51AM BLOOD Calcium-9.7 Phos-4.4 Mg-1.9
Micro:
Bcx ___: NGTD
Imaging:
LUE US ___:
FINDINGS:
There is normal flow with respiratory variation in the left
subclavian vein. The left internal jugular and axillary veins
are patent, show normal color flow and compressibility. The left
brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow. There is left brachial vein
duplication.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
L axilla US ___:
FINDINGS:
Targeted ultrasound evaluation of the left axilla demonstrates a
heterogeneous
anechoic and hypoechoic collection measuring 3.6 x 2.2 x 4.3 cm
with some
vascularity, of which there are areas of vascularized tissue
compatible with
phlegmon and chronic scarring, but areas of fluid also appear to
be present on
the provided images that may represent abscess. A similar
lesion was present
on the ultrasound examination of ___, previously 5.1
x 1.2 cm but
with more homogeneous presence of vascularity.
Targeted ultrasound evaluation of the right axilla did not
reveal any fluid
collections or gross abnormality.
IMPRESSION:
1. Mixed echogenicity subcutaneous region in left axilla
measuring 3.6 x 2.2
x 4.3 cm consistent with chronic scarring and phlegmonous
change, probably
with some confluent fluid that may represent abscess.
2. There is no fluid collection or gross abnormality in the
subcutaneous
tissues of the right axilla.
L axilla US ___:
FINDINGS:
In the left axilla, there is a predominantly hypoechoic area
with
heterogeneous internal echoes and a more focal area of
echogenicity which may
represent bubbles of air. This area measures approximately 3.9
x 1.3 x 2.8
cm, compared to 4.3 x 2.2 x 3.6 cm on prior and again
demonstrates some
vascularity at the posterior aspect.
IMPRESSION:
Mixed echogenicity area in the left axilla is smaller compared
to prior,
likely reflecting phlegmon and abscess. Internal air is noted
which
presumably reflects recent intervention. Clinically correlate.
Brief Hospital Course:
___ with PMHx of hidradenitis suppurativa who presented with
left axillary pain/swelling and new redness concern for
recurrent
cellulitis.
# LUE Cellulitis:
# Hidradenitis suppurativa
# Phlegmon:
Patient with superficial cellulitis extending from chronic HS
with sinus tract. US w probable phlegmon vs. abscess which on
subsequent US showed reduced size. There was possible gas within
collection which was thought to represent presence of large
drainage tract. Surgery was consulted but pt declined
consideration of any intervention at this time. Pt clinically
improved with Cefazolin and Doxy (d1 = ___ and abx were
narrowed to Doxy/Keflex (on ___. Pt was discharged with 7d
po abx to complete a total 10d course. As there was good
drainage of abscess/phlegmon and it was decreased in size, and
given pt's preference for discharge, he was discharged with
recommendation for close follow-up and instructions to seek
immediate medical attention if symptoms were to worsen.
# DM2 controlled:
On ISS
# Asthma/OSA: Stable; no evidence of exacerbation
Transitional Issues:
- Please ensure follow-up with Dermatology and Plastic Surgery
for re-evaluation of L axillary process
- Please obtain repeat axillary US on follow-up to ensure
resolution of draining abscess
- Please ensure follow-up with Rheumatology and Neurology for
continued evaluation of myopathy syndrome (ie EMG), given
intermittent elevations in CPK/rigidity noted on last admission
- Prior recommendation by dermatology was for long-standing
minocycle; per pt he was not able to tolerate this due to GI
effects and this has been DC'd
- Pt not willing to attempt biologic therapy for HS at this
time; would continue to discuss options for HS therapy and
encourage abstinence from smoking and continued pursuit of
weight loss
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 800 mg PO Q6H:PRN Pain
4. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
5. Ranitidine 150 mg PO BID
6. Clindamycin 1 Appl TP BID
7. DiphenhydrAMINE 25 mg PO Q6H:PRN Pruritus
8. Multivitamins 1 TAB PO DAILY
9. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Clindamycin 1 Appl TP BID
3. DiphenhydrAMINE 25 mg PO Q6H:PRN Pruritus
4. Docusate Sodium 100 mg PO BID
5. Ibuprofen 800 mg PO Q6H:PRN Pain
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
8. Psyllium Powder 1 PKT PO TID:PRN constipation
9. Ranitidine 150 mg PO BID
10. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
11. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
LUE cellulitis
Hydradenitis Suppurativa
OSA
Asthma
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 partake in your care at ___. You were
admitted with a recurrent infection this time in your left
armpit. Please complete the antibiotic course prescribed to you
and follow up closely with your PCP. Please also follow up with
your Dermatologist and, if swelling and drainage persists, with
the plastic Surgery clinic.
Best Regards,
Your ___ Team
Followup Instructions:
___
|
10699400-DS-24
| 10,699,400 | 26,496,316 |
DS
| 24 |
2188-03-02 00:00:00
|
2188-03-02 11:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / rifampin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of hidradenitis suppurativa, on narcotics
contract, who presents with nausea, vomiting and diarrhea. He
reports 10 episodes of watery diarrhea per day at least and
vomiting and abd pain. He has been unable to tolerate anything
by mouth for 4 days. He reports countless nonbloody nonbilious
episodes of emesis and episodes of light colored liquid stools
that are not black and nonbloody. He endorses primarily gnawing
epigastric pain that is band-like and radiates to his back. He
states he had these prior symptoms with pancreatitis. The
etiology of his pancreatitis is believed to be related to his
usage of rifampin for treatment of his hidradenitis. He no
longer takes rifampin. Denies any fevers or chills or abrupt
increases in his abdominal pain.
Of note, he completed a course of Bactrim and amox for his
hidradenitis a few weeks ago.
He also reports that he has lost 25lbs since changing his diet.
In the ED, triage vital signs were: 97.5 ___ 20 100% RA.
He was given 4L NS, hydromorphone and ondansetron with
improvement in his symptoms and tachycardia. Was admitted for
further monitoring given poor oral intake. CT Abd and RUQ US
were unrevealing except for Hepatic steatosis.
ROS: 10 pt ROS otherwise neg except as per HPI.
Past Medical History:
# Hidradenitis Suppuritiva; ___ stage III
# Asthma (controlled)
# OSA (sp tonsillectomy, not on CPAP)
# Diverticulosis
# NAFLD
# DM2
# h/o deep vein thrombophlebitis
# Eczema
# pilonidal cyst sp excision ___
# Hyperplastic colonic polyp
# possible hx of malignant hyperthermia in ___
Social History:
___
Family History:
Mother died in her ___ from brain tumor, history of CVA
Father died in ___ from a fall, subsequent blood clot, history
of DM
PGM - DM
Uncle - ___ I
Physical Exam:
VS: 98.6 PO 158 / 90 R Lying 78 16 99 RA
GEN: Appears comfortable, pleasant
HEENT: MMM, PERRLA
Neck: Supple
CV: RRR, no m/g/r
Pulm: CTAB no w/r/r
Abd: Soft, ttp in epigastrium with mild guarding.
Extrem: Warm, no edema
Skin: no rashes
GU: No foley
Neuro: A+OX3, speech fluent
On day of discharge, VSS
He appeared well
++ scarring bilateral axilla
Abd: mild distension, nabs, soft.
Pertinent Results:
___ 10:27PM BLOOD WBC-9.2 RBC-5.55 Hgb-16.0 Hct-47.6 MCV-86
MCH-28.8 MCHC-33.6 RDW-17.4* RDWSD-50.8* Plt ___
___ 10:27PM BLOOD Neuts-74.2* Lymphs-15.6* Monos-9.2
Eos-0.3* Baso-0.3 Im ___ AbsNeut-6.81* AbsLymp-1.43
AbsMono-0.84* AbsEos-0.03* AbsBaso-0.03
___ 10:27PM BLOOD ___ PTT-30.0 ___
___ 10:27PM BLOOD Glucose-141* UreaN-9 Creat-1.0 Na-134
K-3.7 Cl-94* HCO3-22 AnGap-22*
___ 10:27PM BLOOD ALT-71* AST-90* AlkPhos-56 TotBili-1.4
___ 10:27PM BLOOD Albumin-5.0 Calcium-10.0 Phos-2.5* Mg-1.9
___ 10:27PM BLOOD Lipase-94*
___ 10:34PM BLOOD Lactate-1.9
___ 05:25AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:25AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:25AM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
___ 05:25AM URINE Mucous-RARE
Discharge Labs:
___ 05:30AM BLOOD WBC-5.6 RBC-4.96 Hgb-13.9 Hct-42.7 MCV-86
MCH-28.0 MCHC-32.6 RDW-16.5* RDWSD-51.7* Plt ___
___ 05:30AM BLOOD Glucose-118* UreaN-7 Creat-0.9 Na-139
K-3.5 Cl-96 HCO3-30 AnGap-17
___ 05:30AM BLOOD ALT-98* AST-70* AlkPhos-46 TotBili-0.9
CT Abd and pelvis
IMPRESSION:
1. No CT findings of pancreatitis.
2. Hepatic steatosis.
3. Bilateral inguinal and pelvic lymphadenopathy, improved since
the prior
examination.
RUQ U/S:
IMPRESSION:
Hepatic steatosis. No gallstones or gallbladder sludge
identified.
Brief Hospital Course:
A/P: ___ with history of pancreatitis, presents with similar
symptoms.
# r/o pancreatitis, gastroenteritis: The patient was admitted
with abdominal pain, nausea, vomiting and diarrhea, which
pointed to more of a viral gastroenteritis. However, he reports
that his symptoms were similar when he had rifampin-induced
pancreatitis in the past, but lipase only mildly elevated and no
radiographic evidence of pancreatitis. He also reports that
after having taken antibiotics for the nearly the past ___ years
that he often experiences abdominal pain and diarrhea with
antibiotics.
He was treated supportively with IV dilaudid, IVF, and bland
diet and improved. Once Cdiff returned neg he was given Imodium
for diarrhea for one day.
His abdominal pain nearly entirely resolved during his stay and
his diarrhea resolved as well.
# tachycardia: Quite tachycardic in the ED likely from
hypovolemia in the setting of nausea and vomiting. Resolved.
# Hidradenitis suppurativa: Managed by his PCP and by
specialists at ___. They have offered him humira for this,
which he is NOT inclined to take based on what he feels is
inadequate supporting evidence in literature and side effect
profile. He has extensive scarring in axilla, deferred groin
examination on day of discharge/
# Nausea: Occurs occasionally at home, patient believes it is
due to oxycodone, Zofran rx sent to pharmacy for prn use. He
has used it previously as well.
# Chronic pain: Due to hydradenitis. He continued on his home
dose of oxycodone and a new prescription was NOT given to the
patient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
2. Ranitidine 150 mg PO BID
3. Zofran 4 mg po daily prn nausea
Discharge Medications:
1. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
2. Ranitidine 150 mg PO BID
3. Zofran 4 mg po daily prn nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, diarrhea
Hidradenitis suppurativa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with abdominal pain and diarrhea. This may
have been related to pancreatitis, a viral syndrome or your
antibiotics. Your symptoms improved and you were able to
tolerate a normal diet.
I have sent a prescription for your Zofran to your pharmacy
across the street for pickup.
Followup Instructions:
___
|
10699400-DS-26
| 10,699,400 | 21,933,377 |
DS
| 26 |
2188-09-15 00:00:00
|
2188-09-15 14:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / rifampin
Attending: ___
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with hidradenitis suppurtiva s/p multiple I+Ds &
admissions for IV abx presents with 4 days of painful draining
lesions from L axilla and L groin. He denies fever and chills.
He usually manages his HS with topical clindamycin and oral
narcotics (oxycodone 30mg q6h). Over last 1.5 days he has had
increasing pain in L groin area radiating to scrotum that felt
deeper than usual. He denied any urinary or testicular symptoms
but was worried about the pain.
In the ___, initial vitals were: 98.4 108 156/86 18 99% RA
- Exam notable for:
HR 100s, AF, normotensive, uncomfortable. 2 draining lesions
associated w/ tenderness but not fluctuance in L axilla, 1
draining lesion in R axilla. In L groin has 3 draining areas w/o
associated fluctuance but sig tender & TTP along lateral
proximal aspect of L sided scrotum, no testicular pain, normal
testicular lie +cremasteric, no lower abd pain.
- Labs notable for: Hgb 12.1, hyperglycemia to 249
- Imaging was notable for:
1. Normal scrotal ultrasound.
2. Significant subcutaneous edema but no evidence of fluid
collection in the perineum.
- Patient was given: IV unasyn and morphine 4mg x2
Upon arrival to the floor, patient reports above story with
continued pain. He also notes intermittent low back pain and
Past Medical History:
# Hidradenitis Suppuritiva; ___ stage III
# Asthma (controlled)
# OSA (sp tonsillectomy, not on CPAP)
# Diverticulosis
# NAFLD
# DM2
# h/o deep vein thrombophlebitis
# Eczema
# pilonidal cyst sp excision ___
# Hyperplastic colonic polyp
# possible hx of malignant hyperthermia in ___
Social History:
___
Family History:
Mother died in her ___ from brain tumor, history of CVA
Father died in ___ from a fall, subsequent blood clot, history
of DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.1 PO 119 / 78 R Lying 80 20 97 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. Developing erythema/fullness
underneath chin
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Skin: 2 draining lesions associated w/ tenderness but no
fluctuance in L axilla, 1 draining lesion in R axilla. In L
groin has 3 draining areas w/o associated fluctuance but sig
tender & TTP along lateral proximal aspect of L sided scrotum,
no testicular pain, normal testicular lie +cremasteric, no lower
abd pain.
DISCHARGE PHYSICAL EXAM:
97.5 PO 138 / 91 88 20 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. Developing erythema/fullness
underneath chin
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Skin: Two draining lesions associated w/ tenderness but no
fluctuance in L axilla, 1 draining lesion in R axilla.
L groin along crease has ___ draining areas draining
serosanginous fluid, indurated, with one indurated area medial
to groin towards scrotum, exquisitely tender, and with no
associated fluctuance. Extends back to anterior aspect of
perineum. No erythema. Normal scrotum.
Pertinent Results:
ADMISSION LABS:
___ 06:25PM PLT COUNT-226
___ 06:25PM NEUTS-67.3 ___ MONOS-7.6 EOS-1.6
BASOS-0.3 IM ___ AbsNeut-6.64* AbsLymp-2.24 AbsMono-0.75
AbsEos-0.16 AbsBaso-0.03
___ 06:25PM WBC-9.9 RBC-4.55* HGB-12.1* HCT-38.2* MCV-84
MCH-26.6 MCHC-31.7* RDW-16.0* RDWSD-49.3*
___ 06:25PM estGFR-Using this
___ 06:25PM GLUCOSE-249* UREA N-16 CREAT-0.9 SODIUM-135
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-23 ANION ___ TESTICULAR/PERINEAL ULTRASOUND
FINDINGS:
The right testicle measures: 3.9 x 2.7 x 5.0 cm.
The left testicle measures: 3.5 x 2.5 x 4.6 cm.
The testicular echogenicity is normal, without focal
abnormalities.
The epididymides are normal bilaterally.
Vascularity is normal and symmetric in the testes and
epididymides.
The skin between the scrotum and anus was scanned. This showed
extensive
subcutaneous edema. There is no focal fluid collection.
IMPRESSION:
1. Normal scrotal ultrasound.
2. Significant subcutaneous edema but no evidence of fluid
collection in the perineum.
Brief Hospital Course:
___ with hidradenitis suppurtiva and chronic pain presents
with HS flare.
# ___ Stage III HS
# HS flare: Patient presented with multiple draining lesions and
increased pain refractory to his home regimen of oxycodone 30 mg
q6 hours, so was referred by his PCP to the ___. He had no
evidence of systemic infection, with normal wbc and diff, no
fevers or chills. His exam was notable for multiple draining
sinus tracts all along the L groin crease back to the perineum.
He underwent an ultrasound that showed no fluid collection in
the groin or perineum. His pain improved while inpatient on
increased frequency of oxycodone (30 mg q4). His antibiotics
were narrowed to cephalexin/doxycycline on the floor as this
regimen was successful during his last hospitalization.
CHRONIC ISSUES
# Diabetes: Last A1c 6.6%. He is not taking any home
medications.
# HTN: BPs were normal while inpatient. He reported that he was
not taking lisinopril at home.
TRANSITIONAL ISSUES
[] He will continue a 7 day course of PO cephalexin/doxycycline
up to and including ___
[] Discharged home with q4 hour oxycodone
[] He has not been taking lisinopril, metformin, or finasteride
all of which remain on his medication list
[] Please continue to encourage smoking cessation
# CODE: full
# CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain - Severe
2. Clindamycin 1% Solution 1 Appl TP BID
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth q6 hours Disp #*19
Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 30 mg 1 tablet(s) by mouth q4 hours Disp #*12
Tablet Refills:*0
4. Clindamycin 1% Solution 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Hidradenitis suppurativa
SECONDARY DIAGNOSES:
Hypertension
diabetes
tobacco use disorder
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 a flare of your hidradenitis. We
did an ultrasound that did not show any fluid collection. You
were treated with IV and then oral antibiotics. Your pain was
managed with more frequent dosing of oxycodone.
When you leave, please continue the medications doxycycline and
cephalexin up to and including ___.
Please follow up with dermatology about other options for your
hidradenitis. It is very important that you stop smoking which
can help improve hidradenitis.
Your ___ Team
Followup Instructions:
___
|
10699400-DS-9
| 10,699,400 | 29,370,586 |
DS
| 9 |
2183-12-03 00:00:00
|
2183-12-03 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:
scrotal swelling/pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___________________________________________________
PCP: ___
.
CC: scrotal swelling/pain
___________________________________________________
HPI: ___ yo M with h/o hidradenitis suppurativa, OSA, asthma,
bilateral UE DVT (on warfarin) who has had chronic,
intermittent drainage of hidradenitis in R groin. Yesterday, the
drainage stopped and he began to notice increasing swelling of
his scrotum R>L. He notes that the groin had been draining a lot
of pus and blood and he thinks that it is now "all going inside"
as his testicle became heavy and painful. He called to ___ and
was referred to ED. He has not had fevers, chills, abd pain. He
did have a headache all day and was feeling fatigued.
He notes that moxifloxacin and doxycycline have worked well
for him in the past.
In ER: (Triage Vitals: 99 ___ 16 100% RA) Meds Given:
Vancomycin, morphine, ondansetron, percocet. Fluids given: 1L
NS, Radiology Studies: scrotal u/s, CT pelvis. urology
consulted--to see in AM.
.
PAIN SCALE: denies pain currently
___________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [x] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
HEENT: [x] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [x] All Normal
[ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Angina [ ] Palpitations [ ] Edema [ ] PND
[ ] Orthopnea [ ] Chest Pain [ ] Other:
GI: [x] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ ] Diarrhea [ ] Constipation [] Abd pain [ ] Other:
GU: [] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
[x] scrotal swelling
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [x] scrotal edema
MS: [x] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [] All Normal
[x ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [] All Normal
[ ] Easy bruising [x ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[x]all other systems negative except as noted above
Past Medical History:
# Hidradenitis suppurtiva, ___ years, has received multiple
treatments in past including oral abx (clindamycin, rifampin,
cefpodoxime), topical clinda gel, retinoids, topical magnesium
chloride, oral zinc; has required surgical removal of sinus
tract in past. Also complicated by pilonidal cyst.
-s/p L axillary eccrine gland excision ___
-s/p R axillary excision ___
#Post-surgical rhabdomyolysis ___: likely a
succinylcholine-induced, requiring readmission
#Prior rhabdomyolysis (not post-op, per last dc summary)
# OSA, s/p surgery, does not wear CPAP
# Tobacco use
# Asthma, uses inhaler prn
# LUE DVT temporally associated with L axillary surgery
# RUE DVT temporally associated with R axiillary surgery
Social History:
___
Family History:
Mother died in her ___ from brain tumor, history of CVA; Father
died in ___ from a fall, subsequent blood clot, history of DM;
Has 3 sibs, none with hidradentitis.
Physical Exam:
T 97.8 P 77 BP 140/82 RR 18 O2Sat 98% RA
GENERAL: mentating clearly, non-toxic, NAD
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, obese, NT/ND, no masses or organomegaly
noted.
Genitourinary: no flank tenderness. Two areas of bloody drainage
from R groin, + tender, indurated area in R groin. Scrotal
swelling and tenderness R>L.
Skin: R axillary hidradenitis with one area (proximally) of
induration/tenderness that expresses pus.
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: pleasant and interactive
ACCESS: [x]PIV
Discharge Exam:
Notable for reduced right sided scrotal edema. Nontender to
palpation. Mild tenderness to palpation with very small amount
of induration and drainage
Pertinent Results:
Admission Labs:
___ 01:30AM WBC-13.6* RBC-5.15 HGB-13.4* HCT-42.1 MCV-82
MCH-26.1* MCHC-31.9 RDW-15.1
___ 01:30AM NEUTS-77.3* LYMPHS-17.1* MONOS-3.9 EOS-1.2
BASOS-0.6
___ 01:30AM PLT COUNT-240
___ 01:30AM ___ PTT-47.9* ___
___ 03:24AM LACTATE-1.1
___ 01:30AM GLUCOSE-100 UREA N-12 CREAT-1.1 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
Imaging
___ CT pelvis:
FINDINGS: There is severe subcutaneous edema and induration
involving the
scrotal walls, right greater than left. No drainable fluid
collections, and no extension into the thigh. Scattered foci of
air are likely located within the inguinal creases. Bilateral
reactive inguinal nodes measure 10-12 mm.
Within the pelvis, bladder and distal ureters are normal, with
bilateral
ureteral jets visualized. Prostate and seminal vesicles are
normal. Appendix is normal. Scattered sigmoid diverticulosis.
There is no free
intraperitoneal fluid or air.
Osseous structures are unremarkable.
IMPRESSION: Severe scrotal wall edema, without drainable fluid
collections.
___ scrotal U/S:
SCROTAL ULTRASOUND: There is severe right scrotal wall edema and
induration. No drainable fluid collections are identified. The
right testis measures 3.9 x 3.8 x 2.3 cm, and the left testis
measures 4.9
x 3.4 x 2.8 cm. Vascularity is normal to the bilateral testes
and epididymides. Arterial and venous Doppler waveforms are
preserved. There is no evidence of hydrocele.
IMPRESSION: Severe right scrotal wall edema. Normal testicular
ultrasound.
___ Blood cx: pending
Discharge/Notable Labs:
___ 09:00AM BLOOD WBC-10.4 RBC-4.95 Hgb-13.0* Hct-39.0*
MCV-79* MCH-26.3* MCHC-33.3 RDW-15.2 Plt ___
___ 09:00AM BLOOD Glucose-122* UreaN-12 Creat-1.0 Na-140
K-3.7 Cl-102 HCO3-27 AnGap-15
Studies pending on discharge:
Blood cultures
Brief Hospital Course:
___ yo M with h/o hidradenitis suppurativa (axilla, groin), OSA,
asthma, bilateral upper extremity DVTs, now on chronic warfarin
admitted with scrotal swelling and pain.
#Scrotal swelling/Hidradenitis:
Patient had CT and US which showed scrotal edema but no obvious
fluid collection or abscess. Given that the patient noted that
pain and swelling occurred after drainage of groin lesions
stopped, it was felt that the abscence of adequate drainage from
groin hidradenitis may have led to pain and blockage of usual
scrotal drainage. Some pus was expressed from groin lesions and
patient was started on Vancomycin and clindamycin with
improvement in perineal and scrotal pain and reduction in
scrotal swelling. The patient was also seen by Urology who
agreed with antibiotics. Althoug the scrotal swelling was not
completely resolved at the time of discharge it was much
improved as was the patient's pain. In the differential of
scrotal edema was heart failure and venous obstruction. The
patient however did not have any evidence of heart failure and
INR was 3.6 making venous thrombosis unlikely. Also there were
no mass lesions noted on CT to suggest any extrinsiv venous or
lymphatic obstruction although as stated above, lack of groin
drainage could have caused scrotal lymphedema. Given that it is
not entirely clear what caused the patient's presentation, the
patient was instructed to follow up with his PCP ___ ___ weeks.
He was discharged to complete 1 week of moxifloxacin and
doxycycline which has worked for him in the past.
#Chronic upper extremity deep venous thrombosis:
Patient had INR of 3.6 and was started on antibiotics known to
raise the level of INR. His last Coumadin ingestion was ___.
Therefore, the patient was instructed to hold his Coumadin and
have his INR checked at ___ on ___ after which
he could be instructed on how to dose his Coumadin based on his
INR on ___.
#GERD: Continued on H2 blocker
#CODE: Full
#Disposition: Patient was discharged home with instructions to
hold Coumadin until INR check in ___ clinic 2 days from
discharge and to continue 1 week of moxifloxacin and
Doxycycline. He will also make PCP appt in ___ weeks.
Medications on Admission:
warfarin 12.5 mg daily
ranitidine 150mg bid
NOT TAKING:
mirtazapine 15 qhs
oxycodone 10mg prn (none recently)
albuterol prn
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Tablet(s)
2. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. MEDICATION CHANGES
Please do NOT restart your Coumadin until you have your INR
checked in ___ clinic and are instructed on how to adjust
your Coumadin dosing since antibiotics can alter your INR and
your INR was above goal during this hospitalization
4. doxycycline hyclate 100 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 7
days.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hidradenitis suppurtiva
Scrotal edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with right sided scrotal edema and pain which
improved dramatically without intervention. You had a CT scan
and a scrotal ultrasound which did not show any obvious cause
for your swelling and you were seen by the Urology service who
recommended only oral antibiotics for your hidradenitis but no
further Urologic testing.
Since you were having some tenderness in the area of your groin
hidradenitis you are being discharged on a short course of
moxifloxacin and doxycycline as this has worked well for you in
the past.
Since it is not entirely clear the cause of your scrotal pain
and swelling (we suspect it is possibly related to a flare of
your groin hidradenitis), you should make an appointment with
your primary care doctor in the next ___ weeks for follow up and
to determine whether your antibiotic course needs to be
extended.
Additionally, your INR was 3.6 which is above goal. Antibiotics
can also increase your INR. Therefore, you should hold your
Coumadin until you have your INR checked on ___. Your
___ clinic can then instruct you on how to adjust your
Coumadin dosing based on the value of your INR.
Please also call your doctor if you experience, fevers, chills,
or severe pain and swelling while on antibiotics.
Followup Instructions:
___
|
10699751-DS-14
| 10,699,751 | 22,638,972 |
DS
| 14 |
2175-05-07 00:00:00
|
2175-05-07 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dizziness, confusion, gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with breast cancer (ER positive/PR negative, HER-2/neu
negative) s/p Cytoxan/Taxotere, adjuvant radiation and
lumpectomy (___) now on anastrazole, L2 compression fracture,
Alzheimer's disease with mild cognitive impairment, HTN,
recently found lung mass and brain mass likely metastatic who
presented to ED with one day of unsteadiness, dizziness, and ~ 1
week of worsening memory and confusion after bronchoscopy day
before.
Patients family provides most of the history due to patient not
remembering much of the events from yesterday. But they said
that after her bronch on ___ she felt well without issues.
She didn't eat or drink for most of the day for the
bronchoscopy. She woke up the next morning (___) and felt
unsteady on her feet, lightheaded and had episodes of vertigo.
She is unable to describe what she was feeling well as she
doesn't remember much and has been having a very poor memory
recently. She says that worsening of dizziness would be caused
by moving, going from sitting to standing etc. This persisted so
she came to the emergency room for evaluation. She now feels
well without much dizziness or lightheadedness. Her family
agrees that her gait is much better as well.
She also has baseline cognitive decline which per family has
dramatically worsened in the last week or so. She now has severe
short term memory loss and frequently asks the same question
over and over again. For example family says that while she has
been in the ED she has frequently asked why they are there, or
asking where they are.
In regards to her new lung mass patient initially presented to
OSH ED on ___ for chest pain, found to have lung mass in
upper left lobe. She had PET that showed FDG uptake peripherally
in lung lesion c/w malignancy. She had MRI brain as well that
showed 4mm right corona radiata that is peripherally enhancing
with mild surrounding edema. Read as likely metastasis but
differential consideration of abscess.
On neuro ROS, the positives per HPI, 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:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post hysterectomy in ___, ovaries remain in place.
4. Status post tonsillectomy.
5. Status post right rotator cuff tear in ___.
6. Status post appendectomy at ___ years old.
7. History of elevated homocysteine level.
8. Ongoing workup for developing cataracts.
9. RIGHT FRONTAL LOBE LESION
10. LUNG MASS
11. BREAST CANCER
12. MCI
13. DEPRESSION
SHX:
========
iridectomy
appendectomy
hysterectomy
right shoulder surgery
breast lumpectomy
Social History:
___
Family History:
Family history includes her mother, who died at
age ___ with metastatic cancer. Her father died of heart
problems
when he was ___. Her brother died suddenly following a heart
attack at age ___.
Physical Exam:
Physical Exam:
Vitals: T96.9, HR 74, BP 157/69, RR 18, 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity, no carotid bruits
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to ___,
___, she is able to say that she remembers feeling
unsteady yesterday but is unable to give many details about the
history, Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes, gets second 2
words with clues. The pt had good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam performed, revealed crisp disc margins with no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI with gaze evoked nystagmus bilaterally that
extinguishes, 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. With good side-to-side
movement
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, mildly early
extinction to vibration in toes bilaterally(extinguishes at 3
seconds), proprioception in toes only intact to large movements
bilaterally, vibration and proprioception are intact in hands,
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No overshoot with
mirroring, no rebound, no truncal ataxia
-Gait: Patient is able to sit on the side of the bed without
assistance, able to get up off the bed without assistance with
putting her feet close together she becomes very unsteady and
falls off the side of the bed even with her eyes open, her gait
is mildly unsteady but per patient and family it seems back to
baseline, she is unable to tandem.
=================
Discharge physical exam:
Physical Exam:
24 HR Data (last updated ___ @ 417)
Temp: 98.1 (Tm 98.1), BP: 168/73 (___), HR: 65
(65-70), RR: 18, O2 sat: 93% (93-97), 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, no carotid bruits
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to ___,
___, didn't recall what she ate for dinner. able to
recall
___ and ___ ___ backward.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt was able to
name high frequency objects, not low (cuticle, clasp). Speech
was
not dysarthric. Able to follow both midline and appendicular
commands.
Pt was able to register 3 words (apple, table, ___ and recall
2 at one minute, and third with category. At 5 minutes, ___
with
clues. 10 animals in 1 minute.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam performed, revealed crisp disc margins with no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI with gaze evoked nystagmus bilaterally that
extinguishes, 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. With good side-to-side
movement
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pin prick, No extinction
to DSS.
-DTRs: no ___ jerk.
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: Differed
-Gait: Patient is able to sit on the side of the bed without
assistance, able to get up off the bed without assistance with
putting her feet close together she becomes very unsteady.
slightly unsteady gate, but danced to show off.
Pertinent Results:
___ 10:08AM BLOOD WBC-10.5* RBC-4.26 Hgb-13.1 Hct-39.7
MCV-93 MCH-30.8 MCHC-33.0 RDW-13.3 RDWSD-45.2 Plt ___
___ 10:08AM BLOOD Neuts-80.5* Lymphs-13.6* Monos-5.4
Eos-0.1* Baso-0.1 Im ___ AbsNeut-8.43* AbsLymp-1.43
AbsMono-0.57 AbsEos-0.01* AbsBaso-0.01
___ 10:08AM BLOOD Glucose-171* UreaN-12 Creat-0.7 Na-140
K-3.6 Cl-100 HCO3-23 AnGap-17
___ 03:29PM BLOOD ALT-6 AST-16 AlkPhos-44 TotBili-0.6
___ 10:08AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8
___ 10:08AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8
___ 10:08AM BLOOD VitB12-621 Folate-5
___ 01:45PM BLOOD Ammonia-<10
___ 10:08AM BLOOD TSH-3.8
___ 10:08AM BLOOD CRP-2.9
___ 12:05PM BLOOD SED RATE-PND
___ 07:59PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 07:59PM URINE RBC-<1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:59PM URINE Color-Straw Appear-Clear Sp ___
___ 7:59 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 07:45AM BLOOD WBC-6.5 RBC-4.62 Hgb-14.2 Hct-42.5 MCV-92
MCH-30.7 MCHC-33.4 RDW-13.3 RDWSD-45.1 Plt ___
___ 07:45AM BLOOD Albumin-3.5 Calcium-9.3 Phos-4.3 Mg-1.8
___ 10:08AM BLOOD VitB12-621 Folate-5
___ 08:04AM BLOOD ___ pO2-176* pCO2-37 pH-7.44
calTCO2-26 Base XS-1 Comment-GREEN TOP
___ 08:04AM BLOOD ___ pO2-176* pCO2-37 pH-7.44
calTCO2-26 Base XS-1 Comment-GREEN TOP
___ 10:52AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 07:59PM URINE RBC-<1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-<1
EEG final results pending, but no evidence of seizure.
-
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with lung mass and concern for
PNA// pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None
IMPRESSION:
The dominant left upper lobe mass abutting the left hilum is
unchanged. Small left pleural effusion is also stable.
Cardiomediastinal silhouette is stable. There is upper lobe
predominant emphysema. No pneumothorax.
=====
MRI Brain:
___ - MRI Head w/out contrast: IMPRESSION: 1. Right corona
radiata lesion shown to be a peripherally enhancing abnormality
on previous brain MRI appears similar to previous examination.
It remains concerning for metastatic disease. Abscess formation
is also in the differential given the central pattern of its
diffusion abnormality.
2. No new areas of diffusion abnormality are seen to suggest
infarction.
======
CTA Head and Neck:
head:
Re-identified is a neck edema in the right frontal lobe, likely
corresponding
to recently detected enhancing lesion concerning for metastatic
disease,
better visualized on MRI of ___. No significant
mass effect.
There is no evidence of new large territory infarction or
hemorrhage. There
are mild periventricular white matter hypodensities,
nonspecific, most likely
sequela of chronic small vessel disease. The ventricles and
sulci are
enlarged, likely related involutional changes
There is no gross evidence of acute fracture. The ethmoid,
sphenoid, frontal
and maxillary sinuses are clear. The middle air cavities are
unremarkable.
Patient status post bilateral lens replacements.
CTA neck:
Conventional 3 vessel arch with moderate calcifications of the
origins of the
great vessels, including aortic arch. Moderate severe
calcification at the
level of the carotid bifurcation. No significant stenosis of the
internal
carotid arteries by NASCET criteria. CT angiography of the neck
shows normal
appearance of the carotid and vertebral arteries without
stenosis or occlusion
or dissection.
CTA head:
Moderate to severe atherosclerotic calcification of the carotid
siphons. CT
angiography of the head shows normal appearance of the arteries
of the
anterior and posterior circulation without stenosis or occlusion
or aneurysm
greater than 3 mm in size.
Other: Re-identified lung mass measuring 7 x 5.5 cm (3:1) in the
left upper
lobe. Also, apical scarring of the left upper lobe (3:80). There
is a 6.5 mm
thyroid nodule in the left lobe (3:106) and 3.5 mm nodule in the
right lobe
(3:89). Moderate multilevel degenerative changes of the
visualized spine.
There is mild canal narrowing at the level of C6 due to
posterior osteophytes.
Moderate neural foramina narrowing and facet hypertrophy, most
predominantly
seen at C3-C5.
Final report pending reformats.
-
Brief Hospital Course:
Ms. ___ is a ___ woman with history notable for
breast cancer s/p chemotherapy, adjuvant radiation, and
lumpectomy, Alzheimer's disease, HTN, and a recently discovered
left lung mass c/b suspected brain metastatic lesion admitted
with one day of gait disturbance and two days of prominent
disorientation in the setting of about one week of memory
disturbance. Repeat MRI did not reveal evidence of interval
infarct, hemorrhage, or progression of right frontal lobe
rim-enhancing lesion, suspected to reflect metastasis or abscess
(with the latter less likely in the absence of fevers, headache,
interval imaging progression, or systemic risk factors). Routine
EEG without evidence of intercurrent seizures (while
symptomatic) on preliminary review. Examination improved to
baseline on the second day of admission with steady gait, mild
inattentiveness, and mild memory deficits. Urinalysis and chest
x-ray without evidence of infection. Given rapid improvement and
onset following diagnostic bronchoscopy, suspect that symptoms
reflected toxic-metabolic encephalopathy precipitated by recent
procedure and sedation.
Transitional Issues:
1. Follow up elevated ESR.
2. Ongoing follow-up with oncology for lung mass with suspected
brain metastasis; consider delayed repeat brain imaging given
radiologic differential of metastatic lesion vs. abscess (though
currently with very low clinical suspicion for the latter).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Allopurinol ___ mg PO DAILY
3. Vitamin D 1000 UNIT PO EVERY OTHER DAY
4. Propranolol 10 mg PO BID
5. Venlafaxine XR 75 mg PO BID
6. Anastrozole 1 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. Anastrozole 1 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Propranolol 10 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Venlafaxine XR 75 mg PO BID
8. Vitamin D 1000 UNIT PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic-metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital due to dizziness, imbalance,
and disorientation since your bronchoscopy on ___
___. You had another MRI image of your head which showed that
the lesion in your brain had not changed over the past few days,
with no new strokes or bleeds to explain your symptoms. On
___ morning, you were back to your normal self - able to walk
(and dance!) and no longer disoriented. Your lab work and urine
showed some signs of a possible infection so we took an xray of
your chest, and repeated your urine testing, which did not show
signs of a new infection. You also had a routine EEG that did
not show signs of a seizure on preliminary review. Your symptoms
may have been due to delayed recovery from sedation from your
earlier procedure.
Please follow up with your primary care provider within one week
of discharge, and with Neurology at the appointment listed
below. Please contact your primary care provider if you
experience any signs of possible infection such as fevers,
chills, productive cough, burning with or increased frequency of
urination, changes in your thinking or memory, or have trouble
walking.
Thank you for the opportunity to participate in your care,
___ Neurology
Followup Instructions:
___
|
10700130-DS-23
| 10,700,130 | 23,889,435 |
DS
| 23 |
2201-04-04 00:00:00
|
2201-04-05 07:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
leg swelling and lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ DM, Afib on coumadin, HTN brought by EMT from home with
increased lethargy per family. The pt is not able to give a
detailed hx of the events that led her to become hospitalized
and she was not accompanied by a family member today on arrival
to the hospital. Per her daughter ___ who sent her to the
hospital, this am she found her mother to be more confused than
usual. She was not as clear mentally as she normally is and she
was having problems transfering from her bed to her wheelchair
which is something that she normally can do without difficulty.
Her daughter checked a ___ which was 180. She then gave her 10U
of ___ which she is not prescribed. Her confusion continued
and her daughter then called ___. ___ also states that the
erythema and warmth of her RLE started approximately two days
ago. It has not been draining any purulent fluid and she does
not think her mother has had any fevers.
.
In the ED, initial vs were:T99 P84 BP152/80 R16 O2 sat98%RA. Pt
was not accompanied by her family and is a poor historian per ED
notes. Her PE was notable for RLE chronic wound w/ erythema and
warmth. Labs were remarkable for WBC 12 w/ 87%PMNs. CXR and CT
head was wnl. Patient was given Vancomycin and sent to the
floor.
.
On the floor, vs were: T99, HR 84, BP 152/80, RR 16 98%RA.
Review of sytems:
(-) Denies headache, 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:
- Atrial fibrillation, on Coumadin
- Type 2 diabetes, on insulin Lantus
- PVD status post transmetatarsal amp in ___ for ischemic ulcer
and high-grade right RAS and included left internal iliac artery
with occlusion noted in the SFA as well as at the popliteal
trifurcation.
- Hypertension.
- History of breast cancer, status post left mastectomy as
noted.
- MGUS followed by Dr. ___.
- History of TIA in ___ and probable likely TIA in ___.
- Hyperlipidemia.
- Obesity
- Chronic Renal Insufficiency - baseline creatinine 1.4 to 1.7
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99 BP:152/80 P:84 R:16 O2:98%RA
General: Alert, pt able to accurately state name, date but was
not able to state why she was sent to the hospital, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: supple, no LAD
Lungs: wheeze throughout w/ respiratory grunt, pt felt like
breathing was comfortable
CV: irregular rate and rhythm, no murmurs, rubs, gallops, 1+ DP
in RLE
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: L BKA, 4cm superficial wound w/ granulation tissue present
on medial lower calf, erythema and warm present, boarders marked
Neuro:UE strength ___
DISCHARGE PHYSICAL EXAM:
Vitals: T:98 BP:110s-140s/50s-80s P:60s-80s R:20 O2:97%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: supple, no LAD
Lungs: wheeze throughout w/ respiratory grunt, pt felt like
breathing was comfortable
CV: irregular rate and rhythm, no murmurs, rubs, gallops, 1+ DP
in RLE, RLE pulse was also able to be heard with doppler
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: L BKA, 4cm superficial wound w/ granulation tissue present
on medial lower calf, erythema and swelling has resolved
Neuro:UE strength ___
Pertinent Results:
PERTINET LABS:
___ 03:00PM BLOOD WBC-12.7*# RBC-3.94* Hgb-11.4* Hct-38.4
MCV-98 MCH-29.0 MCHC-29.7* RDW-14.4 Plt ___
___ 03:00PM BLOOD Neuts-86.7* Lymphs-7.7* Monos-5.0 Eos-0.2
Baso-0.4
___ 03:00PM BLOOD ___ PTT-39.4* ___
___ 03:00PM BLOOD Glucose-60* UreaN-29* Creat-1.6* Na-143
K-4.5 Cl-109* HCO3-26 AnGap-13
___ 03:00PM BLOOD Calcium-9.2 Phos-2.4* Mg-2.2
___ 03:00PM BLOOD Lactate-1.9
___ 03:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:00PM URINE RBC-1 WBC-1 Bacteri-MANY Yeast-NONE
Epi-<1
MICRO:
___ 3:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:00 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
CT HEAD W/O CONTRAST Study Date of ___ 1:48 ___
FINDINGS: There is no intracranial hemorrhage, edema, or mass
effect. The ventricles and sulci are large, compatible with
atrophic change.
Periventricular hypodensity, most prominent in the left frontal
horn likely reflects sequela of chronic small vessel ischemic
disease. Otherwise, the visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
CHEST (PA & LAT) Study Date of ___ 2:35 ___
FINDINGS: There is mild pulmonary vascular congestion. No
definite pleural effusion or pneumothorax. Heart size is
enlarged. The aorta is calcified and tortuous.
IMPRESSION: Cardiomegaly with mild interstitial edema.
Brief Hospital Course:
Ms. ___ is a ___ w h/o a.fib, PVD, chronic renal
insufficiency who presents with warm erythematous RLE in the
setting of a wound in the corresponding area concerning for
cellulitis.
# Cellulitis- Pt developed RLE wound in ___ which was
believed to be caused by pt hanging her leg over the side of her
bed. Since that time she has been receiving home ___ wound care
services and has been evaluated by her PCP for this wound. This
wound has been slow to heal considering her documented PVD. Her
current physical exam findings were concerning for a cellulitis.
Vancomycin was initiated and the erythema, warmth and
leukocytosis quickly resolved. A wound care consult was obtained
for dressing recommendations. She was discharged on Doxycycline
and Cephalexin to complete a ___.Fib- Pt is on warfarin for anticoagulation with INR goal of
___. Admitting labs showed therapeutic INR. Not on rate control
medication. We continued warfarin 5mg daily. Her INR trended up
to 3.4. We held her warfarin dose and on day of discharge her
INR was 3.0. Instructions were given to rehab facility to
continue to hold warfarin on ___, recheck INR the following
day and restart home warfarin dose of 5mg daily if appropriate.
# Chronic Kidney Disease- Creatine remained w/in her baseline
range. Her medications were renally dosed.
# HTN- Continued her out pt regimen of anti-hypertensive
medications.
- ramipril 2.5mg daily
# DM II- Pt not on insuling at home. Daughter gave her 10U
___ for ___ of 180. On arrival to the ED ___ was 60. She
recovered with PO nutrition in the ED. She was placed on ISS. We
also continued ASA 81mg daily.
# HL- Will continue Simvastatin 40mg
#Transitional:
1. Pt will require rehab post discharge
2. she should be follow up by pcp ___ ___.
3. INR should be checked on ___ and decision to restart home
warfarin dose should be made at that time.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for wheeze .
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
9. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital with an
infection in your right leg. We started you on antibiotics for
this infection and it has significantly improved. We would like
you to continue to take the antibiotics Doxycycline and
Cephalexin to complete a 7 day course.
The following changes have been made to your medications:
START:
Doxycycline and Cephalexin for four more days to complete a 7
day course
HOLD:
We recommend you hold your warfarin dose tonight (___) as
your INR today was 3.0.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10700130-DS-25
| 10,700,130 | 20,804,212 |
DS
| 25 |
2203-02-26 00:00:00
|
2203-02-26 16:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with afib on coumadin, dementia, HTN, CKD, PVD s/p L BKA,
Breast CA s/p mastectomy, presvious TIAs who presents with
confusion found to have a UTI. She was noted by her daughter to
be confused and not her usual "sharp" self over the past 2 days.
Usually able to assist with transitions from bed to wheelchair,
but was very weak over the past ___ days and slid down from her
wheelchair and landed on the ground on day of admission,
prompting call to EMS. Per daughter, patient was having trouble
with urination on day of admission but patient denies. She
further denies any fevers, chills, shortness of breath, nausea,
vomiting, diarrhea, constipation.
In the ED intial vitals were: (unable) 97.0 83 114/86 20 100%RA.
Noted to be very hard of hearing with some TTP on R hip. UA
positive for many WBCs, bacteria, +nitrites ___, started on
ceftriaxone. CT head done and prelim negative. Hip films done
showing no acute fracture. EKG notable for new TWI, trop 0.02
which is baseline for the patient, and no chest pain. CXR
without infiltrate. Vitals on transfer were: 0 67 127/85 22 100%
RA.
On arrival to the floor, she is asking about her engagement
ring. She denies any pain, shortness of breath, or any
discomfort whatsoever. She states she is hungry.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Atrial fibrillation, on Coumadin
- Type 2 diabetes
- PVD status post transmetatarsal amp in ___ for ischemic ulcer
and high-grade right RAS and included left internal iliac artery
with occlusion noted in the SFA as well as at the popliteal
trifurcation, s/p BKA
- Hypertension.
- History of breast cancer, status post left mastectomy as
noted.
- MGUS followed by Dr. ___ previously declined)
- History of stroke in ___ (imaging showed L basal ganglia
hemorrhage per notes)
- probable TIA in ___.
- Hyperlipidemia.
- Obesity
- Chronic Renal Insufficiency - baseline creatinine 1.4 to 1.7
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals - T: 97.5 BP: 170/74 HR: 76 RR: 18 02 sat: 97%RA
GENERAL: NAD, laying in bed asking about engagement ring, very
hard of hearing
HEENT: AT/NC, pupils anisocoric (chronic) sclerae are injected
without discharge and crusting, pink conjunctivae, patent nares,
OP clear, poor dentition,
NECK: large, nontender, no LAD, unable to assess JVP
CARDIAC: irregular, 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
EXTREMITIES: L BKA without lesions or swelling, RLE edematous
with multiple ulcers at distal ___ covered in ointment, no
apparent drainage, leg is erythematous to mid-shin. R
___ distal great toe adjacent to onychomycotic nail is
black without drainage but appears destroyed by infection. No
TTP on R hip
PULSES: trace+ DP pulses RLE
NEURO: alert, following commands, tongue midline
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals: Afebrile 98.1 134/64 74 20 99%RA
GENERAL: Obese woman, disheveled, sleeping comfortably in bed,
NAD, very hard of hearing
HEENT: AT/NC, pupils anisocoric (chronic) sclerae are injected
without discharge and crusting, poor dentition
NECK: Large
CARDIAC: irregular, S1/S2, no murmurs, gallops or LAD, or rubs
LUNG: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: Obese, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: L BKA without lesions or swelling. RLE edematous
with multiple ulcers at distal ___ covered in ointment without no
apparent drainage, venous stasis changes.
PULSES: trace+ DP pulses RLE
NEURO: alert, following commands, tongue midline
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 05:35PM BLOOD WBC-4.1 RBC-4.24 Hgb-12.5 Hct-42.6
MCV-101* MCH-29.5 MCHC-29.3* RDW-14.9 Plt ___
___ 05:35PM BLOOD Neuts-69.0 ___ Monos-7.9 Eos-1.9
Baso-2.3*
___ 05:35PM BLOOD ___ PTT-40.8* ___
___ 05:35PM BLOOD Glucose-142* UreaN-36* Creat-1.5* Na-144
K-4.9 Cl-110* HCO3-23 AnGap-16
___ 05:35PM BLOOD cTropnT-0.02*
ANTICOAGULATION
===============
___ 05:35PM BLOOD ___ PTT-40.8* ___
___ 05:35AM BLOOD ___ PTT-41.3* ___
___ 05:30AM BLOOD ___ PTT-41.4* ___
___ 05:15AM BLOOD ___ PTT-38.8* ___
DISCHARGE LABS
===============
___ 05:15AM BLOOD WBC-4.2 RBC-3.47* Hgb-10.3* Hct-34.4*
MCV-99* MCH-29.8 MCHC-30.0* RDW-15.1 Plt ___
___ 05:15AM BLOOD ___ PTT-38.8* ___
___ 05:15AM BLOOD Glucose-111* UreaN-37* Creat-1.4* Na-144
K-4.6 Cl-110* HCO3-27 AnGap-12
___ 05:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
MICROBIOLOGY
=============
___ BLOOD CULTURE X2
___ 5:35 pm URINE SOURCE: CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
REPORTS
========
___ CT Head
No acute intracranial hemorrhage identified
___ Plain Films R Hip Films
AP view of the pelvis and AP and frogleg views of the right hip.
There is no fracture or acute osseous abnormality. Pubic
symphysis and SI joints are preserved. Dense atherosclerotic
vascular calcifications are noted. Calcific densities projecting
over the pelvis are suggestive of degenerative fibroids.
IMPRESSION: No visualized fracture.
___ Chest X-ray
Two supine views of the chest. The lungs are clear of focal
consolidation, effusion or pulmonary edema. Degree of
moderate-to-severe cardiomegaly is unchanged given differences
in positioning. No displaced fractures identified. IMPRESSION:
Cardiomegaly without definite superimposed acute cardiopulmonary
process.
Brief Hospital Course:
___ with atrial fibrillation on coumadin, type 2 diabetes,
dementia, hypertension, chronic kidney disease, and peripheral
vascular disease who presents with confusion and weakness, found
to have a complicated urinary tract infection.
# Complicated urinary tract infection: Patient presented with
confusion and weakness, found to have urinary tract infection
with urine culture growing two strains of E.coli resistant to
Bactrim and ampicillin but otherwise sensitive to
cephalosporins. Patient was treated with ceftriaxone initially,
transitioned to PO cefpodoxime at the time of discharge. Given
diabetes, patient's urinary tract infection is categorized as
complicated and she will need to complete 7 days of antibiotics
(last day ___.
# EKG changes: Patient was found to have nonspecific T-wave
inversions on EKG at the time of admission. Two sets of cardiac
biormarkers were sent with CK-MB within normal limits and
troponin-T within patient's baseline (0.02). Patient was without
chest pain throughout this admission.
# Atrial Fibrillation on coumadin: Patient's INR was
supratherapeutic to 3.4 in the setting of antibiotics. Warfarin
was held for 2 days, and restarted at a decreased dose of 2.5mg
alternating with 5mg every other day per pharmacist
recommendations. INR on discharge was 2.7 with next INR check
due ___.
# Peripheral Vascular Disease complicated by ulcers: Patient has
long-standing ulcers followed at ___ wound ___.
During this admission, ulcers remained without active signs of
infection, and wound care was provided per wound care nurse
recommendations. She was continued on her home aspirin 81mg
without complications. ___ Vascular surgery follow-up
scheduled for ___
# Hypertension: Remained stable on home ramipril.
# Type 2 Diabetes Mellitus: Home Januvia held while in the
hospital and restarted at the time of discharge. Blood sugars
remained stable on gentle insulin sliding scale during this
admission.
# Chronic Kidney Disease: Patient has baseline Cr 1.3-1.6. Her
renal function was monitored and remained within baseline during
this admission.
# Hyperlipidemia: Remained stable on home simvastatin.
# Medication reconciliation: Continue home timolol and albuterol
without complications.
=================================
TRANSITIONAL ISSUES
=================================
- STARTED cefpodoxime 200mg daily to complete 7 day course for
UTI (last day ___
- DECREASED warfarin to 2.5mg every other day alternating with
5mg every other day. INR at discharge 2.7, next INR check due
___ (goal ___
- Vascular surgery follow-up scheduled for ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ramipril 2.5 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Warfarin 5 mg PO 5X/WEEK (___)
7. Januvia (sitaGLIPtin) 25 mg Oral daily
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
9. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Aspirin 81 mg PO DAILY
3. Ramipril 2.5 mg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Warfarin 5 mg PO EVERY OTHER DAY
6. Warfarin 2.5 mg PO EVERY OTHER DAY
7. Januvia (sitaGLIPtin) 25 mg Oral daily
8. Multivitamins 1 TAB PO DAILY
9. Cefpodoxime Proxetil 200 mg PO Q24H
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Urinary tract infection
SECONDARY DIAGNOSES
Atrial fibrillation on coumadin
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking are of you during this hospitalization.
You were admitted to ___ for
weakness and confusion. This was caused by a urinary tract
infection, for which you were started on antibiotics. You will
need to continue antibiotics for another 4 days. Your warfarin
dose was decreased in the setting of high INR due to
antibiotics. Our physical threapy team saw you and recommend
that you go to rehab from the hospital for further recovery.
Because of your leg ulcers, we scheduled you follow-up with our
Vascular surgery team on ___.
You are now safe to leave the hospital. Please follow-up with
your doctors as ___ and take your medication as
prescribed. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs.
Followup Instructions:
___
|
10700130-DS-27
| 10,700,130 | 22,679,130 |
DS
| 27 |
2203-03-20 00:00:00
|
2203-03-20 16:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Right great toe gangrene
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with Hx of a-fib on coumadin, s/p left fem-pop bypass
followed by TMA then BKA on that side, referred from vascular
surgery clinic to ED for gangrenous right toe. Denies rest pain
but does endorse intermittent R great toe pain x 1 week. Denies
fevers or nausea/vomiting. She is non-ambulatory at baseline and
uses a wheel-chair at home.
Past Medical History:
PMH - dementia, PVD, CVA (___), TIA ___, a-fib on coumadin,
pulm HTN, breast CA s/p mastectomy, MGUS, CKD (baseline Cr
1.4-1.7)
PSH - L fem-pop bypass, L TMA (___), L BKA (___)
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On admission:
VS: 99.8 67 150/51 16 96% RA
Gen - NAD, drowsy yet arousable, difficulty hearing
Abdomen - soft, NT, ND
Extrem -
LLE: s/p well-healed BKA. Well-healed bypass incision.
RLE: Hyperpigmented, dry calf with 2 uninfected ulcers, dry
gangrene of R great toe with discolored toes up to mid-foot; no
erythema or fluctuance or discharge
Pulses -
L: palpable femoral, dopplerable popliteal
RLE: palpable femoral, dopplerable popliteal (monophasic) and
DP (monophasic), ___ not dopplerable
Neuro - active movement and light touch sensation of R great toe
intact
On discharge:
VS: 98.3, 82, 133/51, 20, 99% RA
Gen: NAD, AAOx1
Neuro: CN II-XII intact, active movement and light touch
sensation of R great toe intact
CV: Irregularly irregular
Pulm: No resp distress
Abd: Soft, NT/ND, obese
Ext:
LLE: s/p BKA, well-healed, well-healed bypass incision
RLE: Calf dry with 2 shallow ulcers w/o erythema/induration.
Dry gangrenous lesion to R great toe with dusky coloration but
without ___ evidence of necrosis beyond toe, no
erythema/induration/fluctuance/discharge
Pulses: L: palpable femoral, dopplerable popliteal
RLE: palpable femoral, dopplerable popliteal (monophasic) and
DP (monophasic), ___ not dopplerable
Pertinent Results:
___ 10:30AM BLOOD WBC-4.6 RBC-3.70* Hgb-10.8* Hct-36.5
MCV-99* MCH-29.2 MCHC-29.7* RDW-14.4 Plt ___
___ 06:50AM BLOOD Glucose-106* UreaN-26* Creat-1.4* Na-141
K-4.8 Cl-105 HCO3-19* AnGap-22*
Brief Hospital Course:
Ms. ___ was admitted to the vascular surgery service with HPI
as stated above. She was given her home medicines including
coumadin and aspirin and her wounds were assessed and dressed
without debridement. She was also started on empiric IV
antibiotics; blood cultures were sent and had not grown any
bacteria by the time of her discharge.
On the day after her admission, a discussion was had with her
daughter with regard to the possibility of performing
angiography with planned intervention and also limited
amputation. The patient's daughter stated that in light of the
patient's age and comorbidities, she believes it would not be
compatible with her mother's wishes to proceed with any surgery.
The patient's labs were followed for another day and she did not
develop a leukocytosis and she remained afebrile. It was
decided that the patient should proceed to be discharged to her
former ___ with a 2-week course of Augmentin.
The patient's family is aware of the plan and agrees. The
patient will follow up with Dr. ___ in the office before the
antibiotic course ends.
She is discharged to rehab on the afternoon of ___.
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
2. Ramipril 2.5 mg PO DAILY
3. Warfarin 5 mg PO DAYS (___)
4. Warfarin 2.5 mg PO DAYS (MO,FR)
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Simvastatin 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Januvia (sitaGLIPtin) 25 mg Oral daily
10. Aspirin 81 mg PO DAILY
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
2. Aspirin 81 mg PO DAILY
3. Ramipril 2.5 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Simvastatin 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ipratropium Bromide Neb 1 NEB IH Q6H SOB/wheezing
9. Januvia (sitaGLIPtin) 25 mg oral daily
10. Warfarin 5 mg PO DAYS (___) AS DIRECTED
Duration: 1 Dose
11. Furosemide 40 mg PO DAILY
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right great toe gangrene
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were seen for gangrene of one of your toes. We considered
going ahead with angiography to improve blood flow, followed by
amputation after improved blood flow increased the chance of
good healing, but in discussion with your family it was decided
that you would not undergo this procedure.
You will be discharged to your former rehab facility with a
prescription for an oral antibiotic. This antibiotic is called
Augmentin. Take it as prescribed for a 2-week course.
You have an appointment with Dr. ___ on ___
at 1:15 ___ (see appointments below). Please continue taking the
Augmentin through the time of this appointment.
You should also resume all other home medicines, INCLUDING your
aspirin and warfarin (coumadin). If you have any questions,
call the office at the phone number listed in the appointments
section below.
You may resume your regular level of activity for your upper
extremities; do NOT bear weight on your foot.
You may resume your regular diet.
CALL THE OFFICE FOR: increasing pain, fevers, foul-smelling
drainage, increasing redness, or other concerning symptoms.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Call the office if you have any questions.
Followup Instructions:
___
|
10700223-DS-15
| 10,700,223 | 29,807,841 |
DS
| 15 |
2140-09-23 00:00:00
|
2140-09-23 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Fine needle aspiration of soft tissue swelling in mandible
History of Present Illness:
As per HPI in H&P by Dr. ___ ___:
___ yo M with PMH of DMII and HTN who presented to an OSH with
c/o fever and jaw swelling x 3 days. Reports initially noticing
an "ingrown hair" under his chin 3 days ago. Reports progressive
swelling and "hardness" of the skin under his chin and L side of
face, then developed fever, chills, and night sweats. No
reported drainage, redness, tenderness, or increased warmth of
the concerning area.
Presented to OSH and found to be febrile with WBC 17. NCCT neck
showed submandibular cellulitis, mandibular osteomyelitis, and L
submandibular/cervical adenopathy. Received Unasyn and was
transferred to ___ for ___ consultation.
In the ED, initial VS were: 97.5/60/ ___. Seen by
___ who recommended IV antibiotics and admit to medicine.
ED labs were notable for: WBC 16, Cr 2.1, CRP 245.
Patient was given: vancomycin IV
Upon arrival to the floor, he reports being comfortable and in
no pain. He is visiting from ___ to spend time with family
during the ___ season. Reports having well-controlled DM
over the past couple years with most recent HbA1c of ~ 6.
History of having all toes amputated happened many years ago in
the setting of uncontrolled DM due to homelessness and no access
to prescriptions.
Denies headache, vision change, sinus congestion, cough, sore
throat, difficulty swallowing, chest congestion, chest pain or
pressure, palpitations, shortness of breath, wheezing, abdominal
pain, diarrhea, constipation, increased frequency of urination,
pain with urination, weakness, paresthesias, new rashes or
lesions, joint swelling, change in weight, appetite or mood."
Past Medical History:
diabetes mellitus - type 2
hypertension
chronic kidney disease
Social History:
___
Family History:
Father died from complications of DM.
Physical Exam:
Admission Physical Exam:
Vitals: 98.1 PO 124 / 75 R Lying 63 18 99 Ra
Gen: awake, alert, sitting up in bed, appears comfortable
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear, poor dentition, partial dentures
Head/neck: submandibular induration extending to L mandible
without overlying erythema, tenderness, or increased warmth
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
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, calm mood
Discharge Exam:
EXAM:
Vitals:
24 HR Data (last updated ___ @ 714)
Temp: 97.8 (Tm 98.4), BP: 134/84 (133-141/56-85), HR: 59
(56-71), RR: 18, O2 sat: 99% (98-100), O2 delivery: RA
Gen: awake, alert, appears comfortable
ENT: MMM, OP clear, poor dentition, partial dentures
Head/neck: firm swelling/induration of mandibular,
submandibular, and submental regions. non-tender to palpation.
no
overlying erythema.
CV: NR/RR, no m/r/g
Pulm: CTAB, no wheezes, crackles, or rhonchi
Skin: No visible rash.
Neuro: AAOx3. Face midline. moving all extremities.
Psych: Full range of affect, normal affect
Pertinent Results:
ADMISSION LABS
===============================
___ 05:27AM BLOOD WBC-16.0* RBC-4.23* Hgb-12.0* Hct-35.6*
MCV-84 MCH-28.4 MCHC-33.7 RDW-14.1 RDWSD-43.4 Plt ___
___ 05:27AM BLOOD Neuts-87.9* Lymphs-5.4* Monos-5.4
Eos-0.3* Baso-0.3 Im ___ AbsNeut-14.06* AbsLymp-0.86*
AbsMono-0.87* AbsEos-0.04 AbsBaso-0.04
___ 05:27AM BLOOD Glucose-132* UreaN-50* Creat-2.1* Na-139
K-4.7 Cl-99 HCO3-19* AnGap-21*
___ 05:27AM BLOOD CRP-245.3*
___ 05:33AM BLOOD Lactate-1.3
HEMOGLOBIN A1C
___ 07:32AM BLOOD %HbA1c-9.1
IMAGING:
FACIAL MRI
IMPRESSION:
1. Study is moderately degraded by motion.
2. Please note that prior outside neck CT does not include mid
imaging of
mandible.
3. Multiple areas of bone marrow signal abnormality involving
the bilateral
paramedian mandible, with associated contrast enhancement. Given
the
additional presence of adjacent skin thickening and extensive
adjacent
subcutaneous inflammatory stranding, these findings are most
compatible with infectious etiology such as osteomyelitis with
overlying cellulitis.
Multifocal neoplasm/metastatic disease is felt less likely, but
not excluded. Recommend follow-up imaging to resolution
4. Dominant right anterior paramedian mandibular lesion
demonstrating and
central area of hypoenhancement which may relate to necrosis or
less likely
abscess formation, with associated probable cortical
breakthrough along the
superior medial aspect of the lesion.
5. Multiple small relatively well capsulated T2 hyperintense
enhancing lesions within the subcutaneous tissues underlying the
mandible, which may represent small abscesses or a developing
fistulous/sinus tract.
6. No definite evidence of cervical lymphadenopathy.
7. Paranasal sinus disease, as described.
RECOMMENDATION(S): Multiple areas of bone marrow signal
abnormality involving the bilateral paramedian mandible, with
associated contrast enhancement. Given the additional presence
of adjacent skin thickening and extensive adjacent subcutaneous
inflammatory stranding, these findings are most compatible with
infectious etiology such as osteomyelitis with overlying
cellulitis. Multifocal neoplasm/metastatic disease is felt less
likely, but not excluded. Recommend follow-up imaging to
resolution
CXR, ___:
IMPRESSION:
No prior chest radiographs available.
Right PIC line ends in the low SVC. Lungs clear. Heart size
normal. No
pleural abnormality.
Renal US, ___:
FINDINGS:
The right kidney measures 11.1 cm. There are multiple cysts in
the right
kidney. Two adjacent cysts in the upper pole (versus bilobed
cyst with an
echogenic septation) measure 1.0 x 0.8 x 1.1 cm and 0.9 x 0.8 x
1.0 cm. The lower pole partially exophytic cyst measures 1.0 x
0.5 x 0.8 cm. The
exophytic upper pole cyst measures 1.5 x 1.4 x 1.7 cm.
The left kidney measures 12.2 cm. There are least two simple
cysts in the left kidney, the largest measuring 1.5 x 1.0 x 1.4
cm in the interpolar region.
There is no hydronephrosis, stones, or solid masses bilaterally.
Normal
cortical echogenicity and corticomedullary differentiation are
seen
bilaterally.
The bladder is moderately well distended and normal in
appearance. Echogenic debris is seen within the bladder.
IMPRESSION:
No hydronephrosis.
MICRO:
Blood cultures (___): no growth x2 (final)
Fine needle aspirate culture (from mandible; ___: WOUND
CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-9.0 RBC-3.92* Hgb-10.9* Hct-34.0*
MCV-87 MCH-27.8 MCHC-32.1 RDW-14.8 RDWSD-46.9* Plt ___
___ 05:52AM BLOOD Glucose-142* UreaN-32* Creat-2.1* Na-140
K-4.5 Cl-102 HCO3-22 AnGap-16
___ 05:52AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
___ 05:27AM BLOOD CRP-245.3*
Brief Hospital Course:
This is a ___ yo M with PMH of DMII who presented with 3-day h/o
fever and facial swelling and found to have imaging findings
concerning for mandibular osteomyelitis.
# Sepsis
# Mandibular osteomyelitis
Fever and facial swelling with onset of only 3 days ago that
patient attributes to an ingrown hair vs razor cut. Febrile at
OSH. Upon admission: leukocytosis 16 and CRP 245. NCCT neck at
OSH showed findings suggestive of submandibular cellulitis,
mandibular osteomyelitis, and L submandibular/cervical
adenopathy. Facial MRI findings also c/w osteomyelitis with
small abscesses +/- sinus tract formation. Presentation was
atypical for a common bacterial infection such as staph or strep
in that there was no overlying erythema and no tenderness.
Differential includes cervicofacial actinomycosis, other
granulomatous diseases and malignancy. He was started
empirically on vancomycin and ampicilln/sulbactam. Pt was seen
by ___ and infectious diseases. ___ performed a fine needle
aspiration of the mandibular swelling and the cultures had no
growth. Infectious disease recommending narrowing his
antibiotics to ampicillin/sulbactam alone as the most likely
pathogen was oral flora. ___ plans to do an eventual bone
biopsy of the mandible once possible overlying cellulitis has
subsided. He has follow up scheduled with them on ___ (see
discharge paperwork). He will also be followed by Infectious
Disease in the ___ clinic. His insurance will only pay for 20
days in a rehab, so he will plan to be on ampicillin/sulbactam
q6h for those 20 days and then transition to ertapenem once a
day via an ___. Amp/sulbactam is preferable coverage
for his osteomyelitis but this would not be able to be given at
an ___ due to its frequency. He will likely need at
least 6 weeks of IV antibiotics followed by likely prolonged
oral therapy. Start date of antibiotics was ___.
# ___ on CKD
The patient reports known CKD and is followed by a nephrologist.
His baseline Cr is not known. At admission, his Cr was 2.1. It
was 1.7 at the lowest. At the time of discharge, his Cr was 1.9.
His FeNa was 4.9%, so most consistent with
post-renal/obstructive ___. Because of his PVRs and a renal
ultrasound were performed. The renal ultrasound was performed
and showed some simple renal cysts and no hydronephrosis.
Bladder scans were all <300 mL.
# DMII
He was continued on his home glargine 15 units qpm as well as
sliding scale insulin. His Hgb A1c here was 9.1%. His home
gabapentin 600 mg daily was continued for diabetic neuropathy.
# Hypertension (not on lisinopril due to hyperkalemia)
He was continued on his home amlodipine and torsemide.
Mr. ___ 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. amLODIPine 10 mg PO DAILY
2. Glargine 15 Units Bedtime
3. Torsemide 10 mg PO DAILY
4. Gabapentin 600 mg PO DAILY
5. Ferrous Sulfate Dose is Unknown PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ampicillin-Sulbactam 3 g IV Q6H
3. Ferrous Sulfate 325 mg PO DAILY
4. Glargine 15 Units Bedtime
5. Vitamin D 800 UNIT PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Gabapentin 600 mg PO DAILY
8. Torsemide 10 mg PO DAILY
9.Outpatient Lab Work
ICD-9 730.08 : Acute osteomyelitis, other specified sites.
Labs: CBC with differential, BUN, creatinine weekly (on or
around ___, and ___.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mandibular osteomyelitis
Facial cellulitis
Diabetes mellitus type 2
Chronic kidney disease
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 an infection in your jaw
bone. You were seen by the oral surgery and infectious diseases
team. You had a fine needle aspiration of the area that did not
have any growth on culture. You were treated with antibiotics
and improved. You should continue on IV antibiotics for at least
6 weeks total. You will follow up with Infectious Disease (they
will call you to make an appointment) and ___ (oral surgery) as
detailed below.
Best of luck with your continued healing!
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10700319-DS-21
| 10,700,319 | 27,453,526 |
DS
| 21 |
2128-06-25 00:00:00
|
2128-06-29 19:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with medical history HTN, CAD, HLD, and Parkinsonian
syndrome presenting from home with AMS. Per note in triage,
husband called EMS stating he could not arouse her. On EMS
arrival she responed to voice. In triage she was awake and
talking. Per husband pt was at her baseline in triage. In the
ED, she is AAO x3, however, she is confused about the
circumstances of her admission. She asks why she is in the
hospital. She denies fevers, chills, and endorses some mild
abdominal pain and dysuria. She states that she has been
admitted for UTI before.
In the ED, initial vitals were: 98.0 60 138/62 16 100% RA
Labs notable for UA with >182 WBCs, 31 RBCs, negative nitrites
and many bacteria. Labs otherwise unremarkable
Imaging notable for: CXR with low lung volumes without focal
consolidation.
Patient was given 1g IV CTX. She was also given home
carbidopa/levodopa, atenolol, and HCTZ
Decision was made to admit for treatment of UTI.
Vitals notable for BP elevated to 188/71 (improved to 130s
systolic with home meds)
On the floor, patient feels well. Denied remembering that she
was sleepy yesterday and that she had a decreased appetite.
Patient's husband stated that the patient over the last few days
has had a decreased appetite and appeared more tired and sleepy
to him. According to husband, patient was laying in bed with
eyes open but not responding to any questions. There were no
convulsions or loss of bowel/bladder function. Endorsed that
she was recently treated with nitrafurantoin for a UTI and has
completed as 7 day course on ___. Prior symptoms from UTI
included dysuria.
Past Medical History:
HYPERTENSION
ANGINA PECTORIS
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
HYPERCHOLESTEROLEMIA
PARKINSONIAN SYNDROME
Dementia
Social History:
___
Family History:
Alzheimer's in her mother
Physical ___:
ADMISSION PHYSICAL EXAM
======================
VS: 98.8 58 168/57 18 100RA
Gen: PERRLA, EOMI, NAD, A&Ox3, frail appearing
HEENT: normocephalic, scars from prior surgery on right head,
MMM, oropharynx clear
CV: RRR, no M/R/G
Pulm: normal work of breathing, CTAB
Abd: soft, non-distended, suprapubic tenderness
Ext: warm,2+ DP pulses, no pedal edema
Skin: warm, dry, no rashes
Neuro: A&Ox3, CNs grossly intact, ___ BLE and BUE strength,
normal sensation, moderate facial masking, moderate hypophonia
of voice, mild resting tremor. Cogwheel rigidity.
DISCHARGE PHYSICAL EXAM
======================
VS: 97.8 64 166/88 18 95RA
Gen: PERRLA, EOMI, NAD, A&Ox3, frail appearing, asleep but awoke
to voice.
HEENT: normocephalic, scars from prior surgery on right head,
MMM, oropharynx clear
CV: RRR, no M/R/G
Pulm: normal work of breathing, CTAB
Abd: soft, non-distended, suprapubic tenderness
Ext: warm,2+ DP pulses, no pedal edema
Skin: warm, dry, no rashes
Neuro: A&Ox3, CNs grossly intact, ___ BLE and BUE strength,
normal sensation, moderate facial masking, moderate hypophonia
of voice, mild resting tremor. Cogwheel rigidity.
Pertinent Results:
ADMISSION LABS
=============
___ 06:40AM BLOOD WBC-6.1 RBC-4.21 Hgb-11.7 Hct-38.4 MCV-91
MCH-27.8 MCHC-30.5* RDW-13.6 RDWSD-45.1 Plt ___
___ 06:40AM BLOOD Neuts-54.0 ___ Monos-9.4 Eos-3.0
Baso-1.0 Im ___ AbsNeut-3.30 AbsLymp-1.94 AbsMono-0.57
AbsEos-0.18 AbsBaso-0.06
___ 06:40AM BLOOD Glucose-81 UreaN-31* Creat-0.9 Na-145
K-4.2 Cl-105 HCO3-32 AnGap-12
___ 06:48AM BLOOD Lactate-1.2
DISCHARGE AND PERTINENT LABS
==========================
___ 10:35AM BLOOD WBC-7.9 RBC-4.03 Hgb-11.2 Hct-36.5 MCV-91
MCH-27.8 MCHC-30.7* RDW-13.8 RDWSD-45.4 Plt ___
___ 10:35AM BLOOD Glucose-88 UreaN-14 Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-29 AnGap-11
___ 10:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
MICROBIOLOGY
============
___ CULTUREBlood Culture, Routine-FINAL
NEGATIVE
___ CULTUREBlood Culture, Routine-FINAL
NEGATIVE
Time Taken Not Noted Log-In Date/Time: ___ 1:29 pm
URINE Site: NOT SPECIFIED ADDED TO ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
CEFEPIME >16 MCG/ML sensitivity testing performed by
Microscan.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
CEFEPIME >16 MCG/ML sensitivity testing performed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- 4 S 4 S
CEFTRIAXONE----------- =>64 R 32 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
IMAGING
=======
___ XCR PA&L
IMPRESSION:
Low lung volumes without focal consolidation.
Brief Hospital Course:
___ with PMH of Parkinsonianism, dementia, HTN, CAD, HLD, and
recurrent UTIs presenting from home with altered mental status.
# Altered mental status/Hypoactive delirium: patient has a
history of vascular dementia, parkinsonianism with possible
secondary Alzheimer's. At baseline usually alert and oriented
however on occasion does get confused or agitated per husband.
___ exam is similar to documented exam from her
neurologist in ___. Most likely had a hypoactive delirium in
the setting of poor PO intake and possible UTI on presentation.
Has hx of AMS in setting of UTIs. Patient's presentation of
worsening mentation and lethargy over several days is unlikely
to be a seizure. There is no evidence of syncope as patient
appeared awake and had gradual onset of symptoms. Upon workup
chest x-ray was unremarkable, blood cultures with no growth to
date. Utox was negative. Urinalysis was consistent with a
urinary tract infection. Upon treatment of UTI and IV fluid
administration patient's mental status returned to baseline.
# Urinary Tract Infection - UA remarkable for WBC > 182,
Bacteria - many, 31 RBCs, nitrite neg. Has a history of UTIs w/
last completion of treatment on ___ with nitrofurantoin.
Possibly a repeat UTI as patient has developed resistance to
many antibiotics. Prior cultures from atrius records showed E.
coli and Aerococcus urinea on separate occasions sensitive to
augmentin, nitrofurantoin and resistant to cipro. Patient was
started on amoxicillin/clavulinic acid to complete a 7 day
course on ___.
#Hypertension - Hypertensive to 168/57 on admission, was up to
200s systolic. Patient didn't receive atenolol as slightly
bradycardia on day of admission which could have been
contributing to hypertension. Resolved towards dischargey with
improvement in BP and HR. Was restarted on home
hydrochlorothiazide and atenolol.
# Parkinsonian syndrome: questionable ___ body dementia? Has a
hx of hallucinations and agitation. Per patient's neurologist
has microvascular cerebral disease (vascular dementia) in
combination ___ body vs alzheimers. Patient struggles to
take her medications daily. She is scheduled for sinemet to be
taken 6x daily. Appears that if she misses doses she becomes
more rigid on exam.
TRANSITIONAL ISSUES
===================
- recheck renal panel in 1 week
- recheck blood pressure and consider switching atenolol to
another antihypertensive as patient's heart rate was in the ___
during hospitalization.
- consider goals of care discussion with patient and family as
dementia seems to be progressing
- last day of amoxicillin/clavulinic acid on ___
- f/u urine culture sensitivities and adjust antibiotic if
resistant
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. carbidopa 50 mg oral Q6AM and Q10AM
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Nuvigil (armodafinil) 150 mg oral DAILY
5. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
6. Simvastatin 40 mg PO QPM
7. melatonin 5 mg oral QHS
8. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. carbidopa 50 mg oral Q6AM and Q10AM
4. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Nuvigil (armodafinil) 150 mg oral DAILY
7. Simvastatin 40 mg PO QPM
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
9. melatonin 5 mg oral QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Hypoactive Delirium
SECONDARY DIAGNOSES
====================
Urinary Tract Infection
___ Disease
Dementia
Hypertension
Discharge Condition:
Mental Status: Confused - most of the time.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___. You were admitted to us with a change
in your mentation. Upon work-up in the hospital we determined
that you have a urinary tract infection and started you on
treatment with an antibiotic. You will continue taking it after
you leave the hospital. It is important that you take the rest
of your medications.
Sincerely,
Your Health Care Team
Followup Instructions:
___
|
10700319-DS-22
| 10,700,319 | 23,997,328 |
DS
| 22 |
2128-10-18 00:00:00
|
2128-10-18 18:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
___ for unstable AF ___
History of Present Illness:
HPI: Ms. ___ is an ___ yo F w/ h/o recurrent UTI c/b AMS,
___ disease, dementia, HTN, CAD, HLD p/w altered mental
status. Per pt husband, pt began to be altered (talking less,
difficulty swallowing, decreased PO intake) 4 days prior to
admission. He says that she got progressively worse over the
four days and on the day of admission was totally silent and
took nothing PO. At her baseline, she can walk with a
walker/assistance, and can sit up and do puzzles etc. Given her
hx of UTI presenting with AMS, husband suspected UTI but was
unable to collect a urine sample at home. No trauma or fall.
She was brought to the ___ ED where ___ showed evidence of UTI
and labs showed hypernatremia and ___. She got IVF and IV zosyn
(1 dose) in the ED. Given her poor PO intake and decreased
responsiveness, decision was made to admit to medicine for fluid
resuscitation, electrolyte correction and IV abx for UTI.
Past Medical History:
HYPERTENSION
ANGINA PECTORIS
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
HYPERCHOLESTEROLEMIA
PARKINSONIAN SYNDROME
DEMENTIA
Social History:
___
Family History:
Alzheimer's in her mother
Physical ___:
======================
___ PHYSICAL EXAM:
======================
Exam was limited due to unresponsiveness
Temp: 97.2 HR: 58 BP: 173/83 Resp: 16 O(2)Sat: 100 Normal
General: Frail elderly woman lying in bed with eyes shut. Pill
rolling tremor evident.
HEENT: Dry mucus membranes, PEERL
Cards: RRR, nl s1/s2
Pulm: CTAB anteriorly
Ext: cool extremities, 1+ pulses DP/TP bilaterally
Skin: No lesions, petechial, brusing
Neuro: unresponsive, localizes to pain
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Objective:
VS - 98.0 160/55 64 18 100RA
General: frail appearing elderly woman sitting up in bed, in NAD
HEENT: MMM
CV: RRR, nl s1, s2, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nondistended, nontender
Ext: No UE edema. TEDs on. minimal ___ edema. ___ warm.
Neuro: AAOx3, conversant, moving all 4 extremities.
Pertinent Results:
ADMISSION LABS
===============
___ 02:40PM BLOOD Glucose-121* UreaN-86* Creat-2.5*#
Na-154* K-3.5 Cl-107 HCO3-34* AnGap-17
___ 11:43PM BLOOD Glucose-82 UreaN-75* Creat-2.4* Na-155*
K-3.7 Cl-115* HCO3-29 AnGap-15
___ 02:40PM BLOOD Calcium-9.1 Phos-3.2 Mg-3.2*
___ 02:40PM BLOOD Neuts-79.4* Lymphs-11.2* Monos-7.0
Eos-1.8 Baso-0.2 Im ___ AbsNeut-6.74*# AbsLymp-0.95*
AbsMono-0.59 AbsEos-0.15 AbsBaso-0.02
___ 02:40PM BLOOD WBC-8.5 RBC-4.87 Hgb-13.1 Hct-44.6 MCV-92
MCH-26.9 MCHC-29.4* RDW-14.0 RDWSD-47.3* Plt ___
___ 11:43PM BLOOD WBC-8.1 RBC-4.08 Hgb-11.0* Hct-37.2
MCV-91 MCH-27.0 MCHC-29.6* RDW-14.0 RDWSD-46.9* Plt ___
___ 02:40PM BLOOD TSH-1.7
___ 02:47PM BLOOD Lactate-2.0
___ 07:03AM BLOOD CK-MB-4 cTropnT-0.01
___ 09:57AM BLOOD CK-MB-4 cTropnT-0.01
___ 07:03AM BLOOD CK(CPK)-118
___ 09:57AM BLOOD CK(CPK)-96
*Urine*
___ 03:47PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:47PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 03:47PM URINE RBC-3* WBC-90* Bacteri-FEW Yeast-NONE
Epi-1
___ 03:47PM URINE Mucous-RARE
DISCHARGE LABS
===============
___ 07:06AM BLOOD WBC-5.5 RBC-3.26* Hgb-8.8* Hct-29.4*
MCV-90 MCH-27.0 MCHC-29.9* RDW-15.4 RDWSD-50.1* Plt ___
___ 07:06AM BLOOD Glucose-127* UreaN-28* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-29 AnGap-10
___ 07:06AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
MICRO
=====
___ 3:47 pm URINE Site: NOT SPECIFIED
GRAY TOP HOLD # ___ ___.
**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.
Cefepime Sensitivity testing performed by Etest.
Interpretation of cefepime susceptibility is based on a
dose of 1
gram every 12h. This isolate is intermediate (I) to
cefepime, now
referred to as susceptible-dose dependent (SDD). SDD
isolates can
be treated with cefepime, but an optimized dosing
regimen should
be prescribed. Please contact the AST (pager ___ or
ID for
assistance in determining the appropriate SDD cefepime
dosing.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MICRO
=======================
___ CXR
IMPRESSION:
Low lung volumes without focal consolidation.
___ CXR:
IMPRESSION:
1. The tip of an NG tube is seen folded back on itself and
appears to be in the GE junction.
2. Right lower lung opacities are most likely due to aspiration.
___ CX:
NG tube tip is in unchanged position, the NG tube appears to be
folded back on itself and the tip appears to be in the EG
junction. No other interval change from prior study.
___ Right UE US with Doppler.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
Brief Hospital Course:
Ms. ___ is an ___ yo F w/ h/o recurrent UTI c/b AMS, ___
disease, dementia, who presented with 5 days of altered mental
status in the setting of a UTI.
#New onset Afib with RVR. On the morning of ___ Ms. ___ went
into ___ with RVR, HRs to 170s BPs ___. She was
given 3x5mg metoprolol tartrate and 0.25mg digoxin on the floor
which failed to convert her back to sinus rhythm, so she was
transferred to the ICU for electrical cardioversion. She was
successfully cardioverted back to normal sinus rhythm with 1x
150 joules shock. She was started on metoprolol in the ICU,
continued on metoprolol on the floor before being transitioned
to carvedilol for better BP control.
#Toxic Metabolic Encephalopathy secondary to UTI and
hypernatremia. In the ED Ms. ___ was noted to have altered
mental status (decreased responsiveness). Given her dx of
___ Disease and dementia, she is prone to developing a
superimposed delirium. Her delirium on presentation was likely
multifactorial with contributing factors including UTI and
hypernatremia. CXR showed no focal consolidation making
respiratory infection unlikely. Her mental status waxed and
waned throughout her stay. When she is at her worst, she is
non-verbal but follows most commands. At her best she is
conversant, AxOx3, able to read the newspaper. She can fluctuate
between these points throughout the day.
#Nutrition. Due to her waxing and waning mental status, Ms.
___ ability to eat, drink or reliably take her PO meds was
inconsistent. On ___ a NG tube was placed for nutrition and PO
meds. The patient self discontinued the NG tube on ___, but was
adequately taking nutrition and meds PO at this time so it was
not immediately replaced. On ___, when lucid, AxOx3 she
expressed that she would not want a nasogastric tube. Her goals
of care should continue to be readdressed. Her ability to take
PO did wax and wane but she was able to take her meds most of
the time.
#E.coli UTI. In the ED, UA was remarkable for pyuria, bactiuria,
proteinuria, -Nitrites, +Leukocyte esterase. Pt was afebrile.
Blood cultures were negative. Urine culture grew ceftriaxone
resistant E.coli. She was initially treated with Zosyn in ED
___ which was transitioned to IV ceftazidime on floor. She was
subsequently narrowed to IV unasyn, for a total of 7 days of
appropriate antibiotic therapy.
#Hypernatremia. On admission serum Na was 154. Her free water
deficit was corrected with D5W and her Na returned to normal.
___. On admission pt had evidence ___ (Cr was 2.5, up from
0.8 measured in ___. Her ___ was likely prerenal secondary
to volume depletion with a component of ATN. She was volume
resuscitated with IVF and her Cr slowly improved to 1.5-1.6 on
discharge, which may continue to improve slowly, or may be her
new baseline.
___ Disease. As pt was unable to tolerate PO, her
carbidopa/levodopa was changed to oral dissolving tablets. She
was also given 50mg carbidopa tablets BID, per her home
regiment, when she was taking POs. Her Nuvigil was restarted.
#HTN. Home atenolol was held due to ___ as it is renally
cleared. HCTZ was also held. She was intermittently hypertensive
to the 200s/100s which was treated with IV hydralazine or
labetolol PO. Blood pressure control improved on new regimen of
carvedilol 25mg BID and amlodipine 10mg PO daily.
#HLD. Simvastatin 40mg transitioned to atorvastatin 80mg given
interaction with amlodipine.
=====================
TRANSITIONAL ISSUES
=====================
- Atenolol dc'd because of ___, pt started on metoprolol, then
transitioned to carvedilol 25mg PO BID and amlodipine 10mg
daily.
- In setting ___ and hypernatremia, HCTZ was discontinued.
Consider restarting as an outpatient.
- Simvastatin 40mg transitioned to atorvastatin 80mg given
interaction with amlodipine.
- New onset Afib s/p DCCV - not on anticoagulation.
Risks/benefits of stroke vs. bleed were discussed with husband.
- ___, prerenal with ATN, elevated Cr on discharge (1.5) would
warrant future ___
- Patient's family was put in contact with Palliative Care at
the ___. They have Dr. ___ contact information
and we have also set up an appointment at outpatient palliative
care clinic. Further goals of care discussions recommended.
- Mental status waxes and wanes from non-verbal to conversant
and able to read the newspaper. She can fluctuate between these
points within a given day.
- Code Status: DNR: OK to intubate, no chest compressions or
chemical coding. OK for cardioversion if needed as per HCP.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. carbidopa 50 mg oral q9AM and q12PM
4. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Nuvigil (armodafinil) 150 mg oral DAILY
7. Simvastatin 40 mg PO QPM
8. melatonin 5 mg oral QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. carbidopa 50 mg oral q9AM and q12PM
3. Carbidopa-Levodopa (___) ODT 1 TAB PO 6X/DAY
4. Nuvigil (armodafinil) 150 mg oral DAILY
5. Amlodipine 10 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Carvedilol 25 mg PO BID
11. melatonin 5 mg oral QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- E. coli UTI with sepsis
- Acute renal failure
- Toxic/metabolic encephalopathy
- Atrial fibrillation with RVR
Secondary:
- ___ disease
- Vascular dementia
- Hypertension
- Coronary disease (details unknown)
- ___ s/p right parietal craniotomy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Waxes and wanes between alert and
interactive to Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___.
Why was I in the hospital?
- You were admitted to the hospital because you had altered
mental status.
- You were found to have a urinary tract infection and to be
severely dehydrated that resulted in kidney injury
What was done in the hospital?
- You were given IV antibiotics for your urinary tract infection
- You were given fluids to correct your electrolytes and to help
your kidneys
- Your heart went into an arrhythmia called atrial fibrillation
and you were electrically cardioverted (shocked) back to a
normal rhythm
- A nasogastric tube (feeding tube) was put in to help with
nutrition and medication delivery.
What should I do when I leave the hospital?
- You will be going to a rehab facility
- Take all of your medications as prescribed
- Try to stay hydrated
- You should seek medical attention if you notice any fevers,
chills, changes in mental state, or urinary changes (color,
smell, frequency).
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10700636-DS-20
| 10,700,636 | 21,401,428 |
DS
| 20 |
2162-07-30 00:00:00
|
2162-08-01 10:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ultram / Pollen Extracts / Lipitor / belladonna alkaloids /
Cardizem / betamil
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP ___ with sphincterotomy and stent placement
History of Present Illness:
Ms ___ is a pleasant ___ with hx breast ca, HTN who
initially presented to her PCP ___ few days ago for fatigue and
abd tenderness x ___ and was found to have jandice, labs showing
elevated bili. Denies fevers, wt loss. She was referred to
___ where labs showed bili of 6.0, ALT of 1284,
AST of 721 and CT showed ill-defined mass in the hilum of the
liver with moderately severe intrahepatic bilary dilation no
extrahepatic billary dilation and narrowing of the portal vein
concerning for cholangiocarcinoma. She was transferred to ___
for ERCP. Incidentally, one week prior pt states she was in the
ED for hives after starting betaphyl lotion for dry skin. At
this time she was started on a course of prednisone which was to
be completed today.
In the ED, initial vitals were: 97.9 63 166/73 15 96% RA. She
was given ativan, zofran and fluids. ERCP was notified.
On the floor, pt c/o ongoing mild abd pain, gas and itching.
She also notes that her stools have been light and urine dark.
She endorses chronic shoulder pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-bilateral breast CA
-hypertension
-hyperlipidemia,
-episodic esophageal spasms, managed with Norvasc and Xanax
-right breast lymphedema
-hysterectomy at age ___
-hx of ureretal damage during hysterectomy requiring multiple
subsequent abd surgeries and c/b several hospitalizations for
SBO
-pt states heart stopped for 5 s x2 during colonoscopy but pt
has since had anesthesia without difficulty.
Social History:
___
Family History:
The patient has a family history of breast cancer, farther died
of stroke, uncle with stomach cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: 162/70 97.5 75 18 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera mildly icteric
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP in epigastrium, LUQ, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact and strength grossly intact.
Skin: no rashes/lesions
DISCHARGE EXAM:
No abdominal tenderness
otherwise unchanged
Pertinent Results:
ADMISSION LABS:
___ 03:20AM BLOOD WBC-12.1*# RBC-4.43 Hgb-13.8 Hct-40.7
MCV-92 MCH-31.2 MCHC-33.9 RDW-14.8 RDWSD-49.9* Plt ___
___ 03:20AM BLOOD Neuts-71.9* ___ Monos-7.1
Eos-0.4* Baso-0.2 Im ___ AbsNeut-8.66* AbsLymp-2.32
AbsMono-0.86* AbsEos-0.05 AbsBaso-0.03
___ 03:20AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-136
K-4.3 Cl-102 HCO3-19* AnGap-19
___ 03:20AM BLOOD ALT-857* AST-260* AlkPhos-618*
TotBili-3.8*
___ 03:20AM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-2.3
IMAGING:
___ CT abd/pelvis: Ill defined mass in the hilum of the
liver with moderately severe intrahepatic biliary dilation, no
extrahepatic biliary dilation and narrowing of the portal vein
concerning for cholangiocarcinoma.
___ MRCP:
1. Approximately 2.4 x 1.5 cm ill-defined lesion at the porta
hepatis resulting in severe intrahepatic biliary ductal
dilatation, with abrupt obstruction at the proximal extrahepatic
bile duct highly concerning for a Klatskin-type
cholangiocarcinoma, likely ___ type 2.
2. No abnormal lymph nodes or other evidence of metastatic
disease.
___ ERCP report:
The scout film was normal.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
A 1.5 cm, tight stricture was noted in the common hepatic duct
just above the cystic duct takeoff and below the hilum. There
was evidence of severe post-obstructive dilation. No stricture
was seen involving the left or right hepatic duct.
A small sphincterotomy was made with the sphincterotome. There
was no post-sphincterotomy bleeding.
Brushings were obtained of the common hepatic duct stricture
using a cytology brush.
A ___ Fr x 9 cm was successfully placed above the common hepatic
duct stricture.
Excellent bile and contrast drainage was seen endoscopically
and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-11.3* RBC-4.27 Hgb-12.9 Hct-38.7
MCV-91 MCH-30.2 MCHC-33.3 RDW-15.4 RDWSD-50.4* Plt ___
___ 06:50AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-139
K-3.6 Cl-100 HCO3-27 AnGap-16
___ 06:50AM BLOOD ALT-985* AST-378* AlkPhos-721*
TotBili-5.1*
___ 07:05AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.3
Brief Hospital Course:
This is an ___ year old female admitted for painless jaundice ___
likely cholangiocarcinoma and bile duct obstruction.
# Likely cholangiocarcinoma
# Bile duct obstruction
- MRCP concerning for a Klatskin tumor, also showed evidence of
biliary obstruction accounting for her symptoms of jaundice,
pruritus, and a peak bilirubin of 13. She underwent an ERCP on
___ with stent placement and sphinctertomy with good results.
LFTs improved significantly. Her diet was advanced without any
difficulty. She was seen by the pancreatic surgery service to
discuss options. She will follow-up with them on ___ as an
outpatient to discuss options for surgical resection. She was
treated with hydroxyzine and sarna lotion for her pruritus, she
did not need either on discharge. She was discharged to
complete a 5-day course of ciprofloxacin.
# HTN - continued on her BB, started on lisinopril in-house due
to elevated BPs. She was discharged on both medications and
asked to follow-up in 2 weeks with her PCP for ___ BP check and
kidney function check.
# HL - continued on zetia
# Anxiety - continued on ativan as needed.
# CODE: full
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE Dose is Unknown PO DAILY
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. Atenolol 25 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Ibuprofen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Lorazepam 0.5 mg PO BID:PRN anxiety
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg One tablet(s) by mouth twice daily
Disp #*7 Tablet Refills:*0
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
6. Sarna Lotion 1 Appl TP QID:PRN pruritus
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % one
application to affected areas four times daily as needed
Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
this medication causes sedation; do not drink or drive while
taking
RX *oxycodone 5 mg one tablet(s) by mouth every 8 hours as
needed for pain Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct obstruction
Likely cholangiocarcinoma
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 recent admission at
___. You came because of abdominal pain, nausea and vomiting,
and were found to have an obstruction of your bile duct on CT
imaging due to a mass, concerning for cholangiocarcinoma. An
ERCP was performed and a stent was placed to help with relief of
the obstruction. You will need to complete the antibiotic,
ciprofloxacin, over the next 4 days. As we discussed, you will
follow-up with Dr. ___ team on ___ to discuss options going
forward.
Please also follow-up with your primary care doctor in the next
1 week for your blood pressure and lab follow-up. Dr.
___ will contact you regarding the results from
the biopsies.
MEDICATION CHANGES:
- do NOT take ibuprofen, aspirin, aleve, or motrin for the next
1 week (can take as needed starting ___
- do TAKE ciprofloxacin through ___ (last dose ___ evening)
- use sarna lotion as needed
- do NOT take Tylenol while your liver enzymes are still
elevated
- you can use oxycodone sparingly as needed for pain
- do TAKE lisinopril for your blood pressure, but you will need
to have your BP and kidney function tests in ___ weeks
Followup Instructions:
___
|
10702026-DS-19
| 10,702,026 | 21,143,978 |
DS
| 19 |
2173-07-25 00:00:00
|
2173-07-25 20:16:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / Enablex / lisinopril / flu shot
Attending: ___.
Chief Complaint:
Spell of babbling speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female PMHx A fib, HTN, ___ edema, mild cognitive impairment,
L
sphenoid ridge meningioma who presented to the ED with confusion
and drowsiness. Over the past 24 hours, the family has noted
that
the patient has not been herself. Noted this AM that she was
confused and was unable to name her daughter, with whom she
lives. Also noted some slurred speech with this episode. Family
notes some increased urination over the past couple of days,
with
some chills, but no fevers. Has not mentioned any chest pain,
shortness of breath, headache, nausea or vomiting. She has never
had anything like this before. Due to concern for altered mental
status, the family decided to bring her to the ED for
evaluation.
They were able to help her ambulate down the stairs, though with
some difficult due to weakness, which is similar to her
baseline.
No other observed changes in gait or focal neuro deficits.
- In the ED, initial vitals were:
T 97.7 HR 78 BP 153/97 RR 16 O2 100% RA
- Exam was notable for:
Const: Comfortable, no respiratory distress
Eyes: No conjunctival injection
HENT: NCAT, Neck supple without meningismus
CV: RRR, Warm, well-perfused extremities
RESP: Rales left lung base
GI: soft, non-tender, non-distended
GU: No CVA tenderness
MSK: 1+ pitting edema to the mid shins.
Skin: Warm, dry. No rashes
Neuro: Alert, speech slurred, oriented x1. 5 out of 5 strength
in
all extremities. Possible right visual field cut. Unable to
count
fingers, but question of patient's compliance with this task. CN
II-XII otherwise without deficit. No pronator drift, unable to
comply with FNF.
Psych: Appropriate mood and affect.
- Labs were notable for:
144 108 25 AGap=13
------------<133
4.1 23 1.0
12.2
4.4>-----<171
38.9
___: 21.8 PTT: 32.5 INR: 2.0
ALT: 9 AP: 91 Tbili: 0.6 Alb: 3.9
AST: 17 Lip: 19
- Studies were notable for:
CT HEAD
No acute intracranial process.
1.3 x 1.2 cm subtly hyperdense region at the left planum
sphenoidale, similar to prior MRI given differences in modality,
probable meningioma.
CT NECK
1. No evidence of acute fracture or traumatic malalignment.
2. Mild interval increase in size of a 6.5 cm thyroid goiter
with
persistent mass effect and right lateral displacement the
trachea.
- The patient was given:
___ 18:33 IV CefTRIAXone
___ 19:40 IV Azithromycin
On arrival to the floor, the patient is oriented to self,
situation, not to date. Daughter is at bedside who confirms the
history as above. Feels that her mental status has improved
throughout the course of the day. Notes that she has noticed
some
increased ankle swelling, so she had increased her Lasix for the
last several days. Does note some difficultly with managing
medications with maintaining her job. Also her mother will
occasionally refuse medications.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
-Dementia
-Atrial fibrillation
-Hypertension
-L sphenoid ridge meningioma
-Goiter
-History of breast cancer
Social History:
___
Family History:
Of her five children, two sons died at ___ and ___, both with a
heart attack. Of her 15 siblings, 11 reached adulthood. Her
father died in his ___ with a heart attack, and her mother died
at ___ with a heart
attack.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.2 BP 173 / 116 R Sitting HR 89 RR 20 O2 96 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
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.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3 (self [didn't know year of birth], situation,
and place), CN2-12 intact. Moving all 4 limbs spontaneously. ___
strength in UE and ___, unable to follow finger to nose commands
========================
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Alert and interactive. In no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Irregular rhythm, normal rate. Audible S1, prominent
S2.
No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Able to state name, birthday, but unable to state
date, hospital. DOB forward but not backward. Move all four
limbs
spontaneously.
Pertinent Results:
=====================================
ADMISSION LABS
=====================================
___ 03:14PM BLOOD WBC-4.4 RBC-4.46 Hgb-12.2 Hct-38.9 MCV-87
MCH-27.4 MCHC-31.4* RDW-14.8 RDWSD-47.1* Plt ___
___ 03:14PM BLOOD Neuts-55.6 ___ Monos-7.4 Eos-4.1
Baso-0.9 Im ___ AbsNeut-2.47 AbsLymp-1.41 AbsMono-0.33
AbsEos-0.18 AbsBaso-0.04
___ 03:14PM BLOOD ___ PTT-32.5 ___
___ 03:14PM BLOOD Glucose-133* UreaN-25* Creat-1.0 Na-144
K-4.1 Cl-108 HCO3-23 AnGap-13
___ 03:14PM BLOOD ALT-9 AST-17 AlkPhos-91 TotBili-0.6
___ 03:14PM BLOOD proBNP-2145*
___ 03:14PM BLOOD cTropnT-<0.01
___ 03:14PM BLOOD Albumin-3.9 Calcium-9.9 Phos-3.1 Mg-2.1
___ 03:14PM BLOOD VitB12-749
___ 08:06AM BLOOD %HbA1c-5.8 eAG-120
___ 08:06AM BLOOD Triglyc-71 HDL-66 CHOL/HD-2.5 LDLcalc-82
___ 03:14PM BLOOD TSH-2.4
___ 04:45PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 04:45PM URINE RBC-0 WBC-19* Bacteri-FEW* Yeast-NONE
Epi-1
=====================================
DISCHARGE LABS
=====================================
___ 07:04AM BLOOD WBC-3.9* RBC-4.31 Hgb-11.7 Hct-37.9
MCV-88 MCH-27.1 MCHC-30.9* RDW-14.6 RDWSD-47.0* Plt ___
___ 07:04AM BLOOD Neuts-44.3 ___ Monos-9.6 Eos-6.9
Baso-1.3* Im ___ AbsNeut-1.75 AbsLymp-1.48 AbsMono-0.38
AbsEos-0.27 AbsBaso-0.05
___ 07:04AM BLOOD ___ PTT-35.9 ___
___ 07:04AM BLOOD Glucose-73 UreaN-18 Creat-0.8 Na-145
K-3.7 Cl-109* HCO3-23 AnGap-13
=====================================
PROCEDURES/STUDIES/IMAGING
=====================================
___ C-SPINE W/O CONTRAST
1. No evidence of acute fracture or traumatic malalignment.
2. Mild interval increase in size of a 6.5 cm thyroid goiter
with persistent
mass effect and right lateral displacement the trachea.
___ HEAD W/O CONTRAST
1.3 x 1.2 cm subtly hyperdense region at the left planum
sphenoidale, similar
to prior MRI given differences in modality, probable meningioma.
___ (PA & LAT)
Medial streaky basilar opacities may relate to atelectasis, but
underlying
aspiration or infection is not excluded in the appropriate
clinical setting.
Mild pulmonary vascular congestion.
Persistent enlargement of the cardiomediastinal silhouette in
this patient
with aneurysmal ascending aorta and pulmonary arterial
hypertension.
=====================================
MICRO
=====================================
__________________________________________________________
___ 8:06 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 4:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 3:14 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
===========================
BRIEF SUMMARY
===========================
___ yo F with a PMHx dementia requiring essentially 24 hour care
at home, A fib on warfarin, HTN, L sphenoid ridge meningioma s/p
radiation who was brought by her daughter (primary care giver)
after an episode of "babbling speech" at home.
Labs were overall reassuring except a mildly elevated BUN and a
BNP of ___, but there was no overt evidence of volume overload
on exam. UA was notable for pyuria without bacteria or nitrates
(urine culture mixed flora). Imaging was CT head, CT c-spine,
CXR, and EKG - notable for stable (probable) meningioma, mild
interval increase in size of a 6.5 cm thyroid goiter with
persistent mass effect and right lateral displacement the
trachea, streaky basilar opacities (atelectasis vs. aspiration),
and mild pulmonary vascular congestion.
She was treated with a few days of ceftriaxone and continuation
of her home medications. We discussed with her neuro-oncologist
the possibility of seizure given the description of the
episodes, and we were going to start Keppra empirically (low
yield of EEG given location of her tumor) with outpatient follow
up, but because the spells were infrequent and there was some
concern for fatigue as a side effect, her daughter preferred to
think about the situation further.
We discharged the patient to home with ___ services for home
safety assessment as well as outpatient geriatrics and
___ follow up. Daughter will call clinic if she wants
to start Keppra.
===========================
TRANSITIONAL ISSUES
===========================
[] Discharge weight: 140.6 pounds
[] Warfarin was held on ___ in the setting of antibiotics and a
rising INR (though still within the normal range), patient will
follow up with ___ clinic for further INR
monitoring
[] Continue re-evaluating for home services
[] Consider starting Keppra empirically for seizure
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Warfarin 5 mg PO DAILY16
4. Furosemide 20 mg PO EVERY OTHER DAY
5. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild/Fever
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Potassium Chloride 20 mEq PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild/Fever
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Lidocaine 5% Patch 1 PTCH TD QPM
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dementia
Altered Mental Status
Urinary Tract Infection (?)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
===================================
WHY DID YOU COME TO THE HOSPITAL?
===================================
-You were brought to the hospital for an episode of "babbling
speech". This was the second time this has happened.
================================
WHAT HAPPENED AT THE HOSPITAL?
================================
-We discussed with your daughter a few possibilities to explain
the presentation including mild dehydration, a UTI, or perhaps a
seizure event given your known tumor
-We discussed with Dr. ___ who recommended
starting a new medication called Keppra just incase this event
was a seizure, but your daughter wanted some time to think about
it
-We made no changes to the medications, scheduled follow up, and
discharged you to home with visiting nurse services.
====================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
=====================================================
-Go to the follow up appointments (as below)
-Call Dr. ___ if you decide to start the Keppra
Followup Instructions:
___
|
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2173-08-16 21:04:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / Enablex / lisinopril / flu shot
Attending: ___
___ Complaint:
generalized weakness, falls, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ hx of A fib on coumadin, HTN, chronic ___ edema, mild
cognitive impairment, and L sphenoid ridge meningioma who was
sent to ED from ___ clinic for further evaluation of 3
days of generalized weakness and recent fall.
She was recently admitted from ___ for confusion and
drowsiness - noted to be unable to name her daughter with whom
she lives and with some slurred speech. During that admission
___ had no evidence of stroke and was notable for stable
benign meningioma. UA was notable for pyuria without bacteria or
nitrates, CXR with streaky basilar opacities concerning for
atelectasis vs aspiration and she was treated with a few days of
CTX for possible PNA. Case was discussed with pt's outpt
neuro-oncologist for possibility of seizure and empiric Keppra
was potentially going to be started but given infrequency of
these spells and concern for fatigue as a side effect treatment
was deferred. She was discharged with ___ services with outpt
geriatrics and neuro-oncology follow up. She was seen in
geriatrics follow up on ___ where her daughter had noted her
mother to be doing well.
She was brought into clinic and seen by ___ on ___
by her daughter and primary caretaker for concern of new gait
abnormality. Per her daughter, pt upon waking on ___ had
sudden change in ability to transfer and walk, requiring max
assist of 2. She had previously been ambulating with rolling
walker and transferring independently. She was also noted to
have a fall with head strike about a week prior. She was sent to
the ED for further evaluation given concern for high risk of
falls. Further history is limited as patient is a poor historian
given her baseline cognitive impairment - daughter not at
bedside to give further collateral.
- In the ED, initial vitals were:
T 96.8, HR 78, BP 124/104, 100% RA
- Exam was notable for:
General: Appearing stated age
HEENT: NCAT, PEERL, MMM
Neck: Supple, trachea midline
Heart: RRR, no MRG. Bilateral moderate peripheral edema.
Lungs: CTAB. No wheezes, rales, or rhonchi.
Abd: Soft, NTND.
MSK: Multiple chronic joint deformities. Tenderness to palpation
along the right knee lateral joint line. Pain with flexion to 90
degrees.
Derm: Skin warm and dry
Neuro: CN2-12 intact. PERRLA. Mild right arm drift. Negative
finger-nose-finger.
Psych: Appropriate affect and behavior
- Labs were notable for:
BMP: Cr 0.9, BS 101
CBC: 4.4>11.___<182
Coags: PTT 35.4, INR 1.9
LFTs: WNL, albumin 3.7
Trop-T <0.01 x2
proBNP ___
UA: bland
- Studies were notable for:
NCHCT:
1. No acute intracranial process or fracture.
2. Unchanged 1.2 cm lesion in the region of the left planum
sphenoidale, probably representing a meningioma.
R knee X-ray:
1. No fracture or dislocation.
2. Moderate right knee osteoarthritis, worse in the lateral
compartment.
CXR:
1. No acute intrathoracic process.
2. Persistent cardiomegaly and mild left basilar atelectasis.
EKG: Afib, HR 74, LVH with repol abnl
- The patient was given:
warfarin 2.5mg
metop XL 25mg
Lasix 20mg
losartan 50mg
-Geriatrics fellow was alerted in ED and agreed with admission
to geriatrics service for expedited workup of new onset
weakness.
On arrival to the floor, patient seems intermittently confused
and suspicious, at times believing that she is in her brother's
home and citing distrust of him as the reason why she's here.
She does confirm that she fell at home recently and hit her
right knee which is currently painful. She denies any fevers,
headache, neck pain, chest pain, shortness of breath, cough,
abdominal pain, nausea, vomiting, diarrhea, or dysuria.
Past Medical History:
-Dementia
-Atrial fibrillation
-Hypertension
-L sphenoid ridge meningioma
-Goiter
-History of breast cancer
Social History:
___
Family History:
Of her five children, two sons died at ___ and ___, both with a
heart attack. Of her 15 siblings, 11 reached adulthood. Her
father died in his ___ with a heart attack, and her mother died
at ___ with a heart attack.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Limited by patient participation.
VITALS: T97.8, BP 194/119, HR 79, 98% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: irregularly irregular, normal rate. Audible S1 and S2.
No murmurs/rubs/gallops.
LUNGS: unable to exam - patient refusing to move from supine
position or to allow me to listen anteriorly
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: TTP of bilateral knees, bilateral feet cool,
dopplerable ___
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx1 (person only). CN2-12 intact. Moving all 4
limbs spontaneously. Unable to complete strength testing
DISCHARGE PHYSICAL EXAM:
======================
VITALS: T:98.4 PO BP: 152/82 HR:88 RR:16 O2:94 Ra
GENERAL: NAD.
HEENT: EOMI.
CARDIAC: irregularly irregular, normal rate. Audible S1 and S2.
No murmurs/rubs/gallops.
LUNGS: CTABL
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: no edema.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx1 (self, in bed). R leg strength 1+, 4+ in all
others
Pertinent Results:
ADMISSION LABS
=============
___ 02:40PM BLOOD WBC-4.4 RBC-4.34 Hgb-11.7 Hct-38.0 MCV-88
MCH-27.0 MCHC-30.8* RDW-14.6 RDWSD-47.1* Plt ___
___ 02:40PM BLOOD Neuts-53.3 ___ Monos-7.8 Eos-4.8
Baso-0.9 Im ___ AbsNeut-2.33 AbsLymp-1.44 AbsMono-0.34
AbsEos-0.21 AbsBaso-0.04
___ 02:40PM BLOOD Plt ___
___ 02:40PM BLOOD Glucose-101* UreaN-24* Creat-0.9 Na-144
K-4.0 Cl-108 HCO3-24 AnGap-12
___ 02:40PM BLOOD ALT-7 AST-13 AlkPhos-87 TotBili-0.4
___ 02:40PM BLOOD Lipase-24
___ 02:40PM BLOOD cTropnT-<0.01 proBNP-1858*
___ 08:24PM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD Albumin-3.7 Calcium-9.8 Mg-2.1
___ 02:52PM BLOOD Lactate-1.4
INTERIM LABS
===========
___ 07:17AM BLOOD VitB12-628 Folate->20
___ 07:30AM BLOOD %HbA1c-6.0 eAG-126
___ 07:30AM BLOOD Triglyc-94 HDL-69 CHOL/HD-2.4 LDLcalc-81
LDLmeas-101
___ 07:17AM BLOOD TSH-3.2
___ 07:17AM BLOOD Trep Ab-NEG
___ 06:04PM BLOOD ___ pO2-51* pCO2-53* pH-7.32*
calTCO2-29 Base XS-0 Comment-GREEN TOP
___ 09:56PM BLOOD ___ pO2-88 pCO2-45 pH-7.39
calTCO2-28 Base XS-1 Comment-GREEN TOP
DISCHARGE LABS
==============
___ 05:40PM BLOOD WBC-5.3 RBC-4.71 Hgb-12.7 Hct-41.9 MCV-89
MCH-27.0 MCHC-30.3* RDW-14.6 RDWSD-47.4* Plt ___
___ 06:40AM BLOOD ___ PTT-33.6 ___
___ 06:40AM BLOOD Glucose-95 UreaN-27* Creat-0.9 Na-144
K-3.9 Cl-106 HCO3-26 AnGap-12
___ 06:40AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0
RADIOLOGY
=========
___ HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial process or fracture.
2. Unchanged 1.2 cm extra-axial lesion in the region of the left
planum sphenoidale, probably representing a meningioma.
___ HEAD W & W/O CONTRAS
IMPRESSION:
1. Areas of slow diffusion within the left genu of the internal
capsule, right
corona radiata and left pons raises concern for late acute to
early subacute
infarcts. No hemorrhagic products identified.
2. Extensive chronic microangiopathy.
3. Stable appearance of the known left planum sphenoidale
meningioma.
___ HEAD AND CTA NECK
IMPRESSION:
1. Hypodensity within left hemi pons corresponds to the area of
infarct seen
on the recent MRI. No acute intracranial hemorrhage.
2. Mild stenosis is seen involving the origin of the left
internal carotid
artery.
3. Moderate to severe stenosis at the origin of the right
vertebral artery.
4. Incidental 4 mm aneurysm is seen involving the right internal
carotid
artery (3; 195).
5. Enlarged heterogeneous left thyroid mass with displacement of
the trachea.
6. Calcified pleural plaques, which may suggest prior asbestos
exposure.
___ Echo Report
IMPRESSION: Suboptimal image quality. Atrial fibrillation; no
obvious shunt or mass seen.
___ HEAD AND NECK WITH
Wet Read by ___ on SAT ___ 8:17 ___
Noncontrast CT head:
Again demonstrated are focal hypodensities in the right caudate
nucleus, left
internal capsule, and left pons, compatible with subacute
infarcts better
demonstrated on previous MR. 1.1 cm left frontal lobe density
abutting the
left A1 segment of the anterior cerebral artery with represents
a meningioma.
No acute territorial infarction or intracranial hemorrhage.
Basal cisterns
are patent.
CARDIOLOGY
==========
___ EKG
Atrial fibrillation
LVH with secondary repolarization abnormality
NEUROLOGY
==========
___ EEG
IMPRESSION: This is an abnormal video-EEG monitoring session
because of mild
to moderate diffuse background slowing and disorganization.
These findings
are indicative of mild to moderate diffuse cerebral dysfunction,
which is
nonspecific as to etiology. Common causes include toxic and
metabolic
encephalopathies, infections, and medication effects. There are
no focal
abnormalities, epileptiform discharges, or electrographic
seizures.
___ EEG
IMPRESSION: This is an abnormal video-EEG monitoring session due
to:
1) Occasional bursts and runs of focal slowing seen
synchronously and
independently in the temporal regions bilaterally, left more
than right. This
finding indicates independent focal regions of subcortical
dysfunction that is
nonspecific in etiology.
2) Mild to moderate diffuse background slowing and slow
posterior dominant
rhythm. These findings are indicative of mild to moderate
diffuse cerebral
dysfunction, which is nonspecific as to etiology. Common causes
include toxic
and metabolic encephalopathies, infections, and medication
effects.
There are no pushbutton activations. There are no epileptiform
discharges or
electrographic seizures. Compared to the prior day's study, the
temporal slow
bursts are now apparent, and the degree of encephalopathy has
marginally
improved.
___
IMPRESSION: This is an abnormal video-EEG monitoring session due
to:
1) Occasional bursts and runs of focal slowing seen
synchronously and
independently in the temporal regions bilaterally, left more
than right. This
finding indicates independent focal regions of subcortical
dysfunction that is
nonspecific in etiology.
2) Diffuse background slowing and slowing of the posterior
dominant rhythm.
These findings are indicative of mild to moderate diffuse
cerebral
dysfunction, which is nonspecific as to etiology. Common causes
include toxic
and metabolic encephalopathies, infections, and medication
effects.
There are no pushbutton activations. There are no epileptiform
discharges or
electrographic seizures. Compared to the prior day's study,
there is no
significant change.
Brief Hospital Course:
SUMMARY STATEMENT
=================
___ F w/ hx of A fib on coumadin, HTN, chronic ___ edema, mild
cognitive impairment, and L sphenoid ridge meningioma who was
sent to ED from ___ clinic for further evaluation of 3
days of generalized weakness and recent fall found to have a
stroke. Neuro workup included: MRI which showed stroke in the
left genu of the internal capsule, right corona radiata and left
pons. CT showed no evidence of a brain bleed. CTA showed no
aneurysms, dilatations, or occlusions of major blood vessels in
your head and neck. EEG showed no evidence of seizure. Patient
was found to have subtherapuetic INR which was thought to be the
cause of her embolic stroke. However TTE showed no obvious
shunts of masses. Of note, patient had a trigger event on ___
for minimal responsiveness, thought to be likely episode of
hypoactive delirium vs possible seizure. She was started on
medical management of stroke including apixaban, atorvastatin
(increased to 80mg), 100mg losartan, 5mg amlodipine, continued
with home metoprolol. Discharged to rehab per ___ recs.
TRANSITIONAL ISSUES
===================
[] Patient should follow up with her primary care physician to
ensure good compliance of new medications for stroke and to
clarify code status.
[] Antihypertensives were titrated as an inpatient, continue to
monitor pressures and titrate accordingly
[] Patient should have repeat electrolytes checked in 1 week
given that her losartan was uptitrated
[] Patient should follow up in neurology in 3 months for stroke
management
___ Recommendations for Nursing:
Pt is at high risk for deconditioning please encourage frequent
mobility and maximize independence in ADLs.
Assist of 2 for mechanical lift out of bed to chair 3x/day.
# CODE: FULL presumed
# CONTACT:Proxy name: ___
ACUTE/ACTIVE ISSUES:
====================
#Weakness, Falls ___ late acute stroke
Noted by daughter to have awoken on ___ with new inability to
transfer without assistance or walk and with recent fall with
head strike. Prior to this she had been ambulating with a
rolling walker and transferring independently. ___: MR showed
areas of slow diffusion within the left genu of the internal
capsule, right corona radiata and left pons raises concern for
late acute to early subacute infarcts. ___ TTE showed no obvious
shunt or mass, EF: 54 %. EEG was negative for seizure. ___ CTA
showed no high-grade stenosis, occlusion, or aneurysmal
dilatation of the major vessels of the head and neck. Trigger on
___, likely hypoactive delirium vs seizure. EEG was largely
unrevealing. She was started on atorvastatin 80, losartan was
increased to 100mg daily, and she was transitioned from warfarin
to apixaban given concern that her subtherapeutic INRs could
have led to thromboembolic stroke. Her A1c was 6. She was
started on amlodipine 5mg for further HTN management. ___ and OT
were consulted and recommended rehab.
#Altered mental status- improving, likely due to late acute
stroke vs seizure. She receiveid delirium precautions, frequent
redirection, and management of stroke as above.
#R knee pain
R knee X-ray with evidence of OA, no concern for fracture.
continued home lidocaine patch, Tylenol.
#HTN
Noted to be hypertensive to 194/119 on arrival to the floor with
no HA, vision changes, CP, or SOB. Uptitrated losartan to 100mg
as above and started amlodipine 5mg daily.
CHRONIC/STABLE ISSUES:
======================
#mild cognitive impairment
A&Ox1 which is reportedly her baseline.
#Chronic ___ edema
-continued home Lasix 20mg every other day
#permanent Afib
-Rate: continued home metoprolol XL 25mg daily
-Anticoagulation: Was on home warfarin ___ daily. Initially
patient was dosed warfarin daily to INR goal of ___. However
decision was made to transition her to apixaban which was done
when INR reached <2.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild/Fever
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Warfarin ___ mg PO DAILY16
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Losartan Potassium 100 mg PO DAILY
5. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild/Fever
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Ischemic stroke
Weakness
Delirium
SECONDARY DIAGNOSIS
==================
Right knee pain/osteoarthritis
Hypertension
Dimentia
Chronic lower leg edema
Atrial fibrillation
Discharge Condition:
Mental Status: Waxing and waning delirium with underlying
dementia
Level of consciousness: Alternates between alert and interactive
vs somnolent
Activity status: Limited, decompensated
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for 3 days of generalized weakness,
confusion, and a recent fall.
What was done for me while I was in the hospital?
- We took several images of your brain which showed that you had
a stroke. There were 3 areas of your brain that were affected.
The images showed no evidence of a brain bleed. We also looked
at the blood vessels in your brain which showed no evidence of
any bulging, dilatations, or occlusions of major blood vessels
in your head and neck.
- We also did a took an image of your heart which showed no
abnormal blood patterns or obvious masses in your heart.
- The EEG (a test that measures electrical activity in the
brain) showed no seizures.
- We did a clotting test of your blood and measured the time it
takes for a clot to form. This test showed that you were at
increased risk for developing blood clots. We treated you with a
medicine called warfarin and transitioned you to apixaban, which
you should now take once a day.
- We started you on medications that will help decrease your
risks of having another stroke in the future. We started
apixaban (blood thinner), atorvastatin (lowers lipids),
increased your losartan to 100mg daily and amlodipine for blood
pressure control.
- We also continued your home metoprolol to keep your heart rate
stable.
- You also worked with your physical and occupational
therapists.
What should I do when I leave the hospital?
- Take all your medications as prescribed
-We increased your blood pressure medication called
losartan to 100mg day.
-We started you on a new blood thinning medication called
apixaban, which you should take once daily.
-Please stop taking warfarin.
- Keep all your doctors' appointments
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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2173-10-11 18:42:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hydrochlorothiazide / Enablex / lisinopril / flu shot
Attending: ___.
Chief Complaint:
dysarthria, left facial droop, left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o F w/ hx of A fib on dabigatran, HTN,
chronic ___ edema, mild cognitive impairment, L sphenoid ridge
meningioma and multifocal subacute infarcts on MRI on ___ with
residual RLE weakness who presents today with new left facial
droop, dysarthria and worsening of RLE weakness with LKW at 7pm
last night. Per her facility, she was at her baseline when she
went to bed last night then when she woke up this morning at 5am
she was noticed to have a left sided facial droop and
significant
dysarthria. She was taken to an OSH where a code stroke was
called and she was reportedly found to have an NIHSS of 6. She
went to CT which did not demonstrate a bleed and CTA which did
not demonstrate large vessel occlusion. She was then transferred
to ___ for further management given she was outside the tPA
window.
Per her daughter at bedside, she was found to have a UTI on
___ which she was being treated for. It is unclear
whether she had an associated fever or other details regarding
this.
Past Medical History:
-Dementia
-Atrial fibrillation
-Hypertension
-L sphenoid ridge meningioma
-Goiter
-History of breast cancer
Social History:
___
Family History:
Of her five children, two sons died at ___ and ___, both with a
heart attack. Of her 15 siblings, 11 reached adulthood. Her
father died in his ___ with a heart attack, and her mother died
at ___ with a heart attack.
Physical Exam:
Admission Physical Exam:
Vitals: BP: 133/113 HR: 97
General: Awake, cooperative, NAD. significant dysarthria
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, but not
time (she said it was ___ and situation. Significant
difficulty relating history given severe dysarthria. Got
frustrated with ___ backward given her dysarthria and stopped.
Language is fluent with intact repetition and comprehension.
There were no paraphasic errors. Pt was able to name both high
and low frequency objects except called the hammock the hanging
divider that marks lines at the bank. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. No visual neglect though
unable to determine if tactile neglect given inconsistent exam.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. patient did
not have glasses with her so difficult to assess acuity.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: left sided facial droop. Intense dysarthria.
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 5 5
R 5 ___ 5 ___ * * * 5 5
*effort dependent given pain. she says she never lets people
touch that leg. Refuses to participate in full strength testing
-Sensory: No deficits to light touch, pinprick. reports
difference in sensation of right leg compared to left but able
to
specify. unclear if tactile neglect given she kept changing her
answer upon numerous repeat exams. Complicated by difficulty
understanding.
-DTRs:
Bi ___ Pat Ach
L 2 2 2 1
R 2 2 * *
Plantar response was flexor bilaterally.
* refused reflexes on right lower extremity
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Discharge Physical Exam:
Deceased
Pertinent Results:
MRI-B ___. Acute infarctions in the posterior limb of the
right internal capsule and
in the left pons.
2. No evidence of hemorrhage.
3. Unchanged extra-axial mass arising from the left anterior
clinoid process, likely a meningioma.
___ 06:35AM BLOOD WBC-6.8 RBC-4.39 Hgb-11.4 Hct-37.8 MCV-86
MCH-26.0 MCHC-30.2* RDW-15.4 RDWSD-48.2* Plt ___
___ 09:27AM BLOOD Neuts-51.4 ___ Monos-9.5 Eos-8.4*
Baso-1.7* Im ___ AbsNeut-2.45 AbsLymp-1.36 AbsMono-0.45
AbsEos-0.40 AbsBaso-0.08
___ 06:45AM BLOOD ___ PTT-36.2 ___
___ 06:35AM BLOOD Glucose-134* UreaN-12 Creat-0.6 Na-141
K-3.6 Cl-106 HCO3-25 AnGap-10
___ 06:35AM BLOOD ALT-52* AST-54* LD(LDH)-181 AlkPhos-737*
TotBili-1.2
___ 06:35AM BLOOD GGT-869*
___ 09:27AM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Calcium-9.7 Phos-2.6* Mg-1.8
___ 06:30AM BLOOD %HbA1c-6.0 eAG-126
___ 06:30AM BLOOD Triglyc-51 HDL-79 CHOL/HD-1.6 LDLcalc-38
___ 06:30AM BLOOD TSH-0.15*
Brief Hospital Course:
Ms. ___ is a ___ y/o F w/ hx of A fib on dabigatran, HTN,
chronic ___ edema, mild cognitive impairment, L sphenoid ridge
meningioma and multifocal subacute infarcts on MRI on ___ with
residual RLE weakness who presents today with new left facial
droop, dysarthria and worsening of RLE weakness with LKW at 7pm
last night. Patient was not a candidate for tPA given being
outside the window and no thrombectomy given no LVO. MRI
confirmed stroke in the left pons and posterior limb of the
internal capsule. After discussion between the team, patient,
and family, Ms. ___ decided to pursue comfort measures only.
She remained comfortable and in no distress for the remainder of
her hospitalization. She expired on ___ at 7:10 ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild/Fever
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Lidocaine 5% Patch 1 PTCH TD QPM
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Deceased
Discharge Instructions:
Dear ___,
You were admitted to the hospital with symptoms of left facial
droop, right leg weakness, and profound dysarthria. Your
symptoms were due to an acute ischemic stroke. After extensive
discussions about prognosis and quality of life, you and your
family decided to pursue comfort measures only. You were
comfortable and in no distress throughout the rest of your
hospitalization.
Followup Instructions:
___
|
10702059-DS-18
| 10,702,059 | 23,491,060 |
DS
| 18 |
2118-02-05 00:00:00
|
2118-02-13 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillin G / Shellfish Derived / Bactrim
Attending: ___.
Chief Complaint:
fatigue, weakness, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with mixed connective tissue disorder, on prednisone 10
daily maintenance, now with recurrence of increasing fatigue,
weakness, and dyspnea on exertion. These symptoms are mainly
when she gets up to go to the bathroom. She also complains of
ongoing cough x 1 month more recently dark sputum. She also has
a variety of pains, including the shoulders, right arm, neck,
and throat. Patient discussed with ___, who did not
feel it was necessary to be admitted and decided to follower her
as an outpatient.
In the ED, initial vs were 5 98.0 85 149/92 18 100%. Labs were
notable for elevated Cr. The patient received 1 L normal saline.
Transfer vitals were 98.3 75 146/96 16 100%RA. She was admitted
for workup of her dyspnea on exertion and cough.
On arrival to the floor, patient reports to me that her primary
complaints are pain in her throat, left neck, shoulder, and ear.
She reprts that the pain is exacerbated when she moves around
but is helped somewhat by Advil. Her throat pain is improved
with a cup of warm tea. She denies any weakness in her legs to
me. She does say that her back hurts. She also endorses
occasional cough witha small amount of sputum. She also has felt
feverish and as though she has had chills. She denies GI upset
or urinary symtpoms. Finally, she does mention some substernal
pain, unchanged by activity that she has intermittently
experienced. She denies radiation of this pain andsays it is
burning or achy in quality and somewhat worsened by pressure
applied to sternum.
REVIEW OF SYSTEMS:
Denies night sweats, congestion, sore throat, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- Mixed connective tissue disease - ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods
- LAC positive once
- Hypertension
- Chronic anemia (baseline ___
- Hiatal hernia
- GERD
- Osteoporosis
- Decreased lung function secondary to aspiration
- presumed dx of NSIP
.
Social History:
___
Family History:
No family history of autoimmune diseases or lupus. Father had
prostate cancer. No family history of breast cancer, colon
cancer, or diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 98.4 BP 153/99 HR 79 RR 18 97% RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT, MMM, left eye with no pupillary response and
disconjugate fromrigth eye, sclera anicteric, OP without
erythema or exudate
NECK: supple, no LAD
PULM: Good aeration, CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1/S2, no mrg
ABD: Soft, NT, ND normoactive bowel sounds
EXT: No swollen or tender joints in hands or feet, WWP, 2+
pulses palpable bilaterally, no c/c/e
NEURO CNs ___ intact (except in left eye, as above), motor
function grossly normal, ___ strength in all extremities
LABS: reviewed, see below
DISCHARGE PHYSICAL EXAM:
VS: 98 98.7 ___ 135-159/88-103 18 100RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT, MMM, left eye with no pupillary response and
disconjugate from rigth eye, sclera anicteric, OP without
erythema or exudate, tongue is tremulous
NECK: supple, no LAD
PULM: Good aeration, end inspiratory crackles at L base, no
wheezes, or rhonchi
CV: RRR, normal S1/S2, no mrg
ABD: Soft, NT, ND normoactive bowel sounds
EXT: No swollen or tender joints in hands or feet, WWP, 2+
pulses palpable bilaterally, no c/c/e. fingers appear to have
signs of arachnodactyly with IP contraxtures.
NEURO CNs ___ intact (except in left eye, as above), motor
function grossly normal, ___ strength in all extremities
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD WBC-10.9 RBC-3.60* Hgb-8.3* Hct-28.0*
MCV-78* MCH-23.2* MCHC-29.7* RDW-21.1* Plt ___
___ 05:20PM BLOOD Neuts-91.7* Lymphs-6.4* Monos-1.4*
Eos-0.2 Baso-0.3
___ 05:20PM BLOOD ESR-110*
___ 05:20PM BLOOD Glucose-104* UreaN-25* Creat-1.4* Na-137
K-4.5 Cl-105 HCO3-23 AnGap-14
___ 05:20PM BLOOD CK(CPK)-30
___ 05:20PM BLOOD cTropnT-<0.01
___ 05:20PM BLOOD CK-MB-2
___ 05:20PM BLOOD CRP-24.7*
___ 05:31PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-6.6 RBC-3.49* Hgb-8.1* Hct-27.6*
MCV-79* MCH-23.1* MCHC-29.3* RDW-21.3* Plt ___
___ 04:50PM BLOOD ESR-108*
___ 07:10AM BLOOD Glucose-104* UreaN-19 Creat-1.0 Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
___ 04:50PM BLOOD Ferritn-111
___ 07:10AM BLOOD TSH-1.1
___ 04:50PM BLOOD dsDNA-POSITIVE *
___ 04:50PM BLOOD CRP-13.8*
___ 04:50PM BLOOD C3-99 C4-32
PERTINENT MICRO/PATH:
URINALYSIS ___:
GENERAL URINE ___
___ 08:09 StrawClear1.009
Source: ___
DIPSTICK
U
R
I
N
A
L
Y
S
ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks
___ 08:09 NEGNEG30NEGNEGNEGNEG6.0NEG
Source: ___
MICROSCOPIC URINE
EXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp
___ 08:09 22NONENONE<1
Source: ___
OTHER URINE FINDINGSMucous
___ 08:09 RARE
Source: ___
URINE CX NEG
BLOOD CX NEG X2
PERTINENT IMAGING:
CSR ___: No acute cardiopulmonary process.
EKG ___:
Sinus rhythm. Left axis deviation. Prominent voltage in leads I
and aVL
for left ventricular hypertrophy. Delayed precordial R wave
transition.
Compared to the previous tracing of ___ no diagnostic
interim change.
TRACING #2
Read ___
___
___
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
The patient is a ___ woman with a history of mixted
connective tissue disease disorder with manifestations that are
like both SLE and scleroderma who is presenting with overall
fatigue and malaise and complaints of pain in left neck,
shoulder, as well as headache and sore throat.
ACUTE ISSUES:
MIXED CONNECTIVE TISSUE DISEASE:
The patient presented with a variety of migrating pains presumed
to be due to her history of mixed connective tissue disease. Her
troubling pains, such as chest pain, were worked up with EKG and
troponins. The patient has been taking 10mg prednisone recently
for her MCTD. There had been an attempt to taper her steroids,
but she began to worsen clinically. Her CRP and ESR are both
currently elevated,and has 91% neutrophils (though no
luekocytosis or measured fever). She was seen by rheumatology
while inpatient. They injected depomedrol into the patient's
shoulder, which greatly relieved some of her pains. We continued
her current home dose of prednisone, along with prn
acetaminophen and cyclobenzaprine. She was continued on pepcid
and omeprazole for her GERD/scleroderma symptoms.
DOE/WEAKNESS:
She has been admitted with this diagnosis in the past with
negative CTPA and echo showing LVH and pulm HTN. Treated for
URI/PNA with abx, improved with diuresis. Seen by ___, who
concluded: "With respect to her chronic dyspnea, again recurrent
aspiration, possible ILD, mild PH, anemia, & left heart
dysfunction are all likely contributing." Her symptoms now
appear to be identical based on previous notes. Last echo in
___ showed mild LVH with preserved systolic function. No signs
of fluid overload on exam. ___ strength, no muscle tenderness.
Satting well on RA, not tachypneic. Afebrile. CXR shows no acute
process. Low suspicion for PNA or PE. Likely related to MCTD
(ILD) or anemia (see below). The rheumatology service was
consulted. They performed a depomedrol injection of the shoulder
joint, which greatly improved the patient's pain. Her
rheumatologic regimen was not changed. On the morning following
discharge, she reported that her pains were all resolved, her
cough was better, and the DOE was much improved. She did not
require additional interventions such as diuresis or CTA of the
chest to rule out PE. Labs were ordered for her rheumatologist
to follow up on first thing on ___).
ACUTE KIDNEY INJURY:
Creatinine 1.5 from baseline closer to 1.0. Likely secondary to
decreased PO intake or increased ibuprofen use. Also, pt has
acute interstitial nephritis related to MCTD. She was given IVF
overnight, and her Cr improved.
CHRONIC ISSUES:
ANEMIA:
Previously diagnosed with anemia of chronic disease. Hct
at/above baseline. Could be contributing to dyspnea. No
interventions were performed.
HYPERTENSION: Continued home amlodipine.
TRANSITIONAL ISSUES:
# f/u pending rheumatology labs: C3, C4, ESR, CRP, dsDNA,
Ferritin, Urine analysis, Urine culture, Prot./Creat. ratio
urine. F/u with Dr. ___ at ___.
# f/u blood and urine cultures -> no growth
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Amlodipine 10 mg PO DAILY
Hold for HR < 60, SBP < 100.
2. Famotidine 40 mg PO HS
3. FoLIC Acid 1 mg PO DAILY Start: In am
4. Omeprazole 80 mg PO BID
5. Prochlorperazine 10 mg PO Q8H:PRN nausea
6. Ascorbic Acid ___ mg PO DAILY Start: In am
7. calcium carb-D3-mag cmb11-zinc *NF* ___
mg-unit-mg-mg Oral daily
8. Docusate Sodium 100 mg PO BID Start: In am
9. Ferrous Sulfate 325 mg PO DAILY Start: In am
10. Senna 1 TAB PO BID:PRN constipation
11. PredniSONE 10 mg PO DAILY Start: In am
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold for HR < 60, SBP < 100.
2. Ascorbic Acid ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Famotidine 40 mg PO HS
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Omeprazole 80 mg PO BID
8. PredniSONE 10 mg PO DAILY
9. Prochlorperazine 10 mg PO Q8H:PRN nausea
10. Senna 1 TAB PO BID:PRN constipation
11. calcium carb-D3-mag cmb11-zinc *NF* ___
mg-unit-mg-mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1) mixed connective tissue disease
2) generalized weakness
3) acute kidney injury
Secondary diagnoses:
1) anemia of chronic disease
2) hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ for increasing weakness, shortness of
breath, and shoulder and neck pain. We ran tests to make sure
there was not a life-threatening cause for your symptoms. Those
tests were negative. We monitored you and treated you
supportively, keeping you on your home medications and as needed
pain medicine. You improved dramatically. You were seen by
rheumatology, who ordered blood and urine tests. They would like
you to call ___ clinic first thing in the morning on
___ to make an appointment. The number is ___. Dr.
___ be able to see you promptly. Given your
improvement, we now feel it is safe for you to leave the
hospital.
We have not made any changes to your home medications.
Followup Instructions:
___
|
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2118-06-03 00:00:00
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2118-06-05 12:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillin G / Shellfish Derived / Bactrim
Attending: ___.
Chief Complaint:
Cough and dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with history of mixed connective tissue disease
on chronic prednisone, pulmonary hypertension, hypertension,
ILD, and anemia who presents with shortness of breath and
hemoptysis. Symptoms began 2 weeks ago with malaise, cough, SOB,
and back pain. However last night developed worsening cough with
2 cups of dark red hemoptysis. Denies recent travel or sick
contacts. No malaise. Denied fevers or night sweats. No history
of TB or TB exposures.
Also complained of back pain. No recent trauma. Has had prior
history of compression fracture in the past.
Given symptoms she presented to the ED for evaluation.
In the ED, initial VS were: 97 102 138/84 17 100%
Non-Rebreather. Evaluation was significant for WBC 12.4, Cr 1.3
(baseline 1.0), Hct 28.6 (baseline high ___, lactate 2.3, and
trop of 0.02. CXR revealed LLL PNA and patient received
levofloxacin and 1LNS. Given elevated DDimer, initial hypoxia,
and hemptysis, patient underwent CTA (despite ___, which was
negative CTA. Patient was then admitted to medicine for further
work-up. VS prior to transfer: 99.9 108 135/70 28 100% RA.
Past Medical History:
- Mixed connective tissue disease - ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods
- LAC positive once
- Hypertension
- Chronic anemia (baseline ___
- Hiatal hernia
- GERD
- Osteoporosis
- Decreased lung function secondary to aspiration
- presumed dx of NSIP
.
Social History:
___
Family History:
No family history of autoimmune diseases or lupus. Father died
of prostate cancer. Mother has hypertension and arthritis.
Siblings and her 2 children are healthy. No family history of
breast cancer, colon cancer, or diabetes.
Physical Exam:
Admission exam:
VS: 100.2 138/82 87 31 100% 2LNC
GENERAL - well-appearing female, tachypneic, mildly
uncomfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles at bases b/l
HEART - PMI non-displaced, tachycardic, 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
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
Discharge exam:
VS: 98.2 139/92 93 18 100%/RA
GENERAL - well-appearing female, NAD
HEENT - NC/AT, PERRLA, Strabismus with left eye deviated out,
sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles in left base to mid lung field. Patient
breathing comfortably
HEART - PMI non-displaced, tachycardic, 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 - patient with bilateral hyperpigmented plaques on shins
and calfs. Thighs with extensive hardened, shiny areas with
areas of hyperpigmentation and areas of pitting. No erythema,
bleeding or drainage noted.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
.
Pertinent Results:
Admission labs:
___ 03:40PM BLOOD WBC-12.4*# RBC-3.51* Hgb-8.2* Hct-28.6*
MCV-82 MCH-23.5* MCHC-28.8* RDW-19.8* Plt ___
___ 08:11AM BLOOD WBC-9.2 RBC-2.92* Hgb-6.9* Hct-22.9*
MCV-79* MCH-23.8* MCHC-30.2* RDW-19.6* Plt ___
___ 01:10PM BLOOD WBC-9.5 RBC-3.22* Hgb-7.7* Hct-25.7*
MCV-80* MCH-23.9* MCHC-30.0* RDW-19.8* Plt ___
___ 03:40PM BLOOD Glucose-127* UreaN-29* Creat-1.3* Na-137
K-4.8 Cl-106 HCO3-20* AnGap-16
___ 08:11AM BLOOD Glucose-79 UreaN-22* Creat-1.1 Na-136
K-4.2 Cl-110* HCO3-19* AnGap-11
Chest X-ray ___:
Findings worrisome for left lower lobe pneumonia with possible
associated
small left pleural effusion. Recommend followup to resolution.
Chest CTA ___:
Left lower lobe atelectasis without CT evidence for pulmonary
embolus.
Follow-up to resolution to exclude an obstructing lesion. Mild
centrilobular
and paraseptal emphysema.
Chest X-ray ___:
In comparison with the study of ___, there are continued low
lung
volumes which may account in part for the prominence of the
transverse
diameter of the heart. Continued opacification at the left base
is consistent
with some combination of volume loss in the left lower lobe,
pleural effusion,
or superimposed pneumonia. No definite vascular congestion.
Dermal and breast calcifications are again seen, consistent with
the patient's
mixed connective tissue disease.
X-ray of thoracic and lumbar spine ___:
1. Mild anterior wedge/superior endplate scalloping at multiple
thoracic
vertebral bodies, both in the mid thoracic spine and at T11/T12.
However,
these are similar to prior CT scans. No new compression
fracture detected.
2. Extensive soft tissue calcifications, presumably related to
patient's
known mixed connective tissue disease.
3. Focally severe osteoarthritis, with articular surface defect
in the right
hip.
? osteonecrosis with articular surface collapse.
Brief Hospital Course:
___ with history of mixed connective tissue disease on chronic
prednisone, pulmonary hypertension, hypertension, ILD, and
anemia who presents with shortness of breath and hemoptysis who
triggered on arrival to floor for tachypnea
.
# Community Acquired Pneumonia: Patient presented with fever,
leukocytosis, productive cough and infiltrate on CXR suggestive
of pneumonia. She was treated for community acquired pneumonia
with levofloxacin with significant improvement in respiratory
status. Sputum negative for PCP. Although her prednisone puts at
risk for resistant pathogens, she responded well to levofloxacin
and had no evidence of resistant organisms on culture. Cardiac
enzymes negative x2.
.
# Anemia: Borderline microcytic at baseline. Patient with
initial acute drop in setting of IVF and across all cell lines
suggesting hemodilution. Hematocrit was stable afterwards and
patient had no signs of bleeding or hemolysis.
.
# Acute renal failure: Creatinine 1.3 on admission, likely due
to hypovolemia, resolved with treatment.
.
# Elevated Lactate: Lactate elevated to 2.3 on admission,
normalized with fluids and improvement of respiratory status.
.
# Positive urine culture: Urine culture grew ___
organisms of E. coli which was resistant to Bactrim and Cipro.
UA with negative nitrite, small leuk and patient did not
complain of any urinary symptoms, so this was not treated.
.
# Back pain: Patient with history of compression fractures,
complained of back pain. X-ray of thoracic and lumbar spine
showed chronic changes in multiple thoracic vertebrae but no
evidence of new fracture
Chronic issues
# Mixed connective tissue disease: ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods continued home prednisone.
.
# Hypertension: stable on home amlodipine
Transitional issues:
- repeat chest imaging following course of antibiotics to ensure
resolution of infiltrate and rule out obstructing mass
- X-rays of thoracic and lumbar spine showed focally severe
osteoarthritis, with articular surface defect in the right hip
read as "? osteonecrosis with articular surface collapse".
Correlate clinically and consider further imaging
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
hold for sbp < 100
2. Famotidine 40 mg PO BID
3. Fluoxetine 20 mg PO DAILY
4. FoLIC Acid 1 mg PO BID
5. Minocycline 100 mg PO Q24H
6. Omeprazole 40 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. Ibuprofen 400 mg PO BID:PRN pain
13. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for sbp < 100
2. Ascorbic Acid ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Famotidine 40 mg PO BID
5. FoLIC Acid 1 mg PO BID
6. Omeprazole 40 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. calcium carb-D3-mag cmb11-zinc *NF* ___
mg-unit-mg-mg Oral daily
10. Ferrous Sulfate 325 mg PO DAILY
11. Ibuprofen 400 mg PO BID:PRN pain
12. Minocycline 100 mg PO Q24H
13. Vitamin D 1000 UNIT PO DAILY
14. zoledronic acid-mannitol&water *NF* 5 mg/100 mL Injection
once a year
___. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
16. Ondansetron 4 mg PO DAILY with levofloxacin Duration: 3 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth with levofloxacin pill
Disp #*3 Tablet Refills:*0
17. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ with a pneumonia. You are being
treated with antibiotics and will need to continue these for 3
more days.
Changes to your home medications include:
- levofloxacin 750mg daily (take this with food and with Zofran
to prevent nausea)
- Zofran 4mg taken with your levofloxacin to prevent nausea
- you can also take over the counter tylenol for pain. Do not
take more than 3g of tylenol per day.
It was a pleasure taking care of you during your hospitalization
and we wish you a speedy recovery.
Followup Instructions:
___
|
10702059-DS-20
| 10,702,059 | 27,715,074 |
DS
| 20 |
2118-11-21 00:00:00
|
2118-11-22 11:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillin G / Shellfish Derived / Bactrim
Attending: ___.
Chief Complaint:
worsening of DO
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH ILD, mixed CT disorder on chronic prednisone,
pulmonary HTN, anemia presents with one week of cough, weakness,
dizziness and dyspnea. Symptoms worsening this morning, felt
more weak so came into ED. She also has chills and headache this
morning. Cough is productive of whitish phlegm, no blood. Denies
sore throat, rhinorrhea, chest pain. She has not taken anything
for symptoms. She reports that she occasionally gets pneumonia.
She was admitted in ___ was admitted with similar
symptoms and was treated with levaquin for Left lower lobe PNA
with resolution of symptoms.
In the ED, initial vs were T 98.9 HR 86 BP 166/94 RR 24. Getting
O2 was difficult. Exam was notable for rhonchi and using
accessory muscles. Labs were notable for WBC 12.2, PMN 89.4,
Lactate 0.9, Cr 1.3 (baseline 1.0), K 3.5, H/H 6.4/21.6
(baseline Hct 20's, Hgb ___. FOBT in ED negative. Blood
cultures were sent. EKG showed sinus, rate 80, LAD, LVH, TWI in
III, TW flat in aVF. UA was not impressive for UTI. ABG showed
PH 7.43, pCO2 31 pO2 74. Pt received iv levaquin 750 mg x1 and
500 cc NS. CT chest with and without contrast was done (despite
Cr 1.3) which per prelim report showed no PE or acute aortic
pathology, stable pulmonary hypertension findings, persistent
atelectasis of left base and mild atelectasis at right base.
Mild emphysema. Unchanged mid thoracic vertebral fracture.
Vitals on Transfer: HR 79 BP 180/89 RR 18 SAT 99%
On the floor, pt laying in bed at 30 degrees, slightly tachypnic
but able to speak full sentences, has no complaints.
Review of sytems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies rhinorrhea or
congestion. Denies 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. Ten point review of systems is
otherwise negative.
Past Medical History:
- Mixed connective tissue disease - ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods
- LAC positive once
- Hypertension
- Chronic anemia (baseline ___
- Hiatal hernia
- GERD
- Osteoporosis
- Decreased lung function secondary to aspiration
- presumed dx of NSIP
.
Social History:
___
Family History:
No family history of autoimmune diseases or lupus. Father died
of prostate cancer. Mother has hypertension and arthritis.
Siblings and her 2 children are healthy. No family history of
breast cancer, colon cancer, or diabetes.
Physical Exam:
Vitals: 97.9 188/81 65 22 98% 2L NC
GENERAL - well-appearing female, slightly tachypnic, not using
accessory muscles
HEENT - NC/AT, PERRL, Strabismus with left eye deviated out,
sclerae anicteric, MMM, OP clear, + conjuctival pallor
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles bibasaly (documented on prior exams in the
past), no wheeze or rhonchi
HEART - regular rate and rhythm, normal S1s2, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - bilateral hyperpigmented plaques on shins and calfs.
Thighs with extensive hardened, shiny areas with areas of
hyperpigmentation and areas of pitting. No erythema, bleeding or
drainage noted.
NEURO - awake, A&Ox3
DISCHARGE PE
Vitals: Tm/c 98.6 175/95 HR 96 RR 16 98%RA
GENERAL - NAD, comfortable
HEENT - NC/AT, PERRL, Strabismus with left eye deviated out,
sclerae anicteric, MMM, OP clear
LUNGS - faint dry crackles bilaterally (documented on prior
exams in the past), no wheeze or rhonchi
HEART - regular rate and rhythm, normal S1s2, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - bilateral hyperpigmented plaques on shins and calfs.
Thighs with extensive hardened, shiny areas with areas of
hyperpigmentation and areas of pitting. No erythema, bleeding or
drainage noted.
NEURO - awake, A&Ox3
Pertinent Results:
ADMIT LABS:
===========================
___ 04:20PM BLOOD WBC-12.2* RBC-2.78* Hgb-6.4* Hct-21.6*
MCV-78* MCH-23.2* MCHC-29.8* RDW-20.0* Plt ___
___ 04:20PM BLOOD Neuts-89.4* Lymphs-8.0* Monos-2.1 Eos-0.2
Baso-0.3
___ 04:20PM BLOOD Plt ___
___ 04:20PM BLOOD Ret Aut-0.8*
___ 04:20PM BLOOD Glucose-107* UreaN-27* Creat-1.3* Na-140
K-3.5 Cl-108 HCO3-23 AnGap-13
___ 04:20PM BLOOD LD(LDH)-220 TotBili-0.0
___ 04:20PM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0 Iron-12*
___ 04:20PM BLOOD calTIBC-169* Hapto-407* Ferritn-71
TRF-130*
___ 04:36PM BLOOD Type-ART pO2-74* pCO2-31* pH-7.43
calTCO2-21 Base XS--2
___ 04:36PM BLOOD Lactate-0.9
___ 04:28PM BLOOD Lactate-1.2
DISCHARGE LABS:
============================
___ 07:25AM BLOOD WBC-5.7 RBC-3.63* Hgb-8.7* Hct-28.6*
MCV-79* MCH-24.1* MCHC-30.6* RDW-19.6* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-80 UreaN-18 Creat-1.4* Na-140
K-4.1 Cl-107 HCO3-23 AnGap-14
___ 09:27AM BLOOD proBNP-2986*
___ 07:25AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9
___ 04:20PM BLOOD calTIBC-169* Hapto-407* Ferritn-71
TRF-130*
MICRO:
============================
___ BCx pending x2
IMAGING:
============================
___ CXR
IMPRESSION: No definite acute cardiopulmonary process.
___ CT CHEST
IMPRESSION:
1. No evidence of a pulmonary embolism or acute aortic
pathology.
2. Volume loss with associated consolidation at the left base
which is likely atelectasis. This is slightly improved from the
prior exam in ___.
3. Stable enlargment of the main pulmonary artery trunk, likely
due to
pulmonary hypertension.
4. Unchanged mild-to-moderate emphysema.
5. Unchanged mid thoracic vertebral body compression fracture.
Brief Hospital Course:
___ with history of mixed connective tissue disease on chronic
prednisone, pulmonary hypertension, ILD, and anemia who presents
with cough, chills, worsening of baseline DOE, being treated as
PNA. Also found to have acute worsening of her baseline anemia.
# DOE: DOE worsened from occurring when walking 1 block to now
walking to bathroom and back from bed. DDX given leukocytosis,
cough, fever, chills c/f PNA. ___ was treated with levofloxacin
for a 5 days course for pneumonia given clinical picture, and
while cough and fevers resolved, she continued to c/o DOE. She
was also given 1 u PRBCs for HCT 21 and HCT increased to ___
appropriately. She still did not improve subjectively based on
DOE. On hospital day 2, pt was always satting high ___ on RA,
but on ambulation she desatted to mid ___ though the pleth was
not tracking well and occasionally O2 sat precipitously feel
without any apparent clinicl change in her breathing. A BNP was
checked, given prior h/o elevated BNP and lasix responsive DOE,
it was 3000. She was given 20 IV lasix on hospital day 4 and
while no weight or I/Os were recorded, she subequently felt
better. On the subseqent day (day of discharge), with ambulation
she was at 94% on RA without any e/o of tachypnea, though her HR
increased from ___ to low 100s. She felt well and at baseline
and was discharge.
# HTN: Pt was not taking amlodipine and not clear if was taking
chlorthalidone (per pharmacy not refilled since early ___.
___ was given 10mg po hydral PRN with improvement, but given that
she did not take norvasc and chlorthalidone at home, we did not
think she could take a QID dosing regimen. She was DC-ed on the
home medications, but with Rx for them and discussion that she
needs to take them. Her BPs ranged from 160-180s/80-100s during
hte hospitalization. She may benefit from ACE inhibitor for its
beneficial renal effects given her mixed connective tissue
disease.
# Med noncompliance: Pt seems to DNK appts and self dc-ed
medicatrions (like cell cept, and stopped taking ferrous sulfate
1 week prior to admission, and did not refill amlodipine and
chlorthalidone since ___. She was enrolled in ___ PACT
program and will benefit from close med reconciliation
# Anemia: Rec'd 1 uPRBCs. Known Fe def anemia and anemia of chr
dz. Baseline Hct high 20's, Hgb ___. On admission Hgb 6.4 Hct
21.6. Borderline microcytosis at baseline. Stopped taking iron
supplements 1 week ago and did not refill. Fe studies consistent
with Fe def anemia and anemia of chronic disease likely. DRE
heme negative in ED (per report but not documented). Pt
underwent subsequent DRE without any stool in vault to test for
stool guaiac. Despite lack of documented guaiac stool,
encouraged pt to undergo colonoscopy. Pt is very hesistant to
undergo ___ ___ to prep, and prior experience where she went to
ED ___ to reaction to prep (not really clear what that was).
Also suggested that she talk with PCP ___: virtual colonography
as a starting point, though would not be a sensitive, would be
better than no imaging.
# Acute renal failure: Creatinine 1.3 on admission from baseline
of 1 - 1.3. She did not appear dry, and remained at 1.3-1.4. She
was continued on chlorthalidone.
# Osteoporosis, with vertebral fractures. Secondary to chronic
illness plus prednisone. She received her annual Reclast
infusion ___. Current CT chest showed stable mid thoracic
fracture.
# Mixed connective tissue disease: ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods. She was continued on home pred 10
qd.
# GERD, GI dysmotility, from her rheumatologic illness:
Endoscopy ___ showing esophageal ___, mucosa
suggestive of ___ esophagus. Biopsy showing inflammation.
Pt was continued on home PPI.
# CODE: full - confirmed
# CONTACT: ___ ___
TRANSITION ISSUES:
# Pt requires screening ___, particularly in the setting of
acute on chronic anemia. Fe definiciency anemia. Also pt c/o
gastritis, so may also consider endoscopy. Also consider virtual
colonography if pt refusing to ___ prep, as she has refused
in the past
# Consider pulm referral for PFTs, as last were done in ___
# f/u ___ BCx x2
# med reconcile the pt at each clinic visit, as pt dc-es
medications or may not always refill them
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Reclast *NF* (zoledronic acid-mannitol-water) 5 mg/100 mL
Injection yearly
last dose ___
3. Omeprazole 40 mg PO BID
4. Ascorbic Acid ___ mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium Carbonate 333 mg PO DAILY
9. Magnesium Oxide 133 mg PO DAILY
10. Zinc Sulfate 5 mg PO DAILY
11. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 200 mg Oral
daily
12. Senna 1 TAB PO HS:PRN constipation
13. Ibuprofen 200-400 mg PO BID:PRN pain
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO BID
4. Omeprazole 40 mg PO BID
5. Senna 1 TAB PO HS:PRN constipation
6. Calcium Carbonate 333 mg PO DAILY
7. Ibuprofen 200-400 mg PO BID:PRN pain
8. Magnesium Oxide 133 mg PO DAILY
9. Reclast *NF* (zoledronic acid-mannitol-water) 5 mg/100 mL
Injection yearly
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 200 mg Oral
daily
12. Zinc Sulfate 5 mg PO DAILY
13. PredniSONE 10 mg PO DAILY
14. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Chlorthalidone 12.5 mg PO DAILY
RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
17. Levofloxacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute anemia
Pneumonia
Diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ for feeling short of breath when you
were walking, in addition to 2 weeks of cough with fevers and
chills. We treated you for a pneumonia and gave you blood, and
you started to feel slightly better, and your cough improved.
Ultimately, we gave you a lasix (the water pill) to remove fluid
from your lungs. You felt better after receiving the lasix.
.
On discharge, we want you to continue taking the lasix as
prescribed.
.
In addition, you were not taking your blood pressure medications
and your pressures were quite high during your hospitalization.
It is very important that you take all your medications as
prescribed to better control your blood pressure.
.
Finally, it is very important that you re-consider having a
colonoscopy as a screening test for colon cancer, because you
could be anemic from blood loss in your stool. If you cannot
tolerate the colonoscopy prep, then your primary care doctor can
talk to you about alternative tests.
Followup Instructions:
___
|
10702059-DS-21
| 10,702,059 | 29,846,127 |
DS
| 21 |
2119-01-31 00:00:00
|
2119-02-06 03:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Bactrim / Penicillins
Attending: ___.
Chief Complaint:
fatigue/weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o mixed connective tissue disorder presents with
generalized weakness. Patient reports approximately 2 weeks of
generalized weakness. On day of presentation noted onset of
diffuse pain including left sided chest pain radiating to her
left shoulder. Pain is exacerbated by movements. Notes that she
recently started taking chlorthalidone (months ago) and feels
that she might be "dehydrated" which is making her feel weak.
In the ED, initial vs were: 97.6 90 166/94 24 98% 2L . Labs were
remarkable for Cr 1.4, Na 130, HCT 24. Bedside u/s: no
pericardial effusion. Patient was given tylenol 1g, ass 325.
Vitals on Transfer: 98.3 90 161/92 20 98% RA
On the floor, pt is sleepy but alert. She reports she had some
pain in her finger joints earlier but no other pains. Denies
chest pain. Feels fatigued.
Past Medical History:
- Mixed connective tissue disease - ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods
- LAC positive once
- Hypertension
- Chronic anemia (baseline ___
- Hiatal hernia
- GERD
- Osteoporosis
- Decreased lung function secondary to aspiration
- presumed dx of NSIP
.
Social History:
___
Family History:
No family history of autoimmune diseases or lupus. Father died
of prostate cancer. Mother has hypertension and arthritis.
Siblings and her 2 children are healthy. No family history of
breast cancer, colon cancer, or diabetes.
Physical Exam:
Admission Exam:
Vitals- 98.5 181/93 80 22 100%ra
General- sleepy but easily arrousable, no acute distress
HEENT- Sclera anicteric, mildly dry mucus membranes, oropharynx
clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
SKin: calcinosis on elbows and thighs
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam:
Vitals: T 97.8 BP 140/92 HR 106 RR 18 O2 Sat 97%
General- alert and orieted, no acute distress
HEENT- Sclera anicteric, lazy L eye with no pupilary reaction, R
eye reactive, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- bilateral crackles heard at the bases, L greater than R,
L-sided crackles to mid-lung
CV- Regular rate and rhythm, II/VI systolic murmur without
radiation to carotids heard best left sternal border
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no swelling of the hands or feet noted, nontender hands
and feet
Neuro- CNs2-12 intact, ___ strength upper extremities, ___
strength lower extremities
Pertinent Results:
Admission Labs:
___ 01:40AM BLOOD WBC-10.0 RBC-3.12* Hgb-7.5* Hct-24.4*
MCV-78* MCH-23.9* MCHC-30.6* RDW-19.4* Plt ___
___ 01:40AM BLOOD Neuts-87.2* Lymphs-8.9* Monos-3.2 Eos-0.4
Baso-0.2
___ 01:40AM BLOOD Glucose-153* UreaN-30* Creat-1.4* Na-130*
K-5.1 Cl-100 HCO3-23 AnGap-12
___ 08:00AM BLOOD CK(CPK)-32
___ 01:00PM BLOOD LD(LDH)-185
___ 01:40AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:00PM BLOOD Hapto-405*
___ 08:00AM BLOOD C3-68* C4-27
___ 08:00AM BLOOD ESR-95*
___ 08:00AM BLOOD Ret Aut-1.1*
Discharge Labs:
___ 07:07AM BLOOD WBC-6.4 RBC-3.23* Hgb-7.8* Hct-25.1*
MCV-78* MCH-24.1* MCHC-31.0 RDW-19.5* Plt ___
___ 07:07AM BLOOD Glucose-87 UreaN-24* Creat-1.1 Na-134
K-5.3* Cl-104 HCO3-21* AnGap-14
___ 12:45PM BLOOD Na-136 K-4.2 Cl-104
Imaging:
___ CXR:
IMPRESSION: No acute cardiopulmonary process. Moderate
cardiomegaly.
___ CT chest
IMPRESSION:
1. No evidence of disseminated interstitial lung disease.
2. Sequela of patient's known systemic sclerosis including
calcinosis cutis and patulous distal esophagus.
3. Evidence of pulmonary hypertension.
4. Moderate cardiomegaly and coronary artery calcifications.
5. Atrophic adrenal glands.
Brief Hospital Course:
Impression: ___ h/o mixed connective tissue disorder c/b signs
and sx of lupus and scleroderma who presents with generalized
weakness and chest pain.
**ACUTE ISSUES**
# Fatigue and weakness / MCTD flare: Patient endorses multiple
nonspecific symptoms such as fatigue and weakness, althralgias,
burning eye pain, chest pain, and DOE. Lasix was discontinued in
the event she was dehydrated. ESR was elevated to 95, CRP
elevated to 17.7, C3 low at 68, and normal C4, consistent with a
flare of her Mixed Connective Tissue Disease. Rheumatology was
consulted and recommended r/o infectious etiologies, which was
done with CT chest, urine and blood cultures. They recommended
increasing prednisone dose to 20mg daily and starting Imuran
50mg. Prior authorization was obtained for this medication and
patient encouraged to start it.
# Chest pain: Likely pleurisy from MCTD flare. She was ruled out
for ACS with serial troponins and an EKG without ischemic
changes. While PE was on the differential, her lack of hypoxia
and tachycardia made it less likely. Her chest pain resolved by
HD2.
# Hyponatremia: Na mildly decreased to 130 on admission. Likely
___ hypovolemia as patient was taking 2 diuretics and endorsed
poor PO intake. Lasix was discontinued as above. Na improved to
136 at discharge without any other interventions.
**CHRONIC ISSUES**
# Anemia: Patient has significant history of anemia, thought to
be multifactorial from anemia of chronic disease, h/o
thalassemia, and possible iron deficiency. Her baseline is
approximately hb ___ and on admission, Hb was 7.5.
# GERD, GI dysmotility, from her rheumatologic illness:
Continued home PPI.
# HTN: Continued home chlorthalidone. Lasix discontinued as
above.
# Raynaud's syndrome: Continued home amlodipine.
**TRANSITIONAL ISSUES**
- started Imuran 50mg daily, prior authorization obtained
- prednisone increased to 20mg daily, with close f/u with
primary rheumatologist
- Lasix discontinued
- consider Pulm referral for her dry crackles on exam
- monitoring for signs/symptoms of adrenal insufficiency
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Ascorbic Acid ___ mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO BID
9. Calcium Carbonate 333 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin D3 (cholecalciferol (vitamin D3)) 200 mg Oral daily
12. Zinc Sulfate 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Calcium Carbonate 333 mg PO DAILY
4. Chlorthalidone 12.5 mg PO DAILY
RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO BID
7. Omeprazole 40 mg PO BID
8. Zinc Sulfate 5 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Vitamin D3 (cholecalciferol (vitamin D3)) 200 mg Oral daily
11. Azathioprine 50 mg PO DAILY
RX *azathioprine 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. PredniSONE 20 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: mixed connective tissue disease and lupus
flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted because you
were feeling weak and had some chest pain. We were concerned for
a flare of your mixed connective tissue disease and lupus. We
consulted the rheumatologists who recommended that you increase
your prednisone to 20mg daily and restart Imuran at 50mg daily.
We are working with your pharmacy to get this medication
approved.
Thank you for allowing us to be a part of your care.
The following medication was STARTED
1. imuran 50mg daily
The following medication was CHANGED
1. increase Prednisone to 20mg daily (2 tabs)
The following medication was STOPPED:
1. Furosemide (Lasix) 20mg daily
Followup Instructions:
___
|
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2119-03-29 00:00:00
|
2119-03-29 17:36:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Bactrim / Penicillins
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
right heart catheterization
History of Present Illness:
The patient is a ___ female with history of mixed connective
tissue disease who presents from home to the ED with two weeks
of progressive dyspnea with exertion. She denies symptoms at
rest but feels dyspnea with even minimal movement at times. She
reports her symptoms are worse when lying flat. She has a stable
cough. She denies fever, palpitations, or chest pain. She denies
leg swelling, recent surgery, long distance air travel.
Associated with this is worsening fatigue and left shoulder
joint discomfort.
In the ED, initial vital signs were 98.9 100 147/88 26 100% 2L
Nasal Cannula. Per signout - discussed with rheumatology - ___
current need for increased steroids but if she is tachypnic
overnight she can have an additional 10mg prednisone PO. O2 as
needed. Patient was given acetaminophen.
Review of Systems:
(+)
(-) headache, vision changes, abdominal pain, nausea, vomiting,
diarrhea, constipation.
Past Medical History:
- Mixed connective tissue disease - ___, DS-DNA, ___, Ro, LA,
and high titer RNP, history of anemia, alopecia, arthritis,
cerebritis, acute interstitial nephritis, calcinosis cutis with
prominent infiltration of the thighs, esophageal dysmotility,
ILD-last rituxan dose was ___ c/b by aseptic necrosis of four
major joints due to steriods
- LAC positive once
- Hypertension
- Chronic anemia (baseline ___
- Hiatal hernia
- GERD
- Osteoporosis
- Decreased lung function secondary to aspiration
- presumed dx of NSIP
.
Social History:
___
Family History:
-___ known history of SLE or other rheumatologic diseases.
Physical Exam:
Vitals: BP:134/92 HR:81 RR:20 O2: 97%RA
General: speaking in complete sentence, comfortable
HEENT: anicteric
Neck: JVP not appreciated at 45 degrees
CV: S1, S2 regular rhythm, normal rate
Lungs: unlabored, CTA bilaterally
Abdomen: soft, non-tender, ___ rebound
GU: ___ foley
Ext: trace edema, Right > left that pt reports is chronic
Neuro: awake, alert, speech fluent
Pertinent Results:
___ 06:20PM BLOOD WBC-9.8# RBC-3.21* Hgb-7.3* Hct-26.4*
MCV-82 MCH-22.6* MCHC-27.4*# RDW-19.3* Plt ___
___ 06:20PM BLOOD Neuts-87.7* Lymphs-8.3* Monos-2.8 Eos-0.7
Baso-0.4
___ 06:20PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Tear Dr-2+ Acantho-1+ Ellipto-1+
___ 06:20PM BLOOD Glucose-147* UreaN-24* Creat-1.3* Na-134
K-4.2 Cl-102 HCO3-19* AnGap-17
.
CXR (___):
FINDINGS: Frontal and lateral views of the chest were obtained.
There is stable enlargement of the cardiomediastinal
silhouette. Prominence of the right hilum is also stable dating
back to at least ___. Minimal blunting of the
costophrenic angles is stable, again may relate to scarring. ___
new focal consolidation is seen. There is ___ evidence of
pneumothorax.
IMPRESSION: ___ significant interval change.
echocardiogram ___
This study was compared to the prior study of ___.
LEFT ATRIUM: Severely increased LA volume.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. ___ ASD by 2D or color Doppler. The IVC was
not visualized. The RA pressure could not be estimated.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Estimated cardiac
index is normal (>=2.5L/min/m2). Doppler parameters are most
consistent with Grade I (mild) LV diastolic dysfunction. ___
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. TASPE depressed
(<1.6cm)
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP. Normal mitral valve supporting structures. ___ MS. ___ to
moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. ___ TS. Mild [1+] TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
___ PS. Mild PR.
Conclusions
The left atrial volume is severely increased. ___ atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Quantitative
(biplane) LVEF = 61 %. The estimated cardiac index is normal
(>=2.5L/min/m2). Doppler parameters are most consistent with
Grade I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is depressed (1.1 cm) consistent with right
ventricular systolic dysfunction. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and ___ aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is ___ mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension.
IMPRESSION: Normal left ventricular regional/global systolic
function. Mild to moderate mitral regurgitation. It appears that
the longitudinal right ventricular function is mildly depressed.
Borderline pulmonary systolic hypertension. Pulmonary diastolic
pressures were 8 mm Hg plus right atrial pressure. The right
atrial pressure could not be assessed in this exam.
Compared with the prior study (images reviewed) of ___, the
right ventricle seems less vigorous. Pulmonary pressures are
likely similar with borderline to mild pulmonary hypertension
present.
cardiac catheterization ___
Assessment & Recommendations
1. Mild pulmonary hypertension.
2. Normal right ventricular diastolic pressure.
3. Normal PCW.
4. There was ___ oxymetric evidence of significant intra-cardiac
shunting.
5. Findings discussed by telephone with the Pulmonary Consult
fellow. Vasodilator study not undertaken as PVR ~3 ___ with
mildly
elevated PASP and mean PA in a patient already on calcium
channel
blockers.
6. RFV sheath to be removed.
7. Return to ___
8. Additional plans per the Pulmonary Consult Service.
Brief Hospital Course:
The patient is a ___ female with history of mixed connective
tissue disease who presents with two weeks of dyspnea with
exertion.
She has been evaluated by pulmonary in the past (see note from
___ for chronic dyspnea, which was thought to be
multifactorial from pulmonary hypertension, anemia, and possibly
left heart dysfunction or recurrent aspiration or ILD. Most
recent CT chest (non-contrast) from ___ with evidence of
pulmonary hypertension but without findings of ILD. Pt underwent
evaluation with echocardiogram which showed decrease in function
of RV. She had a RHC that showed normal wedge and that there
was not significant pulmonary hypertension. Pulmonary team was
consulted. She underwent PFts which are pending at this time of
this notes. She is recommended to f/u with cardiology as an
outpatient to eval for RV failure and ischemic disease.
Hematology was consulted as well. Based on their evaluation her
anemia is likely from thalassemia and chronic disease. A
hemoglobin electrophoresis was ordered and is pending at this
time. TSH and G6PD were ordered and are pending at discharge as
well. Rheumatology recommended that the pt have an increase in
her imuran and prednisone in order to better control the MCTD
and ILD that is ___ contributing to her DOE. She was seen by
___ and did not desat with walking and therefore cannot have home
oxygen covered. She was discharged to home with follow up
appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO BID
4. Omeprazole 40 mg PO BID
5. Azathioprine 50 mg PO DAILY
6. PredniSONE 10 mg PO DAILY
7. Calcium Carbonate Dose is Unknown PO DAILY
8. Vitamin D Dose is Unknown PO DAILY
9. Ascorbic Acid Dose is Unknown PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO BID
4. Omeprazole 40 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Ascorbic Acid ___ mg PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. PredniSONE 20 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
10. Azathioprine 75 mg PO DAILY
RX *azathioprine 50 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
worsening of the mixed connective tissue disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to worsening of your chronic shortness of
breath. We think that this may be due in part to a flare of
your mixed connective tissue disorder. Your imuran dose was
increased. You had a right heart catheterizaton which showed
that you have not had worsening pulmonary hypertension (or
increase in pressure in vessels between heart and lungs). You
are recommended to see the cardiologist in the future to
evaluate that righ side of the heart that is not pumping as well
as it should be. The hematologist were called to determine if
there is a way to correct your chronic anemia (or low blood
counts). There is not a clear way to increase them. The lung
function tests were performed as well to determine if there is
more than can be done with your lungs to help the breathing.
Followup Instructions:
___
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2122-10-31 00:00:00
|
2122-10-31 13:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Bactrim / Penicillins / Tessalon Perles
Attending: ___
Chief Complaint:
chest pain and SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of HTN, GERD, CKD, osteoporosis (recently on
teriparatide), dCCF (LVH, EF 55%, ___ multiple
arthroplasties, and MTCD ___ positive
SLE/scleroderma overlap syndrome) c/b alopecia, arthritis,
cerebritis with residual left eye blindness, calcinosis cutis of
thighs, esophageal dysmotility, probable NSIP, PHTN (PASP 33+
per TTE ___ and anemia on prednisone 5mg and azathioprine
100mg (previously received MMF, Rituximab) with Recent flight to
___ two months ago.
Presented ___ with two weeks of left pleuritic chest pain,
exertional shortness of breath (from 1 block baseline to few
steps), subjective fevers and chills but no cough and no other
accompanying symptoms. On presentation to the ED VS were 100.4
80 123/66 18 97% RA with ambulatory desat to 87%. Pt had CTA
negative for PE, ECG non ischemic, negative trop X2. Labs
notable for stable normocytic anemia and CKD. New non gap
metabolic acidosis with HCO3 16 AG 13. D-Dimer 894, BNP 728. No
leukocytosis. CTA did show left lower lobe bronchiectasis with
volume loss, bronchial wall thickening and mild ground-glass
opacification, bibasilar atelectasis and emphysema.
She was managed with fluids and given IV Levofloxacin for CAP
coverage.
On presentation to the medical floor she reported continuous
pleuritic type left sided chest pain worse on lying flat and
inspiration, dyspnea at minimal exertion. No cough.
11 point ROS was otherwise negative. She denies any h/o sick
contacts.
Past Medical History:
- MCTD, with mainly scleroderma/SLE overlap. Primary
manifestations of polyarthritis, calcinosis cutis, serositis,
Raynaud's, history of cerebritis (early ___, left with
unilateral blindness). Also with possible mild interstitial lung
disease and PAH. High titer RNP, positive ___, Ro, ___, Sm,
dsDNA.
Currently on prednisone 5/Imuran100; previously received MMF,
Rituximab.
- Pulmonary arterial hypertension (mPAP 29 in ___ mPAP 24 in
___ not on treatment). She was started on treatment
(macitencan) which she did not tolerate. She was more
recently tried on sildenafil in ___ but she stopped this after
one dose.
- Possible NSIP/very mild interstitial lung disease on prior CT
scans. PFTs moderately but stabily restricted
- Diastolic dysfunction by echo
- Hyponatremia when on diuretics
- Chronic kidney disease (creatinine 1.2 to 1.4)
- GERD
- Chronic anemia: thalessemia trait, iron deficiency (on iron
supplementation) and anemia of chronic disease.
- Raynauds
- recurrent pericarditis
- Osteoporosis
- Hypertension
- History of AVN of hip
- s/p R total shoulder arthroplasty ___ and L total shoulder
___
- Blindness of left eye (secondary to MCTD/SLE cerebritis)
- Postmenopausal x ___ years
- Smoking history: never
Social History:
___
Family History:
-no known history of SLE or other rheumatologic diseases.
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: 98.8 106/71 71 18 98 RA
GEN: Alert, mildly tachypnic but in NAD
EYE: EOMI, PERRL, no conjuctival pallor or irritation.
ENT: MMM, no oral lesions
Neck: no LAD, no nuchal rigidity, JVP WNL
CV: RRR, no M/R/G
RESP: Bil air movement with mild end expiratory bi-basilar
crackles r>l
GI: Soft, NTND, no HSM, Normal Bowel Sounds
EXT: No cyanosis, clubbing or edema. No signs of DVT.
MSK: non inflamed chronic synovial hypertrophy of MCP's in Bil
hands with boutonniere deformity of bil thumbs.
SKIN: ichthiosis on the back, otherwise no rash, no pressure
ulcers.
NEURO: A+OX3, no focal motor or sensory deficits
PSYCH: Calm and Appropriate
DISCHARGE EXAM:
===============
VITALS: 98.2PO 111 / 64 65 18 97 RA
GEN: Laying in bed in NAD
EYES: EOMI, PERRL, no conjuctival pallor or irritation.
ENT: MMM, no oral lesions
Neck: no LAD, no nuchal rigidity, JVP WNL
CV: RRR, no M/R/G
RESP: Bil air movement with mild end expiratory bi-basilar
crackles r>l. There is reduced air entry, slightly decrease
timpani to precussion over the right lung base but equal
fremitus.
GI: Soft, NTND, no HSM, Normal Bowel Sounds
EXT: No cyanosis, clubbing or edema. No signs of DVT.
SKIN: ichthiosis on the back, otherwise no rash, no pressure
ulcers.
NEURO: A+OX3, no focal motor or sensory deficits
PSYCH: Calm and Appropriate
Pertinent Results:
ADMISSION LABS:
===============
___ 05:00PM BLOOD WBC-7.6 RBC-3.08* Hgb-8.2* Hct-26.7*
MCV-87 MCH-26.6 MCHC-30.7* RDW-20.0* RDWSD-62.0* Plt ___
___ 05:00PM BLOOD Neuts-86.7* Lymphs-8.4* Monos-3.7*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.57*# AbsLymp-0.64*
AbsMono-0.28 AbsEos-0.01* AbsBaso-0.02
___ 05:00PM BLOOD ___ PTT-24.0* ___
___ 05:00PM BLOOD Glucose-97 UreaN-30* Creat-1.5* Na-133
K-4.9 Cl-104 HCO3-16* AnGap-18
___ 05:00PM BLOOD proBNP-728*
___ 05:00PM BLOOD D-Dimer-894*
___ 05:00PM BLOOD HCG-<5
DISCHARGE LABS:
==============
___ 05:55AM BLOOD WBC-2.9* RBC-2.93* Hgb-7.6* Hct-25.2*
MCV-86 MCH-25.9* MCHC-30.2* RDW-19.9* RDWSD-61.7* Plt ___
___ 05:50AM BLOOD Glucose-84 UreaN-22* Creat-1.4* Na-135
K-4.4 Cl-103 HCO3-19* AnGap-17
___ 05:10PM BLOOD ALT-10 AST-27 CK(CPK)-41 AlkPhos-73
TotBili-0.2
___ 05:55AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
IMAGING:
========
___: CXR:
Patchy opacities in the lung bases, which may reflect a
combination of
atelectasis with chronic aspiration and bronchiectasis in the
left lower lobe,
but infection cannot be excluded in the correct clinical
setting.
___ CTA chest:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Left lower lobe bronchiectasis with volume loss, bronchial
wall thickening
and mild ground-glass opacification, may represent chronic
aspiration.
Bibasilar atelectasis.
3. Moderate centrilobular emphysema and mild paraseptal
emphysema.
4. Dilatation of the main pulmonary artery to 3 cm may suggest
underlying
pulmonary arterial hypertension.
5. Dilated esophagus and moderate size hiatal hernia.
ECG ___ (my read): sinus 75, borderline left axis deviation, PR
= 0.23, wide p wave in II suggesting ___, borderline
voltage criteria for LVH in precordial leads with lateral
repolarization abnormality consistent with this. Largely
unchanged from previous ECG in ___ except 1st degree AV block
which is new, no dynamic changes compared to previous tracing
from ___.
Brief Hospital Course:
___ with history of HTN, GERD, CKD, osteoporosis (recently on
teriparatide), dCCF (LVH, EF 55%, ___ multiple
arthroplasties, and MTCD ___ positive
SLE/scleroderma overlap syndrome) c/b alopecia,
arthritis, cerebritis with residual left eye blindness,
calcinosis cutis of thighs, esophageal dysmotility, probable
NSIP, PHTN (PASP 33+ per TTE ___ and anemia on prednisone 5mg
and azathioprine 100mg, presenting with pleuritic chest pain and
worsening DOE and mild ambulatory desats.
# L pleuritic CP
# Possible acute pericarditis vs. CAP\
# Low-grade fever
Pt presented with several weeks of DOE and pleuritic CP, found
to have mild ambulatory desat's to 87% (though difficult to get
good waveform given her dark nailpolish), and low grade temp of
100.4. PE/MI ruled out in ED per neg CTA and trop X2.
Differential included CAP, viral pneumonitis, acute exacerbation
of MTCD-related chronic pneumonitis or acute pericarditis. On
review of note, pt has had similar symptoms in the past with PAH
but has not tolerated tx so was monitored only. Symptoms also
could have been d/t recurrent pericarditis, given her history
though she did not meet full clinical criteria as she did not
have a friction rub, characteristic ECG changes or pericardial
effusion (per CTA on admission and TTE on ___. She was
treated for CAP (given fevers and CXR findings on admission)
with CTX/azithro->Levaquin (for completion of 7 day course with
improvement). Pt was seen by Rheumatology who did not feel that
this was an exacerbation of her chronic ILD/PAH and recommended
either increasing her pred vs. starting colchicine for presumed
pericarditis. However, pt refused doses of colchicine and
increased pred d/t GI distress and symptoms had improved with
significant medication changes. She will not be discharged with
tx with pericarditis as there was not convincing evidence of
this and pt refusing new meds. Of note, pt also has repeat PFT's
scheduled for next week.
# elevated inflammatory markers: ESR 120/CRP 85.8 these are
significantly higher then most previous checks on OMR. Possibly
d/t CAP per above. ___ need to be rechecked after discharge.
# normocytic anemia
# Chronic anemia/thalessemia trait/iron deficiency/anemia of
chronic disease: H/H was largely at baseline.
Chronic:
# MCTD - scleroderma/SLE overlap-- Continued home prednisone and
azathioprine, seen by Rheum per above who felt that her disease
was at baseline.
# Chronic kidney disease (creatinine at baseline 1.2 to 1.4)
# GERD/Hiatal hernia: Continued PPI
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. AzaTHIOprine 100 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Dexilant (dexlansoprazole) 60 mg oral daily
5. Famotidine 20 mg PO QHS
6. Ascorbic Acid ___ mg PO DAILY
7. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral daily
8. Vitamin D 1000 UNIT PO DAILY
9. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth every
day Disp #*2 Tablet Refills:*0
2. Cyanocobalamin 100 mcg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. AzaTHIOprine 100 mg PO DAILY
6. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral daily
7. Dexilant (dexlansoprazole) 60 mg oral daily
8. Famotidine 20 mg PO QHS
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pnemonia\nMixed connective tissue disorder
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with fever and chest pain and were
treated for a possible pneumonia. You were treated with
antibiotics and your condition improved.
Please return if you have worsening shortness of breath, chest
pain, nausea, vomiting, fevers, or if you have any other
concerns.
It was a pleasure taking care of you at ___
___.
Followup Instructions:
___
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2122-12-07 00:00:00
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2122-12-07 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Bactrim / Penicillins / Tessalon Perles
Attending: ___
Chief Complaint:
progressive weakness, DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of HTN, GERD, CKD, osteoporosis, dCHF, s/p
multiple arthroplasties, and MTCD ___
positive SLE/scleroderma overlap syndrome) c/b alopecia,
arthritis, cerebritis with residual left eye blindness,
calcinosis cutis of thighs, esophageal dysmotility, probable
NSIP, moderate pHTN, and multifactorial anemia on prednisone 5mg
and azathioprine 100 mg (previously received MMF, Rituximab),
admitted ___ with CAP vs pericarditis, presenting with
progressive weakness and DOE.
With respect to hospitalization at end of ___, pt initially
presented with L sided pleuritic chest pain, DOE, and subjective
F/C, very similar to current presentation. CTA was negative for
PE, and she was treated empirically for CAP. Rheumatology
advised
treatment for pericarditis with increased steroid doses, but
patient apparently declined ___ GERD associated with higher
doses
of prednisone. She recalls that she was weak when she left the
hospital, still not back to prior to that hospitalization.
Breathing had improved but was not quite back to baseline. She
has had cough, productive of yellow sputum, nonbloody. She
endorses subjective fever and drenching sweats the evening prior
to presentation. She has been developing L sided chest pain,
sharp, radiating to L shoulder and L jaw, without associated
diaphoresis, up to ___ with movement or exertion, worse with
deep inspiration and with lying flat in bed. She has had this
pain before, but is now more intense. She has had only liquid
intake at home ___ anorexia on the day prior to admission. ___
edema has been improving. She did have an episode of emesis
prior
to coming to the ED, brown, nonbloody.
In the ___ ED:
VS 98.2, 88, 140/76, 96% RA
Ambulatory SaO2 in the ___, with tachypnea, no wheeze on exam
Labs notable for WBC 6.0, Hb 7.8, plt 300, Na 130, BUN 25, Cr
1.3, proBNP 530, TnT<0.01, UA negative for UTI, lactate 1.5
Sent BCx, UCx
Received albuterol nebs, ipratropium nebs
CXR without acute process
Admitted for ?COPD exacerbation
On arrival to the floor, pt endorses L sided chest pain and DOE.
L sided chest pain is ___ at rest. She was markedly SOB with
transfer from stretcher to bed, and has improved but is still
labored.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
- MCTD, with mainly scleroderma/SLE overlap. Primary
manifestations of polyarthritis, calcinosis cutis, serositis,
Raynaud's, history of cerebritis (early ___, left with
unilateral blindness). Also with possible mild interstitial lung
disease and PAH. High titer RNP, positive ___, Ro, La, Sm,
dsDNA.
Currently on prednisone 5/Imuran100; previously received MMF,
Rituximab.
- Pulmonary arterial hypertension (mPAP 29 in ___ mPAP 24 in
___ not on treatment). She was started on treatment
(macitencan) which she did not tolerate. She was more
recently tried on sildenafil in ___ but she stopped this after
one dose.
- Possible NSIP/very mild interstitial lung disease on prior CT
scans. PFTs moderately but stabily restricted
- Diastolic dysfunction by echo
- Hyponatremia when on diuretics
- Chronic kidney disease (creatinine 1.2 to 1.4)
- GERD
- Chronic anemia: thalessemia trait, iron deficiency (on iron
supplementation) and anemia of chronic disease.
- Raynauds
- recurrent pericarditis
- Osteoporosis
- Hypertension
- History of AVN of hip
- s/p R total shoulder arthroplasty ___ and L total shoulder
___
- Blindness of left eye (secondary to MCTD/SLE cerebritis)
- Postmenopausal x ___ years
- Smoking history: never
Social History:
___
Family History:
-no known history of SLE or other rheumatologic diseases.
Physical Exam:
ADMISSION EXAM:
===============
VS: 99.7 PO 139 / 81 56 30->22 measured by me 95 ra
GEN: chronically ill appearing female, lying in bed, alert,
tachypneic, appears uncomfortable, speaking in interrupted
sentences
HEENT: R pupil is round and reactive to light, +strabismus with
blindness in L eye, anicteric, conjunctiva pink, oropharynx
without lesion or exudate, moist mucus membranes
LYMPH: Bilateral few submandibular and supraclavicular LNs, all
<0.5 cm in diameter, smooth, mobile, nontender
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops, JVP is 7 cm H20.
LUNGS: Dry crackles at L base extending ___ up, good air
movement
GI: soft, trace diffuse TTP, without rebounding or guarding,
nondistended with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema, 2+ DPs
GU: no foley
SKIN: no rashes, petechia, or echymoses, warm to palpation
NEURO: Chronic L eye deviation, otherwise grossly intact
PSYCH: normal mood and affect
DISCHARGE EXAM:
==============
VS: 98.2PO 136 / 77 69 18 100 ra
GEN: chronically ill appearing female, lying in bed, alert,
tachypneic, appears uncomfortable, speaking in interrupted
sentences
HEENT: R pupil is round and reactive to light, +strabismus with
blindness in L eye, anicteric, conjunctiva pink, oropharynx
without lesion or exudate, moist mucus membranes
LYMPH: Bilateral few submandibular and supraclavicular LNs, all
<0.5 cm in diameter, smooth, mobile, nontender
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops, JVP is 7 cm H20.
LUNGS: Dry crackles at L base extending ___ up, good air
movement
GI: soft, trace diffuse TTP, without rebounding or guarding,
nondistended with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema, 2+ DPs
GU: no foley
SKIN: no rashes, petechia, or echymoses, warm to palpation
NEURO: Chronic L eye deviation, otherwise grossly intact
PSYCH: normal mood and affect
Pertinent Results:
ADMISSION LABS:
===============
___ 07:39PM BLOOD WBC-6.0 RBC-3.04* Hgb-7.8* Hct-25.8*
MCV-85 MCH-25.7* MCHC-30.2* RDW-19.3* RDWSD-59.1* Plt ___
___ 07:39PM BLOOD Glucose-109* UreaN-25* Creat-1.3* Na-130*
K-5.6* Cl-96 HCO3-21* AnGap-19
___ 06:15AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.1
___ 06:15AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.1
DISCHARGE LABS:
===============
___ 06:23AM BLOOD WBC-4.3# RBC-2.86* Hgb-7.3* Hct-23.9*
MCV-84 MCH-25.5* MCHC-30.5* RDW-18.9* RDWSD-58.1* Plt ___
___ 06:23AM BLOOD Glucose-89 UreaN-22* Creat-1.0 Na-136
K-4.7 Cl-105 HCO3-22 AnGap-14
___ 06:23AM BLOOD Calcium-8.2* Mg-2.3
___ 06:15AM BLOOD ___ dsDNA-PND
___ 07:39PM BLOOD CRP-77.3*
___ 06:15AM BLOOD C3-80* C4-21
IMAGING:
========
CXR ___: Persistent mild cardiomegaly with hilar congestion
and no frank edema.
CT CHEST ___:
1. No evidence of pulmonary consolidation to suggest pneumonia.
2. Persistent bronchiectasis, mild bronchial wall thickening,
and atelectasis
versus scarring in the bilateral pulmonary bases, left greater
than right.
This may represent sequela of chronic aspiration, and appear
similar to prior.
3. Enlarged main pulmonary artery is compatible with the
patient's history of
pulmonary arterial hypertension.
4. Moderate hiatal hernia.
.
Brief Hospital Course:
___ with history of HTN, GERD, CKD,
osteoporosis, dCHF, s/p multiple arthroplasties, and MTCD
___ positive SLE/scleroderma overlap
syndrome) c/b alopecia, arthritis, cerebritis with residual left
eye blindness, calcinosis cutis of thighs, esophageal
dysmotility, probable NSIP, moderate pHTN, and multifactorial
anemia on prednisone 5mg and azathioprine 100 mg (previously
received MMF, Rituximab), admitted ___ with CAP vs
pericarditis, presenting with progressive weakness and DOE.
# Generalized fatigue
# Adrenal insufficiency likely due to chronic prednisone
Pt presented with worsening DOE and fatigue. On HD1, pt was
evaluated and did appear quite fatigued and was noted to be very
weak, states fatigue is new but DOE was at recent baseline.
Differential for increased fatigue was broad and included
viral/infectious processes, psychosocial (pt noted to have
flattened affect with minimal participation on prior interviews
suggestive of possible depression), and inflammatory. Cortisol
was checked and found to be low at 0.5 so this was felt to be
likely contributor to pt's symptoms. She was started on
increased dose of prednisone of 20mg after which her symptoms
improved. She had improved energy and was ambulating around the
room on discharge. She will be discharged with 15mg prednisone
x1 week followed by 10mg until rheum/endocrine f/u. Pt has Endo
apt tomorrow but states she wants to reschedule. I encouraged
her to f/u with Endo soon.
# DOE
# PAH/ILD
Repeat CT chest did not show acute findings suggestive of ILD
flare. Attempted to obtain inpatient TTE but pt did not want to
wait d/t weekend and holiday. Scheduled for outpatient TTE on
___. She did not have any new hypoxia or O2 requirement. Was
treated with CTX/azithro for CAP initially but this was d/c'ed
after Chest CT returning with no e/o pna.
# Hyponatremia/Hyperkalemia: Likely ___ adrenal insufficiency
per above and poor PO intake with resulting intravascular volume
depletion.
# Normocytic anemia: Chronic, at baseline, multifactorial
including thalassemia trait, iron deficiency, and anemia of
chronic disease.
# MCTD/scleroderma/SLE overlap: Prednisone increased as above.
Continued home azathioprine. Rheum was consulted and rec
checking lupus studies. C3/C4 was not decreased and ___ and
DS-dna still pending on discharge. Urine Protein/Cr ratio was
0.5.
Greater than 30 minutes spent on discharge counseling and
coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. AzaTHIOprine 100 mg PO DAILY
4. Famotidine 20 mg PO QHS
5. PredniSONE 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral daily
8. Cyanocobalamin 100 mcg PO DAILY
9. Dexilant (dexlansoprazole) 60 mg oral daily
10. Ferrous Sulfate 325 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. PredniSONE 15 mg PO DAILY
Take 15mg daily (3 tabs) until ___, then decrease to 10 mg
daily (2 tabs) until directed otherwise
RX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*67 Tablet
Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. AzaTHIOprine 100 mg PO DAILY
5. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral daily
6. Cyanocobalamin 100 mcg PO DAILY
7. Dexilant (dexlansoprazole) 60 mg oral daily
8. Famotidine 20 mg PO QHS
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Adrenal Insufficiency
Mixed Connective Tissue Disorder
Interstitial Lung Disease
Pulmonary Artery Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with fatigue. We did a CT scan of your chest which
did not show any new changes. We also wanted to get a repeat
echocardiogram of your heart but you did not want to stay to get
this done. We also did some labwork which revealed that you
have abnormally low levels of a stress hormone called cortisol.
We increased your dose of prednisone and you felt better. We
are sending you out with a prednisone taper which you can
continue until your Rheumatology or Endocrine follow-up.
Please return if you have recurrent fatigue, joint pain,
fevers/chills, worsening shortness of breath, or if you have any
other concerns.
Followup Instructions:
___
|
10702059-DS-35
| 10,702,059 | 21,803,195 |
DS
| 35 |
2124-03-26 00:00:00
|
2124-03-27 20:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Bactrim / Penicillins / Tessalon Perles /
tomato
Attending: ___.
Chief Complaint:
Fevers, generalized malaise and pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ year-old woman has a history of mixed
connective tissue disease, anemia of chronic disease, pulmonary
hypertension, GI dysmotility, ILD, chronic kidney disease,
chronic corticosteroid use with AVN of the right hip, and
osteoporosis with T6 compression fracture who presented to the
emergency department for evaluation of weakness and subjective
fevers. Patient endorses 1 week of feeling generalized weakness
with "pain all over". Patient also feeling subjective fevers,
sweating, and chills but did not measure his temperature. She
has a decreased appetite and nausea but no emesis x1 week. She
also endorses chronic back pain which is not new for her but she
feels that this is been hurting more than usual. Wounds on
thighs from calcinosis cutis are slightly more painful on left,
but no drainage currently. Her joint stiffness is at baseline.
She denies any cough, runny nose. No sick contacts. No abdominal
pain or vomiting. Denies any melena or bright blood per rectum.
Does not have chest pain but does endorse some shortness of
breath with exertion which is not new for her. No syncope or
presyncope. No dysuria or hematuria.
In the ED, patient had an EKG which showed T wave inversions in
lead III and flattening of T waves on lateral leads. She
subsequently got cardiac enzymes which were elevated TnI 0.26 ->
0.24 with flat MB of 1. Given concern for NSTEMI, patient was
started on heparin gtt and given ASA.
In the ED, initial VS were: HR 88 BP 138/86 RR 16 SpO2 100 ECG:
EKG-normal sinus rhythm at 72, left axis deviation, T wave
inversions in lead III and flattening of T waves on lateral
leads
Labs showed: Hgb 7.6, BUN/Cr ___, Na 130 TnI 0.26 -> 0.24 MB
1 BNP 1071
Imaging showed: ___ CXR: 1. Possible small focus of
developing pneumonia in the mid right lung, though this finding
could reflect residua of pneumonia seen in ___. 2. A small
right pleural effusion is new.
Patient received: ___ 00:29 PO Acetaminophen 1000 mg
___ 00:29 IVF NS 500cc ___ 01:24 IV Ondansetron 4
mg ___ 01:24 PO Aspirin 324 mg ___ 02:25 IVF NS
500 mL ___ 02:25 IV Heparin 3900 UNIT ___ 02:25 IV
Heparin Started 750 units/hr
Transfer VS were: HR 60 BP 120/73 RR 18 SpO2 100% RA On arrival
to the floor, patient reports nausea and slight dizziness while
sitting up. She denies chest pain or shortness of breath at
rest.
Past Medical History:
- MCTD, with mainly scleroderma/SLE overlap. Primary
manifestations of polyarthritis, calcinosis cutis, serositis,
Raynaud's, history of cerebritis (early ___, left with
unilateral blindness). Also with possible mild interstitial lung
disease and PAH. High titer RNP, positive ___, Ro, La, Sm,
dsDNA.
Currently on prednisone 5/Imuran100; previously received MMF,
Rituximab.
- Pulmonary arterial hypertension (mPAP 29 in ___ mPAP 24 in
___ not on treatment). She was started on treatment
(macitencan) which she did not tolerate. She was more
recently tried on sildenafil in ___ but she stopped this after
one dose.
- Possible NSIP/very mild interstitial lung disease on prior CT
scans. PFTs moderately but stabily restricted
- Diastolic dysfunction by echo
- Hyponatremia when on diuretics
- Chronic kidney disease (creatinine 1.2 to 1.4)
- GERD
- Chronic anemia: thalessemia trait, iron deficiency (on iron
supplementation) and anemia of chronic disease.
- Raynauds
- recurrent pericarditis
- Osteoporosis
- Hypertension
- History of AVN of hip
- s/p R total shoulder arthroplasty ___ and L total shoulder
___
- Blindness of left eye (secondary to MCTD/SLE cerebritis)
- Postmenopausal x ___ years
Social History:
___
Family History:
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM
===============
VS: T 97.6 PO BP 140 / 79 L Sitting HR 60 RR 16 100%
GEN: Comfortable, in no acute distress
HEENT: NCAT. PERRLA, no icterus. L eye temporal deviation.
Neck: no JVD
LUNGS: No incr WOB, fine crackles in midlung fields bilaterally.
No wheezing, rhonci, or rales.
CV: RRR. Distant heart sounds. Normal S1/S2. 2+ radial pulse
bilaterally
Abd: Soft, nondistended, mild RUQ TTP, no guarding.
Back: No midline tenderness. Mild paraspinal tenderness. NO
tenderness over spinous processes.
DRE: Brown stool, guaiac negative
MSK: Ulnar deviation of both hands, no tenderness or acutely
swollen joint. ___ with trace edema.
Skin: Coalescing hard nodules on thighs bilaterally with
thickened, shiny skin. A few small opens areas without drainage.
Tenderness L>R.
Neuro: AOx3, speech fluent, face with left eye deviation
(chronic, previously described), moves all 4 ext to command.
Psych: Normal mentation
DISCHARGE EXAM
===============
___ ___ Temp: 98.6 PO BP: 126/78 HR: 67 RR: 18 O2 sat:
98% O2 delivery: RA
GENERAL: NAD, A&Ox3
HEENT: Anicteric sclera, MMM, nonerythematous oropharynx.
NECK: supple, no LAD
CV: RRR, ___ RUSB systolic murmur.
PULM: RLL crackles ins/exp
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: skin thickening over bilateral thighs without
erythema or drainage, no cyanosis, clubbing, or edema
NEURO: No focal deficits.
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 11:09PM BLOOD WBC-6.4 RBC-3.36* Hgb-7.6* Hct-26.1*
MCV-78* MCH-22.6* MCHC-29.1* RDW-18.9* RDWSD-52.4* Plt ___
___ 11:09PM BLOOD Neuts-94.5* Lymphs-2.5* Monos-1.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-6.02 AbsLymp-0.16*
AbsMono-0.12* AbsEos-0.00* AbsBaso-0.01
___ 11:09PM BLOOD Glucose-124* UreaN-22* Creat-1.1 Na-130*
K-5.7* Cl-98 HCO3-18* AnGap-14
___ 11:09PM BLOOD cTropnT-0.26* proBNP-1071*
___ 03:05AM BLOOD cTropnT-0.24*
PERTINENT INTERIM LABS
=======================
___ 01:15PM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.2 Mg-1.8
Iron-11*
___ 01:15PM BLOOD calTIBC-166* Ferritn-143 TRF-128*
___ 03:05AM BLOOD CRP-101.7*
___ 06:58AM BLOOD CRP-94.6*
MICROBIOLOGY/AUTOIMMUNE
===========================
Blood Culture, Routine (Final ___: NO GROWTH.
___ 07:21
CARDIOLIPIN ANTIBODIES (IGG, IGM:
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB <9 <=20 ___
___ 07:21
B-GLUCAN
Test Result Reference
Range/Units
FUNGITELL(R) ___ <31 <60 pg/mL
GLUCAN ASSAY
INTERPRETATION Negative
QUANT GOLD PENDING
IMAGING
========
+CXR ___
IMPRESSION:
1. Possible small focus of developing pneumonia in the mid right
lung, though this finding could reflect residua of pneumonia
seen in ___.
2. A small right pleural effusion is new.
+TTE ___
IMPRESSION: Moderately depressed right ventricular free wall
systolic function. MIld to moderate tricuspid regurgitation.
Moderate to severe pulmonary hypertension. Normal left
ventricular wall thicknesses, cavity size, and regional/global
systolic function. Mild mitral regurgitation.
Compared with the prior TTE (images not available for review) of
___ and ___ right ventricular free wall systolic
function is more depressed, the degree of tricuspid
regurgitation is greater, and
the estimated PASP is greater.
+CTA Chest ___
IMPRESSION:
1. Segmental pulmonary embolism in the right lower lobe.
2. Multifocal opacities in each lung, most suggestive of
pneumonia in the appropriate clinical setting.
+US bilateral lower extremities ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
DISCHARGE LABS
==============
___ 06:46AM BLOOD WBC-3.8* RBC-3.75* Hgb-8.9* Hct-29.2*
MCV-78* MCH-23.7* MCHC-30.5* RDW-19.7* RDWSD-55.2* Plt ___
___ 09:06AM BLOOD ___ PTT-23.0* ___
___ 06:46AM BLOOD Glucose-89 UreaN-22* Creat-1.2* Na-136
K-5.2 Cl-101 HCO3-18* AnGap-17
___ 09:06AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year-old woman has a history of mixed
connective tissue disease, anemia of chronic disease, pulmonary
hypertension, GI dysmotility, chronic corticosteroid use with
AVN of the right hip, and osteoporosis with T6 compression
fracture, and calcinosis cutis who presented with 1 week of
generalized weakness, pain, and subjective fevers, found to have
segmental pulmonary embolism and multifocal pneumonia.
ACUTE ISSUES
=============
#Pulmonary embolism:
Submassive RLL segmental PE shown on CTA ___ after echo showed
worsened RV function and increased PA pressure. Hemodynamically
stable and not hypoxic. Already on heparin gtt for NSTEMI (as
below). No prior history of DVT/PE. With regards to whether PE
is provoked or unprovoked, patient does appear to have acute
infection with GGOs suggestive of pneumonia and fever to 102.5F,
which would favor provoked PE. However, patient also with MCTD
and may have underlying hypercoagulability. She has had 2
negative tests
for lupus anticoagulant and 1 positive test. In house
hypercoaguable work-up included anticardiolipin antibodies
(which were pending at time of discharge) and
Beta-2-glycoprotein 1 antibodies (NEGATIVE). For treatment, she
was transitioned to DOAC w/ apixaban 10 mg BID x7 days, then 5mg
BID with duration to be determined by outpatient PCP.
[] Follow up anticardiolipin antibodies and consider further
workup of hypercoaguable state
[] Discuss indefinite anticoagulation given unclear precipitant
[] Please ensure patient up to date with age appropriate
screenings
# Multifocal community acquired pneumonia
Patient immunosuppressed on long term corticosteroids for MCTD
and with subjective fevers, sweats, and poor appetite for the
past week. Infection suspected. Patient with no cough or urinary
symptoms. She did endorse epigastric burning and leg pain over
nodular calcinosis cutis. Overnight ___ spiked fever to
102.5. As CT showed diffuse infiltrates, patient started on CAP
treatment with ceftriaxone and azithromycin for 5 days. CRP
elevated to 102. Urine, blood cultures are NGTD. Quantiferon
gold was pending. B-glucan negative. Symptoms not much improved
in 48hrs and has been having round the clock Tylenol for
discomfort, so may be blunting fever curve.
[] Follow up quantiferon-gold
[] Consider repeat CT chest in future to look for underlying
lung disease
[] Repeat CRP
[] Continue PO vancomycin for 7 days after antibiotics complete
to prevent recurrent c. diff
#NSTEMI:
Patient without chest pain. Troponin T elevation to 0.26,
downtrended to 0.24 in 5 hours, CK-MB of 1 in ED with EKG
showing T wave inversion in inferior leads, T wave flattening in
precordial leads. Likely
type II NSTEMI in the setting of acute illness (nausea, poor PO
intake, subjective fevers, chills) and pulmonary embolism.
Patient
has had prior episodes of pericarditis, though presentation not
consistent (no rub on exam, no chest pain, and trivial effusion
on echo). Less likely to be ruptured plaque needing acute
intervention. Only angina equivalent is nausea, which does not
appear to be related to exertion, but rather an ongoing symptom.
Received AS 324 mg in ED and started on heparin gtt, which she
received for PE. She was started on aspirin 81 mg PO daily and
atorvastatin 40 mg PO daily.
# Leukopenia
WBC 3.8 on day of discharge. Patient did not want to stay for
further workup. No fevers or new infectious symptoms.
[] Repeat CBC w/ diff as outpatient
# Dysphagia
Patient endorsed three months of worsening dysphagia with food
getting stuck in esophagus. Speech & Swallow consulted, but
patient declined consult. They recommended barium swallow study,
but patient refused to stay in house for it. Concerning for
scleroderma involvement in esophagus
[] Outpatient GI appointment requested for workup of
dysphagia/possible esophageal dysmotility
#RUQ tenderness
#Nausea:
RUQ initially tender on palpation but has since improved, no
jaundice or emesis. Patient does have GERD and esophageal
dysmotility at baseline. LFTs and lipase not elevated. No recent
abdominal imaging. Think most likely chronic GERD and esophageal
dysmotility with acute illness and poor oral intake. Continues
home PPI, famotidine, and added Maalox PRN.
#MCTD:
Continued home prednisone 7 mg daily. Held home azathioprine in
setting of acute infection. Rheumatology was consulted and
offered thought symptoms more likely infectious than acute flare
of autoinflammatory condition.
[] Holding azathioprine until outpatient Rheum follow-up
#Anemia
Patient with chronic anemia due to thalessemia trait, iron
deficiency (on iron supplementation) and anemia of chronic
disease. Hgb slightly down from baseline and given 1 unit PRBC
on ___. Iron is low at 11, ferritin normal, and TIBC elevated.
Hemolysis labs drawn prior to transfusion demonstrated no
evidence of hemolysis.
#Calcinosis cutis:
Tender nodules on thighs bilaterally with
increased tenderness in past 2 day since admission. No pus
draining
or fluctuance, but several open areas on Left thigh. Restarted
home mupirocin. The patient was known to dermatology and they
felt lesions were at baseline for patient and had low suspicion
for cellulitis. Follow up as outpatient scheduled.
___ on CKD
Patient with baseline Cr of 1.0 increased to 1.3 on admission.
FeNa of 0.5, demonstrated pre-renal etiology. Most likely due to
poor PO intake in setting of infectious illness as above. Given
IVF fluids. Discharge Cr was 1.2.
# Coagulopathy
Patient's ___ slightly elevated after starting
anticoagulation, thought to be secondary to apixaban. Discharge
INR 1.6
# Disposition
Patient with multiple ongoing issues including unexplained
dysphagia/?esophageal dysmotility, and she did not feel better
than admission. Discussed that the medical recommendation would
be to stay inpatient for further workup of her issues, but she
declined and opted for close outpatient follow up. Given her
stable vital signs and labs, we felt this was reasonable.
Patient appeared to understand the risks of leaving the hospital
and had capacity.
CHRONIC ISSUES
==============
# Left shoulder pain
Patient described L-sided shoulder pain that was chronic when
she moved around in bed. No deformities, erythema, fluid, or
induration seen on exam. Recommended outpatient follow up.
#HFpEF
#Pulmonary HTN
Patient with mild arterial pulm HTN and normal EF, but diastolic
dysfunction with BNP of 1071 in the setting of fever. RHC in
___
with mPAP of 25 and euvolemia. Volume status here was euvoleic.
#Hypertension
Held home amlodipine as patient volume depleted due to poor PO
intake at home. Later restarted.
#Possible NSIP/very mild interstitial lung disease on prior CT
scans. PFTs moderately but stabily restricted. Patient follows
with outpatient pulmonary
#GERD
Continued home H2 blocker and PPI
# Blindness of left eye (secondary to MCTD/SLE cerebritis)
Follows with outpatient optho
TRANSITIONAL ISSUES
===================
[] Reschedule ___ dermatology ___
___ appt for consultation regarding calcinosis cutis
[] Holding azathioprine until outpatient Rheum follow-up
[] Outpatient GI appointment requested for workup of
dysphagia/possible esophageal dysmotility
[] Please ensure patient up to date with age appropriate
screenings
[] Follow up quantiferon-gold
[] Consider repeat CT chest in future to look for underlying
lung disease
[] Repeat CRP, CBC w/ diff, BMP on ___
[] Workup of L shoulder pain
[] Follow up anticardiolipin anitbodies and consider further
workup of hypercoaguable state
[] Discuss indefinite anticoagulation given unclear precipitant
CODE: Full
CONTACT: Son ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. dexlansoprazole 60 mg oral DAILY
7. Famotidine 20 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. PredniSONE 7 mg PO DAILY
10. TraMADol 50 mg PO Q8H:PRN BREAKTHROUGH PAIN
11. Vitamin D 1000 UNIT PO DAILY
12. AzaTHIOprine 50 mg PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 2 Days
Last day ___
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. Apixaban 5 mg PO BID
Start on ___
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % apply to legs twice a day Refills:*1
6. Vancomycin Oral Liquid ___ mg PO BID
Take for 7 days (last day ___
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*13 Capsule Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. amLODIPine 10 mg PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
DAILY
11. Cyanocobalamin 100 mcg PO DAILY
12. dexlansoprazole 60 mg oral DAILY
13. Famotidine 20 mg PO QHS
14. Ferrous Sulfate 325 mg PO DAILY
15. PredniSONE 7 mg PO DAILY
16. TraMADol 50 mg PO Q8H:PRN BREAKTHROUGH PAIN
17. Vitamin D 1000 UNIT PO DAILY
18. HELD- AzaTHIOprine 50 mg PO DAILY This medication was held.
Do not restart AzaTHIOprine until you see Rheumatology
19.Outpatient Lab Work
Labs: CRP, CBC w/ diff, BMP on ___
ICD-9 code: ___.1
Please fax to ___. at ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Segmental pulmonary embolism
Multifocal community acquired pneumonia
SECONDARY DIAGNOSIS
Mechanical shoulder pain
Dysphagia
Abdominal pain
Mixed connective tissue disorder
Chronic anemia
Calcinosis cutis
Type II NSTEMI
GERD
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had fevers and were feeling
unwell.
What happened while I was in the hospital?
==========================================
- You were found to have an infection in your lungs called
pneumonia. You were given antibiotics for this.
- You were seen by the skin doctors (___) who gave you
topical antibiotic cream for your legs.
- You were found to have blood clots in your lungs are were
started blood thinners (anticoagulation).
- You were given antibiotics to prevent you from getting an
infection called c. diff that gives you diarrhea.
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Do not start retaking your azathioprine until you see
Rheumatology.
- Please have labs drawn on ___.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10702735-DS-12
| 10,702,735 | 21,015,371 |
DS
| 12 |
2167-11-07 00:00:00
|
2167-11-07 07:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck pain s/p fall
Major Surgical or Invasive Procedure:
___ C5/C6 ___ (___)
History of Present Illness:
___ male who sustained fall onto back of head with CT showing
widening of the anterior disc space at C5/C6 without fracture.
C/f ligamentous instablity/injury. Neuro exam intact.
Past Medical History:
PMH/PSH:
Very hard of hearing
BPH, HTN, GERD
Social History:
SH: denies tobacco, alcohol, illicit drug use. lives alone
Physical Exam:
PHYSICAL EXAMINATION:
Vitals:
98.5
92
200/98
16
99% RA
General: Well-appearing male in no acute distress.
Spine exam:
nontender to palpation over C-spine
reports pain with attempted gentle active neck flexion. no pain
with extension or neck rotation
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Hoffmans: neg
Babinski: downgoing
Clonus: none
Perianal sensation: deferred
Rectal tone: deferred
Pertinent Results:
___ 05:45PM BLOOD WBC-10.9* RBC-4.21* Hgb-13.4* Hct-39.1*
MCV-93 MCH-31.8 MCHC-34.3 RDW-13.4 RDWSD-46.2 Plt ___
___ 06:00AM BLOOD WBC-9.9 RBC-3.71* Hgb-12.0* Hct-34.4*
MCV-93 MCH-32.3* MCHC-34.9 RDW-13.4 RDWSD-45.1 Plt ___
___ 04:47AM BLOOD Neuts-70.9 ___ Monos-5.7 Eos-0.8*
Baso-0.4 Im ___ AbsNeut-8.00* AbsLymp-2.42 AbsMono-0.64
AbsEos-0.09 AbsBaso-0.04
___ 05:45PM BLOOD Plt ___
___ 06:00AM BLOOD Plt ___
___ 04:47AM BLOOD ___ PTT-30.9 ___
___ 05:45PM BLOOD Glucose-137* UreaN-19 Creat-0.9 Na-132*
K-3.5 Cl-92* HCO3-28 AnGap-16
___ 06:00AM BLOOD Glucose-86 UreaN-22* Creat-1.0 Na-134
K-3.4 Cl-95* HCO3-28 AnGap-14
___ 04:47AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-132*
K-3.8 Cl-91* HCO3-29 AnGap-16
___ 05:45PM BLOOD Calcium-9.5 Phos-4.1 Mg-1.9
___ 09:36AM BLOOD WBC-7.6 RBC-4.09* Hgb-13.0* Hct-37.9*
MCV-93 MCH-31.8 MCHC-34.3 RDW-13.0 RDWSD-44.3 Plt ___
___ 10:37AM BLOOD Neuts-71.0 Lymphs-18.7* Monos-8.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-7.47* AbsLymp-1.97
AbsMono-0.87* AbsEos-0.09 AbsBaso-0.03
___ 09:36AM BLOOD Plt ___
___ 01:19PM BLOOD Plt ___
___ 09:33PM BLOOD Glucose-123* UreaN-13 Creat-0.6 Na-137
K-3.8 Cl-100 HCO3-23 AnGap-18
___ 09:36AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-139
K-3.2* Cl-98 HCO3-26 AnGap-18
___ 01:19PM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-137
K-2.6* Cl-99 HCO3-26 AnGap-15
___ 09:36AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7
___ 01:19PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
CXR ___:
FINDINGS:
Moderate cardiomegaly is unchanged. Mild pulmonary vascular
congestion is
seen without pulmonary edema. The patient is low lung volumes
however no
focal consolidations are seen. Previously seen crescent shaped
lucency is not clearly seen on current study.
IMPRESSION:
Previously seen crescent shaped lucency is not seen on current
study and is better evaluated on plain film abdominal radiograph
of ___.
CXR ___:
FINDINGS:
Moderate cardiomegaly is unchanged. Low lung volumes with
vascular crowding are seen. Previously seen question of
pneumoperitoneum is minimal if any. If definitive answer is
needed, recommend follow-up CT abdomen or CT torso for further
evaluation. Small right pleural effusion is unchanged.
IMPRESSION:
1. Questionable pneumoperitoneum is minimal if any.
2. Stable right pleural effusion.
KUB ___:
FINDINGS:
There is free air seen under the right hemidiaphragm on lateral
decubitus
films. There are air-filled dilated loops of small and large
bowel. Air is seen to the level of the sigmoid colon. There are
skin staples noted
projecting over the left iliac bone. Osseous structures are
notable for
degenerative changes of the spine.
IMPRESSION:
Pneumoperitoneum, likely postoperative. Comparison of serial
chest x-rays
from today reveal that pneumoperitoneum appears to be
decreasing. Bowel-gas pattern suggestive of postoperative ileus
versus obstruction. Recommend a repeat evaluation with upright
chest x-ray to ensure continued resolution of pneumoperitoneum.
KUB ___:
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as tolerated.
Post op Problems:
UTI: Foley was removed on POD#2 and failed his void trial. UA
was + for UTI. He was started on Ciprofloxacin for a ___ void trial was attempted on ___ and was able to
void independently.
Hypertension: Mr. ___ was hypertensive ___ to 180's and
restarted on his home BP meds with good effect.
Hypokalemia: Mr ___ was hypokalemic on ___ and was
repleted with potassium and normalized by ___.
Dysphagia: Mr. ___ main problem ___ op has been his
difficulty swallowing post surgery. Speech and Swallow was
consulted and following him during his hospital course. He
required to be NPO status for several days and advanced to
pureed/pre-thickened liquid diet with meds crushed in applesauce
by pod5. He remains on this diet per S&S recommendations and
should be advanced as assessed at Rehab.
Speech and Swallow Diet Recommendations:
RECOMMENDATIONS:
1. PO diet: Nectar-thick liquids, pureed solids
2. Pills crushed in applesauce
3. 1:1 supervision
4. Aspiration precautions:
- Small bites/sips
- Slow rate of intake
- Take extra dry swallow as needed
- If coughing, take a break
Pneumoperitoneum: In his work-up to evaluate for aspiration
pneumonia given his swallowing difficulties, imaging on ___
was negative for infectious process but did ___ lung
volumes and no lucency seen indicating improvement in
pneumoperitoneum. Pneumoperitoneaum was likely caused from iliac
crest surgical site. A KUB was also done on ___ to confirm
improvement in the penumoperitoneum.
Physical therapy and Occupational therapy were consulted for
mobilization OOB to ambulate and ADL's and recommend Rehab.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
pecoset, finasteride, tamsulosin, ambien, alprazolam,
omeprazole, lisinopril, triamterene-HCTZ
Discharge Medications:
1. ALPRAZolam 1 mg PO QHS:PRN insomnia
2. Bisacodyl 10 mg PO/PR DAILY
3. Cetirizine 10 mg PO DAILY:PRN allergies
4. Ciprofloxacin HCl 500 mg PO Q12H UTI
___
5. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medication
6. GuaiFENesin ER 600 mg PO Q12H:PRN for cough
7. Heparin 5000 UNIT SC BID
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY constipation
10. Pregabalin 75 mg PO Q12H
11. Finasteride 5 mg PO DAILY
12. Lisinopril 20 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
ACDF:
You have undergone the following operation:Anterior Cervical
Decompression and Fusion.
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.
Swallowing:Difficulty swallowing is not
uncommon after this type of surgery.This should resolve over
time.Please take small bites and eat slowly.Removing the collar
while eating can be helpfulhowever,please limit your movement
of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace:If you have been
given a soft collar for comfort, you may remove the collar to
take a shower or eat.Limit your motion of your neck while the
collar is off.You should wear the collar when walking,especially
in public.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time. f you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so plan ahead.You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call in narcotic
(oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound,or have any questions.
Physical Therapy:
1)Weight bearing as tolerated.2)No lifting >10 lbs.3)No
significant bending/twisting.
Treatments Frequency:
Remove the dressing in 2 days.If the incision is draining cover
it with a new sterile dressing.If it is dry then you can leave
the incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Call the office at that time. f you have an incision on your
hip please follow the same instructions in terms of wound care.
Followup Instructions:
___
|
10703146-DS-22
| 10,703,146 | 23,322,816 |
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| 22 |
2183-09-16 00:00:00
|
2183-09-16 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left foot gangrene s/p guillotine below the knee amputation
Major Surgical or Invasive Procedure:
___ R amp site debridement, packed w/pods
___ BK pop-distal ___ ipsilateral SV bypass
___ debridement & R ___ amp
___ transmetatarsal amputation
History of Present Illness:
___ recently admitted on vascular surgery service
___ for a an infected diabetic right ___ toe, for
which he underwent a right ___ toe amputation (initially left
open), an angioplasty of his R peroneal artery, and ultimately a
R ___ met head resection and wound closure, discharged to rehab
on IV cefepime for his polymicrobial infection (pseudomonas,
group B strep, corynebacterium, coag neg staph), now presents
with 1 day of altered mental status at rehab. Per the patient's
family, he was acting normally until this morning when he became
increasingly confused, agitated, and hostile with the staff at
rehab. On questioning the patient with the ___ interpreter
in
the ED, the patient was unable to provide any appropriate
answers
and was mumbling obscene words at the interpreter and
non-participatory with examiner.
Past Medical History:
DM
esophageal dysmotility
Chronic abdominal pain
Dysthymia
Erectile dysfunction
Eczema hands
Diabetic Retinopathy
Social History:
___
Family History:
Noncontributory
Physical Exam:
PE on discharge:
Vitals: T 98.6 HR 106 BP 154/104 RR 16 SPO2 92% RA
GEN: A&Ox3
HEENT: No scleral icterus, mucus membranes moist
CV: regular, regular rhythm, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mild distention, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: RUE ___ site without any erythema, fluctuance, or
drainage.
Trace b/l ___ edema, superficial L shin ulcer with no surrounding
erythema or drainage, R TMA site incision site c/d/i. Good ROM.
Pulse exam: R p/d/TMA, L p/d/p/p
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 06:30AM 8.5 3.09* 8.9* 26.1* 85 28.8 34.0 16.4*
194
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:24AM 113* 20 1.5* 138 4.3 99 28 15
Culture:
___ 8:12 am SWAB RIGHT PLANTER FOOT.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
YEAST, PRESUMPTIVELY NOT C. ALBICANS. STRAIN 2.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ART EXT (REST ONLY) (___)
IMPRESSION:
Significant bilateral tibial disease at rest, left greater
than right.
ART DUP EXT LO UNI;F/U RIGHT
IMPRESSION:
Patent arteries of the right lower extremity, with good flow and
velocities as
described above.
___ DUP EXTEXT BIL (MAP/DVT) (___)
IMPRESSION: Patent bilateral great saphenous veins with
diameters as
described above
EEG (___)
MPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of occasional generalized epileptiform discharges,
sometimes with higher amplitude over the right frontal region.
These findings are indicative of a propensity to generate
epileptic seizures, but cannot distinguish between a generalized
and right frontal focus. Background activity is otherwise
normal. No electrographic seizures are present.
Brief Hospital Course:
Patient was readmitted to the vascular surgery servise. At the
time, he had normal vitals, WBC of 13. He was continued on
IV-Cefepime that he was discharged with on his previous
admission. Podiatry was reconsulted and his sutures were removed
on HD2 and was taken for a debridement of his right foot ulcer
on ___ by Podiatry.
The debridment was without complications and the wound was
packed with wet-to-dry dressings. On the night of debridment, he
was shown to be very agitated and agressive with the staff
requiring haldol x2 and restraints. He had normal neurological
exam and normal labs. On HD 3 patient was shown to have another
episode of agitation with Glucose level of 36 which was treated
with Dextrose. On HD3, patient Vancomycin was readded to his
regimen because his toe-amputation tissue cultures from his
previous admission was finalized as GBS, Pseudomonas and
Enterococcus. Patient continued to show agitation mainly at
night time which responded well to ativan. He received a carotid
duplex on ___ and EEG on ___ for workup of his continued
agitation/neurologic status which were negative. He was taken
back to the OR by podiatry for another debridment on ___ without
event. Patient had difficulty voiding requiring a straight
catheterization of 800ccs with good relief. He received a
duplex peroneal of right leg on ___ which showed patent
posterior tibial artery, with peak systolic velocity proximally
of 55 cm/sec, and distally of 24 cm/sec, patent R peroneal
artery with peak systolic velocity proximally of 120 cm/sec, 57
cm/sec at its mid segment, and 60 cm/sec at its distal aspect,
however had severe bilateral tibial disease at rest, left
greater than right. Patient received a below the knee pop-distal
___ ipsilateral SV bypass on ___ without complications. His
metoprolol was increased from 25 TID to 50TID on ___ for high
blood pressure with good response per cardiology
recommendations. His Vancomycin was redosed several times for
suptratherapeutic levels to 1G every 48hrs starting ___. He had
an episode or emesis on ___ with indeterminant KUB findings,
was placed on aggressive bowel regimen with good return of bowel
function by ___. A foley was placed for failure to void on
___. His Vancomycin was redosed to 1gram Q24hrs on ___.
Patient had a gradual increase in his creatinine from his
baseline 1.0-1.2 to 1.6 on ___, ACE and metformin was held. He
was also seen by psychiatry to evaluate his agitation and was
started on scheduled Haldol 1mg bedtime with frequent QTC
monitoring. Patient received a right transmetatarsal amputaion
on ___ without complications. He was resumed on a diabetic diet
with good pain control and adequate recooperation from the
amputation with physical and occupational therapy. However, he
had difficulty voiding on ___ requiring straight
catheterization x2 and a foley cathet was placed on ___.
He was seen by podiatry who offered surgical shoe. He was
assessed several times by Infectious disease who suggested that
he continues on his IV-vanc and cefepime as originally planned
from his previous admission. He is to follow up with infectious
disease clinic as an outpatient with weekly labs to be sent to
them as well. He is also to follow up with Urology and Vascular
surgery as shown in his discharge instructions.
Medications on Admission:
cefepime 2g IV Q8 hours,
ASA 81 QD, plavix 75 QD
gabapentin 300 TID
detemir 40U in morning
lisinopril 40 QD
simvastatin 10 QD
bupropion SR 150 TID
HCTZ 25 QD
plavix 75'
ibuprofen 400 prn, tylenol ___ prn, sildenafil 20 prn
Family contact/HCP: ___
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO BID
4. CefePIME 2 g IV Q8H
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 100 mg by mouth twice a day
Disp #*60 Capsule Refills:*0
7. Gabapentin 300 mg PO TID
8. Guaifenesin ___ mL PO Q6H:PRN cough
9. Hydrochlorothiazide 25 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO TID
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 5 mg by mouth every ___ hrs Disp #*30 Tablet
Refills:*0
12. Simvastatin 10 mg PO DAILY
13. Vancomycin 1000 mg IV Q 24H
14. Outpatient Lab Work
Weekly CBC, Chem10, LFT, ESR, CRP
Fax to ___
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral arterial disease
Discharge Condition:
Stable
Discharge Instructions:
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
AMPUTATION DISCHARGE INSTRUCTIONS
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Followup Instructions:
___
|
10703146-DS-24
| 10,703,146 | 29,035,920 |
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| 24 |
2184-04-01 00:00:00
|
2184-04-01 21:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man w/PMH insulin-dependent Diabetes Mellitus Type II,
severe peripheral vascular disease s/p left toe amputation and
multiple vascular surgeries, presenting w/pain and swelling of
left lower extremity for 3 days. He states that he is minimally
ambulatory at home and spending significant time in a wheel
chair following a surgery on his right leg last year. The
swelling has been gradually increasing and is accompanied by
minor pain.
In the ED, initial vitals were: Temp: 98.1 HR: 100 BP: 117/75
Resp: 18 O(2)Sat: 100. He was found to have a left sided DVT by
ultrasound and ___ bilaterally by doppler. He was guiac
negative and was given heparin bolus + drip. He was admitted
for heparin bridge.
Review of systems:
(+) Per HPI (poor PO intake, chronic abdominal pain that is
unchanged).
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion, hemoptysis. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-Diabetes mellitus Type 2 complicated by peripheral vascular
disease
-C. diff colitis s/p metronidazole
-CKD, baseline Cr 1.1-1.6
- Esophageal dysmotility
- Chronic abdominal pain, has been treated with gabapentin.
element of constipation.
- Dysthymia
- Erectile dysfunction
- Eczema
- HTN
- Kidney stones
- Hyperlipidemia
PAST SURGICAL HISTORY:
-Right peroneal artery PCI
-Right femoral-posterior tibial bypass surgery
-Right transmetatarsal amputation ___
Social History:
___
Family History:
No family history of bleeding or clotting
Father died of prostate cancer
Mother died of MI
Son is healthy
Physical ___:
=====================
ADMISSION
=====================
Vitals: T:97.8 BP: 157/98 P: 102 R: 16 O2: 100% RA
General: Sitting comfortably in bed, NAD
HEENT: Dry MMM, PERRL,
Neck: Supple, JVP low
CV: Tachycardic, S1, S2, no rubs gallops or mumurs
Lungs: Clear to auscultation bilaterally, good air movement and
no increased work of breathing
Abdomen: Soft, non-distended, diffuse mild tenderness, no
palpable organomegaly
Ext: RLE post-TMA, appears to have healed well. Left leg with
significant 2+ non-pitting edema to the mid thigh. No palpable
cords and ___ sign absent. Tissue compartments soft.
Difficult to palpate L sided DP. Both extremities mildly cool
but symmetric.
Neuro: CN II - XII intact, all extremities are antigravity
======================
DISCHARGE
======================
Vitals: T:98.4 BP: 141/78 P: 74 R: 18 O2: 100% RA
General: Sitting comfortably in bed, NAD
HEENT: MMM, PERRL
Neck: Supple, JVP normal
CV: Tachycardic, S1, S2, no rubs gallops or mumurs
Lungs: Clear to auscultation bilaterally, good air movement and
no increased work of breathing
Abdomen: Soft, non-distended, diffuse mild suprapubic tenderness
(pt states chronic), no palpable organomegaly
Ext: RLE post-TMA, appears to have healed well. Left leg with
significant ___ non-pitting > pitting edema to the upper thigh,
improved from admission. Tissue compartments soft. Difficult
to palpate L sided DP and ___, but both are dopplerable. Both
extremities mildly cool but symmetric.
Neuro: Awake, alert, appropriate, motor function of all
extremities are antigravity
Pertinent Results:
ADMISSION:
___ 03:30PM WBC-8.8# RBC-4.08* HGB-11.2* HCT-34.8* MCV-85
MCH-27.5 MCHC-32.2 RDW-13.5
___ 03:30PM NEUTS-67.6 ___ MONOS-7.6 EOS-1.0
BASOS-0.6
___ 03:30PM GLUCOSE-99 UREA N-39* CREAT-2.0* SODIUM-138
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 03:30PM ___ PTT-34.5 ___
DISCHARGE:
___ 05:15AM BLOOD WBC-4.8 RBC-3.52* Hgb-9.8* Hct-29.7*
MCV-84 MCH-27.9 MCHC-33.1 RDW-13.4 Plt ___
___ 05:15AM BLOOD Glucose-82 UreaN-24* Creat-1.3* Na-134
K-4.8 Cl-100 HCO3-26 AnGap-13
INRs:
___ 03:30PM BLOOD ___ PTT-34.5 ___
___ 03:49AM BLOOD ___ PTT-93.3* ___
___ 09:10AM BLOOD ___ PTT-34.3 ___
___ 08:50AM BLOOD ___ PTT-59.4* ___
___ 05:15AM BLOOD ___ PTT-75.9* ___
___ 05:15AM BLOOD ___ PTT-67.3* ___
___ 06:00AM BLOOD ___ PTT-57.9* ___
___ 05:15AM BLOOD ___ PTT-81.6* ___
STUDIES:
Bilateral ___ duplex Ultrasound shows significant LLE DVT
involving superficial and deep venous system with possible
extension into the left common iliac vein places patient at risk
for phlegmasia cerulea dolens.
Brief Hospital Course:
___ yo man w/PMH insulin-dependent Diabetes Mellitus Type II,
severe peripheral vascular disease, and multiple vascular
surgeries presenting wtih 3 days of pain and swelling of left
lower extremity and imaging consistent with proximal deep vein
thrombosis.
# Deep vein thrombosis: This is likely provoked by his
immobilization. It is recommended he follow up with primary care
physician to ensure he is uptodate with age specific cancer
screening. He was initially bridged with heparin gtt due to
___ but as his renal function improved he was transitioned to
lovenox. He completed the bridge while hospitalized due to
insurance issues concerning obtaining and administering lovenox
at home. He had an INR >2 for two consecutive days so his
lovenox was discontinued and he was discharged on Coumadin 5mg
QD. He will be followed by ___ clinic going
forward. He reported improvement in the swelling and discomfort
during the hospitalization.
# ___: Baseline Cr around 1.2 - 1.6 but Cr 2.0 on admisison. He
appeared dry on exam, reported decreased PO intake, and had
urine lytes consistent with a pre-renal insult. He was given
IVF and his Cr improved back to baseline.
# Deconditioning: Patient with a poor baseline in wheelchair
most of the time which likely precipitated his DVT. Had been
worked up during previous admission with neurology consult
attributing it largely to diabetic neuropathy. ___ did not feel
he would benefit significantly from more intensive rehab and the
patient wished to go home rather than to a rehab facility.
# Positive UA: Patient without any acute abdominal symptoms. He
has a foley at baseline. He has a history of MDR UTIs that have
required prolonged treatment and no other signs of ongoing
infection such as fevers or elevated WBC. Therefore antibiotic
treatment was deferred.
#Urine retention: The patient's foley was discontinued but he
failed a voiding trial and it was replaced. He has outpatient
followup with urology.
# LLE PAD - the patient has an existing diagnosis of PAD, with
treatment mainly affecting his right leg. In the setting of his
DVT, distal pulses in his left leg were difficult to palpate but
remained dopplerable throughout his hospital stay. He had good
cap refill and the extremity remained warm. He has followup
with vascular in place
# DM - cont home insulin, reduced long-acting ___ insulin due to
low AM FSBG
# Hyperlipidema - cont home statin
# HTN - cont amlodipine, metoprolol
# BPH - cont finasteride
# GERD - cont ompeprazole
# S/p bypass - cont ASA81
TRANSITIONAL
- urology followup re: foley
- vascular followup
- establish ___ clinic appointment with HCA anticoag
- next INR to be drawn on ___
- follow up with PCP to ensure age specific cancer screening
---- last colonoscopy ___ recommended follow up in ___ yr due to
limited prep
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Gabapentin 200 mg PO BID
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 250 mcg PO DAILY
9. insulin lispro
150-200:2;201-250:3;251-300:4;301-350:6;351-400:8;401-500:10
subcutaneous TID
10. Levemir (insulin detemir) 14 units subcutaneous QHS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 250 mcg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Gabapentin 200 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. insulin lispro
150-200:2;201-250:3;251-300:4;301-350:6;351-400:8;401-500:10
subcutaneous TID
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 2.5 tablet(s) by mouth daily Disp
#*75 Tablet Refills:*0
12. Outpatient Lab Work
Long term use of anticoagulant
___ on ___
Contact ___ for Dr. ___
13. Levemir (insulin detemir) 5 units subcutaneous QHS
14. Senna 17.2 mg PO HS
15. Docusate Sodium 100 mg PO BID
16. Hydrocerin 1 Appl TP ASDIR
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Simethicone 80 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Deep venous thrombosis, proximal
Acute kidney injury
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
You were admitted because you had a blood clot in your leg.
This is likely related to your impaired mobility and difficulty
with walking. You were admitted to start blood thinners. You
should continue your coumadin blood thinner for at least 6
months. This medication requires frequently monitoring for
levels and your dose will likely change based on those levels.
This medication carries an elevated risk of serious bleeding, so
please come to the emergency room for any bleeding or if you
develop black stool.
When you were admitted it was noted that you were dehydrated.
Please try to drink plenty of water throughout the day.
Followup Instructions:
___
|
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2185-11-07 00:00:00
|
2185-11-09 07:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperkalemia and acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of DM2, PVD, who presents from
clinic with laboratory values showing increased creatinine and
hyperkalemia. Patient was seen in clinic by PCP ___ on
___ and was found to have elevated K+ 6.0 (from prior 4.5) and
Creatinine to 2.5 (from prior 1.8). Patient was called by PCP to
present to ED but patient could not arrange transportation and
did not want to take ambulance. Patient was able to obtain
transportation today (___) and thus presented to ED.
In the ED, initial vitals: 97.5 79 156/67 18 100% RA. He had no
complaints.
Labs were significant for H/H 8.___.3, K 6.4->6.5->5.9,
___: 18.7 PTT: 39.0 INR: 1.7
In the ED he received insulin 10 units with 50% dextrose, 40mg
IV Lasix, 2L NS.
Chest x-ray showed retrocardiac opacity, that was considered to
be atelectasis versus pneumonia.
Vitals prior to transfer: 69 174/71 18 99% RA
On arrival to the floor patient had vitals: T:97.3 HR:78
BP:142/88 RR:18 O2:100% RA
Patient is ___ speaking and interview was conducted with the
aid of a ___ interpreter. Patient is not very familiar with
his medications or past medical history. Currently, patient is
lying in bed without any complaints.
Past Medical History:
-Diabetes mellitus Type 2 complicated by peripheral vascular
disease
-C. diff colitis s/p metronidazole
-CKD, baseline Cr 1.1-1.6
- Esophageal dysmotility
- Chronic abdominal pain, has been treated with gabapentin.
element of constipation.
- Dysthymia
- Erectile dysfunction
- Eczema
- HTN
- Kidney stones
- Hyperlipidemia
PAST SURGICAL HISTORY:
-Right peroneal artery PCI
-Right femoral-posterior tibial bypass surgery
-Right transmetatarsal amputation ___
Social History:
___
Family History:
No family history of bleeding or clotting
Father died of prostate cancer
Mother died of MI
Son is healthy
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: T:97.3 HR:78 BP:142/88 RR:18 O2:100% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple
PULM: CTAB
COR: RRR
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, 1+ pitting edema to mid calf.
NEURO: CN II-XII grossly intact, ___ strength throughout
LABS: see below
DISCHARGE PHYSICAL EXAM:
VS: T:98.5 HR:69 BP:163/79 RR:18 O2:99% RA
I/O: pMN: 36/550 (PVR 200) 24HR: ___
FSBG:141 (113-167)
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple
PULM: CTAB
COR: RRR
ABD: Soft, non-tender, non-distended, +BS
EXTREM: Warm, well-perfused, trace pitting edema to mid calf.
NEURO: CN II-XII grossly intact, ___ strength throughout
Pertinent Results:
PRE-ADMISSION LABS:
___ 10:50AM BLOOD UreaN-30* Creat-2.5* Na-142 K-6.0* Cl-106
HCO3-24 AnGap-18
___ 10:50AM BLOOD ALT-19 AST-20
___ 10:50AM BLOOD TotProt-7.3 Albumin-4.4 Globuln-2.9
ADMISSION LABS:
___ 03:15PM BLOOD Glucose-96 UreaN-29* Creat-2.3* Na-142
K-6.4* Cl-112* HCO3-22 AnGap-14
___ 03:21PM BLOOD Glucose-94 K-6.5*
___ 05:20PM URINE HOURS-RANDOM UREA N-148 CREAT-28
SODIUM-138 POTASSIUM-33 CHLORIDE-144
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
INTERVAL LABS:
___ 04:56PM BLOOD K-5.9*
___ 09:47PM BLOOD Glucose-105 Lactate-1.6 Na-143 K-5.3*
Cl-112* calHCO3-19*
___ 04:58AM BLOOD Glucose-76 UreaN-25* Creat-2.0* Na-141
K-4.6 Cl-110* HCO3-20* AnGap-16
___ 01:40PM BLOOD Glucose-137* UreaN-26* Creat-2.1* Na-138
K-4.6 Cl-105 HCO3-21* AnGap-17
DISCHARGE LABS:
___ 01:00PM BLOOD WBC-5.6 RBC-3.39* Hgb-9.0* Hct-28.5*
MCV-84 MCH-26.5 MCHC-31.6* RDW-14.6 RDWSD-44.2 Plt ___
___ 11:20AM BLOOD PTT-73.1*
___ 04:16AM BLOOD Glucose-138* UreaN-25* Creat-2.1* Na-138
K-4.3 Cl-107 HCO3-23 AnGap-12
___ 04:16AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.0
IMAGING:
___ U.S.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Large postvoid residual.
3. Bilateral renal cysts, unchanged from prior.
___ (PA & LAT)
IMPRESSION:
Retrocardiac opacity, question atelectasis versus pneumonia.
Brief Hospital Course:
___ year old male with history of DM2, PVD, who presents from
clinic with laboratory values showing increased creatinine and
hyperkalemia.
# Hyperkalemia:
Patient presented to clinic for routine follow up (___) and
was found to have hyperkalemia with K of 6.0 without symptoms.
He was informed by his PCP that he should present to the ED but
he was unable to present to the ___ ED until ___. His EKGs on
___ and ___ did not show widened QRS or peaked T waves and
were stable from prior EMR EKG dating ___. His hyperkalemia
was thought to be due to his acute on chronic kidney failure. We
also considered other possible causes of his hyperkalemia
including medication effect but thought this was less likely
given his concomitant kidney injury. The patient received IVF,
insulin, and dextrose in the ED. Upon transfer to the floor,
patient continued to receive IVF and kayexelate. He was
monitored on telemetry without notable events. His potassium
normalized to 4.6 by ___ and remained within normal range
upon discharge (4.3).
# Acute on Chronic Kidney Injury:
Patient has history of stage II CKD with baseline Cr 1.1-1.6. He
had intermittent follow up with his primary care physician and
the last recorded creatinine prior to this admission was 1.8
(___). Upon presentation to PCPs office, patient was found
to have a Cr of 2.5, concerning for acute kidney injury. We
considered whether this may represent gradual worsening of his
underlying chronic kidney disease secondary to diabetes or
hypertension. He was treated with IVF fluids and his lisinopril
was held in the setting of his kidney injury. We also considered
prerenal causes but patient denied any recent diarrhea or
vomiting. We considered post-renal etiology due to his history
of urinary retention. Renal ultrasound (___) did not show
evidence of hydronephrosis but showed large post-void residual
volume. We continued to monitor his creatinine and he was
discharged with Cr of 2.1. We additionally held creatinine at
time of discharge that could be restarted upon follow up pending
repeat creatinine to ensure stabilization.
# Peripheral edema:
Most likely due to proteinuria from his renal failure. It is
possible that patient has cardiac or liver pathology that has
not yet been diagnosed. LFTs wnl and no stigmata of cirrhosis on
exam. Given his PVD history, could consider CAD and possible R
sided dysfunction. Patient can consider TTE to assess cardiac
function as an outpatient.
# Anticoagulation:
Patient is on chronic DVT prophylaxis for history of unprovoked
DVT (___) and ongoing risk factor of immobility. He has been
subtherapeutic on admission here with INR 1.6 (___). He also
appears to be chronically subtherapeutic. During his admission
we bridged the patient with heparin (not lovenox given renal
dysfunction) while increasing his warfarin to 7.5 mg to bring
him into the therapeutic range. He was discharged with an INR of
2.1 with follow up with primary care physician.
CHRONIC:
# Diabetes: We started the patient on glargine 10 QHS and ISS in
lieu of his home levemir and SS insulin. He was transferred back
to his home regimen upon discharge.
# Hypertension: continued home amlodipine. Lisinopril held as
above
# TRANSITIONAL ISSUES:
======================
- F/U with PCP regarding kidney injury and chronic kidney
disease for further workup and management. Please repeat chem-7
at follow to monitor potassium and creatinine.
- F/U with your primary care provider regarding your iron
deficiency anemia and stating iron supplementation
- F/U with ___ clinic for continued management of
INR (goal ___ Next INR draw on ___.
- Consideration of starting tamsulosin should be made as an
outpatient given post-void residual that may be from BPH.
- Warfarin increased to 7.5 mg daily during this hospitalization
- F/U with your PCP regarding your insulin regimen, need for
metoprolol
- F/U with your PCP regarding any further evaluation of your
heart or liver such a TTE
- F/U restarting lisinopril after meeting with primary care
provider to evaluate kidney function (BUN/Creatinine)
-Enoxaparin stopped for bridging purposes given new decreased
creatinine clearance
- Please follow up with your regularly scheduled ophthalmology
appointments
# CONTACT: ___ (wife) ___
# CODE STATUS: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 250 mcg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Gabapentin 200 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. insulin lispro
150-200:2;201-250:3;251-300:4;301-350:6;351-400:8;401-500:10
subcutaneous TID
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Warfarin 6 mg PO DAILY16
12. Levemir (insulin detemir) 5 units subcutaneous QHS
13. Senna 17.2 mg PO HS
14. Docusate Sodium 100 mg PO BID
15. Hydrocerin 1 Appl TP ASDIR
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Simethicone 80 mg PO TID
18. Enoxaparin Sodium 80 mg SC BID:PRN INR< 1.8
Start: ___, First Dose: Next Routine Administration Time
19. Lisinopril 2.5 mg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 17.2 mg PO HS
10. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Hydrocerin 1 Appl TP ASDIR
12. Levemir (insulin detemir) 5 units subcutaneous QHS
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Polyethylene Glycol 17 g PO DAILY
15. Simethicone 80 mg PO TID
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. Gabapentin 200 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hyperkalemia, acute kidney injury
Secondary: Diabetes, hypertension, chronic kidney 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 pleasure taking care of you here at ___
___. You were referred to us by your
primary care physician because of high levels of potassium in
your blood and decreased kidney function. You did not have
severe symptoms related to either of these conditions. You
received several EKGs which did not show any problems with your
heart due to the high levels of potassium. You received
medication to help remove the excess potassium from your blood
(insulin, dextrose, kayexelate). You received IV fluids which
also improved your kidney function. You received an ultrasound
of your kidneys which did not show buildup of fluid in the
kidney. We believe that this may have partly been caused by your
chronic kidney disease, and your urinary retention. We stopped a
medication called lisinopril and restarting this medication
should be discussed with your primary care provider.
During your admission, we found that your anticoagulation with
coumadin was not at a therapeutic level. We increased your dose
of coumadin and put you on a temporary anticoagulation (heparin)
while you were in the hospital.
You should have close follow up with your primary care physician
and your anticoagulation (coumadin) management services.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
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2185-12-28 10:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/IDDM, PVD, CKD, DVT on Coumadin, presenting with back pain
___ for the past 5 days.
Patient reports that his back pain started suddenly 5 days ago.
He reports that it is an intense pain ___ pain. It is worse in
the lower right back and radiates to the left. It is constant
and is improved with Tylenol. No dysuria or abnormal colored
urine. No N/V, diarrhea or constipation. No pain with movement
and no unusual activities this past week.
He has a visiting nurse that comes 3x/week. She takes his vitals
and noted that he had a fever to 100.7 today with O2 sats
ranging between 88-90%. He reports nightly fevers for the past
___ days. Also reports that he has a cold: non-productive cough
and sore throat; denies ear pain, rhinorrhea/nasal congestion.
Has decreased PO intake but is hydrating well.
The patient had a recent admission from ___ to ___ with
hyperkalemia to 6.0, thought to be ___ to ___ on CKD. He was
treated with insulin initially, then IVF. His lisinopril was
held. Patient has since missed follow up appointments with his
___ clinic and PCP.
In the ED, initial vitals were: T 98.7, HR 80, BP 170/100, 16,
99% RA. Exam was significant for: guaiac negative stool.
Labs significant for: leukocytosis to 13.5 with left shift, H/H
below baseline at 7.5/___.2, creatinine 2.l (likely baseline)
Lactate: 1.2, INR subtherapeutic at 1.6. Imaging in ED notable
for CT abd/pelvis with signs of a recently passed kidney stone
(stone in bladder) and CXR with opacity c/f ?PNA.
Patient was given:
___ 19:24 IVF 1000 mL NS 500 mL
___ 19:24 PO Acetaminophen 1000 mg
___ 19:24 IV CeftriaXONE 1 gm
___ 19:41 PO/NG Azithromycin 500 mg
Transfer vitals: 98.0, 76, 154/90, 16, 100% RA
On the floor, the patient is feeling better. He still reports
___ pain.
Review of systems:
(+) Per HPI
(-) 10 pt ROS is otherwise negative.
Past Medical History:
-Diabetes mellitus Type 2 complicated by peripheral vascular
disease
-C. diff colitis s/p metronidazole
-CKD, baseline Cr 1.1-1.6
- Esophageal dysmotility
- Chronic abdominal pain, has been treated with gabapentin.
element of constipation.
- Dysthymia
- Erectile dysfunction
- Eczema
- HTN
- Kidney stones
- Hyperlipidemia
PAST SURGICAL HISTORY:
-Right peroneal artery PCI
-Right femoral-posterior tibial bypass surgery
-Right transmetatarsal amputation ___
Social History:
___
Family History:
No family history of bleeding or clotting
Father died of prostate cancer
Mother died of MI
Son is healthy
Physical ___:
ADMISSION EXAM:
Vital Signs: 98.0 136/76 76 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
Back: Pain with palpation in the lower back, R>L. No CVA
tenderness
GU: No foley
Ext: Warm, well perfused, no edema
Neuro: Grossly intact
DISCHARGE EXAM:
Vitals: Tm 98.7 Tc 98.7 P 73 BP 167/81 RR 18 SpO2 95% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - Regular rate and rhythm, normal S1+S2, no murmurs, rubs,
or gallops
LUNGS - Lungs clear to auscultation bilaterally, no wheezes,
rubs, or rhonchi. Occasionally coughing during exam.
ABDOMEN - +Bowel sounds, soft, nontender, nondistended, no
masses appreciated
BACK - Tenderness to palpation in lower back, worse over right
paraspinal muscles.
EXTREMITIES - Warm with 2+ radial, DP, and ___ pulses, no
clubbing, cyanosis, or edema. S/p R TMA. No knee or ankle
erythema or effusion, stable on exam. Mild anterior knee
tenderness, +crepitus.
NEURO - ___ strength in bilateral hip flexion, knee flexion and
extension, foot dorsi/plantarflexion. Sensation intact to light
touch throughout feet bilaterally.
Pertinent Results:
LABS ON ADMISSION:
___ 03:15PM GLUCOSE-141* UREA N-28* CREAT-2.1* SODIUM-133
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
___ 03:34PM LACTATE-1.2
___ 03:15PM ALT(SGPT)-35 AST(SGOT)-27 ALK PHOS-133* TOT
BILI-0.2
___ 03:15PM LIPASE-56
___ 03:15PM ALBUMIN-3.4*
___ 03:15PM WBC-13.5*# RBC-2.90* HGB-7.5* HCT-24.2*
MCV-83 MCH-25.9* MCHC-31.0* RDW-14.3 RDWSD-43.3
___ 03:15PM PLT COUNT-546*#
___ 03:15PM NEUTS-77.9* LYMPHS-12.3* MONOS-7.2 EOS-1.0
BASOS-0.3 IM ___ AbsNeut-10.50*# AbsLymp-1.66 AbsMono-0.97*
AbsEos-0.13 AbsBaso-0.04
___ 04:16PM ___ PTT-33.9 ___
___ 04:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG
___ 04:25PM URINE RBC-1 WBC-5 BACTERIA-MANY YEAST-NONE
EPI-1
PERTINENT LABS:
___ 11:14AM BLOOD PEP-NO SPECIFI
___ 06:45AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Target-OCCASIONAL Schisto-OCCASIONAL
Burr-OCCASIONAL
___ 07:04AM BLOOD Ret Aut-2.2* Abs Ret-0.06
___ 06:21AM BLOOD LD(LDH)-251* TotBili-0.1
___ 07:04AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.5* Iron-20*
___ 06:21AM BLOOD Hapto-565*
___ 07:04AM BLOOD calTIBC-226* Ferritn-136 TRF-174*
___ 07:39AM BLOOD %HbA1c-6.8* eAG-148*
MICRO:
___ 7:00 pm BLOOD CULTURE
__________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- 0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Further workup requested by ___. ___ (___) ON
___.
NEGATIVE FOR GROUP B BETA STREP.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 16 R
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
LABS ON DISCHARGE:
___ 06:19AM BLOOD WBC-10.3* RBC-3.18* Hgb-8.4* Hct-26.7*
MCV-84 MCH-26.4 MCHC-31.5* RDW-14.5 RDWSD-44.4 Plt ___
___ 06:19AM BLOOD ___
___ 06:19AM BLOOD Glucose-68* UreaN-22* Creat-1.7* Na-133
K-4.8 Cl-101 HCO3-19* AnGap-18
___ 06:19AM BLOOD Calcium-8.0* Phos-4.4 Mg-1.8
___ 02:10PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:10PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:10PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
___ 02:10PM URINE CastHy-1*
___ 02:10PM URINE Mucous-RARE
IMAGING:
Chest x-ray ___:
IMPRESSION: Subtle streaky left base retrocardiac opacity could
be due to atelectasis/scarring or pneumonia or aspiration.
CT abdomen/pelvis ___:
IMPRESSION:
1. Findings compatible with recently passed right ureteral stone
with punctate stone identified within the urinary bladder.
2. No additional renal or ureteral stones.
3. Small bilateral pleural effusions.
Brief Hospital Course:
Mr. ___ is a ___ with IDDM, PVD, CKD, DVT on
Coumadin, who presented with 5 days of back pain, found to have
group B strep bacteremia.
#Home safety: As ___ initially recommended discharge to rehab,
and given his need for daily IV antibiotic infusions that could
not be done at home, need for frequent straight cath and BG
checks, he was recommended to go to rehab. He refused rehab
placement. On day of discharge, he was able to demonstrate
ability to go up and down stairs as he lives on second floor.
His wife agreed to assist with straight caths and son agreed to
take him to the ___ daily, and both felt comfortable
with this discharge plan. Home services were arranged and he
will have ___ come to clear out excessive medications in the
home, to avoid polypharmacy complications. PACT RN, SW and
pharmacists were all involved with discharge planning and will
continue to follow him as an outpatient.
#Group B strep bacteremia: Likely secondary to urinary
obstruction, as he has both retention and evidence of a recently
passed stone. Urine cultures had mixed growth, primarily
enterococcus and no group B strep, but were obtained after
antibiotic initiation in the ED. UA and urine culture were
repeated and pending at the time of discharge, and if positive
for enterococcus, recommend consideration for treatment (on
ceftriaxone only). His only urinary symptom was obstruction, no
dysuria. He improved on IV ceftriaxone and was discharged with a
midline IV for a 14 day course of IV ceftriaxone, with last dose
to be administered ___. It was recommended that he go to rehab
to receive antibiotics, but he refused, and he was set up for
daily appointments at the ___.
#Back pain: ___ be multifactorial, with etiologies including
musculoskeletal, recently passed kidney stone, and UTI. He had
no neurologic symptoms to suggest spinal cord involvement. His
pain improved over his stay. SPEP was normal and UPEP was
pending at the time of discharge to rule out multiple myeloma as
an etiology for his back pain, CKD and anemia.
#Anemia: His Hgb on arrival was 7.5, which downtrended requiring
1U pRBC with appropriate increase in Hgb. He was asymptomatic
throughout, stool guaiac was negative, and labs were not
concerning for hemolysis. His anemia is likely multifactorial
with contribution from underlying CKD, anemia of chronic
inflammation in the setting of infection, and possibly iron
deficiency. As above, SPEP was normal and UPEP was pending on
discharge.
#Urinary retention: He has a history of urinary retention and
bladder hypersensitivity, with a need for straight
catheterization at home in the past but not recently. His home
finasteride was continued, and tamsulosin was started in house.
He required regular straight catheterization during his stay. He
was discharged with a plan for home straight catheterization ___
times/day with the help of his wife. Outpatient urology
follow-up is recommended.
#Diabetes: Given low insulin requirement with hemoglobin A1c of
6.8% and concern that home dosing may be inappropriate, he was
discharged on glipizide 2.5mg once daily with lunch. He was
instructed to check blood glucose twice daily. Outpatient
follow-up is recommended.
#Right knee pain: He developed right knee pain at the end of his
hospitalization without trauma or known inciting event. The pain
was similar to pain he has had in the past, and his exam was
consistent with arthritis. His pain was controlled with Tylenol.
#History of unprovoked DVT: He was subtherapeutic on admission
with INR of 1.6. Warfarin was increased to 5mg daily. His INR on
discharge was 2.4.
#GERD: Home omeprazole was discontinued, as he reported not
taking it regularly. Given his dry cough, ranitidine was
started.
#Cough: He had a dry cough that persisted throughout his stay,
with a clear lung exam and no sputum production. For possible
GERD component, he was started on ranitidine. Recommend
outpatient follow-up.
TRANSITIONAL ISSUES:
-Ceftriaxone 2g IV q24hr for 14 day course, first dose ___,
last dose ___. To be done daily at the ___. Son
agrees to bring him daily.
-Follow up urine culture and consider treating enterococcus if
still positive (not treated as sample likely contaminated and
obtained after antibiotics).
-Straight cath 3 times daily.
-Started tamsulosin. Recommend outpatient Urology follow up
-Discontinued levemir, discharged on glipizide 2.5mg once daily
with lunch for diabetes; recommend outpatient follow-up
-Recommend outpatient follow-up of anemia, knee pain, chronic
cough (started on ranitidine)
-SPEP normal, UPEP pending
-Warfarin increased to 5mg daily. Continue to follow with
___ clinic. Next INR check ___
-Per report, the patient was not taking metoprolol or lisinopril
prior to admission, although he was prescribed them. He received
these medications in house and was discharged with them.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Senna 17.2 mg PO QHS
7. Warfarin 4 mg PO DAILY16
8. Levemir 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Simethicone 80 mg PO TID
10. Gabapentin 200 mg PO BID
11. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Finasteride 5 mg PO DAILY
5. Gabapentin 200 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Senna 17.2 mg PO QHS:PRN constipation
8. Simethicone 80 mg PO TID:PRN constipation
9. Warfarin 5 mg PO DAILY16
10. CeftriaXONE 2 gm IV Q24H
11. GlipiZIDE 2.5 mg PO 2X/DAY
12. Lisinopril 2.5 mg PO DAILY
13. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
14. Lidocaine Jelly 2% 1 Appl TP TID:PRN pain
15. Ranitidine 150 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Bacteremia
Anemia
Diabetes
Urinary retention
SECONDARY DIAGNOSIS:
History of unprovoked deep vein thrombosis, on coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___. You came to the hospital because of back pain
and fevers. You were found to have bacteria in your blood
stream. Your symptoms improved with IV antibiotics. It is VERY
IMPORTANT that you go to the ___ EVERY DAY to
continue this treatment through ___.
You were also found to have low red blood cells. You received a
transfusion, which brought your levels up. Your levels were
stable when you left the hospital.
While you were here, you had trouble urinating. We started a new
medication to help with this. You will need to catheterize
yourself AT LEAST TWICE A DAY. Please go to the appointment with
the urologist to manage this.
We adjusted your diabetes medications while you were here. We
stopped your injected insulin and started a pill for diabetes
that you should take once a day with lunch. It is very important
that you eat full meals while on this medication. You should
check your blood sugars at least twice a day.
You had pain in your right knee that is probably from arthritis.
Please take Tylenol for this pain.
You also had a cough. We gave you a new medication and an
inhaler that should help this cough.
You were recommended to go to a rehab center to work with ___ and
regain your strength. You declined to go to rehab. Please take
your medications as prescribed, and follow-up at the
appointments below.
We wish you the best!
-Your ___ Team
Followup Instructions:
___
|
10703181-DS-18
| 10,703,181 | 20,550,557 |
DS
| 18 |
2172-09-13 00:00:00
|
2172-09-14 19:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE pain, chills
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
Capsule endoscopy
History of Present Illness:
Ms ___ is a ___ with h/o hx of traumatic brain injury and
developmental delay, Hep C, DM and pseudoseizures, on coumadin
since ___ for persistant LLE DVT, who presents with pain in
RLE and subjective fever/chills. Care taker found her in a cold
sweat, and less responsive, so called EMS. History limited by pt
being a poor historian. The symptoms began earlier on day of
admission, and associated with general body weakness. She also
complains of feeling SOB and with mild mid-chest pain, pt unable
to further characterize. She denies dysuria or other urinary
changes. She denies any other pain. She denies nausea, vomiting,
diarrhea, cough, or headaches. She had a fall 2 days ago and
broke her left radial head, and per pt did hurt her leg as well.
.
Of note, her prior history is significant for an unprovoked DVT
on ___ involving the left superficial femoral vein,
nonocclusive. The record notes no recent travel, trauma,
surgeries, OCPs. She has no known malignancy. She has been on
warfarin since that time with INR goal to 2.5-3 range. She had
ongoing symptoms in ___ and had ___ done at that time
which showed non-occlusive thrombus of the left common femoral
vein is similar in appearance to prior imaging studies. Prior CT
has demonstrated thrombus in the left pelvic vein. She is now on
coumadin indefinitely. She was seen in the ED at that time and
found to have an INR of 1.0. Unclear if she was taking coumadin
but was restarted and given lovenox to bridge.
.
In the ED, initial VS were: T: 99.6, BP: 102/59, P: 127, RR: 20,
O2 Sat: 100% on RA. Her INR was found to be 24, with severely
elevated ___ and PTT as well. There was concern for spontaneous
bleed vs compartment syndrome, so ortho was consulted who felt
that this was not compartment syndrome, but instead cellulitis.
She was given vancomycin and unasyn, as well as morphine for
pain and vitamin K 10mg IV x1. An EJ line was placed. Ortho did
feel that she should get Q2H serial compartment checks, with
measurement of compartment pressure if exam changes.
On arrival to the MICU, she is in NAD though complaining of pain
in RLE, mostly in the calf. She also has mild SOB and is mildly
tachypneic, though was 100% on room air.
Past Medical History:
- TBI in childhood after fall from window; had R parietal
craniotomy and subsequent L hemiparesis and cognitivie deficits
- Adult pseuodseizures (with multiple negative EEGs), says last
seizure was over ___ years ago
- Childhood epilepsy
- Hep C
- DM
- Anemia
- Anxiety Disorder
- s/p tubal ligation
Social History:
___
Family History:
denies family history of blood clots. otherwise
non-contributory.
Physical Exam:
Admission exam
Tcurrent: 37.4 °C (99.3 °F)
HR: 127 (127 - 129) bpm
BP: 96/68(76) {96/60(69) - 105/68(76)} mmHg
RR: 17 (17 - 21) insp/min
SpO2: 94%
General: Alert, oriented though poor historian, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, unable to assess JVP ___ strong/fast carotid
pulsations, no LAD
CV: tachycardic, no mrg, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
RLE: Skin clean and intact, +warmth RLE>LLE; Thigh is soft. Leg
compartments firm but compressible, firmer than
contralateral side. No pain w/ passive stretch. 2+ DP pulse. No
obvious erythema. ___ pitting edema up to knee.
LLE: Skin clean and intact, Compartments soft. No pain w/
passive
stretch. 2+ DP pulse
Neuro: CNII-XII intact, LUE: ___ bicep, ___ wrist
extension/flexion, intraosseious, RUE: ___ strength throughout,
LLE: ___ strength throughout; RLE: ___ strength; Sensation to LT
intact throughout
___ strength upper/lower extremities, grossly normal sensation,
2+ reflexes bilaterally, gait deferred, finger-to-nose intact
..
Discharge PE:
24hr Tmax 99.7 Tc 96.7 HR 80 BP 100/50 RR 18 SaO2 95 on RA
General: Alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVP, no LAD
CV: tachycardic, no mrg, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
RLE: Skin clean and intact, No pain w/ passive stretch. 2+ DP
pulse. No obvious erythema. trace edema.
Neuro: CNII-XII intact, RUE: ___ bicep, ___ wrist
extension/flexion, intraosseious, LUE: ___ strength throughout,
RLE: ___ strength throughout; LLE: ___ strength; Sensation to LT
intact throughout
Pertinent Results:
Admission labs:
___ 05:18PM BLOOD WBC-8.9 RBC-2.81*# Hgb-9.2*# Hct-27.0*#
MCV-96 MCH-32.6* MCHC-34.0 RDW-14.2 Plt ___
___ 11:27PM BLOOD WBC-7.8 RBC-2.13* Hgb-7.2* Hct-21.2*
MCV-99* MCH-33.8* MCHC-34.0 RDW-14.2 Plt ___
___ 04:45AM BLOOD WBC-8.9 RBC-2.27* Hgb-7.3* Hct-21.4*
MCV-95 MCH-32.3* MCHC-34.2 RDW-15.0 Plt ___
___ 07:48AM BLOOD WBC-9.0 RBC-2.67* Hgb-8.5* Hct-24.4*
MCV-92 MCH-31.7 MCHC-34.7 RDW-16.2* Plt ___
___ 05:18PM BLOOD ___ PTT-146.1* ___
___ 11:27PM BLOOD ___ PTT-37.6* ___
___ 11:27PM BLOOD Ret Aut-1.4
___ 06:01AM BLOOD Ret Aut-2.9
___ 05:18PM BLOOD Glucose-216* UreaN-20 Creat-1.3* Na-139
K-4.2 Cl-101 HCO3-25 AnGap-17
___ 11:27PM BLOOD Glucose-190* UreaN-17 Creat-1.0 Na-139
K-4.2 Cl-106 HCO3-20* AnGap-17
___ 04:45AM BLOOD Glucose-137* UreaN-15 Creat-0.8 Na-141
K-4.2 Cl-110* HCO3-24 AnGap-11
___ 05:18PM BLOOD ALT-25 AST-35 AlkPhos-36 TotBili-0.5
___ 11:27PM BLOOD ALT-28 AST-54* LD(LDH)-239 AlkPhos-31*
TotBili-0.9
___ 05:18PM BLOOD Albumin-3.6
___ 04:45AM BLOOD Albumin-2.8* Calcium-7.4* Phos-3.3 Mg-1.9
Iron-128
Iron studies/B12, folate
___ 04:45AM BLOOD calTIBC-286 VitB12-404 Folate-11.4
Ferritn-87 TRF-220
___ 06:43AM BLOOD TSH-4.0
___ 06:43AM BLOOD T4-6.6
___ 06:43AM BLOOD Vanco-3.2*
lactate trend:
___ 05:21PM BLOOD Lactate-6.6*
___ 06:38PM BLOOD Lactate-4.4*
___ 09:04PM BLOOD Lactate-3.8*
___ 04:59AM BLOOD Lactate-1.4
INR Trend:
___ 05:18PM BLOOD ___ PTT-146.1* ___
___ 11:27PM BLOOD ___ PTT-37.6* ___
___ 04:45AM BLOOD ___ PTT-34.7 ___
___ 03:19AM BLOOD ___ PTT-38.3* ___
___ 06:45AM BLOOD ___ PTT-40.0* ___
___ 06:43AM BLOOD ___
___ 06:01AM BLOOD ___
___ 05:48AM BLOOD ___
___ 05:50AM BLOOD ___
___ 06:55AM BLOOD ___
___ 08:32AM BLOOD ___
___ 07:20AM BLOOD ___
___ 06:00AM BLOOD ___
___ 07:00AM BLOOD ___ PTT-39.4* ___
Discharge labs:
___ 07:00AM BLOOD WBC-7.5 RBC-2.88* Hgb-8.7* Hct-27.6*
MCV-96 MCH-30.1 MCHC-31.4 RDW-15.3 Plt ___
___ 07:00AM BLOOD ___ PTT-39.4* ___
___ 06:00AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-142
K-4.6 Cl-105 HCO3-28 AnGap-14
RUQ Ultrasound: ___
1. No focal liver lesions identified.
2. Mild gallbladder wall edema is likely related to third
spacing in the
setting of hypoalbuminemia.
3. Small volume perihepatic ascites.
4. Tiny bilateral pleural effusions, as on recent CT from
___.
ECHO ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The 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.
No mass or vegetation is seen on the mitral valve. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Indeterminate pulmonary artery systolic pressure. Very small,
circumferential pericardial effusion without echocardiographic
evidence of tamponade.
Intestinal Biopsies ___
A. Ileocecal valve:
1. Colonic mucosa with no diagnostic abnormalities recognized;
multiple levels examined.
2. Scant adipose tissue is present.
B. 50 cm:
Colonic mucosa with no diagnostic abnormalities recognized;
multiple levels examined.
CTA Chest ___
1. There is no evidence of central pulmonary embolism. The
visualization of more peripheral branches is limited due to
patient motion, suboptimal contrast bolus, and contrast flow
artifact; the segmental and subsegmental pulmonary arteries
cannot be reliably assessed for pulmonary embolism.
2. Mild bibasilar atelectasis.
3. New small pleural effusions.
CT Abd/ pelvis: ___
1. No retroperitoneal hematoma. No acute intra-abdominal
abnormality on this non-contrast CT.
2. Bibasilar dependent consolidation, probably atelectasis.
CT Lower Extremities: ___
1. No acute fracture.
2. No hematoma identified.
3. Slight enlargement of the right lower extremity when compared
to the left. There is subcutaneous swelling and edema most
prominent along the right lateral thigh.
4. Degenerative changes as described above.
Brief Hospital Course:
Ms ___ is a ___ with h/o hx of traumatic brain injury and
developmental delay, Hep C, DMII and pseudoseizures, on coumadin
since ___ for persistant LLE DVT, who presents with pain in
RLE and subjective fever/chills, 2 days after a fall.
.
# Tachypnea: On initial presentation to the MICU, the patient
was tachypneic with a Wells score is 6, putting her at high risk
for PE. She was not hypoxic, but given her history of LLE DVT,
as well as her sinus tachycardia, the patient underwent CTA
while on the general medicine floor, which was negative for any
central pulmonary embolus.
.
# RLE pain/erythema: While in the MICU, the patient was started
on Vanc/Unasyn for possible cellulitis. Ortho was also
following her and doing serial compartment checks. She also had
a R ___, which was negative for any DVTs. The patient also had
a CT pelvis and extremities to evaluate for any RP bleed or
bleeding into thigh that could account for this pain, given her
elevated INR on presentation; both were negative.
.
On transfer to the general medicine floor, it was decided to
stop the vanc/unasyn as there was low clinical suspicion for
cellulitis based on exam. The patient continued to elevated her
RLE. She was initially pain controlled with oxycodone and
tylenold; but because of her increased lethargy on arrival to
the floor, the patient's narcotics were d/ced and her pain was
controlled on tylenol. Upon discharge, her pain was resolved.
She also was seen by ___ while in patient.
.
# Supratherapeutic INR: The patient is anticoagulated for her
chronic LLE DVTs. She was found to have an INR of 24 in the ED,
and after getting 10 mg Vitamin K IV in the ED, her repeat INR
was down to 2.4. Possible that this was a spurious result. The
patient was evaluated for evidence of RP bleed, or bleeding into
extremities with CT, which were negative. She was also
initially followed by ortho out of concern for compartment
syndrome. On transfer to the floor, the patient's INR was
subtherapeutic and the patient's coumadin was increased to 4mg
daily. The patient's INR was 1.9 at the time of discharge and
was continued on her coumadin 4mg daily. She will need to
follow up in ___ clinic for INR monitoring and dose
adjustments after rehab.
.
# Acute kidney injury: The patient has a baseline creat of 0.8,
and on admission, creat found to be 1.3. Likely prerenal and
after fluids, her creat had returned to her baseline.
.
# fever of unclear etiology: After being called out from the
MICU, the patient had fever of unclear etiology, with
temperatures ranging from 100.5 to ~101. She had a negative
infectious work up, including, blood cultures, urine cultures,
ECHO, Cdiff; her PICC line was also pulled. CMV, EBV, and Parvo
virus labs were also were sent, as it was thought that a viral
syndrome could have accounted for her fevers and her anemia (see
below). EBV demonstrated past infection and CMV and parvo were
pending at the time of discharge.
.
Although no source was ever found, the patient remained afebrile
for 96 hours prior to discharge from hospital.
.
# lactic acidosis: The patient was found to have lactate of 6.6
on admission with unclear etiology. Possible that this could
have been do to some underlying infection, but no source of
infection was indentified. More likely, however, is that lactic
acidosis occurred secondary to metformin use in the setting of
acute kidney injury due to dehydration. The patient's metformin
was held while in patient and she was given fluids in the MICU.
Upon transfer to the medicine floor, the patient's lactic
acidosis had resolved. Her metformin was held during the
hospitalization. Upon discharge, the patient's creat had
normalized, and she was discharge on a insulin sliding scale.
Here outpatient primary care provider should determine if she
should be restarted on metformin.
.
# Anemia: The patient has baseline crit in the high ___, with
most recent crit in our system from ___ at 38.0. On
presentation crit was found to be 27 and downtrended in the MICU
as low as 21, with no active source found. In the setting of her
elevated INR, CT abdomen and extremities were done to rule out
any hematomas, or RP bleed that could account for crit drop.
Iron studies, B12, folate, and hemolysis labs were all normal
although these were obtained after 1 unit of blood was given.
The patient was found to have guaic positive brown stool in the
ED. She was also found to have inappropriately low retic count.
.
On transfer to the floor, the patient had anemia work up that
included EGD, capsule endoscopy, and colonoscopy by GI. The
patient did not have any possible sources of bleeding, as per
GI. The patient had an inappropriately low retic count, and her
peripheral smear was viewed which did not show significant
evidence of schistocytes or teardrop cells. SPEP/UPEP was also
within normal limits.
.
# Left radial head fracture: pt was seen for fall on ___ and
found to have have Left radial head fracture. As per her ___
clinic appt, no acute intervention was indicated, and her pain
was controlled as above.
.
# epilepsy: The patient follows with Neurology at ___ while
in patient she was continued on her home gabapentin, divalproax,
and lorazepam.
.
# Anxiety/psychotic disorder: The patient's mood has been
stable while in patient; she was continued on risperdal,
amitryptiline, and lorazepam at home doses.
.
#DM last A1c 6.0% in ___. On metformin at home, was stop
due to lactic acidosis (see above) and acute illness and put on
HISS.
.
#Hep C - no evidence of decompensation. It is unclear if she
would be a candidate for therapy given possible difficulties
with compliance and psychiatric history. HCV viral load in
___ was 31,000 IU/mL.
..
Transitional Issues:
- Liver follow-up: The patient was instructed by her PCP to
follow up in the liver clinic in regards to her Hep C; another
appointment was set up for her to follow with liver as an
outpatient.
- metformin induced lactic acidosis: It is possible that the
patient's initial lactic acidosis was secondary to metformin use
in the setting of acute kidney injury. Her metformin was not
restarted upon discharge.
- ___ for a less than 30 day stay for evaluation and
treatment.
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet
- 1 Tablet(s) by mouth q4-6 ___ ___
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1 puff IH q4-6
as needed for wheeze, cough
ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
AMITRIPTYLINE - (Prescribed by Other Provider) - 10 mg Tablet -
2 Tablet(s) by mouth at bedtime
CICLOPIROX - 0.77 % Cream - Apply to soles of feet twice a day
as
directed.
COMPRESSION STOCKING - - apply one large compression stocking
to Right Calf Daily With activity
DIVALPROEX - (Prescribed by Other Provider) - 500 mg Tablet
Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth Qweekly once a week for 6 weeks
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray IN twice a day
GABAPENTIN - (Prescribed by Other Provider) - 400 mg Capsule -
1
Capsule(s) by mouth twice a day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime at
night
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth twice a day
RISPERIDONE - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth twice a day
TOLTERODINE [DETROL LA] - 2 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth daily
WARFARIN - 2 mg Tablet - Take up to 3 Tablet(s) by mouth daily
or
as directed by ___ clinic
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth every six
(6) hours as needed for pain; Do not exceed ___ mg/day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
to
monitor your blood sugar up to 4 times a day or as directed
BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - Kit - use as
directed to monitor blood glucose twice daily and as needed
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
LANCETS [FREESTYLE LANCETS] - Misc - use as directed to
monitor
your blood sugar up to 4 x per day as directed
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for Constipation
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for SOB or
wheeze.
2. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. ciclopirox 0.77 % Cream Sig: One (1) Topical twice a day:
apply to soles of feet twice daily.
4. divalproex ___ mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO BID (2 times a day).
5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 4 gm in 24 hours.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
10. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. warfarin 4 mg Tablet Sig: One (1) Tablet PO ___, ___,
___: adjust for goal INR ___.
14. warfarin 3 mg Tablet Sig: One (1) Tablet PO ___:
adjust for goal INR ___.
15. insulin lispro 100 unit/mL Solution Sig: One (1) injection w
meals Subcutaneous ASDIR (AS DIRECTED): per sliding scale .
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
Metformin induced lactic acidosis
Anemia
Secondary Diagnosis:
Traumatic Brain Injury
Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
not feeling well at home; in the emergency room, there was
concern you had a leg infection and some of your other blood
markers were elevated. Because of this, you were initially
admitted to the intensive care unit. while you were in the
intensive care unit, you were started on antibiotics. Your
antibiotics were stopped when there was no sign of any infection
in your leg.
You had fevers and we did not determine the cause. Your fevers
resolved on their own and no source of infection was found.
You also had low blood counts. You had no sign of any bleeding
and all your studies were normal.
We made the following changes to your medications:
-Stopped metformin
-Stopped tolterodine
-Started insulin sliding scale
-Started pantoprazole 40 mg by mouth daily
It is VERY important that you follow up with your outpatient
doctors ___ below for appointments).
Followup Instructions:
___
|
10703181-DS-19
| 10,703,181 | 26,486,387 |
DS
| 19 |
2174-02-04 00:00:00
|
2174-02-04 21:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
metformin
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
___ y/o female with h/o traumatic brain injury s/p craniotomy
with residual left upper and lower extremity paresis and
cognitive deficits who presents to the ED with c/o a headache
which has been present for approximately 2 days and has
progressively worsened. She denies falling or striking or head.
She was seen by the nurse at her adult day program who
recommended she present to the ED as she does not ususally
experience headaches and was experiencing tremors within all
four
extremities. She notes a headache which is localized to the
front
of her head. She denies any diplopia, confusion, blurred vision,
word-finding difficulty or speech production. She c/o nausea but
denies vomiting.
Past Medical History:
- TBI in childhood after fall from window; had R parietal
craniotomy and subsequent L hemiparesis and cognitivie deficits
- Adult pseuodseizures (with multiple negative EEGs), says last
seizure was over ___ years ago
- Childhood epilepsy
- Hep C
- DM
- Anemia
- Anxiety Disorder
- s/p tubal ligation
Social History:
___ y/o female with h/o traumatic brain injury s/p craniotomy
with residual left upper and lower extremity paresis and
cognitive deficits who presents to the ED with c/o a headache
which has been present for approximately 2 days and has
progressively worsened. She denies falling or striking or head.
She was seen by the nurse at her adult day program who
recommended she present to the ED as she does not ususally
experience headaches and was experiencing tremors within all
four
extremities. She notes a headache which is localized to the
front
of her head. She denies any diplopia, confusion, blurred vision,
word-finding difficulty or speech production. She c/o nausea but
denies vomiting.
PMHx: h/o TBI as child s/p craniotomy with residual left-sided
weakness; Hepatitis C; pseudoseizures; psychiatric history; DM
Type II; h/o chronic DVTs on Coumadin
All: Metformin
Medications prior to admission:
Humalog Mix Insulin ___ SQ 100unit/mL BID; Acetminophen 500mg
PO Q6H; Amitriptyline 20mg PO QHS; Divalproex ER 500mg Q24H;
Docusate 100mg PO BID; Gabapentin 400mg PO BID; Glyburide 5mg O
BID; Nicotine patch; Pantoprazole 40mg PO Q24H; Risperidone
0.5mg
PO QD PRN; Risperidone 4mg PO BID; Sennosides 8.6mg PO BID PRN;
Warfarin 2mg PO per recommendations of ___
Social Hx: ___
Family Hx: NC
ROS: In HPI
PHYSICAL EXAM:
T: 97.6 BP: 141/95 HR: 78 R: 16 O2Sats 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric with
left nasolabial fold.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Right upper extremity.
tremors. Strength full power ___ throughout.
Pronator Drift: Unable to assess secondary to residual left UE
paresis.
Sensation: Intact to light touch bilaterally.
Handedness: Right
CT: Right frontal intraparenchymal hemorrhage measuring 3x4 cm
CTA: Right AVM
Family History:
denies family history of blood clots. otherwise
non-contributory.
Physical Exam:
PHYSICAL EXAM:
T: 97.6 BP: 141/95 HR: 78 R: 16 O2Sats 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric with
left nasolabial fold.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Right upper extremity.
tremors. Strength full power ___ throughout.
Pronator Drift: Unable to assess secondary to residual left UE
paresis.
Sensation: Intact to light touch bilaterally.
Handedness: Right
Pertinent Results:
Head CT ___:
1. 3.2 x 4.1 cm intraparenchymal hemorrhage with surrounding
vasogenic edema in the inferior right frontal lobe with mass
effect on the right lateral ventricle and mild leftward midline
shift.
2. Likely a combination of intraparenchymal and subarachnoid
hemorrhage in the medial right temporal lobe with subarachnoid
blood also seen within the suprasellar cistern and possibly the
___ ventricle.
3. Global volume loss is inappropriate for age and likely a
consequence of
prior head injury.
CTA Head ___:
1. Redemonstration of right frontal lobe parenchymal hemorrhage
with
associated mass effect, with the overall volume of hemorrhage
appearing
similar to the recent comparison.
2. Right arteriovenous malformation, measuring approximately
4.6 x 4.2 cm. Arterial supply appears to be primarily via the
right middle cerebral artery, with additional contributions
noted from the right anterior and posterior cerebral arteries.
There are numerous associated intracranial arterial aneurysms,
as described above. Venous drainage is primarily via enlarged
cortical veins, which are seen bilaterally. There are numerous
focal venous varices, as above.
Angiogram ___:
___ underwent cerebral angiography which shows a 5 x 4
x 4 cm
arteriovenous malformation of the right frontoparietal area
predominantly
supplied by the right middle cerebral artery with pial
collaterals. There is no deep venous drainage. There are
multiple feeding vessel aneurysms on the right internal carotid
artery and middle cerebral artery, the largest of which measures
6 x 5 mm.
Lower Extremity Ultrasound Study ___:
Limited study due to inability to evaluate common femoral veins.
Within this limitation, no evidence of deep venous thrombosis
in the bilateral lower extremities.
Head CT without Contrast ___:
Limited evaluation due to metallic artifact without evidence for
significant interval change.
Head CT without Contrast ___:
Stable head CT.
Lower Extremity Ultrasound Study ___:
There is again appreciated nonocclusive thrombus within the left
common
femoral vein, unchanged from previous.
No evidence of DVT in the right common femoral vein.
Brief Hospital Course:
Patient presented to the hospital complaining of a headache and
underwent a head CT that revealed a right temporal IPH
suspicious for underlynig aneurysm clips, a CTA was ordered that
showed a large underlying AVM. Patient went for a cerebral
angiogram for an attempted embolization of the AVM, but we were
not able to. Patient was taken to the ICU post angiogram for
recovery and observation.
___: Patient was started on antibiotics for a proteus UTI and
underwent a cranial CT for new lethargy and confusion,
ventricular size and hemorrhage were stable.
On ___, she was febrile to 103. She received a dose of
Acetaminophen in and her temperature improved to 101.9.
Bilateral ___ LENIs showed a nonocclusive thrombus within the
left common femoral vein, unchanged from previous. No evidence
of DVT in the right common femoral vein.
On ___, patient was alert to self, place and month on exam. She
followed commands on her R side. LUE w/d to nox and LLE ___. She
was seen to have RUE tremor in which she received ativan. It was
found that that is her baseline. Her depakote level was stable
at 53 and cipro was changed to ceftriaxone. She was febrile and
a culture was sent.
On ___ trasnfer orders were written for the floor and she was
scheduled for an IVC filter planned for ___.
On ___ she had an IVC filter placed and surgical planning was
underway with possibility of transfer to another facility.
On ___ the patient remained stable.
At the time of transfer she is tolerating a regular diet,
afebrile with stable vital signs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Divalproex (EXTended Release) 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 400 mg PO BID
6. GlyBURIDE 5 mg PO BID
7. Nicotine Patch 14 mg TD DAILY
8. Pantoprazole 40 mg PO Q24H
9. RISperidone 0.5 mg PO DAILY:PRN agitation
10. RISperidone 4 mg PO BID
11. Senna 1 TAB PO BID:PRN constipation
12. Warfarin 2 mg PO DAILY16
13. HumaLOG Mix ___ *NF* (insulin lispro protam & lispro) 100
unit/mL (75-25) Subcutaneous BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Amitriptyline 20 mg PO HS
3. Divalproex (EXTended Release) 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 400 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. RISperidone 0.5 mg PO DAILY:PRN agitation
8. RISperidone 4 mg PO BID
9. Senna 1 TAB PO BID:PRN constipation
10. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
11. Bisacodyl 10 mg PO DAILY
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
15. Heparin 5000 UNIT SC TID
16. HydrALAzine ___ mg IV Q6H:PRN sbp>140
17. NPH 16 Units Breakfast
NPH 16 Units Dinner
Insulin SC Sliding Scale using REG Insulin
18. Labetalol 400 mg PO TID
19. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebral hemorrhage
Cerebral AVM
Urinary tract infection
Previous DVT, nonocclusive thrombus in Left Common Femoral Vein
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10703209-DS-13
| 10,703,209 | 23,425,794 |
DS
| 13 |
2134-08-07 00:00:00
|
2134-08-07 08:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R arm pain and deformity
Major Surgical or Invasive Procedure:
I&D and ORIF R open distal humerus fracture
History of Present Illness:
HPI: ___ female RHD nursing student with anxiety/depression with
history of sleepwalking presents with the above fracture after
reported episode of falling out of bed last night. Patient has
history of sleepwalking and falling out of bed with resultant
injuries in the AM and has been followed by neurology. This am
patient woke up at 7 am with R elbow pain and small pokehole
with
persistent slow bloody drainage since she awoke. Patient states
she feels safe at home, was not under the influence of
alcohol/drugs, and her suite-mates states that they heard a thud
last night but attributed it to nearby construction.
On interview, patient has r elbow pain and endorses numbness
over
Radial distribution. Denies other numbness in other
distributions. States she has issues holding her wrist up since
the injury. No recent illnesses/fevers/chills.
Past Medical History:
Past Medical History:
-Endometriosis on continuous OCP
-Bilateral ruptured ovarian cysts s/o lap cystectomy (___)
-Migraine headache
-Seizure disorder (remote)
-Concussion
-Anxiety
Past Surgical History:
-Bilateral lap cystectomy (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
AFVSS
Gen: NAD, calm & comfortable
RUE:
Dressing / splint clean dry intact
Sensation intact to light touch in axillary, radial, median &
ulnar nerve distributions
Ably to slightly extension all fingers at IPs/MCPs, no wrist
extension motor function
Radial pulse palpable, fingers warm & well perfused, brisk
capillary refill in all digits
Pertinent Results:
___ 10:52AM BLOOD WBC-17.6*# RBC-4.21 Hgb-12.3 Hct-36.9
MCV-88 MCH-29.2 MCHC-33.3 RDW-13.3 RDWSD-42.2 Plt ___
___ 10:52AM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-141
K-4.4 Cl-105 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Type I open right T-type distal humerus fracture and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for I&D and ORIF of this
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. Her
post-operative splint was transitioned to a long arm,
wrist-inclusive splint by OT on POD1. The patient's home
medications were continued throughout this hospitalization. The
patient worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the right upper extremity, and will be discharged on
aspirin 325mg for DVT prophylaxis. The patient will follow up
with Dr. ___ routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 50 mg PO DAILY
2. ClonazePAM 0.75 mg PO QHS:PRN anxiety
3. Propranolol 20 mg PO BID
4. Amitriptyline 85 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 325 mg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 10 mg 1 tablet(s) by mouth BID PRN Disp #*20
Tablet Refills:*0
4. Amitriptyline 85 mg PO QHS
5. ClonazePAM 0.75 mg PO QHS:PRN anxiety
6. HydrOXYzine 50 mg PO DAILY
7. Propranolol 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
R open T-type distal humerus fracture with radial nerve palsy
Discharge Condition:
AVSS
NAD, A&Ox3
RUE: Dressing clean and dry. Does not fire EPL, ECR. Fires
FPL/FDP/FDS/DIO. Decreased sensation radial n distribution. SILT
median/ulnar n distributions. wwp distally.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing right upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10703349-DS-12
| 10,703,349 | 21,238,711 |
DS
| 12 |
2160-08-02 00:00:00
|
2160-08-03 17:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male with a history of sleep-disordered breathing
non-compliant with his BiPAP who presents with several days of
dyspnea on exertion. The patient works as an ___,
and is exposed to multiple noxious fumes. He reports that his
shortness of breath is no worse or better on weekends. He
reports he breathes fine while at rest, and denies orthopnea or
weight gain. He denies leg swelling. He does not have a large
reduction in his exercise tolerance, and the shortness of breath
is not associated with wheezing or stridor.
The patient notes he feels well in house, and has had some
improvement with albuterol.
Past Medical History:
Benign Hypertension
Left Ventricular Hypertrophy
Sleep-disordered breathing
Social History:
___
Family History:
Mother died of MI at age ___
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.9, 137/78, 68, 20, 93%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: b/l crackles at bases, no wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 05:40AM BLOOD WBC-4.5 RBC-4.96 Hgb-14.9 Hct-43.5 MCV-88
MCH-30.0 MCHC-34.2 RDW-13.5 Plt ___
___ 06:06PM BLOOD WBC-4.8 RBC-4.98 Hgb-15.3 Hct-44.1 MCV-89
MCH-30.7 MCHC-34.7 RDW-13.3 Plt ___
___ 06:06PM BLOOD Neuts-44.5* Lymphs-49.4* Monos-3.5
Eos-2.0 Baso-0.6
___ 05:40AM BLOOD Plt ___
___ 06:06PM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
___ 06:06PM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-142
K-3.8 Cl-104 HCO3-27 AnGap-15
___ 05:40AM BLOOD CK(CPK)-229
___ 06:06PM BLOOD ALT-20 AST-28 CK(CPK)-284 AlkPhos-81
TotBili-0.4
___ 05:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:06PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-12
___ 06:06PM BLOOD Albumin-4.7
___ 06:06PM BLOOD D-Dimer-318
CHEST (PA & LAT) Study Date of ___ 8:44 ___
IMPRESSION:
No acute cardiopulmonary process.
Chest CT: Prelim Read: no lung findings noted
Brief Hospital Course:
1. Dyspnea
- Patient likely has some pneumonitis from chemical exposures or
a mild viral pneumonitis
- He already has a pulmonologist (Dr. ___ and he should
probably be referred back
- Would give an albuterol MDI
- Patient has no hypoxemia and feels well enough to discharge
- Follow up CT-Chest read
2. Benign Hypertension
- Triamterene-Hydrochlorothiazide and nifedipine
Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. NIFEdipine CR 90 mg PO DAILY
please hold for sbp<100
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
please hold for sbp<100
Discharge Medications:
1. NIFEdipine CR 90 mg PO DAILY
please hold for sbp<100
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
please hold for sbp<100
3. Albuterol Inhaler ___ PUFF IH Q2H:PRN SOB, cough
RX *albuterol sulfate 90 mcg ___ puffs inhaled Every 2 hours
Disp #*1 Inhaler Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Shortness of Breath
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 shortness of breath. We
determined that your breathing problems were not related to your
heart. We performed a CT scan of your lungs that did not show an
infection or abnormality that would explain your symptoms. We
think that your symptoms were from the combination of exposure
to paint fumes and also a mild viral respiratory illness. Please
try to work in well-ventilated areas to prevent breathing in
paint fumes. Also, please wear a well fitted mask when you are
sanding, painting, or stripping paint. We have prescribed you an
inhaler that you should use as needed if you have shortness of
breath. We also made you a follow-up appointment with your
primary doctor and our pulmonary office will call you with an
appointment as well.
Followup Instructions:
___
|
10703777-DS-12
| 10,703,777 | 23,711,980 |
DS
| 12 |
2117-01-31 00:00:00
|
2117-02-02 13:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
heparin
Attending: ___.
Chief Complaint:
Shortness of breath, syncope
Major Surgical or Invasive Procedure:
EKOS (catheter-directed thrombolysis)
History of Present Illness:
___ Female recently diagnosed severe pulm HTN w/PAsyst 60-70,
mean 43, presenting after syncopal episode. Patient reports she
had worsening SOB at rest and felt faint. Per patient's wife,
she then turned blue, syncopized, and spontaneously came to. EMS
found her to be hypoxic to the ___ and she was taken to ___
___. She was transferred to ___ for further evaluation of
her shortness of breath.
Patient reports she has been having worsening dyspnea on
exertion for months, and acute worsening in the last week. She
presented to ___ on ___ x2day of DOE. There
was concern for MI so patient underwent a L/RHC showing clean
coronaries but she was diagnosed with pulmonary hypertension and
told to follow-up with a specialist. She re-presented to ___
___ on ___ to her syncopal episode; they attempted
a CT w/contrast via a R EJ-line which was complicated by
infiltration. Per patient, the imaging was concerning for PNA.
She was transferred here for further eval.
Of note, patient traveled to ___ in the last month; she
reports wearing compression stockings and moving around. She
denies hormone use, recent immobility, trauma, surgery. She
denies a history of miscarriage.
On arrival to the ED, vitals were 98.3 76 128/89 22 80% on RA.
She triggered for hypoxia and put on 5L NC with improvement in
sats to 95%. She denied chest pain, diaphoresis, N/V. Labs were
significant for a BNP 5901, trop I 0.069, WBC 13.3, Cr 0.8. EKG
showed NSR w/TWI c/w previous EKG (___). CTA revealed (wet
read) "Large saddle emboli originating in the distal portions of
the right and left pulmonary arteries. The right ventricle is
dilated and the interventricular septum is deviated towards the
left ventricle, suggesting right heart strain." Bedside echo was
significant for RV strain. She was started on a heparin gtt and
transferred to the CVICU.
On arrival to the CVICU, vitals were aferbile, 76, 124/79, 94%
on ___. Patient reports she still feels short of breath ___
moving to use the bathroom but it is improving. She denies CP,
dizziness/lightheadedness, nausea/vomiting, pain.
Past Medical History:
OSTEOARTHRITIS, UNSPEC
HEARING LOSS, UNSPEC
FRACTURE - METATARSAL
VENOUS INSUFFIC, UNSPEC
ALCOHOLISM IN FAMILY(aka FAMILY)
DIVERTICULOSIS
RHINITIS - ALLERGIC, UNSPEC CAUSE
SLEEP APNEA, OBSTRUCTIVE
HEADACHE - MIGRAINE, UNSPEC
IRRITABLE BOWEL SYNDROME
ENDOMETRIAL HYPERPLASIA
COLONIC ADENOMA
Social History:
___
Family History:
Father- multiple strokes
Mother- "cardiac failure"
Otherwise no family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION:
VS: 76, 124/79, 94% on 3___
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. (+)bruise on R lateral neck ___
EJ placement
CV: PMI in ___ intercostal space, mid clavicular line. RRR.
normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
EXT: (+) 2+ pitting edema in b/l ___. Full distal pulses
bilaterally. No femoral bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout.
DISCHARGE:
VS: T: 97.7, BP: 100-120s/60s-70's, HR: 66, RR: 18 , Sp02: 98%RA
Wt 140.3
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP 8. (+)bruise on R lateral neck ___
catheter
CV: RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Obese.
EXT: (+) 2+ pitting edema in b/l ___ (increase from ___. R > L
Full distal pulses bilaterally. No femoral bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout.
Pertinent Results:
ADMISSION
___ 08:44AM ___ PTT-30.1 ___
___ 08:44AM WBC-13.3* RBC-4.75 HGB-14.5 HCT-44.0 MCV-93
MCH-30.5 MCHC-33.0 RDW-14.9 RDWSD-49.4*
___ 08:44AM D-DIMER-8504*
___ 08:44AM proBNP-5901*
___ 08:44AM cTropnT-<0.01
___ 08:44AM GLUCOSE-154* UREA N-28* CREAT-0.8 SODIUM-136
POTASSIUM-8.5* CHLORIDE-112* TOTAL CO2-19* ANION GAP-14
___ 08:50AM O2 SAT-90
___ 08:50AM ___ PO2-63* PCO2-33* PH-7.38 TOTAL
CO2-20* BASE XS--4
___ 09:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG
PERTINENT
___ 04:57AM BLOOD WBC-11.7* RBC-4.42 Hgb-13.1 Hct-42.0
MCV-95 MCH-29.6 MCHC-31.2* RDW-15.2 RDWSD-51.9* Plt ___
___ 06:00AM BLOOD WBC-10.2* RBC-3.96 Hgb-12.0 Hct-38.0
MCV-96 MCH-30.3 MCHC-31.6* RDW-15.0 RDWSD-51.5* Plt Ct-96*
___ 06:30AM BLOOD WBC-7.6 RBC-4.03 Hgb-12.1 Hct-38.5 MCV-96
MCH-30.0 MCHC-31.4* RDW-15.3 RDWSD-51.9* Plt Ct-58*
___ 07:10AM BLOOD WBC-7.2 RBC-3.83* Hgb-11.7 Hct-37.2
MCV-97 MCH-30.5 MCHC-31.5* RDW-15.2 RDWSD-52.4* Plt Ct-63*
___ 06:30AM BLOOD ___ PTT-35.8 ___
___ 12:50PM BLOOD ___ PTT-36.3 ___
___ 03:00PM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-140
K-4.1 Cl-101 HCO3-30 AnGap-13
___ 07:10AM BLOOD ALT-28 AST-24 AlkPhos-84 TotBili-0.8
DISCHARGE
___ 05:30AM BLOOD WBC-8.9 RBC-4.00 Hgb-12.0 Hct-37.4 MCV-94
MCH-30.0 MCHC-32.1 RDW-15.1 RDWSD-51.1* Plt Ct-78*
___ 05:30AM BLOOD ___ PTT-34.5 ___
___ 05:30AM BLOOD Glucose-86 UreaN-22* Creat-0.6 Na-139
K-3.8 Cl-102 HCO3-26 AnGap-15
___ 05:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.3
IMAGING
CTA Chest (___): 1) Extensive bilateral pulmonary emboli
with evidence of right heart strain, 2) Evidence of contrast
infiltration in the right supraclavicular region from attempt at
contrast enhanced CT at outside institution the evening prior.
TTE (___): Moderate right ventricular dilation with severe
free wall hypokinesis and sparing of the right ventricular apex
___ sign). Severe pulmonary hypertension. Right
ventricular pressure/volume overload. Moderate to severe
tricuspid regurgitation. Findings c/w pulmonary embolism.
___ (___): 1) Deep vein thrombosis in the right popliteal
vein, 2) No evidence of deep vein thrombosis in the left lower
extremity.
EKG (___): Atrial flutter, possibly atypical atrial flutter
with rapid ventricular response.
Brief Hospital Course:
___ yo F WITH recently diagnosed pulmonary hypertension p/w
syncope and hypoxia found to have submassive PE on CTA w/right
heart strain, admitted to the CCU for treatment of her
submassive pulmonary emboli.
#) Pulmonary emboli: Unclear if provoked, patient had recent
flight to ___, but otherwise no known risk factors for
PE. Negative prognostic factors include leukocytosis, RV strain
on echo, elevated BNP. On admission, patient had new O2
requirement, but otherwise was hemodynamically stable. Echo was
significant for RV strain. She was started on a heparin gtt.
LENIs were (+) for right popliteal DVT. Patient remained stable
on 6L NC until the morning of ___, when patient went into
SVT consistent with atrial tachycardia. She spontaneously
converted and was started on metoprolol XL 25mg. The decision
was made to elevate treatment of her PE with EKOS with direct
tPA administration to her clots; she underwent the procedure on
___. She tolerated the procedure well and there were no
complications. She was maintained on the heparin gtt until
___, when it was noted that the patient's labs were
significant for thrombocytopenia. She was initially started on
xarelto, but was transitioned to fondaparinux per hematology
recommendations. She was weaned off O2 and was discharged
without an oxygen requirement. She will follow-up with
cardiology, pulmonology, hematology, and her PCP.
#) Thrombocytopenia: on ___, it was noted that the patient's
platlets had been downtrending (129 on admission, lowest 58 on
___. Although she was low probability on the 4T score, the PF4
antibody was sent which was equivocal initially, but positive on
follow-up. She was started on fonaparinux. She will follow-up
with hematology as an outpatient.
#) Pulmonary hyptertension: Patient with new diagnosis of
pulmonary hypertension at ___ diagnosed via
___/RHC. However, no imaging was performed to assess for PE
however. The most likely ___ to acute on chronic pulmonary
emboli.
Her PE was treated per above. She will follow-up with
pulmonology as an outpatient and a catheterization will be
repeated in the future.
#) Diastolic congestive heart failure: As noted on echo, patient
had significant RV strain in the setting of her PE. She was
volume overloaded on exam. She received IV diuresis and was
started on 20mg po lasix to continue as an outpatient.
#) SVT: In the setting of her PE, on the morning of ___ the
patient went into SVT consistent with atrial tachycardia with
rates into the 130s. She spontaneously converted and was started
on metoprolol XL 25mg. She was discharged on this medication and
if it recurs, will follow-up with cardiology.
#) Transitional issues:
- Per ___ -> rehab x1 week
- Dr. ___ to determine whether patient will need follow up
catheterization
- Will need to determine anticoagulation choice, likely
rivaroxaban, after final HIT eval by hematology
- Discharge weight 140.3
- Discharged on 20mg furosemide PO and metoprolol 25mg
- Discharged on fondaparinux pending above, PF4 pending
- CODE STATUS: FULL CODE
- Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. Lorazepam 1 mg PO Q8H:PRN anxiety
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levalbuterol Neb 0.63 mg NEB BID:PRN wheeze
Discharge Medications:
1. Sertraline 100 mg PO DAILY
2. Fondaparinux 10 mg SC DAILY
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Levalbuterol Neb 0.63 mg NEB BID:PRN wheeze
7. Lorazepam 1 mg PO Q8H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Pulmonary embolism
- Thrombocytopenia, likely ___ heparin-induced thrombocytopenia
- Supraventricular tachycardia
- Diastolic congestive heart failure
SECONDARY DIAGNOSES:
- Depression/anxiety
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 transferred to ___ for evaluation of your shortness
of breath. You were found to have a large clot in your lungs
that likely came from the clot in your leg. You underwent a
procedure called catheter-directed thrombolysis which put
clot-busting medication directly into the clots. You were also
started on systemic anticoagulation to prevent the formation of
new clots. There was concern that you may have had an autoimmune
reaction to heparin, the first anti-clotting medication you were
on. You were switched to a different anti-clotting medication
called fondaparinux; you should continue injecting yourself with
this medication once a day. While treating your clots, your
heart went into an abnormal rhythm. Please continue to take the
metoprolol daily to control the rhythm. In addition, you were
noted to have some extra fluid on exam; you were started on 20mg
lasix that you should take daily. Please follow up with Dr.
___ your pulmonary hypertension and hematology to
discuss your anti-clotting medications.
Thank you for letting us be a part of your care!
- Your ___ Team
Followup Instructions:
___
|
10703833-DS-10
| 10,703,833 | 21,027,122 |
DS
| 10 |
2144-04-20 00:00:00
|
2144-04-24 13:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx CABG ___, UC, and prior DVT's p/w chest pressure to
___. Patient notes chest discomfort yesterday evening that
resolved on its own, then reoccurred early this morning at 3am.
His symptoms waxed and waned, but resolved after 4 hours. Denies
any sweating, although mild nausea present. He took his AM ASA
and lopressor, but then went to ___ to be evaluated
given his cardiac history. Of note, patient was able to rake his
lawn several days ago with no problems besides mild SOB. He also
attested to driving from ___ to ___ within the last 3
weeks.
At the OSH, labs showed a normal CMP with a creatinine of 1.2
(around baseline). Troponins were read as less than 0.06 (WNL).
CBC was WNL with a HCT of 40.1 and a WBC of 6.9. EKG reportedly
showed small ST depression in V5 and V6. Given chest pain
symptoms, patient was transferred to ___ for unstable angina.
In the ED, initial vitals were: T98.6 HR47 BP153/63 RR14 99% on
RA. He recived aspirin full strength on admission. Labs showed a
T of <0.01, and a D-Dimer of 535. Coags were normal. EKG showed
sinus bradycardia but otherwise no other wave form or interval
abnormalities. CXR showed no acute process. Had an ETT which
showed no anginal symptoms or objective evidence of myocardial
ischemia at a high cardiac demand and good functional capacity.
Given high D-Dimer a f/u CTa of the chest showed evidence of a
pulmonary embolism in the right middle lobar artery, as well as
evidence of chronic emboli in the right lower lobe arteries. The
patient was given a full strength aspirin and started on a
heparin gtt. Vitals prior to transfer were T98 HR49 RR16
BP145/63 98% RA.
On the floor, patient is stable in NAD.
ROS: Attests to mild nausea that resolved. Had 2 HA's the last 2
AM's that resolved on their own. Has been having SOB, worse with
exertion in the last month, and feels very SOB after climbing
steps. Denies orthopnea. No weight changes. Denies fever,
chills, night sweats. Had brief "yellow flashers" at his
opthamologist several days ago, but resolved on their own.
Denies rhinorrhea, congestion, sore throat, cough, abdominal
pain, vomiting. Has chronic diarrhea s/p colectomy. No BRBPR,
melena, hematochezia, dysuria, hematuria. No rashes.
Past Medical History:
1. Hypertension.
2. Ulcerative colitis.
3. Status post colectomy for ulcerative colitis.
4. Deep venous thrombosis with pulmonary embolism in ___ (after
colon surgery).
5. Status post non-Q-wave myocardial infarction in ___.
6. Unstable angina.
7. Relative bradycardia.
8. CABG ___
Social History:
___
Family History:
Positive for coronary artery disease in 2 of his
brothers and both parents.
Physical Exam:
PHYSICAL EXAM:
VS: 97.7| 149/69| HR 47| RR 18 100% on RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: Bradycardic with soft heart sounds. No MRG.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Abdominal midline scar c/w prior surgery. Small nodular
lesion slightly lateral to midline scar c/w surgical change.
Mild distention with tympany to ercussion. Soft/NT, no HSM, no
rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout.
Pertinent Results:
PERTINENT LABS:
___ 06:35AM BLOOD WBC-5.8 RBC-4.11* Hgb-13.0* Hct-39.5*
MCV-96 MCH-31.6 MCHC-32.9 RDW-12.9 Plt ___
___ 06:33PM BLOOD ___ PTT-30.2 ___
___ 06:35AM BLOOD Glucose-132* UreaN-16 Creat-1.1 Na-141
K-4.0 Cl-105 HCO3-29 AnGap-11
___ 06:35AM BLOOD ALT-17 AST-21 AlkPhos-67 TotBili-0.6
___ 06:35AM BLOOD Calcium-9.8 Phos-2.5* Mg-2.1
___ 03:40PM BLOOD D-Dimer-535*
IMAGING:
Stress Study Date of ___
INTERPRETATION: This ___ yo man s/p CABG x4 ___ was referred to
the
lab for evaluation of chest pain. The patient exercised for 8
minutes on
___ protocol and stopped for fatigue. The estimated peak MET
capacity was 9.2 which represents a good exercise tolerance for
his age.
The patient denied any arm, back, neck, or chest discomfort
throughout
the procedure. At peak exercise there was 0.5-1 mm upsloping ST
segment
depression in leads I and V5-6. These changes resolved by 1
minute in
recovery. The rhythm was sinus with rare isolated APBs and VPBs.
Appropriate hemodynamic response to exercise.
IMPRESSION: No anginal symptoms or objective evidence of
myocardial
ischemia at a high cardiac demand. Good functional capacity.
CHEST (PA & LAT)
PA AND LATERAL VIEWS OF THE CHEST: The patient is status post
median
sternotomy and CABG. The heart size is normal. The aortic knob
is calcified.
The mediastinal and hilar contours are unremarkable. The
pulmonary
vascularity is not engorged. The lungs are hyperinflated with
flattening of
the diaphragms suggestive of underlying COPD. Lungs are
otherwise clear. No
pleural effusion or pneumothorax is present. There are no acute
osseous
abnormalities.
IMPRESSION: No acute cardiopulmonary process. COPD.
CTA CHEST W&W/O C&RECONS, NON-CORONARY
IMPRESSION:
1. Findings compatible with pulmonary embolism in the right
middle lobar
pulmonary artery. Other web-like filling defects in the right
lower lobe
pulmonary arteries as above suggestive of chronic pulmonary
emboli.
2. 4-mm left lower lobe pulmonary nodule. Given background
changes of
emphysema, dedicated followup suggested in one year to document
stability.
3. Bronchial wall thickening with mucous plugging seen
bilaterally.
Brief Hospital Course:
___ yo male with history of CABG, UC s/p colectomy, prior DVTs,
presenting with chest discomfort found to have PE's on CTA.
#Pulmonary Embolism: Evidence of new PE in the right pulmonary
artery seen on CTA of chest. Troponins were negative x2 and ETT
was not consistent with ACS. On arrival to the floor his chest
pain had resolved and he was sating well on RA. Pt was initially
started on heparin gtt then switched over to LMWH injections
with bridge to Warfarin. Plan was discussed with his primary
care physician who agreed. His primary care physician agreed to
follow up on INR levels in his office post discharge.
#CAD with history of NSTEMI and CABG: Pt's initial Chest pain
was most likely from pulmonary embolism. No EKG changes were
noted, and ETT was not suggestive of active CAD. Pt currently
takes Lisinopril daily which per pt has been increasing his
potassium levels. He has had to take Kayexalate daily to help
control his potassium. We discussed with his PCP about
decreasing the dose of lisinopril or discontinuing this
medication at this point considering he is so far away from MI.
We continued simvastatin, aspirin, metoprolol and lisinopril.
#HLD: continued simvastatin
#Hypertension: continued lisinopril and metoprolol for now
#Hx of glaucoma: continued latanoprost
#Transitional:
1. Plan for anticoagulation was discussed with his pcp
2. Pt was instructed to have his INR drawn at his pcp's office
on ___. He has follow up appointment with his pcp to determine when
LMWH injections can be discontinued once warfarin is therapeutic
4. Pt has 4 mm left lower lobe pulmonary nodule and should have
follow up chest CT in one year to document stability.
Medications on Admission:
1. Metoprolol 12.5 mg p.o. b.i.d. (dose cut in half).
2. Simvastatin 40 mg p.o. daily.
3. Lisinopril 10 mg p.o. daily.
4. Aspirin 81 mg p.o. daily.
5. Kayexalate 15 grams qday
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days.
Disp:*14 syringes* Refills:*0*
2. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig:
Fifteen (15) grams PO DAILY (Daily) as needed for Hyperkalemia.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
___.
Disp:*60 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
please draw INR on ___ and Fax results to Dr. ___ @
___
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital with chest
pain and found to have a blood clot in your lungs. We started
treatment with two blood thinning medications: Enoxaparin and
Warfarin. You should continue to take the Enoxaparin injections
twice per day along with Warfarin until your primary care
physician instructs you to stop. You will need to continue to
take Warfarin on a daily basis to make sure another blood clot
does not occur.
The following changes have been made to your medications:
START:
Enoxaparin injections until INR is therapeutic
Warfarin for blood thinning
Please see below for follow up appointments that have been made
on your behalf.
Followup Instructions:
___
|
10704894-DS-6
| 10,704,894 | 21,600,455 |
DS
| 6 |
2184-02-12 00:00:00
|
2184-02-24 13:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
Mr. ___ is a ___ yo M with a PMH pertinent for self-inflicted
abdominal ___ in ___ s/p ex-lap and probably sigmoid
colectomy with primary anastamosis at ___.
Since then he has undergone multiple subsequent surgeries.
Operative reports were unable to be immediately obtained, but
based on the records reviewed and history given, his course has
been complicated by enterocutaneous and colocutaneous fistulas
and wound dehiscence requiring SBR and takedown of ECF, ventral
hernia repair with mesh, and STSG to the abdominal midline
incision. His last procedure was on ___ and was the SBR,
ECF takedown and attempted primary wound closure. Since then he
has had ongoing feculent output from the inferior pole of the
wound as well as persistent abdominal pain and nausea. He
describes his pain as ___ stabbing pain, ___ and
involving his midline incision with radiation to the left side.
He endorses occasional association with sweats, chills and
fevers
to 102.4 ___s a recent cough and wheezing. His stools
have
been liquid and he endorses no urinary symptoms. On exam he has
a
midline surgical incision with three distinct areas of
dehiscence
likely connected underneath the skin. All three have
fibrinopurulent debris and pieces of a thin mesh exposed. The
most inferior of the three has a scant amount of feculent
drainage. There are many indurated prolene sutures partially
overgrown by skin. He is afebrile, and has no leukocytosis or
significant metabolic derangement. A CT abdomen/pelvis was taken
which demonstrated subcutaneous tunneling from the level of the
wound to the sigmoid anastomosis.
Past Medical History:
PAST MEDICAL HISTORY:
- Migraines
- GERD
- Anxiety
PAST SURGICAL HISTORY:
- Lap cholecystectomy ___ years ago
- Ex-lap for self-inflicted ___ with likely sigmoid
colectomy and primary anastamosis c/b enterocutaneous and
colocutaneous fistulas s/p multiple revisions, ventral hernia
repair with mesh, SBR, ECF takedown, split-thickness skin graft
and wound dehiscence
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 96.7 83 101/70 16 98%RA
GEN: NAD, well-nourished, appropriately groomed.
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Abdomen soft, non-tender and non-distended. No rebound
tenderness or guarding. Dull to percussion. Bowel sounds
normoactive. Rectal exam deferred
EXT: WWP no CCE
Discharge Physical Exam:
VS: 98.1, 69, 96/60, 18, 99%ra
GEN: AA&O x 3, NAD, calm, cooperative.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, non tender to palpation incisionally,
non-distended. Midline Incision with 3 openings, no evidence of
cellulitis and no odor. Drainage from top 2 wounds thick light
green, scant amounts, drainage from distal wound light brown,
small amount
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 05:39AM BLOOD WBC-6.5 RBC-4.76 Hgb-11.0* Hct-36.2*
MCV-76* MCH-23.1* MCHC-30.4* RDW-18.0* RDWSD-47.8* Plt ___
___ 05:04AM BLOOD WBC-5.6 RBC-4.63 Hgb-10.8* Hct-34.9*
MCV-75* MCH-23.3* MCHC-30.9* RDW-17.7* RDWSD-46.5* Plt ___
___ 04:20AM BLOOD WBC-5.3 RBC-4.18* Hgb-9.6* Hct-31.7*
MCV-76* MCH-23.0* MCHC-30.3* RDW-17.2* RDWSD-45.9 Plt ___
___ 05:35AM BLOOD WBC-4.7 RBC-4.27* Hgb-9.9* Hct-31.2*
MCV-73* MCH-23.2* MCHC-31.7* RDW-17.4* RDWSD-45.0 Plt ___
___ 05:00AM BLOOD WBC-4.5 RBC-4.01* Hgb-9.2* Hct-30.1*
MCV-75* MCH-22.9* MCHC-30.6* RDW-17.1* RDWSD-45.6 Plt ___
___ 11:45AM BLOOD WBC-6.1 RBC-4.43* Hgb-10.2* Hct-32.7*
MCV-74* MCH-23.0* MCHC-31.2* RDW-17.4* RDWSD-45.7 Plt ___
___ 05:04AM BLOOD Glucose-102* UreaN-16 Creat-0.8 Na-136
K-4.1 Cl-102 HCO3-24 AnGap-14
___ 04:20AM BLOOD Glucose-125* UreaN-17 Creat-0.7 Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
___ 05:35AM BLOOD Glucose-101* UreaN-14 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 05:00AM BLOOD Glucose-110* UreaN-7 Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-25 AnGap-15
___ 11:45AM BLOOD ALT-23 AST-25 AlkPhos-87 TotBili-0.2
___ 05:04AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
___ 04:20AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
___ 05:35AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8
IMAGING:
CT A/P:
1. Extraluminal air, trace free fluid, and fat stranding
adjacent to the
suture material at the descending colon tracking along the left
abdominal wall and anterior midline abdominal wall, suggestive
of leak. No drainable fluid collection is identified.
2. Diastases of rectus muscles.
Brief Hospital Course:
___ with PMH of abdominal ___ s/p multiple ex-laps, SBR, ECF
takedown, and ventral hernia repair with mesh transferred his
care to ___ for management of a non-healing midline wound and
colocutaneous fistula. The patient underwent bedside debridement
of exposed mesh and sutures, which he tolertated well. The
patient was admitted for bowel rest, IV antibiotics, TPN, and
wound care. The patient was hemodynamically stable.
A PICC line was placed and the patient started receiving TPN and
continued on bowel rest for ___ RN was consulted
and provided recommendations for the 3 openings of his incision.
The fistula output greatly decreased. On HD5 diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The fistula output remained scant and only
draining from the most inferior opening. TPN was stopped.
Antibiotics were stopped on HD5 and the patient remained
afebrile with a normal WBC. The wound cellulitis had resolved.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ for wound
care. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
..
Medications on Admission:
Zoloft
Protonix
Prazosin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 3 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
4. ClonazePAM 1 mg PO TID:PRN anxiety
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Enterocutaneous fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You transferred your care to ___ after undergoing multiple
abdominal surgeries at ___ that were
complicated by enterocutaneous fistulas and wound dehiscence.
You were placed on bowel rest and given nutrients through your
vein (TPN) and given IV antibiotics. Your fistula output has
slowed down and you are now tolerating regular food. You pain is
well controlled on oral medication, and your lab work and vital
signs are all normal. You are medically cleared for discharge
home with nursing services for wound care. 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.
Followup Instructions:
___
|
10705019-DS-5
| 10,705,019 | 24,633,595 |
DS
| 5 |
2177-03-13 00:00:00
|
2177-03-14 21:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
broad spectrum abx
Attending: ___
Chief Complaint:
Low abdominal/bladder pain x 1 week
Major Surgical or Invasive Procedure:
___ Foley Exchange
___ Left Midline Placement
___ Left Midline Removal
History of Present Illness:
Ms. ___ is a ___ year old female with history of MS ___
neurogenic bladder requiring chronic foley p/w lower abdomen
pain. Pt states that over the past week has had worsening lower
abdominal pain now ___ across the abdomen, with bilateral
lower back pain, subjective fevers and chills, no
nausea/vomting/cp. She has had a cough and increasing sputum
production and shortness of breath.
ED Plan: Likely UTI/Pyelo she states she is allergic to all abx
except IV medications. Her symptoms are consistent with
pyelonephritis and will treat.
In the ED, initial vitals were: 97.4 120/80 88 18 100%RA
- Exam notable for: soft ttp to the lower abdomen CVAT rrr
CTABL
- POCUS- 25ml in bladder clear yellow in foley bag
- Labs notable for: no leukocytosis (WBC 9.4 with 68%N),
thrombocytosis 577; Cr 0.5
- UA was hazy with large leuk and moderate bacteria with
negative nitrites and <1 epi
- Imaging was notable for: PA/LAT CXR - No acute cardiopulmonary
process.
- Patient was given: 400mg IV ciprofloxacin (@1820) and 1000mg
acetaminophen PO
- Vitals prior to transfer: 98.0 152/78 76 20 97%RA
Upon arrival to the floor, patient reports a week of fevers and
chills, up to 103, as well as a productive cough. She has
frequent loose stools, which is her baseline as she attributes
this to her MS.
___ OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Secondary progressive multiple sclerosis ___ neurogenic
bladder with chronic indwelling foley
- No history of resistant organisms in UCx
- Asthma
- Hypertension
- Anxiety
- Irritable Bowel Syndrome
- History of recurrent L5-S1 laminectomy, discectomy
- History of cholecystectomy
- History of resected ovarian cysts
- History of fibromyalgia
Social History:
___
Family History:
Sister with schizophrenia; Father with heart disease.
Physical Exam:
ADMISSION EXAM:
==============
Vital Signs: 97.9 160/92 73 16 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI,
anisocoria R pupil 1mm L pupil 2mm, reactive to light.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: patient declined neuro exam, stating it would cause her
to spasm.
DISCHARGE EXAM:
==============
VS: 97.9 98 / 68 78 16 98 RA
GENERAL: chronically ill appearing female, NAD, alert and
oriented
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tender RLQ around area of hep
injection sites, no rebound or guarding
EXTREMITIES: contracted upper extremities, warm and well
perfused. L arm midline site without erythema or purulence.
NEURO: CN II-XII grossly intact
SKIN: pressure ulcers covered with mepilex
Pertinent Results:
ADMISSION LABS:
=============
___ 05:30PM BLOOD WBC-9.4 RBC-4.42 Hgb-12.7 Hct-39.2 MCV-89
MCH-28.7 MCHC-32.4 RDW-13.7 RDWSD-44.8 Plt ___
___ 05:30PM BLOOD Neuts-68.3 ___ Monos-6.2 Eos-1.1
Baso-0.3 Im ___ AbsNeut-6.43* AbsLymp-2.15 AbsMono-0.58
AbsEos-0.10 AbsBaso-0.03
___ 05:30PM BLOOD Glucose-99 UreaN-8 Creat-0.5 Na-141 K-3.4
Cl-93* HCO3-36* AnGap-15
___ 05:15PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:15PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 05:15PM URINE RBC-86* WBC-68* Bacteri-MOD Yeast-NONE
Epi-<1 TransE-<1 RenalEp-<1
___ 05:15PM URINE CastHy-3*
___ 06:30AM URINE NonsqEp-<1
___ 05:15PM URINE Mucous-OCC
DISCHARGE LABS:
=============
___ 05:48PM BLOOD WBC-11.0* RBC-4.21 Hgb-12.4 Hct-37.4
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.9 RDWSD-44.7 Plt ___
___ 09:20AM BLOOD Glucose-115* UreaN-7 Creat-0.4 Na-140
K-3.5 Cl-96 HCO3-32 AnGap-16
___ 09:20AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
MICROBIOLOGY:
============
___ 5:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 6:30 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
< 10,000 CFU/mL.
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
WORK UP FOR GRAM NEGATIVE RODS AND STAPHYLOCOCCUS AUREUS.
NO STAPHYLOCOCCUS AUREUS ISOLATED.
ESCHERICHIA COLI. ~1000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STONE ANALYSIS:
=============
___ 04:34PM OTHER BODY FLUID STONE ANALYSIS
___ 16:34
STONE ANALYSIS
Test Result Reference
Range/Units
SPECIMEN SOURCE Bladder
NIDUS Not observed
COMPONENT 1 See Below
Calcium Oxalate Dihydrate (Weddellite) 20%
Carbonate Apatite (Dahllite) 80%
Test Result Reference
Range/Units
COMPONENT 2 DNR
STONE WEIGHT 0.1850 g
The image will follow, unless test is cancelled or no picture
is available to report.
This test was developed and its analytical performance
characteristics have been determined by ___
___. It has not been cleared or approved by the
___
Food and Drug Administration. This assay has been validated
pursuant to the ___ regulations and is used for clinical
purposes.
REPORT COMMENT:
BLADDER STONE ___
THIS TEST WAS PERFORMED AT:
___, ___
___
Comment: ___, BLADDER
Brief Hospital Course:
___ year old F with PMHx secondary progressive multiple sclerosis
___ neurogenic bladder with chronic foley who presented with
lower abdominal pain, right flank pain, fevers and chills
concerning for pyelonephritis.
# Right Pyelonephritis
Presents with a week of abdominal/back pain with pyuria,
bacteriuria and fevers. Past UCx ___ pan sensitive pseudomonas
treated with ciprofloxacin. Urine Culture obtained after foley
exchange on ___ grew pan sensitive E. Coli. Given inability to
tolerate oral antibiotics given nausea/vomiting, she was treated
for mild pyelonephritis with 7 days of IV antibiotics ___
after foley exchange). First initiated ciprofloxacin BID then
transitioned to levofloxacin in attempts to arrange discharge
home with IV infusion. Unable to discharge home safely with IV
antibiotic infusion thus finished her course on ___.
# Secondary Progressive MS
# Neurogenic Bladder
Continued home medications for spasms and pain: diazepam,
tramadol, naltrexone. Foley exchanged in house by Urology on
___.
TRANSITIONAL ISSUES:
===================
- Bladder stone expelled during foley exchange, sent to
pathology by Urology. Stone analysis pending at time of
discharge.
- Urology office will call patient to arrange outpatient follow
up appointment. Recommending continue 3way Foley catheter.
Recommend continuing home regimen of exchanging foley every ___
weeks with weekly irritations of 60 cc saline.
- Wound Assessment:
-- Right glut healed pressure injury 0.2cm partial thickness
-- Right ischium ~2cm dry peeling skin, not denuded
-- Right heel Stage 1 pressure injury
- Wound Care Recommendations:
-- Pressure relief per pressure ulcer guidelines; turn and
reposition as able every ___ hours off affected areas; heels off
bed surface at all times with waffle boots; when out of bed, sit
on pressure redistribution cushion.
-- Commercial wound cleanser or normal saline to cleanse wounds.
Pat tissue dry with gauze. Apply moisture barrier ointment to
the periwound tissue with each dressing change
-- Apply Mepilex Border dressing and change q3 days
-- Apply thin layer of Citric Acid Clear twice daily to ischium
# CODE: DNR/DNI confirmed (has MOLST)
# CONTACT: HCP ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 100 mg PO BID
2. Temazepam 15 mg PO QHS:PRN insomnia
3. Lisinopril 2.5 mg PO BID
4. Diazepam 5 mg PO Q6H:PRN spasm
5. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
6. IBgard (peppermint oil) 90 mg oral DAILY
7. Naltrexone 3.5 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Diazepam 5 mg PO Q6H:PRN spasm
2. IBgard (peppermint oil) 90 mg oral DAILY
3. Lisinopril 2.5 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Naltrexone 3.5 mg PO QHS
6. Temazepam 15 mg PO QHS:PRN insomnia
7. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
8. Verapamil SR 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Pyelonephritis
Urinary Retention With Indwelling Chronic Foley
Secondary Progressive Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain, back pain
and urinary symptoms for a week.
WHAT WAS DONE FOR YOU?
- You were treated for 7 days with IV antibiotics to treat a
kidney infection.
- Your catheter was exchanged on ___.
- A stone was expelled from your bladder when the catheter was
exchanged and this was sent to pathology for characterization.
- You were seen by Urology who did not recommend changing the
type of catheter you have.
- You were seen by Wound Care for your pressure sores that look
well healing.
WHAT TO DO NEXT?
- Please take your medicines as instructed.
- Please follow up with your doctors as ___.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10705568-DS-10
| 10,705,568 | 28,914,695 |
DS
| 10 |
2132-05-09 00:00:00
|
2132-05-10 05:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ Coronary angiography
History of Present Illness:
Ms ___ is a ___ woman with HTN and PAD, who presents with
2 weeks of chest pain and shortness of breath.
About 2 weeks ago, she developed substernal chest pain, and was
evaluated at ___. She was discharged home, then
readmitted 12 hours later with the same chest pain. She
describes
the pain as a soreness in her chest. It is associated with
dyspnea on exertion, no dyspnea at rest. At ___, TTE was
essentially normal. Nuclear stress test showed predominantly
fixed defects of the distal anterior and apical walls with
residual distal anterior ischemia suggested; LV EF: 66%.
Since discharge from ___, she has been having worsening
dyspnea on exertion, but no chest pain. No leg swelling or
orthopnea. She has gained ___ pounds (160 to 167 pounds). No
prior blood clots. No fevers, or chills. She has had a cough,
productive of yellow sputum.
She presented to her PCP ___ ___, and had dyspnea with O2 drop
to
90% on room air while walking 50 feet. CXR showed small
bilateral
pleural effusions and cardiomegaly, consistent with CHF. EKG was
concerning for inferior ischemia, so she was referred to the ED.
Past Medical History:
1. CARDIAC RISK FACTORS
- No Diabetes (pre diabetes)
- + Hypertension
- + No Dyslipidemia
2. CARDIAC HISTORY
- Coronaries: No known CAD
- Pump: EF normal at ___
- Rhythm: normal sinus
3. OTHER PAST MEDICAL HISTORY
- PAD
- GERD
- vitamin d deficiency
- vitamin b12 deficiency
- osteopenia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Exam:
======================
V:94 128/71 20 95% 2L NC
GENERAL: Well developed, well nourished woman in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
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.
PULSES: Distal pulses palpable and symmetric.
Discharge Exam:
===================
PHYSICAL EXAMINATION:
=======================
24 HR Data (last updated ___ @ 511)
Temp: 97.8 (Tm 98.3), BP: 105/54 (80-105/48-60), HR: 70
(68-72), RR: 18 (___), O2 sat: 93% (91-94), O2 delivery: RA,
Wt: 159.39 lb/72.3 kg
I/Os= 620/425--> 195
LOS- -5300
Weight today: 72.3<--72.6
weight on admission: 73.8 kg
Gen: Standing up at bedside, no acute distress
NECK: JVP not elevated
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Unlabored, no crackles
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: WWP, no ___ edema
Pertinent Results:
Admission labs:
==================
___ 05:40PM BLOOD WBC-6.5 RBC-3.93 Hgb-13.4 Hct-40.8
MCV-104* MCH-34.1* MCHC-32.8 RDW-14.4 RDWSD-54.7* Plt ___
___ 05:40PM BLOOD Neuts-59.3 ___ Monos-9.1 Eos-1.7
Baso-0.9 Im ___ AbsNeut-3.85 AbsLymp-1.86 AbsMono-0.59
AbsEos-0.11 AbsBaso-0.06
___ 05:40PM BLOOD ___ PTT-33.2 ___
___ 05:40PM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-142
K-4.8 Cl-105 HCO3-20* AnGap-17
___ 05:40PM BLOOD ALT-34 AST-41* LD(LDH)-329* AlkPhos-56
TotBili-0.5
___ 05:40PM BLOOD ___
___ 05:40PM BLOOD cTropnT-0.02*
___ 11:27PM BLOOD cTropnT-0.02*
___ 05:40PM BLOOD Mg-2.4
___ 07:02AM BLOOD %HbA1c-6.1* eAG-128*
___ 05:40PM BLOOD TSH-6.3*
___ 01:10PM BLOOD T4-6.8
___ 05:53PM BLOOD Lactate-2.3*
Reports:
===============
___ CXR
In comparison with the study of ___, the
cardiomediastinal silhouette
is stable. There has been improvement in pulmonary vascular
status, with only
mild vascular congestion at this time.
Prominent hyperexpansion of the lungs with flattening
hemidiaphragms is again
seen, consistent with chronic pulmonary disease. Specifically,
no evidence of
acute focal consolidation.
___ Viability study
IMPRESSION:
Severe reduction in photon counts involving the distal anterior
wall, apex,
distal lateral wall, distal inferior wall, and the mid
inferolateral wall,
consistent with a low probability of recovery of function of
these segments
after revascularization. The remaining myocardial segments show
normal uptake,
consistent with a high probability of recovery of function after
revascularization
___ Cath:
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD is 100% occluded proximally and fills weakly via
collaterals.
* Circumflex
The Circumflex has 40% ___ stenosis.
The ___ Marginal is a large vessel with tandem 60% stenoses.
* Right Coronary Artery
The RCA has 70% mid stenosis.
Intra-procedural Complications: None Impressions:
3 vessel CAD including 100% occlusion of LAD.
___ TTE:
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with severe hypookinesis of the anterior septum and
anterior wall. The distal ventricle is mildly aneurysmal and
akinetic. The remaining segments contract normally (LVEF = ___
%). No masses or thrombi are seen in the left ventricle. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. A left
pleural effusion is present.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w CAD (mid-LAD distribution) or
Takotsubo cardiomyopathy. Mild mitral regurgitation. Mildly
dilated aortic arch.
___ CXR:
Mild interstitial pulmonary edema and small bilateral pleural
effusions.
Bibasilar atelectasis.
Discharge labs:
====================
___ 06:05AM BLOOD WBC-5.1 RBC-3.58* Hgb-12.2 Hct-36.8
MCV-103* MCH-34.1* MCHC-33.2 RDW-14.1 RDWSD-53.7* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-138* UreaN-38* Creat-1.0 Na-143
K-4.6 Cl-105 HCO3-23 AnGap-15
___ 06:18AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:25AM BLOOD Calcium-9.9 Phos-4.7* Mg-2.2
___ 07:02AM BLOOD %HbA1c-6.1* eAG-128*
___ 05:40PM BLOOD TSH-6.3*
___ 01:10PM BLOOD T4-6.8
___ 06:00AM BLOOD 25VitD-23*
Brief Hospital Course:
Patient Summary:
=====================
___ woman with HTN and PAD, who presented with 2 weeks of chest
pain and shortness of breath, found to have evidence of new
heart failure, with stress test at OSH 2 weeks prior to
admission showing fixed defects in anterior & apical walls, with
distal ischemia and EF 66% and found to have EF ___ on repeat
TTE. Underwent RHC and coronary angiogram showing 3 vessel CAD
including 100% occlusion of LAD. Underwent a viability study
which showed low probability of recovery of function after
revascularization. She was discharged home with optimized
medical management
# CORONARIES: 3 vessel CAD including 100% occlusion of LAD
# PUMP: EF ___
# RHYTHM: NSR
ACTIVE ISSUES:
===============
# DYSPNEA:
# Acute HFrEF (___)
Patient presented with chest pain, followed by worsening
shortness of breath on exertion to OSH. New hypoxemia with O2
requirement, weight gain of 7lbs, elevated BNP, and CXR with
pulmonary edema, suggestive of new heart failure which has been
confirmed on TTE with EF ___. With complete occlusion of LAD
demonstrated on angio, suspected to be ___ to missed ischemic
event over the last weeks. Diuresed with IV Lasix 40mg and
transitioned to PO lasix 20mg every other day with dry weight of
160 pounds on discharge. Continued on home ASA, atorvastatin,
metop succinate 25mg, and losartan 20mg
Dry weight: 160 lb (72.6 kg)
Discharge Cr: 1.1
Discharge regimen: Lasix 20mg every other day
# CAD w/ 3 vessel disease, 100% occlusion of LAD
Patient did not have chest pain on arrival with a troponin
elevation to 0.02 with flat MB. S/p cath ___ with 3 vessel
disease including acute thrombosis of LAD. She completed a 2-
day viability study ___ which showed severe reduction in
photon counts involving the distal anterior wall, apex, distal
lateral wall, distal inferior wall, and the mid inferolateral
wall, consistent with a low probability of recovery of function
of these segments after revascularization, so medical management
was continued. She was continued on aspirin 81mg daily,
Atorvastatin 80mg daily, metoprolol succinate 25mg, and losartan
25mg. She did have some chest pain while in house, though it was
more consistent with musculoskeletal pain and resolved with
monitoring. Did not have new ischemic changes on EKG or elevated
troponin with this pain.
#Leukocytosis
Increase in WBC to 10.9 on ___ from 3.9. Did endorse new
rhinorrhea and cough on ___. Some decreased air movement in
bases, but on RA. Infectious work-up, including CXR remained
negative for signs of infection.
# HTN- Continued Metoprolol 25 daily and changed to losartan
25mg daily.
================
CHRONIC ISSUES:
================
# NEUROPATHIC PAIN: ___ shingles, mostly on R ear. Has been
treated and without current manifestations. Continued Gabapentin
300 mg PO BID and Acetaminophen 650 mg PO/NG TID
Transitional Issues:
====================
NEW MEDICATIONS
----------------
LOSARTAN 25MG DAILY
LASIX 20MG EVERY OTHER DAY
STOPPED MEDICATIONS
--------------------
CANDESARTAN
CHANGED MEDICATIONS
--------------------
ATORVASTATIN INCREASED FROM 40MG TO 80MG
[]Would uptitrate metoprolol and losartan as tolerated
[]Pt stated a CT scan at previous hospital demonstrated
something in her neck. Would review OSH records for this
[]Check BMP in 1 week (___) for electrolytes and creatinine
with new medications
# CODE STATUS: presumed full
# CONTACT : Daughter ___, a cardiac nurse) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Gabapentin 300 mg PO BID
3. candesartan 16 mg oral DAILY
4. Atorvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO EVERY OTHER DAY
RX *furosemide 20 mg 1 tablet(s) by mouth every other day Disp
#*30 Tablet Refills:*1
2. Losartan Potassium 25 mg PO DAILY
RX *losartan [Cozaar] 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Gabapentin 300 mg PO BID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute exacerbation of Heart failure with reduced ejection
fraction
Cornary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital because you were experiencing
more shortness of breath and requiring oxygen.
What happened in the hospital:
- You received intravenous medications to remove extra fluid
from your body to help you breath more comfortably
- You had an ultrasound of your heart that showed the pump
function of the heart was not working as well as it had been
previously
- The cath procedure showed a major vessel in your heart was not
getting blood flow
- You had another test that showed major surgery wouldn't help
your heart function much.
- We started you on medications that will help your heart
health.
What you should do when you leave the hospital:
-Your weight at discharge is 160 pounds. Please weigh yourself
today at home and use this as your new baseline
-Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
-If you have chest pain, pressor, or dizziness, please come to
the ER immediately.
Followup Instructions:
___
|
10705688-DS-23
| 10,705,688 | 22,414,338 |
DS
| 23 |
2186-09-28 00:00:00
|
2186-09-30 14:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine / Aspirin / Lidocaine
Attending: ___.
Chief Complaint:
Chest pain
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of insulin-dependent diabetes
mellitus, hypertension, and chronic HCV, who presented to ___
from her PCP's office with ___ days of pain in her left chest,
side, and back.
She states that the pain had started in her L abdomen and
migrated up to her chest, then spread to the side toward the
shoulder and wrapped around the back. She describes the pain as
constant, increasing over the first three days, but decreasing
over the past six hours. The pain was exacerbated by movement or
exertion. During periods of exertion, the increased pain is
associated with shortness of breath, nausea, and sweating. She
has also had night sweats and nonproductive cough during this
time. She denies vomiting, diarrhea, or any changes in bowel
habits. She also denies focal weakness or numbness, except for
long-standing numbness in her feet.
She presented to the ___ ___ with these symptoms on ___. CT
Abd/Pel was performed due to her complaint of abdominal pain at
the onset of symptoms, and was notable for consolidation in the
lingula suggestive of pneumonia. Her labs were notable for
amylase 142. Imaging and labs were otherwise within normal
limits. She was advised to be admitted for stress test, but had
to leave to take care of her disabled son. On ___ advice, she
presented at her PCP's office on ___. She had an EKG done
(without stress testing) and was sent to the ___ ___.
In the ___, initial vitals: 97.4 93 134/76 18 99% RA
Troponin negative x2. Other routine labs unremarkable. Per
report, OSH imaging suggestive of lingular pneumonia. Patient
given IV levofloxacin for CAP.
She was admitted for cards consultation given inability to
stress w/ ___ medical condition.
EKG showed sinus tachycardia w/ HR 119. Otherwise unremarkable.
Records note another EKG with NSR 84, NL axis, TWF AVL, V2, NL
intervals.
Vitals prior to transfer: 98.4 75 122/68 18 99% RA
At admission, she reports pain as above, decreased in intensity
since receiving levofloxacin in the ___.
Past Medical History:
DM2 on insulin
Chronic HCV, genotype 1B - seen in GI clinic
Reactive airway disease
GERD
Allergic rhinitis
CAT scan from ___ that shows a bulbous pancreas that has never
had any followup.
Substance use disorder (cocaine, MJ)
History of domestic violence (stab wound to abdomen)
Social History:
___
Family History:
Mother w/ CAD and CHF. First MI at age ___. No known pancreatic
disease or neoplasms.
Physical Exam:
EXAM ON ADMISSION:
VS: T 97.5, HR 92, BP 111/81, RR 20, O2S 99 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
EXAM AT DISCHARGE:
VS: T 97.5, Tm 98.0, HR 82 (80s-91), BP 112/76
(110s-130s/69-91), RR 18 (___), O2S 98+ RA
I/O: 700/NR
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CHEST: diffusely TTP over L chest/side wall including sternum,
decreased from yesterday
CV: RRR, Nl S1, S2, No MRG
ABD: Mild TTP diffusely, soft, ND bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
Pertinent Results:
___ 12:05AM GLUCOSE-100 UREA N-15 CREAT-1.1 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-31 ANION GAP-10
___ 12:05AM ALBUMIN-4.0 CALCIUM-9.5 PHOSPHATE-3.4
MAGNESIUM-1.9
___ 12:42PM CK-MB-2 cTropnT-<0.01
___ 12:05AM ALT(SGPT)-47* AST(SGOT)-40 ALK PHOS-90 TOT
BILI-0.2
___ 12:05AM LIPASE-51
___ 12:42PM AMYLASE-142*
___ 12:05AM WBC-5.7 RBC-4.11 HGB-12.2 HCT-36.8 MCV-90
MCH-29.7 MCHC-33.2 RDW-13.8 RDWSD-45.0
___ 12:05AM NEUTS-32.1* ___ MONOS-12.8 EOS-2.3
BASOS-0.9 IM ___ AbsNeut-1.84# AbsLymp-2.95 AbsMono-0.73
AbsEos-0.13 AbsBaso-0.05
___ 12:05AM PLT COUNT-202
___:45AM ___ PTT-27.7 ___
DISCHARGE LABS:
no new labs
IMAGING:
___ Chest X-ray
COMPARISON: ___ and ___.
+FINDINGS: Mild biapical pleural parenchymal scarring is
unchanged.
IMPRESSION: No acute intrathoracic process.
___ CT Abdomen/Pelvis
COMPARISON: CT abdomen pelvis from ___.
+FINDINGS: LOWER CHEST: A small focus of ground-glass
consolidation is seen in the inferior lingula which may
represent an early pneumonia.
VASCULAR: The abdominal aorta contains mild atherosclerotic
calcifications but is of normal caliber without aneurysmal
dilatation.
BONES AND SOFT TISSUES: Mild degenerative changes are seen in
the lower lumbar spine.
IMPRESSION:
1. No acute process within the abdomen or pelvis to explain the
patient's pain.
2. Small focus of consolidation in the lingula, which may
represent early pneumonia.
___ Chest X-ray
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a ___ yoF w/ h/o DM2 and HTN who presented
to ___ w/ 3 days of chest pain, dyspnea, cough, and CT
suggestive of pneumonia.
# Chest pain, dyspnea: The patient's initial presentation was
consistent with a differential diagnosis including CAP w/
pleurisy, pericarditis, costochondritis, or angina. Troponin
negative x2 and normal EKG strongly suggested that unstable
angina is not the cause of her current symptoms. She was treated
with levofloxacin for CAP. Her pain is most likely ___ CAP,
since she has radiographic evidence of pneumonia, and her
atypical symptoms (tender to palpation over entire left chest
wall) could be due to spread of inflammation from lingula
pneumonia or from costochondritis (though also atypical since
entire side as well as LUQ is tender to palpation). Her pain was
resolving at time of discharge and was not worked up further.
Her progressive dyspnea is more likely to be related to COPD.
She carries a diagnosis of reactive airways disease; however,
heavy smoking history and COPD w/ emphysematous changes seen on
imaging is more suggestive of COPD.
CHRONIC ISSUES:
# DM2: Continued home insulin. Using glargine instead of detemir
while in house. COntinued lisinopril 2.5mg for microalbuminuria
# GERD: Continued home omeprazole
TRANSITIONAL ISSUES:
# Antibiotics: On levofloxacin 750mg q48h for 5d course
(___)
# Cardiac risk: Patient may very well have coronary disease;
however, her current symptoms are very unlikely to represent
unstable angina. If she does have underlying coronary disease,
there is no evidence of active/unstable ischemia, so further
evaluation was deferred to the outpatient setting after treating
for CAP.
-recommend outpatient stress test
-recommend outpatient PFTs
-started ASA 81mg daily and atorvastatin 80mg daily for primary
prevention in patient with multiple risk factors for coronary
disease
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. HydrOXYzine 10 mg PO QAM
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Humalog 7 Units Breakfast
Levemir 20 Units Breakfast
5. Omeprazole 20 mg PO QAM
6. Loratadine 10 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. ProAir HFA (albuterol sulfate) 2 puffs inhalation DAILY
9. Ipratropium Bromide MDI 2 PUFF IH DAILY
Discharge Medications:
1. Humalog 7 Units Breakfast
Levemir 20 Units Breakfast
2. Lisinopril 2.5 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. HydrOXYzine 10 mg PO QAM
7. Ipratropium Bromide MDI 2 PUFF IH DAILY
8. Loratadine 10 mg PO DAILY
9. Omeprazole 20 mg PO QAM
10. ProAir HFA (albuterol sulfate) 2 puffs inhalation DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Levofloxacin 500 mg PO Q48H
Please take one dose only on ___.
RX *levofloxacin 500 mg 1 tablet(s) by mouth q48h Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Community-Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ with chest pain and shortness of breath with activity.
You had an EKG and blood tests done to make sure you were not
having a heart attack. An X-ray of your chest showed a small
area of pneumonia in your lungs, which was also shown in your CT
scan from your ___ visit on ___. You continued to take
antibiotics for the pneumonia, and your pain decreased.
Your pain was likely related to inflammation and coughing from
the pneumonia. It is very unlikely that your pain was related to
heart disease. However, you have several risk factors for heart
disease. You were started on aspirin and a statin to decrease
these risks. Please continue taking these medications. You had
thrown up aspirin in the past, but you did not have problems
with this aspirin. You should also see your primary care doctor
and ___ lung doctor to make sure you won't have heart or breathing
problems in the future.
Please continue taking the antibiotics for five days total, from
___.
Please call a doctor if you develop chest pain or shortness of
breath again, especially deep pain that does not get worse when
you press on your chest. Please call a doctor if you have
trouble breathing or get a cough with a fever, or if you cough
up blood.
Two of the best things that you can do for your health are to
reduce smoking as much as possible (every puff counts!), and to
get your muscles and heart back in shape with exercise. Start
exercising gently, and do a little more each week.
It has been a pleasure taking care of you!
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10705890-DS-10
| 10,705,890 | 21,780,971 |
DS
| 10 |
2166-02-20 00:00:00
|
2166-02-21 16:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
CC: Back pain
Major Surgical or Invasive Procedure:
Spinal surgery for severe L3-S1
History of Present Illness:
___ w/ CAD s/p CABG ___, ESRD on HD 5x/week (except ___,
HTN, severe L3-S1 spinal stenosis w/radiculopathy, recently
admitted for back pain, re-presenting with subacute back pain.
The patient is unable to stand/walk, has been lying on the floor
at home all week. He spoke with his PCP, who is concerned that
he was discharged too early. Recent MR showed significant lumbar
spinal stenosis and multilevel disc disease. Has oxycodone for
this for 2 weeks, but feels this is not adequately controlling
his pain. Plan was made for appt for operative planning ___,
however patient has been in too much pain. Given severe ongoing
pain/inability to function, he was admitted for pain control.
Has not had a bowel movement in 5 days, only urinating once
daily (although is on HD so this is only slightly less than
normal), urinated this morning but didn't for 24 hours before
that. He reports that the bowel and urinary symptoms are chronic
since the onset of this pain, without significant change since
his MRI.
ROS neg for new bowel or bladder changes, other neurological
changes.
Past Medical History:
-ESRD (due to HTN) on home HD 5x/week via L forearm button-hole
AVF
-CAD s/p CABG ___
-Hypertension
-Hyperlipidemia
-Peripheral vascular disease s/p RLE stent
-Stage III multifocal papillary carcinoma with local nodal
disease s/p thyroidectomy in ___ followed by RAI treatment in
___.
-Hypogonadism
-GERD
-Gout
-Anemia
-Remote alcohol and tobacco abuse
Social History:
___
Family History:
Father died of CHF at ___ and brother died in his ___ with an
MI. Mother died of bone cancer in her ___. Brother and sister
were on dialysis, sister died of blood clot.
Physical Exam:
Exam on Admission:
Vitals: T98.1 156/___-195/83 84-100 18 100RA 88kg
General: Alert, oriented, no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear, no wheezes or rales
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mild distention, bowel sounds present
GU: no Foley
Ext: warm, well perfused, no edema. Lumbar tenderness to
palpation. Exam limited due to severe pain.
Pain limited bilat hip flexion/other ___ groups are ___. C/w
recent baseline. ___ R hip flexion, ___ L hip flexion, ___ knee
extension, foot dorsi and plantar flexion
Exam on Discharge:
Pertinent Results:
ADMISISON
___ 06:55AM BLOOD WBC-11.2* RBC-2.79* Hgb-7.6* Hct-25.1*
MCV-90 MCH-27.2 MCHC-30.3* RDW-14.8 RDWSD-49.1* Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-83 UreaN-84* Creat-9.3* Na-134
K-5.0 Cl-90* HCO3-24 AnGap-25*
___ 06:55AM BLOOD Calcium-11.7* Phos-9.9* Mg-2.7* Iron-42*
___ 06:55AM BLOOD calTIBC-238* Ferritn-1836* TRF-183*
PERTINENT
___ 06:55AM BLOOD calTIBC-238* Ferritn-1836* TRF-183*
___ 06:05AM BLOOD Calcium-10.8* Phos-6.8*# Mg-2.7*
___ 06:05AM BLOOD WBC-15.1* RBC-2.50* Hgb-6.9* Hct-22.8*
MCV-91 MCH-27.6 MCHC-30.3* RDW-15.7* RDWSD-52.0* Plt ___
DISCHARGE
STUDIES
___ ABD XR
IMPRESSION:
Moderate stool burden within the colon.
___ LUMBAR XR
IMPRESSION:
There are metallic probes at what appear to be the L4 and L5
levels. Further information can be gathered from the operative
report
Brief Hospital Course:
___ w/ CAD s/p CABG ___, ESRD on HD 5x/week (except ___,
HTN, gout, severe L3-S1 spinal stenosis w/radiculopathy,
recently admitted for back pain, re-presenting with subacute
back pain admitted with severe low back pain and inability to
ambulate, MRI negative except for severe spinal stenosis.
#Chronic low back pain, Spinal stenosis, radiculopathy: Plain
film and MR ___ negative for cord compression or acute
changes. MRI demonstrates significant spinal canal stenosis and
degenerative changes. He does have some red flag symptoms but
imaging is negative; therefore this is likely multifactorial
with radiculopathy, acute muscle strain on chronic spinal
stenosis. His pain was managed on oxycodone 7.5mg-15mg PO Q6H
with Dilaudid 0.25mg IV for breakthrough. He was given 1 week
prescriptions of both. ___ evaluated him and recommended
outpatient ___ and rolling walker, which was provided to him on
discharge. We consulted the orthopedic spine team, who
recommended surgical intervention to relieve his back pain. This
was performed on ___ and he tolerated it well. He had one
episode of urinary retention after his surgery which required
him to be straight cath'd. The next day and on day of discharge
he was passing urine on his own.
#Constipation: patient reported being constipated x 5 days,
likely in the setting of narcotic use for pain medications. We
gave him one dose of methylnaltrexone, suppositories, and enema,
he had a BM.
#ESRD on HD: 5x/week at home, converted 3x/week inpatient. We
continued to dialyze him per renal recs during this admission.
# HTN: we continued his home antihypetensives during this
admission.
========================================================
Transitional Issues:
[] please follow-up with him post-operatively and assess
symptomatic control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cinacalcet 90 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Rosuvastatin Calcium 10 mg PO DAILY
12. sevelamer CARBONATE 2400 mg PO TID W/MEALS
13. OxycoDONE (Immediate Release) 7.5 mg PO Q6H
14. Acetaminophen 650 mg PO Q6H
15. Bisacodyl 10 mg PO/PR DAILY
16. Docusate Sodium 100 mg PO BID
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Acetaminophen 650 mg PO Q6H
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO/PR DAILY
6. Cinacalcet 90 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Levothyroxine Sodium 200 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
14. Senna 8.6 mg PO BID
15. Rosuvastatin Calcium 10 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. OxycoDONE (Immediate Release) 7.5 mg PO Q6H
18. Nephrocaps 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Severe L3-S1 spinal stenosis, constipation,
ESRD on HD.
Secondary Diagnoses:
-AVF
-CAD s/p CABG ___
-Hypertension
-Hyperlipidemia
-Peripheral vascular disease s/p RLE stent
-Stage III multifocal papillary carcinoma with local nodal
disease s/p thyroidectomy in ___ followed by RAI treatment in
___.
-Hypogonadism
-GERD
-Gout
-Anemia
-Remote alcohol and tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after presenting with
worsening back pain from your severe spinal stenosis. While you
were here, we treated you with pain medications for your back
pain, and consulted the spine surgeons, who recommended that we
perform surgery to relieve your pain. This occurred on ___ and
you tolerated it well. Additionally, we gave you medications to
treat your constipation, which subsequently resolved.
It was a pleasure to care for you during this admission.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10705890-DS-11
| 10,705,890 | 26,252,425 |
DS
| 11 |
2167-12-15 00:00:00
|
2167-12-15 20:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with PMH significant for CAD s/p
CABG ___, ESRD on HD 5x/week (except ___, HTN, gout, severe
L3-S1 spinal stenosis w/radiculopathy s/p laminectomy who
presented to the ED for evaluation of right hip pain. Patient
had
traveled to ___ for a ___ tournament over the weekend
and notes walking around without any issues on ___. Patient
states that he awoke ___ morning with severe left lower back
and hip pain radiating down his left leg. Pain is aggravated by
movement and walking. Patient states he has had similar pain in
the past, specifically following his laminectomy in ___. Pain
has been so severe that it has prevented him from walking over
the past 2 days. States pain is 10 out of 10 and describes it
as
a lightening type pain. Patient took left over Dilaudid from
prior back surgery at home with some improvement in pain.
Patient
denies any fevers or chills but does note having some night
sweats particularly in his left leg. Patient denies any urinary
or fecal incontinence or numbness or tingling in his lower
extremities. Denies any perianal anesthesia.
In the ED, patient continued to endorse lower back pain with
radiation into the right hip and leg. Initial vitals
hypertensive
160/70 HR, 90 bpm, and RA 100% sat. Initial labs showed
hyperkalemia (K 8.0) with hemolyzed sample; repeat K was 6.6.
Last HD session was ___ (3 days ago). EKG showed peaked T
waves. Nephrology was consulted for emergent HD. Patient
received
IV calcium gluconate 2g x1, 10U insulin x1, IV furosemide 80mg
x1, and HD, w/ improvement in K to 4.3.
Additionally, patient was also found to have a leukocytosis
(20K). Pain control w/ acetaminophen 1000mg po x1 and IV
hydromorphone 1mg x2. Patient was also started on Vancomycin
1000mg x1.
Upon arrival to the floor, the patient states his left hip pain
is improved as he had just received a dose of Dilaudid prior to
transfer to the floor. Continues to deny any urinary/ fecal
incontinence, saddle anesthesia, or numbness/tingling of the
lower extremities. Patient does note having a nonproductive
cough
that began today. Cough appears to be aggravated based on the
position of the patient. Patient notes some SOB associated with
the cough. Additionally, patient's wife is concerned about the
presence of a new tremor. Patient has a tremor that occurs with
rest; occurs in both hands. Tremor resolves with movement or
when
the patient's attention is brought to the tremor. Believe this
to
be secondary to recent Dilaudid administration.
Past Medical History:
1. Coronary artery disease -- status post cardiac bypass.
2. End-stage renal disease, on transplant list; home dialysis
five days a week.
3. Hyperlipidemia.
4. Hypertension.
5. Diabetes type 2.
6. Hypogonadism.
7. Hypothyroidism.
8. Intermittent claudication.
9. Lumbar spondylosis with radiculopathy/spinal stenosis.
10. Papillary carcinoma of thyroid gland.
11. Hyperparathyroidism.
12. Cerebrovascular disease.
13. History of AV block, first-degree.
14. Carpal tunnel syndrome.
Social History:
___
Family History:
Father died of CHF at ___ and brother died in his ___ with an
MI. Mother died of bone cancer in her ___. Brother and sister
were on dialysis, sister died of blood clot.
Physical Exam:
ON ADMISSION:
==================
VITALS: 99.5 122 / 69 101 18 96 Ra
GENERAL: Well-developed male resting in bed. Describes feeling
loopy secondary to recent Dilaudid dose.
HEENT: Normocephalic atraumatic. Pupils constricted. EOMI.
NECK: Supple. No cervical lymphadenopathy.
CV: Tachycardic. Normal S1-S2. No murmurs gallops or rubs. No
lower extremity edema.
RESP: Nonlabored respirations. No adventitious sounds noted.
GI: Soft, nondistended. Nontender to palpation. Normoactive
bowel sounds.
GU: Normal rectal tone.
MSK: No spinal or paraspinal tenderness to palpation. No CVA.
Exam somewhat limited by right hip pain. ___ right hip flexion
with weakness possibly . ___ left hip flexion. Positive right
straight leg raise and crossed leg raise.
ON DISCHARGE:
==================
VITALS: 98.1 100s-140s / 40s-60s ___ 18 95-98% Ra
GENERAL: Well-developed male resting in bed.
HEENT: Normocephalic atraumatic. EOMI.
CV: Regular rate and rhythm. No murmurs gallops or rubs.
RESP: Clear to auscultation bilaterally. No rhonchi, rubs, or
wheezes.
GI: Soft, nondistended, nontender to palpation. Normoactive
bowel sounds.
MSK: Some tenderness to palpation over R buttocks. Exam somewhat
limited by right hip pain. ___ right hip flexion. ___ left hip
flexion.
Neuro: Sensation intact and equal in bilateral lower
extremities.
Pertinent Results:
ADMISSION LABS:
================
___ 09:22PM GLUCOSE-182* UREA N-46* CREAT-9.3*#
SODIUM-137 POTASSIUM-4.9 CHLORIDE-90* TOTAL CO2-27 ANION GAP-20*
___ 09:22PM CALCIUM-8.9 MAGNESIUM-2.2
___ 09:22PM CRP-567.4*
___ 05:58PM K+-4.3
___ 02:50PM GLUCOSE-154* UREA N-52* CREAT-7.9*#
SODIUM-137 CHLORIDE-90* TOTAL CO2-23 ANION GAP-24*
___ 02:50PM CALCIUM-8.9 PHOSPHATE-3.2# MAGNESIUM-2.2
___ 02:50PM HBsAg-NEG HBs Ab-POS HBc Ab-POS*
___ 02:50PM HCV Ab-NEG
___ 11:34AM COMMENTS-GREEN TOP
___ 11:34AM K+-6.4*
___ 11:09AM COMMENTS-GREEN TOP
___ 11:09AM K+-6.6*
___ 10:26AM GLUCOSE-259* UREA N-103* CREAT-15.6*#
SODIUM-127* POTASSIUM-8.0* CHLORIDE-84* TOTAL CO2-17* ANION
GAP-26*
___ 10:26AM estGFR-Using this
___ 10:26AM WBC-20.3*# RBC-3.32*# HGB-9.6* HCT-30.5*#
MCV-92 MCH-28.9# MCHC-31.5* RDW-17.4* RDWSD-57.7*
___ 10:26AM NEUTS-92.2* LYMPHS-1.2* MONOS-4.7* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-18.66*# AbsLymp-0.25*
AbsMono-0.96* AbsEos-0.00* AbsBaso-0.03
___ 10:26AM PLT COUNT-184
NOTABLE LABS:
====================
___ 05:57AM BLOOD %HbA1c-5.6 eAG-114
___ 02:50PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*
MICROBIOLOGY:
====================
___ 12:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 12:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
(___).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 12:26 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 7:44 pm BLOOD CULTURE Source: Venipuncture X1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:29 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 5:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
NOTABLE IMAGING:
====================
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. Findings highly suspicious for discitis-osteomyelitis at
L5-S1 with
involvement of right iliopsoas muscle.
2. Probable posterior epidural abscess measures 1.7 x 1.6 x 4.2
cm resulting in severe spinal canal narrowing. Suspect at least
crowding of the cauda equina nerve roots at this level. Lumbar
spine MRI with contrast is required for further evaluation.
2. 4 mm right middle lobe ground-glass nodule.
RECOMMENDATION(S):
1. Lumbar spine MRI with contrast.
2. For an incidentally detected single ground-glass nodule
smaller than 6mm, no CT follow-up is recommended.
___ MR ___ & W/O CONTRAST; MR ___ &W/O
CONTRAST; MR ___ W/O CONTRAST
1. Irregularity and remodeling of the L5-S1 disc and endplates
are compatible with sequela of discitis/osteomyelitis. Compared
to ___, signal abnormality in the endplates has
decreased, and fatty replacement of the L5 vertebral body is
seen, without increased loss of height at L5 or S1, suggesting
healing response to the infection. Given the contrast
enhancement within the L5-S1 disc, active indolent infection
cannot be excluded definitively.
2. Anterior epidural tissue from L4-L5 through S1-S2, stable in
extent
compared to ___, is largely T1 hyperintense with small
T1
hypointense, enhancing foci. There is enhancing epidural tissue
in the
lateral spinal canal on both sides, contiguous with enhancing
tissue in the
laminectomy beds and medial posterior paravertebral tissues.
This may
represent postsurgical granulation tissue, but superimposed
phlegmon cannot be excluded. No drainable abscess.
3. Multilevel thoracic degenerative disease without spinal cord
compression.
4. Phlegmon and abscess in the right iliacus muscles are
partially visualized, better assessed on this abdominal/pelvic
CT.
5. Severe compression of the thecal sac by the epidural
collection, and severe bilateral neural foraminal narrowing at
L5-S1 by disc disease, endplate osteophytes, and facet
osteophytes, are unchanged since ___.
6. Moderate spinal canal stenosis at L3-L4 and L2-L3, and mild
spinal canal
stenosis at L1-L2, due to congenital factors, posterior epidural
lipomatosis, and degenerative disease, similar to ___.
7. Nonspecific trace prevertebral edema or fluid in the cervical
spine. No
evidence for diskitis, osteomyelitis, epidural collection in the
cervical or thoracic spine.
8. Multilevel cervical degenerative disease with severe spinal
stenosis at
C5-C6 and moderate to severe spinal stenosis at C6-C7, and
associated
effacement and near effacement of CSF around the spinal cord,
respectively.
No definite cord signal abnormalities allowing for motion
artifact.
9. Multilevel thoracic degenerative disease without spinal cord
compression.
DISCHARGE LABS:
====================
___ 07:30AM BLOOD WBC-10.8* RBC-2.63* Hgb-7.3* Hct-23.2*
MCV-88 MCH-27.8 MCHC-31.5* RDW-17.2* RDWSD-55.8* Plt ___
___ 07:30AM BLOOD Glucose-93 UreaN-88* Creat-11.0*# Na-133
K-4.6 Cl-87* HCO3-22 AnGap-24*
___ 07:30AM BLOOD Calcium-7.4* Phos-7.7* Mg-2.6
Brief Hospital Course:
Mr. ___ is a ___ man with PMH significant for CAD s/p
CABG ___, ESRD on HD 5x/week (except ___, HTN, gout, severe
L3-S1 spinal stenosis w/radiculopathy s/p laminectomy who
presented to the ED for evaluation of R hip pain. Blood cultures
grew E coli. The patient was started on vancomycin (___),
cefepime (___), and flagyl (___). CT showed abscess of
iliopsoas with potential extension to the epidural space. MRI
showed potential acute on chronic osteomyelitis and potential
epidural collection (postsurgical changes vs. phlegmon) with no
evidence of cord compression, which appeared stable from prior
MRI. Orthopedic surgery recommended no surgical intervention at
this time due to the small size of the epidural collection and
no cord compression. The patient was narrowed based on blood
culture sensitivities to ceftazidime (___) to be
dosed with dialysis based on ID recommendations. This should be
continued for a total 6 week course, with last dose on ___.
ACTIVE ISSUES:
# Bacteremia
# R Iliopsoas Abscess
# Chronic Osteomyelitis:
The patient initially presented with R hip pain with radiation
down leg impairing ability to walk without saddle anesthesia/
bowel changes. Blood cultures grew pansensitive E coli. The
etiology of the patient's bacteremia was unclear with suspected
GI/urinary source given gram negative rods. The most likely
source at time of discharge was anal fissures from constipation.
Other possible sources included decreased peritoneal bacterial
clearance given HD and ESRD, or less likely patient's HD fistula
as the fistula clinically did not appear infected and would have
grown Gram + bacteria. CT Abd/ pelv showed possible abscess
collection in epidural L5/S1 region with potential cord
compression and iliopsoas phlegmon. MRI showed
"- Potential sequela of discitis/osteomyelitis at L5-S1 improved
from prior, but could not exclude active infection.
- Enhancing epidural tissue which may represent postsurgical
granulation tissue, but could not exclude superimposed phlegmon.
- No drainable abscess and no evidence of cord compression."
The patient was started on vancomycin (___), cefepime
(___), and flagyl (___). The patient received daily
blood cultures until 48 hours with negative cultures. Ortho
spine was consulted, and stated no surgical intervention needed
at this time, as MRI showed no drainable abscess. It was thought
that the findings on MRI were chronic. ID was consulted for
further antibiotic management, and recommended narrowing based
on susceptibilities with final recommendation of 6 wk course of
ceftazidime (___-) administered after HD, with last dose
___. The patient's pain was controlled with dilaudid and
trazodone.
# Hyperkalemia
# ESRD on HD:
Initial K 6.6 with last HD session 4 days prior (___).
Emergent HD, IV Ca gluconate, insulin, furosemide done. K was
5.0 on the floor. Patient denied symptoms of hyperkalemia such
as nausea, palpitations. Repeat EKG showed resolution of T
waves.
The patient received HD based on renal recommendations. The
patient was continued on home Sensipar, Renvela, nephrocaps.
# HTN
Elevated BPs on floor with SBPs in 150-160s but otherwise
stable.
Most likely ___ to pain and fever with tachycardia. THe patient
was continued on home amlodipine 10mg daily, losartan 100mg
daily, metoprolol 100mg daily with improvement in pressures.
CHRONIC ISSUES:
# L eye Redness: The patient presented with 3 months of L eye
redness without worsening. He was diagnosed with stye as an
outpatient. The patient was given saline drops while in the
hospital, with improvement in symptoms.
# Hyperlipidemia. Pt was continued on home rosuvastatin 10mg QPM
# Hypothyroidism. Pt was continued on home levothyroxine 200 mcg
daily.
# CAD s/p CABG ___. Pt was continued on home rosuvastatin 10mg
QPM and
aspirin 81mg daily.
# DM. HgbA1C 5.6%. Pt not currently on any therapy.
# Anemia. The patient received EPO during HD. Nephrology was
consulted for dosing of EPO during HD.
# Bone/Mineral. Pt was continued on home sensipar 90mg QAM and
30mg QPM and Renvela 2400mg TID w/ meals.
# Gout. Patient was continued on home allopurinol ___ daily.
======================
TRANSITIONAL ISSUES
======================
- The patient should receive ceftazidime 2mg ___ and
___ after HD and 3mg ___ after HD. This course should
continue for a 6 week course with last dose ___.
- The patient should follow-up with Infectious Diseases.
- All questions regarding outpatient parenteral antibiotics
after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
- WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK PHOS, CRP
ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC FAX:
___
- HBcAb positive
- Last positive blood cultures ___
- ___ admission 20.3, discharge 12.6
- CRP ___: 567.4
- 4 mm right middle lobe ground-glass nodule.For an incidentally
detected single ground-glass nodule smaller than 6mm, no CT
follow-up is recommended.
# Code status: Full (presumed)
# Contact: ___ (wife) ___
Patient seen and examined on day of discharge and stable for
discharge to rehab. >30 minutes on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 10 mg PO QPM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Cinacalcet 90 mg PO QAM
5. Cinacalcet 30 mg PO QPM
6. Losartan Potassium 100 mg PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. sevelamer CARBONATE 2400 mg PO TID W/MEALS
10. Nephrocaps 1 CAP PO DAILY
11. Levothyroxine Sodium 200 mcg PO DAILY
12. Testosterone Cypionate 2 tubes transdermally DAILY
13. PredniSONE 40 mg PO ONCE:PRN gout flare
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Artificial Tears Preserv. Free ___ DROP RIGHT EYE QID:PRN
dry eyes, irritation
3. Bisacodyl ___AILY:PRN constipation
4. CefTAZidime 2 g IV POST HD (MO,WE)
5. CefTAZidime 3 g IV POST HD (FR)
6. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q6H:PRN sore throat
7. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q6hrs
Disp #*40 Tablet Refills:*0
8. Lactulose 30 mL PO BID:PRN constipation
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Allopurinol ___ mg PO DAILY
14. amLODIPine 10 mg PO DAILY
15. Cinacalcet 90 mg PO QAM
16. Cinacalcet 30 mg PO QPM
17. Levothyroxine Sodium 200 mcg PO DAILY
18. Losartan Potassium 100 mg PO DAILY
19. Metoprolol Succinate XL 100 mg PO DAILY
20. Nephrocaps 1 CAP PO DAILY
21. Omeprazole 20 mg PO DAILY
22. PredniSONE 40 mg PO ONCE:PRN gout flare
23. Rosuvastatin Calcium 10 mg PO QPM
24. sevelamer CARBONATE 2400 mg PO TID W/MEALS
25. Testosterone Cypionate 2 tubes transdermally DAILY
26.Outpatient Lab Work
Dx: K68.12 iliapsoabscess
WEEKLY starting ___: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Iliopsoas abscess
?Epidural abscess
Secondary Diagnosis:
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having right hip pain and fevers.
- You had bacteria (E. coli) in your blood, and a collection of
bacteria in your R buttock.
WHAT DID WE DO IN THE HOSPITAL?
- You got imaging which showed a collection of bacteria in your
R buttock.
- Orthopedic surgery saw you and did not recommend surgery due
to the small size of the bacterial collection.
- You were treated with antibiotics.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Continue antibiotics for 6 weeks - ceftazidime (end date
___. This will be administered through your hemodialysis.
- You should follow-up with your primary care doctor.
Wishing you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10705890-DS-6
| 10,705,890 | 21,239,116 |
DS
| 6 |
2163-10-31 00:00:00
|
2163-10-31 13:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1) Cardiac catheterization
2) Coronary artery bypass grafting x3 with a left
internal mammary artery to left anterior descending artery,
reverse saphenous vein graft to the posterior descending
artery and the diagonal artery on ___
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of CAD, HTN, DM2 who
presented with chest pain for the past 3 weeks that continued to
worsen prompting his visit to ED.
This morning he had ___, non-exertional chest pain
characterized as "chest caving in" with radiation to his R arm.
He endorsed mild nausea, sensation of feeling hot. He also
endorses worsening pain when swallowing. He notes that the pain
is exertional at times and last approximately ___ minutes. He
denies improvement in pain when leaning forward, or pain on
inspiration. He notes that he has been somewhat anxious and
stressed with the recent tax season.
In the ED intial vitals were 98.2 95 189/92 100% RA. EKG was
read as unremarkable however was noted to have a trop of 0.14.
He was given a full dose aspirin and a cards consult was
initiated. He was subsequenlty started on a heparin drip and
admitted to the cardiology service for concern of ACS. Cardiac
cath was done. Cardiac surgery consulted for coronary
revasculariztion.
Past Medical History:
Type 2 diabetes on glyburide, followed at the ___
Hypertension
Dyslipidemia
Stage 3 CKD, followed in ___ clinic
PVD s/p stent in the RLE
Hypogonadism
Reflux disease
Remote history of alcohol and substance abuse
Social History:
___
Family History:
Patient notes that his father died of CHF at the age of ___ and
his brother died in his ___ with an MI. Mother died of bone
cancer in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= 98.0 BP= 164/83 HR= 77 O2 sat= 95 RA
General: patient appeared comfortable and in NAD
HEENT: MMM, no LAD or thyromegaly
Neck: supple
CV: RRR, -m/r/g, S1/S2 appreciated, no JVD appreciated
Lungs: CTA-B, no w/r/r good air movement
Abdomen: NABS, soft, nontender, nondistended, no rebound or
guarding
Ext: no edema, cyanosis or clubbing appreciated
Neuro: CN2-12 grossly intact, ___ strength both upper and lower
extremity
Skin: no rashes appreciated
Pertinent Results:
___ TEE
Overall left ventricular systolic function is severely depressed
(LVEF= 30 %). with mild global free wall hypokinesis. There are
simple atheroma in the ascending aorta. The aortic arch is
markedly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation.
Post Bypass
The patient is s/p CABGX3
The patient is on a neo drip at 0.5 mcg/kg/min
The LVEF is improved @ 50%
The infero septal wall that was akinetic now demonstrates normal
wall motion
The rest of the valvular exam is similar to prebypass
The aorta is intact post decannulation.
___ 05:48AM BLOOD WBC-8.6 RBC-2.88* Hgb-8.3* Hct-25.4*
MCV-88 MCH-28.8 MCHC-32.6 RDW-13.3 Plt ___
___ 07:50PM BLOOD WBC-6.6 RBC-3.76* Hgb-10.7* Hct-33.5*
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.5 Plt ___
___ 06:00PM BLOOD ___ PTT-27.6 ___
___ 05:48AM BLOOD Glucose-80 UreaN-70* Creat-3.8* Na-139
K-4.7 Cl-105 HCO3-23 AnGap-16
___ 07:50PM BLOOD Glucose-205* UreaN-52* Creat-3.1* Na-141
K-4.5 Cl-108 HCO3-23 AnGap-15
___ 07:10PM BLOOD ALT-15 AST-15 CK(CPK)-153 AlkPhos-60
Amylase-108* TotBili-0.2 DirBili-0.0 IndBili-0.2
___ 05:48AM BLOOD Albumin-3.4* Calcium-12.1* Phos-4.8*
Mg-2.6
___ 05:36AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.4
___ 10:56AM BLOOD PTH-406*
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of CAD, HTN, DM2 who
presented with progressive chest pain for 1 month and was found
to have elevated troponins concerning for NSTEMI. He underwent
cath and was found to have 3vd.
# Acute Coronary Syndrome:
Progressive exertional SSCP and elevated TnT consistent with
NSTEMI. Interpretation was difficult in setting of AOCKD so ddx
included unstable angina. Pt underwent catheterization on
___, showing 3-vessel disease. He received Aspirin 325mg
daily, Crestor at 40mg po daily, Metoprolol succinate 100mg
daily and heparin/nitro IV. Initially, pt only received heparin
for 24hrs but CP recurred at rest ___, SSCP), so heparin and
nitro gtt were restarted. He underwent CABG on ___.
# AOCKD (Stage III):
Pt of Dr. ___ in Nephrology. His creatinine appeared to have
worsened since his last visit with nephrology. This was likely
___ progression of CKD vs. more acute (in setting of NSTEMI).
O/N on ___, pt developed further AOCKD (Cr 3.2-->3.6), likely
in setting of HoTN from nitro gtt. Quinipril was held.
# HTN
Poorly controlled. Continued hydralazine 50mg po qid, Imdur at
30mg, Nifedipine ER 90 bid, Metoprolol XL 100mg daily. Quinapril
40mg po bid was held given AOCKD. Chlorthalidone was not started
as pt not actually on this med at home.
# Controlled Type 2 Diabetes c/b nephropathy:
His last A1c was 6 and is on oral medications. He is followed at
the ___. Held glyburide. Pt treated with HISS.
# Dyslipidemia: Continued Crestor 40mg po daily
# Hypogonadism: Continued Testim gel
TRANSITIONAL ISSUES:
#CODE: Full
SURGICAL COURSE:
The patient was admitted to the hospital and brought to the
operating room on ___ where the patient underwent coronary
artery bypass grafting surgery (see operative note for details).
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin and
ancef were used for surgical antibiotic prophylaxis. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. Multiple antihypertensive
medications were added for hypertension with a SBP goal 140
(kept higher for renal perfusion.) Post op course also
complicated by renal failure. Baseline crea 2.9 - peak
creatinine 4.1. Renal was consulted and Lasix was stopped. He
maintained good urine output off diurectics. The patient was
transferred to the telemetry floor for further recovery.
Creatinine trended down to 3.8 at the time of discharge. His
calcium was 12.1 and PTH was 406. Renal was consulted prior to
discharge. recommendations made. Pt was advised of need to
follow up with PCP regarding hypercalcemia and monitoring his
calcium level. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 5, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with services in
good condition with appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 40 mg PO BID
hold for SBP<90
2. Metoprolol Succinate XL 100 mg PO DAILY
hold if SBP<90, HR<50
3. NIFEdipine CR 90 mg PO BID
hold for SBP<90, HR<50
4. Rosuvastatin Calcium 20 mg PO DAILY
5. esomeprazole magnesium *NF* 40 mg Oral daily as needed
6. Aspirin 81 mg PO DAILY
7. Fexofenadine 60 mg PO PRN PRN
8. Glyburide Prestab 3 mg PO BID
9. Chlorthalidone 25 mg PO DAILY
hold if SBP<90
10. Levothyroxine Sodium 175 mcg PO DAILY
(One) tablet(s) by mouth once a day for 6 days weekly and 1.5
tablets daily for one day weekly
11. Vitamin D ___ UNIT PO DAILY
12. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
13. Fish Oil (Omega 3) 1000 mg PO BID
14. testosterone *NF* 1 %(50 mg/5 gram) Transdermal daily as
directed
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*30 Tablet Refills:*1
2. Fexofenadine 60 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Levothyroxine Sodium 262.5 mcg PO QSUN
5. Levothyroxine Sodium 175 mcg PO ___
6. NIFEdipine CR 60 mg PO BID
RX *nifedipine 60 mg 1 tablet extended release 24hr(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q4H:PRN fever/pain
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*1
10. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*1
12. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
13. Glyburide Prestab 3 mg PO BID
14. testosterone *NF* 1 %(50 mg/5 gram) Transdermal daily as
directed
15. HydrALAzine 50 mg PO Q6H
RX *hydralazine 50 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*1
16. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1)Coronary Artery Disease (Coronary Artery Bypass Grafting on
___
2) Type 2 diabetes, followed at the ___
3) Hypertension
4) Dyslipidemia
5) Stage 3 CKD, followed in ___ clinic by Dr. ___
6) Peripheral Vascular Disease (Superficial Femoral Artery stent
in the Right Lower Extremity by Dr. ___
7) Hypogonadism
8) Reflux disease
9) Thyroid cancer (Thyroidectomy by Dr. ___
10) Remote history of alcohol and substance abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10705890-DS-8
| 10,705,890 | 21,242,261 |
DS
| 8 |
2164-07-27 00:00:00
|
2164-07-27 23:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
Dyspnea, Weakness
Major Surgical or Invasive Procedure:
R IJ Dialysis Catheter Placement (Tunneled 2-Lumen)
R Brachial Artery PICC line placement (removed before discharge)
___ L forearm radiocephalic AVF
History of Present Illness:
___ with CAD s/p CABG in ___, DM, HTN, HLD, stage ___ CKD, PVD
s/p stent in the RLE, who p/w SOB and DOE for the past three
days. Pt noted increased fatigue and DOE over this period of
time with exertion. Does not measure his weight at home but his
usual weight is 187 lbs. Notes orthopnea, non-productive cough
that worsens with lying flat, and PND. He also endorses
increased ankle edema, mild abdominal distention, and slightly
decreased appetite. Denies anginal symptoms, palpitations,
fevers, chills, infectious symptoms. Has been compliant with
medications and urinating "a lot" to his daily lasix but has not
been as careful with his diet recently, eating out more.
Of note, pt had recent admission (___) for chest pain with
indeterminate troponins, flat CK-MB and nuclear stress test with
normal myocardial perfusion, icreased LV cavity dilation since
___ and global hypokinesis.
In the ED, initial vitals were: 98 74 128/48 18 85% (triggered
on arrival for hypoxia). Labs significant for troponin 0.07
(0.05 on discharge ___, proBNP 2678, H/H 8.5/___.1 (baseline
range 8.3-9.___-30 in ___, INR 0.9, Bicarb 17, BUN/Cr
92/7.5 (previously 64/5.6). CXR showed bilateral pulmonary edema
through the mid-lungs. EKG NSR with occasional conducted PACs,
rate 75, nl axis, nl intervals, no ST segment elevation or
depression, ?LVH by voltage. Patient was placed on CPap for two
hours while diuresed with 40mg IV lasix. Initially weaned to NC
but O2 requirement was increasing to 89% on 6L and pt had
increasing tachypnea so he was put back on CPAP and given
another 40mg IV lasix at 6p. Vitals prior to transfer were HR 79
BP 128/64 RR ___ O2 Sat 95% on CPAP.
Upon arrival to the floor, patient appeared comfortable so CPAP
was discontinued. He still had an intermittent cough but felt
his breathing had improved.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes (A1c 6.0% ___,
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: ___
-Diagnostic Cardiac Cath: ___
3. OTHER PAST MEDICAL HISTORY:
PVD s/p stent in the RLE
CKD IV-V, plan to obtain L-sided HD access soon
Papillary Thyroid Cancer, s/p thyroidectomy
Hypogonadism
Reflux disease
Remote history of alcohol and substance abuse
Gout
Anemia
Social History:
___
Family History:
Patient notes that his father died of CHF at the age of ___ and
his brother died in his ___ with an MI. Mother died of bone
cancer in her ___.
Physical Exam:
ADMISSION EXAM:
===============
General: well-appearing in NAD
HEENT: MMM
Neck: JVD 4cm above clavicle
CV: RRR, no m/r/g
Lungs: decreased breath sounds at the bases b/l, coarse breath
sounds, no wheeze or crackles
Abdomen: obese, soft, not distended
Ext: no edema, wwp
DISCHARGE EXAM:
===============
Tmax/Tc: 98.9, HR 69-72, 128-133/58-74, RR 18, 99% RA
Weight: (78.9k)
General: A/ert, oriented, lying flat
HEENT: no JVD
CV: RRR, no M/R/G
Resp: clear bilat
ABD: soft NT
Extr: no edema, feet warm
Neuro: A/O
Pertinent Results:
ADMISSION LABS:
===============
___ 12:30PM ___ PTT-29.5 ___
___ 12:30PM PLT COUNT-202
___ 12:30PM NEUTS-82.6* LYMPHS-11.6* MONOS-3.8 EOS-1.3
BASOS-0.7
___ 12:30PM WBC-6.8 RBC-2.97* HGB-8.5* HCT-26.1* MCV-88
MCH-28.5 MCHC-32.4 RDW-13.9
___ 12:30PM TSH-0.41
___ 12:30PM CALCIUM-8.8 PHOSPHATE-6.5* MAGNESIUM-2.3
___ 12:30PM CK-MB-4 cTropnT-0.07* proBNP-2678*
___ 12:30PM CK(CPK)-219
___ 12:30PM GLUCOSE-154* UREA N-92* CREAT-7.5*#
SODIUM-137 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-17* ANION GAP-19
___ 07:17PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 07:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:56PM O2 SAT-78
___ 11:56PM TYPE-ART TEMP-39.0 O2-95 O2 FLOW-15 PO2-50*
PCO2-35 PH-7.38 TOTAL CO2-22 BASE XS--3 AADO2-602 REQ O2-97
INTUBATED-NOT INTUBA COMMENTS-FACE MASK
PERTINENT LABS:
==============
___ 03:18AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-1+ Burr-1+
___ 12:30PM BLOOD CK(CPK)-219
___ 04:39AM BLOOD CK(CPK)-191
___ 03:18AM BLOOD LD(LDH)-532* TotBili-0.3
___ 02:50PM BLOOD ALT-13 AST-30 LD(LDH)-528* AlkPhos-67
TotBili-0.6
___ 12:30PM BLOOD CK-MB-4 cTropnT-0.07* proBNP-2678*
___ 04:39AM BLOOD CK-MB-3 cTropnT-0.06*
___ 03:18AM BLOOD Hapto-381*
___ 06:09AM BLOOD calTIBC-222* Ferritn-947* TRF-171*
___ 12:30PM BLOOD TSH-0.41
___ 02:11AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 02:11AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY:
===========
__________________________________________________________
___ 6:42 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.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 1:57 pm
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:17 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:39 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:08 pm MRSA SCREEN 2230.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 12:30 pm BLOOD CULTURE
THERE IS NO ORDER FOR THE BLOOD CULTURE SET..
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=======
CXR ___: FINDINGS: PA and lateral views of the chest. A right
dialysis catheter ends in the right atrium. The sternotomy
wires are intact. Cardiomediastinal and hilar contours are
normal. No focal consolidation, pleural effusion or
pneumothorax. IMPRESSION: No acute cardiopulmonary process.
EKG ___: 74, 208, 96, 426/450, Sinus rhythm with borderline
prolonged P-R interval. Prominent left ventricular hypertrophy
with repolarization abnormalities.
CTA ___: 1. Bilateral peribronchial vascular ground-glass
opacities compatible with mild to moderate alveolar pulmonary
edema. Atelectasis in the left lower lobe.
2. No pulmonary embolism
3. Left renal cyst measuring 2.7cm.
CXR ___:
Bilateral consolidation previously strongly basilar has improved
at the lung bases, but now is more extensive in the upper lungs.
Suspect this is
pulmonary edema. Heart size is normal. Pleural effusions are
presumed, but not large. Upright conventional chest radiographs
would be extremely helpful in evaluating these findings.
Dual-channel right supraclavicular dialysis catheter ends in the
right atrium and SVC. No pneumothorax.
___ ___:
No evidence of deep venous thrombosis in bilateral lower
extremities.
TTE ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate left ventricular hypokinesis secondary
to hypokinesis of the interventricular septum and inferior free
wall. Quantitative (biplane) LVEF = 38%. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no left ventricular outflow obstruction
at rest or with Valsalva. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic arch is mildly dilated. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CXR ___:
Findings suggestive of mild pulmonary vascular congestion.
Right
greater left basilar opacities potentially in part due to
overlying soft
tissues and atelectasis. If desired, PA and lateral views of
the chest could help clarify.
EKG ___:
Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization
changes. Compared to tracing #1 no change. TRACING #2
EKG ___:
Sinus rhythm. Left ventricular hypertrophy by voltage. Compared
to the
previous tracing of ___ no change.
DISCHARGE LABS:
================
___ 04:24AM BLOOD WBC-11.7* RBC-2.58* Hgb-7.7* Hct-24.2*
MCV-94 MCH-29.7 MCHC-31.7 RDW-14.6 Plt ___
___ 04:24AM BLOOD Plt ___
___ 04:24AM BLOOD Glucose-245* UreaN-64* Creat-7.8*# Na-135
K-4.5 Cl-96 HCO3-25 AnGap-19
___ 04:24AM BLOOD Calcium-10.0 Phos-7.0*# Mg-2.8*
Brief Hospital Course:
___ with CAD s/p CABG in ___, DM, HTN, HLD, stage ___ CKD, PVD
s/p stent in the
RLE, who presents with SOB and DOE concerning for acute systolic
CHF exacerbation.
ACUTE ISSUES:
==============
# Hypoxia: Patient significantly hypoxic (to mid-80s) on
admission, requiring NIPPV and high-flow nasal cannula for most
of his ICU stay. In addition to pulmonary edema, concern for
pneumonia or pulmonary embolus. Patient developed productive
cough and fever during hospitalization so was started on HCAP
antibiotic coverage. Also empirically started on heparin IV drip
for presumed PE; eventually ruled-out by CTA once bedside HD was
initiated. Respiratory status improved with ongoing diuresis by
dialysis, with patient sat'ing well on room air on discharge.
# Acute on Chronic Systolic Heart Failure Exacerbation: TTE
showed EF 38% w/LV hypokinesis (unchanged from previous echo in
___, BNP elevated, CXR with bibasilar fluid collection, 7kg
up from last documented weight (82kg) and 8lbs up from
self-reported dry weight, and presented with symptoms of dyspnea
on exertion and orthopnea consistent with acute exacerbation.
Thought most likely due to volume overload from worsening kidney
function and increased resistance to diuretics. Other
contributing factors include his highly resistant hypertension
(per ___ PCP visit note and patient report, systolic BPs have
been in the 170s recently, and he is on 3 medications for
attempted control) and dietary non-compliance. When patient did
not respond adequately to high dose furosemide, he was initiated
on dialysis with resolution of his symptoms. Discharge weight
was 78.9Kg.
# End Stage Renal Disease, now on Hemodialysis: Gradually
worsening since ___, but Creatinine 7.5 on admission was
acute jump from baseline of 5.5-5.6. Not hyperkalemic. He has
marked increase in his BUN since last admission (92 from 64),
and a mildly worsening metabolic acidosis (delta/delta = 1).
Initially suspected to be secondary to poor forward flow from
___ exacrebation, but creatinine and uremia actually worsened
in setting of diuresis. A tunneled line was placed and dialysis
was initiated, which the patient tolerated well. He was started
on Sevelamer and nephrocaps. Sensipar was continued. A
left-sided AVF was placed prior to discharge.
# Healthcare-Associated Pneumonia: Patient was febrile with
productive cough. He was treated with vancomycin and cefepime
for HCAP coverage x8 days.
# Anemia: Admission H/H 8.5/___.1 (baseline range 8.3-9.1/___-30
in ___. MCV 88, low-normal iron studies ___. Likely
represents progression of renal disease, with contribution from
anemia of inflammation / anemia of iron deficiency. On oral iron
supplementation per Nephrology.
# Hypertension: Poorly controlled on home regimen with SBPs in
the 170s, which may represent worsening of his renal disease.
Carvedilol recently added to his regime. Nifedipine, Carvedilol
and hydralazine were discontinued after initiation of dialysis.
Patient was started on metoprolol XL 100mg and losartan 25mg
daily.
# Type 2 Diabetes c/b Nephropathy: Well-controlled on insulin
# Dyslipidemia: Continuing home rosuvastatin.
# Hypogonadism: Patient has not been on testosterone cream at
home. To follow up outpatient with endocrinology for further
management.
# Gout: Per last D/C Summary, was supposed to have started 100mg
allopurinol. Was started on this medication here.
# Papillary Thyroid Ca s/p Thyroidectomy: Per last D/C Summary,
on levothyroxine 175 6x/week and 262.5 1x/wk. Last TSH ___
0.95. TSH on recheck here 0.41. Discharged on levothyroxine
175mcg daily.
TRANSITIONAL ISSUES:
=====================
- Patient to follow-up with Endocrinology hypothyroidism and
hypogonadism.
- Patient to follow-up with Transplant Surgery for L-sided AVF.
- Patient will follow-up with ___ for his diabetes.
- Patient is scheduled for ___ outpatient dialysis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO BIW
3. Cinacalcet 30 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Furosemide 40 mg PO DAILY
7. HydrALAzine 50 mg PO Q6H
8. Levothyroxine Sodium 262.5 mcg PO QSUN
9. Levothyroxine Sodium 175 mcg PO ___
10. NIFEdipine CR 90 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. Rosuvastatin Calcium 10 mg PO DAILY
13. testosterone 1 %(50 mg/5 gram) Transdermal daily as directed
14. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
15. Carvedilol 25 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cinacalcet 30 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg one tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*2
7. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg one
capsule(s) by mouth daily Disp #*30 Capsule Refills:*2
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg three tablet(s) by
mouth three times a day Disp #*180 Tablet Refills:*2
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Glargine 6 Units Breakfast
12. Levothyroxine Sodium 175 mcg PO DAILY
13. Allopurinol ___ mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic systolic heart failure exacerbation
Initiation of hemodialysis
End stage renal disease
Anemia of chronic disease
Acute on chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with symptoms of shortness of breath and
lethargy and diagnosed with a heart failure exacerbation likely
because of both your diet and your renal disease. A heart
failure exacerbation occurs when the heart cannot effectively
supply the body with as much oxygenated blood as it needs. This
can be made worse by eating a diet high in salty foods which
increases blood volume making the heart work harder. This can
also be made worse with renal failure and uncontrolled high
blood pressure when the kidneys are not able to get rid of
excess fluid efficiently.
Since your admission we have titrated your medications and
started you on dialysis to help your kidneys get rid of the
extra fluid and toxins that it is not able to do on its own. You
have both an indwelling line for hyemodyalisis that was placed
as well as a surgical fistula that will need to mature before it
can be used.
You are now doing well enough to be discharged home with the
plan for outpatient hemodyalysis.
WE have made quite a few changes to your medications that are
listed in your paperwork.
For your diagnosis of heart failure it is important that you
weigh yourself every morning, call Dr. ___ your weight
goes up more than 3lbs in 1 day or more than 5 pounds in 2 days.
Followup Instructions:
___
|
10705949-DS-13
| 10,705,949 | 20,413,900 |
DS
| 13 |
2131-01-27 00:00:00
|
2131-01-27 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Shortness of breath
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with past medical history of COPD, Asthma,
Chronic LBP, Hepatitis C, Hypercholesterolemia, PUD, Ovarian
Cysts who presents with shortntess of breath. The patient
reports that about two weeks ago she had a cold with cough
productive of yellow sputum. This lead to progressively
worsening shortness of breath despite use of her inhalers and
nebulizers. She presented to her PCP who treated her with high
dose oral steroids and Bactrim. CXR taken at the time was
negative for pneumonia. She reports some initial improvement in
symptoms but overall has continued to decline over the past
week. She completed a steroid taper yesterday and is still
taking Bactrim. She reports continued shortness of breath over
the past week worsened by minimal exertion. She continues to
have productive cough although mucus is no longer green. She
denies fevers but reports subjective chills. Denies sore throat,
sinus pressure, congestion, rhinorrhea. She is using Symbicort
BID, Albuterol nebulizer TID, and Albuterol inhaler BID. She
presented to clinic today where her O2 SAT today was 90%, down
from 92% last week when she saw her PCP and prior levels were
97%. She was referred to the ED for further management.
In the ED, initial vs were: Triage 17:09 0 96.6 90 152/95 22 95%
She was given azithromycin 500 mg PO x 1, combivent nebulizers x
1, solumedrol 125 mg. Peak flow was assessed and initially 200;
(baseline at max is 400) Repeat was 190. CXR was performed with
no focal or acute cardiopulmonary process. ECG showing normal
sinus rhythm similar to prior dated in ___. Labs : WBC 8.2 Hgb
16.3 (H) Hct 48.8 Plt 248; Na 139 K 6.3 (hemolyzed) --> 4.2 Cl
105 HCO3 25 BUN 16 Cr 0.8 Glc 96; Blood culture x 2. She is
being admitted for a COPD exacerbation. Amission Vitals: 18:54 0
97.7 83 146/99 14 94%.
On arrival to the floor, patient reports continued shortness of
breath although she felt better after initial nebs in ED. Denies
chest pain, palpitations, lightheadedness.
Review of systems:
(+) Per HPI
(-) Denies fever, 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.
Past Medical History:
Past Medical History:
- COPD
- Asthma
- Chronic low back pain
- Hepatitis C
- Hypercholesterolemia
- PUD
- Ovarian cysts
- Depression.
- Fibroid uterus.
- Eating disorder.
- Trauma, third degree burn, left leg.
PAST SURGICAL HISTORY:
1. Status post laparoscopic ovarian cystectomy.
2. Status post salpingectomy secondary to ectopic pregnancy.
3. Status post total abdominal hysterectomy secondary to
fibroids.
4. Status post multiple skin grafts
Social History:
___
Family History:
Positive for CAD in her brother, positive for breast cancer in
her grandmother. No family history of hypertension or diabetes.
Physical Exam:
Admission PE
Vitals: T: 97.7 BP:182/100-> repeat P:75 R: 18 O2: 91 on 2L NC
General: Alert, oriented, mild resp distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Diffuse expiratory wheezing throughout.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses
Neuro: AOOX3, grossly non-focal
Discharge PE
VS - 98.2 90 100/58 18 93% RA
General: Alert, oriented, breathing comfortably
HEENT: Sclera anicteric, oropharynx clear, dry mucous membranes
Neck: supple, no LAD
Lungs: wheezing diffusely
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses
Neuro: AOOX3, grossly non-focal
Pertinent Results:
___ 06:15PM BLOOD WBC-8.2# RBC-5.22 Hgb-16.3* Hct-48.8*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.0 Plt ___
___ 06:15PM BLOOD Neuts-63.4 ___ Monos-5.4 Eos-0.2
Baso-1.0
___ 06:15PM BLOOD ___ PTT-30.2 ___
___ 06:15PM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-139
K-6.3* Cl-105 HCO3-25 AnGap-15
___ 10:40AM BLOOD ALT-93* AST-57* AlkPhos-115* TotBili-0.2
___ 06:15PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3
___ 07:40AM BLOOD WBC-9.5 RBC-4.96 Hgb-15.7 Hct-46.7 MCV-94
MCH-31.7 MCHC-33.7 RDW-13.2 Plt ___
___ 07:50AM BLOOD WBC-8.8 RBC-5.02 Hgb-15.8 Hct-48.2*
MCV-96 MCH-31.5 MCHC-32.8 RDW-13.2 Plt ___
___ 07:30AM BLOOD WBC-8.8 RBC-4.85 Hgb-15.2 Hct-45.6 MCV-94
MCH-31.4 MCHC-33.4 RDW-13.4 Plt ___
CXR : ___
FINDINGS: PA and lateral views of the chest were provided. The
lungs are
hyperinflated with upper lobe lucency and splaying of
bronchovasculature
compatible with emphysema. There is no focal consolidation to
suggest the
presence of pneumonia. No effusion or pneumothorax. No signs of
congestive
heart failure. The heart and mediastinal contours are normal.
Bony
structures are intact. No free air is seen below the right
hemidiaphragm.
IMPRESSION: COPD without superimposed pneumonia.
Brief Hospital Course:
___ past medical history of COPD/Asthma presented with shortness
of breath consistent with moderate to severe exacerbation with
poor response to outpatient treatment without evidence of
underlying pneumonia. Patient treated with steroids,
Azithromycin, nebulizers, and supplemental oxygen with
improvement in symptoms and air movement. Patient's oxygen
saturation was monitored and improved to 92% on room air with
ambulation. Given her long history of smoking and significant
pulmonary disease, she was counseled about smoking cessation and
provided with a nicotine patch while hospitalized. She was also
scheduled for an appointment with ENT to follow-up for
outpatient evaluation of her tongue lesion.
At the time of discharge, her lung sounds remained diffusely
wheezy but her oxygen requirements improved. She completed her
course of antibiotics and was discharged with a Prednisone taper
over 9 days. Her home medications were not changed on this
hospitalization.
She has follow-up appointments scheduled with her primary care
doctor this week and an appointment with ENT for her tongue
lesion next week.
Also, she should get follow up evaluation of her transaminitis,
which is stable from her prior hospitalization.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dysnea, wheezing
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. Gabapentin 300 mg PO TID
5. Quetiapine Fumarate 300 mg PO QAM
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
2 puffs BID
7. BusPIRone 15 mg PO TID
8. Escitalopram Oxalate 20 mg PO DAILY
9. Zolpidem Tartrate 5 mg PO HS
10. Quetiapine Fumarate 600 mg PO QHS
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dysnea, wheezing
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. Gabapentin 300 mg PO TID
5. Quetiapine Fumarate 300 mg PO QAM
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
2 puffs BID
7. BusPIRone 15 mg PO TID
8. Escitalopram Oxalate 20 mg PO DAILY
9. Zolpidem Tartrate 5 mg PO HS
10. Quetiapine Fumarate 600 mg PO QHS
11. Prednsione Taper
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted to the hospital for cough and
shortness of breath likely caused by an asthma/COPD
exacerbation. You were given steroids, breathing treatments, and
an antibiotic that helps decrease the inflammation in your
lungs. Please follow up with your Primary care physician and
consider quitting smoking which aggravates your condition.
You received a course of antibiotics in the hospital that you
completed. You are receiving a a prescription for steroids at
home. You should take this medication as a tapered dose as
described below:
A) Prednisone 60mg once a day for the first 3 days
B) Prednisone 40mg once a day for the next 3 days
C) Prednisone 20mg once a day for the following 3 days
You also have a lesion on the base of your tongue that you
should have biopsied as an outpatient. We were able to make an
appointment with the ENT doctors (___) for you to
have it evaluated.
Followup Instructions:
___
|
10706009-DS-7
| 10,706,009 | 26,562,553 |
DS
| 7 |
2177-04-14 00:00:00
|
2177-04-14 18:43:00
|
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 ___ toe pain
Major Surgical or Invasive Procedure:
s/p podiatric left ___ digit amputation ___
History of Present Illness:
___ with a hx notable for HIV, IDDM, CKD, neuropathy, GERD and
HTN who presents as a transfer from her ___ clinic for
assessment and admission for amputation of her Left ___ toe.
Pt has been seeing their podiatrist for the last 3 weeks for a
poorly healing ulcer which had been healing poorly, and today
was
with exposed bone on the anterior aspect of the proximal/middle
phalangeal joint. Pt notes that the left leg in now swollen up
the the knee, no other associated symptoms, no prior history of
this severity.
Pt seen and evaluated in ___ this morning. Left ___
toe ulceration with exposed bone. Concern for osteomyelitis.
would benefit from likely admission to medical service and left
___ toe amputation.
In the ED:
- Initial vital signs were notable for:
T96.4 HR 74 BP 133/56 RR 16 100% RA
- Exam notable for:
"gen: aox3, pleasant, obese
extrem: L leg with 2+ pitting edema to knee, Left ___ toe with
exposed bone on the anterior aspect of the proximal/middle
phalangeal joint
vascular: DP and ___ 2+ ___ "
- Labs were notable for:
WBC 7.6, Hgb 9.0, Hct 29.3, Plt 384
Cr 1.9, BUN 23
Blood CX pending
- Studies performed include:
Foot xray :
1. The reported ulcer adjacent to the second ray is difficult to
appreciate on this study. There may be mild relative osteopenia
of the second proximal and middle phalanges of the second ray
which can be very early finding of osteomyelitis.
2. No definite subcutaneous emphysema is seen to suggest
osteomyelitis, however, a dedicated MRI can be obtained for
further evaluation if there is strong clinical concern. "
- Patient was given:
Vancomycin 1000 mg IV ONCE
Piperacillin-Tazobactam 4.5 g IV ONCE
1000 mL NS Bolus 1000 ml
- Consults:
Podiatry: Despite no clear signs of OM on x-ray and no systemic
signs, there is likely deep contamination, infection of tissues
necessitating amputation of the toe.
Vitals on transfer:
97.3 PO 173 / 74 77 18 98 RA
Upon arrival to the floor, patient feeling well. She reports
improvement in pain of her foot. She says that she has had
ongoing swelling of the left leg.
She denies fevers, denies chills, denies head ache, denies
nausea, denies vomiting, denies abdominal pain, denies diarrhea,
denies chest pain, denies shortness of breath.
Past Medical History:
HIV
Diabetes
Morbid Obesity
CKD
Chronic Anemia
GERD
HTN
Neuropathy
Social History:
___
Family History:
Mother died of renal disease
Father died of old age
Has DM in family
Physical Exam:
ADMISSION
=========
VITALS: 97.3 PO 173 / 74 77 18 98 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, Sclera anicteric and without injection.
MMM.
CARDIAC: Distant heart sounds, regular rhythm, normal rate.
Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Obese, Normal bowels sounds, non distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: Left greater than right swelling; left leg more
erythematous and warm than right. DP pulse bilateral
Wound: superficial aspect of L second toe with visible bone,
foul
smelling; gauze overlying with serosanguinous saturation
DISCHARGE
=========
T 97.8 BP 144 / 54 HR 77 RR 18 SaO2 97 Ra
Obese woman resting comfortably in bed, L foot wrapped in clean
dressing. Lungs clear b/l, heart rhythm regular without murmurs.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:11PM WBC-7.6 RBC-3.09* HGB-9.0* HCT-29.3* MCV-95
MCH-29.1 MCHC-30.7* RDW-14.4 RDWSD-49.6*
___ 05:11PM NEUTS-57.8 ___ MONOS-8.6 EOS-3.1
BASOS-0.5 IM ___ AbsNeut-4.41 AbsLymp-2.25 AbsMono-0.66
AbsEos-0.24 AbsBaso-0.04
___ 05:11PM PLT COUNT-384
___ 03:50PM GLUCOSE-188* UREA N-23* CREAT-1.9* SODIUM-142
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 03:50PM estGFR-Using this
___ 03:50PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.0
___ 03:15PM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO RDWSD-UNABLE TO
___ 03:15PM NEUTS-UNABLE TO LYMPHS-UNABLE TO
MONOS-UNABLE TO EOS-UNABLE TO BASOS-UNABLE TO NUC RBCS-UNABLE
TO IM ___ TO AbsNeut-UNABLE TO AbsLymp-UNABLE TO
AbsMono-UNABLE TO AbsEos-UNABLE TO AbsBaso-UNABLE TO
___ 03:15PM PLT COUNT-UNABLE TO
MICROBIOLOGY:
=============
___ 1:15 pm TISSUE LEFT TOE SECOND DIGIT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
STAPH AUREUS COAG +. RARE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
__________________________________________________________
___ 3:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING STUDIES:
================
___ FOOT PLAIN FILM
1. The reported ulcer adjacent to the second ray is difficult to
appreciate on
this study. There may be mild relative osteopenia of the second
proximal and
middle phalanges of the second ray which can be very early
finding of
osteomyelitis.
2. No definite subcutaneous emphysema is seen to suggest
osteomyelitis,
however, a dedicated MRI can be obtained for further evaluation
if there is
strong clinical concern.
Non-invasive arterial studies of LEs ___
FINDINGS:
On the right side, triphasic Doppler waveforms were seen at the
right femoral,
popliteal, posterior tibial and dorsalis pedis arteries. The
right ABI is
1.27 at rest.
On the left side, triphasic Doppler waveforms were seen at the
left femoral,
popliteal, posterior tibial and dorsalis pedis arteries. The
left ABI is 1.32
at rest.
Pulse volume recordings showed symmetric amplitudes at all
levels,
bilaterally.
IMPRESSION:
No evidence of arterial insufficiency to the lower extremities
at rest.
LLE US ___. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. 3.0 ___ cyst.
___ f/u Plain film of L foot
FINDINGS:
There has been interval amputation at the second MTP joint.
Cortices appear
well delineated without erosive change. Mild degenerative
change first MTP
joint. No acute fracture or malalignment. Vascular
calcifications noted in
the forefoot. Small plantar calcaneal spur.
IMPRESSION:
Interval amputation at the second MTP joint. No radiographic
evidence for
osteomyelitis.
DISCHARGE LABS:
===============
___ 05:14AM BLOOD WBC-7.7 RBC-2.70* Hgb-7.8* Hct-25.3*
MCV-94 MCH-28.9 MCHC-30.8* RDW-14.2 RDWSD-48.3* Plt ___
___ 05:14AM BLOOD Glucose-104* UreaN-22* Creat-1.8* Na-141
K-4.4 Cl-106 HCO3-24 AnGap-11
___ 05:14AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
Brief Hospital Course:
___ is a ___ year old woman with past medical history
of morbid obesity, HIV, poorly controlled type 2 diabetes who
presented with three week left toe wound that probed to bone who
underwent podiatric left ___ digit amputation ___ after
non-invasive vascular studies confirmed good blood flow. She
will continue on augmentin until at least follow-up in ___
clinic
===================================
ACUTE ISSUES
===================================
#Toe osteomyelitis:
s/p ___ toe amputation by podiatry ___. Sent for pathology,
microbiology which was pending at time of discharge (prelim with
GPCs, unspeciated). For pain control she will continue Tylenol
___ TID as well as oxycodone 2.5-5mg BID PRN for
breakthrough pain. She will continue PO Augmentin for 12 days to
finish a 14-day course of antibiotics.
===================================
CHRONIC ISSUES
===================================
#Diabetes Type 2: Poorly controlled, A1c 8.0 in ___,
follows with ___. Lantus 52 units nightly as well as ISS as
described in patient ___ note from ___.
#Normocytic Anemia, Chronic: Stable from baseline, has iron
studies wnl as recently as ___. Former patient of
hematology at ___ who attributed anemia to HIV medications,
anemia of chronic disease
#Chronic Kidney Disease: Cr 1.9, has been 1.4- 2.0 over the past
six months, continued vitamin D
# HIV: continued home Biktarvy.
# GERD: continued home PPI
# HTN: goal 140/90 per ACCORD, continued home lisinopril
(although held on day of procedure per VISION trial)
#Neuropathy: continued home gabapentin
===================================
TRANSITIONAL ISSUES
===================================
[] Continue augmentin Broad spectrum abx: Amoxicillin-Clavulanic
Acid ___ mg PO/NG Q12H for 12 Days (until ___ or podiatric
follow-up
[] OR Micro: GPCs; Path: (proximal margin ___ toe) pending
[] Wound Care: Betadine dressing to left foot
[] WB Status: Heel weightbearing to left foot in surgical shoe
[] f/u with Dr. ___ ~1 week after discharge (appointment
being established; patient will receive call)
[] Advise Orthopedic Surgery outpatient appointment for further
evaluation and management of ___ Cyst of left knee
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. Biktarvy (bictegrav-emtricit-tenofov ala) 50-200-25 mg oral
DAILY
2. Lisinopril 40 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. lantus 52 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H toe osteo s/p
amputation Duration: 12 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*23 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO BID:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
4. lantus 52 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Aspirin 81 mg PO DAILY
6. Biktarvy (bictegrav-emtricit-tenofov ala) 50-200-25 mg oral
DAILY
7. Gabapentin 300 mg PO TID
8. Lisinopril 40 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Osteomyeltitis
SECONDARY: Diabetic Foot Ulcer
Diabetes Mellitus Type 2
Hypertension
HIV
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a badly infected ulcer of your toe
What was done for me while I was in the hospital?
- You had the infected toe amputated by podiatry
- We gave you antibiotics to prevent the spread of infection
- We gave you Tylenol and oxycodone to alleviate your pain
What should I do when I leave the hospital?
- Take all medications as prescribed (use the oxycodone only
when you need it)
- Keep all of your doctors' appointments
- Seek medical attention if you experience any of the "warning"
symptoms listed below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10706185-DS-18
| 10,706,185 | 29,573,799 |
DS
| 18 |
2126-03-31 00:00:00
|
2126-03-31 12:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
pollen extracts
Attending: ___.
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man who is two weeks s/p coranary
artery bypass grafting. His post-op course was uneventful and he
was discharged to home on
post-operative day five. Once he was home he developed nausea
and weakness. He vomited last night five to six times. He
reports having a poor appetite and limited intake of fluids. His
bowel movements are regular and he denies diarrhea or
constipation. He discontinued narcotic use three days ago. He
presents to the emergency room for further evaluation.
Past Medical History:
___ year old man with hypertension and diabetes, noticed
occasional mild chest pressure this past ___ when walking,
easily resolving with rest. Was recently seen by his local
doctor
where it was discussed that he should join the "___/60"program at
___ and ___. Prior to doing this he was
referred for stress testing which indicated possible ischemia in
the LAD territory. Cardiac cath today 100% LAD and multivessel
disease. Now being referred to cardiac surgery for CABGfor
coronary angiogram.
Social History:
___
Family History:
His sister had an MI in her ___ s/p stenting. Father had
lung cancer and emphysema and had an MI at age ___.
Physical Exam:
Pulse: 97 Resp: 12 O2 sat: 100%
B/P Right: Left: 135/66
Height: 6' 1" Weight:222 lbs
General: pale, NAD
Skin: Dry [x] intact [x]- sternotomy and left EVH sites healing
well- no erythema or drainage
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema [] _none_
Varicosities: None [x] early venous stasis changes
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Pertinent Results:
___ 05:25AM BLOOD WBC-11.4* RBC-3.65* Hgb-11.2* Hct-33.6*
MCV-92 MCH-30.7 MCHC-33.3 RDW-14.5 RDWSD-46.4* Plt ___
___ 05:25AM BLOOD Glucose-158* UreaN-21* Creat-0.8 Na-132*
K-4.5 Cl-97 HCO3-23 AnGap-17
___ 03:00PM BLOOD ALT-15 AST-16 AlkPhos-75 TotBili-0.9
Brief Hospital Course:
Mr. ___ was admitted for observation through the emergency
department. He was given fluid and zofran. The nausea subsided
but he complained of gastric reflux symptoms so he was given
maalox and zantac to good effect. He stated that he had GERD in
the past when he weighed more than currently. He stayed
overnight in the hospital but by the next morning he had 24
hours without nausea. His labs, including LFTs were all normal.
He was discharged home with visiting nursing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Multivitamins 1 TAB PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN rhinitis
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
9. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK
10. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg one tablet(s) by mouth two times daily
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
gastric reflux
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10706377-DS-22
| 10,706,377 | 27,736,324 |
DS
| 22 |
2128-10-25 00:00:00
|
2128-10-28 09:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nitroglycerin
Attending: ___
Chief Complaint:
chest pain, shortness of breath, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with hx CAD s/p CABG x5 (___) presenting with exertional
CP as a transfer from ___. ASA given PTA. ___ has been having
dizziness with exertion and SOB which has been increasing
recently. He's also had weakness over the past few days which
has been accompanied by dizziness, worse with standing/exertion.
Currently CP free.
Labs at ___:
hgb 14 (up from ___
Trop T ___ 0.04
TSH ___ 1.24
Glucose 432
EKG at ___ reportedly had ST elevations with reciprocal
changes in lateral leads. (EKGs from ___ were not in
chart upon transfer to the floor).
CXR was only bedside portable with mild cardiomegaly increased
interstitial markings. no focal consolidations, no pneumothorax.
At ___, he received 12 U Regular insulin prior to
transfer
In the ED initial vitals were:
EKG: Temp 95.2 F 97.2F ( HR 75 102/70 RR 18 97% RA
Labs/studies notable for:
WBC 8.6 hgb 13.5 hct 38.7 plt 186
INR 1.0
Na+ 136 K+ 4.6 BUN 34 Cr 1.0 (baseline 0.6-0.7) Glucose 330
Trop 0.03
No imaging in the ED
Patient was given: nothing
Vitals on transfer: Temp 97.9 HR 72 114/54 RR 20 98% RA
Cardiology was consulted in the ED, EKG showing ST changes most
consistent with LVH strain pattern with no urgent indication for
cath at this time; recommended heparin gtt if trop positive with
recommended stress in morning.
In terms of his previous cardiac history, patient presented in
___ with chest pain, The patient presented with an
elevated troponin (0.05 --> 0.04 --> 0.04) associated with
ischemic changes on EKG that technically did not meet definition
of STEMI (would have to be 2 contiguous leads of STE), Cath
showed severe calcific three vessel coronary artery with chronic
total occlusion of the collateralized distal RCA, eccentric
subtotal occlusion of the proximal LAD, moderate mid LAD
disease, and severe disease involving the proximal CX and OM1.
CSurg was consulted and patient underwent Coronary artery bypass
grafting x5 with the left internal mammary artery to left
anterior descending artery, and reverse saphenous vein graft to
the posterior descending artery. ___ and ___ obtuse marginal
artery and the first diagonal artery on ___. TEE completed
in the operating room showed left-to-right shunt across a PFO
throughout the cardiac cycle.
Patient was not taking his simivstatin as prescribed otherwise
he has been compliant with his medications. He states he has not
been sleeping well recently given the fact he ran out of
trazadone. He lives alone and manages his own medications. He is
currently getting enough to eat and drink. No change in urinary
output. Diarrhea likely metformin induced. He states his mood
has been somewhat depressed, no recent maniac episodes, no SI.
Upon arrival to the floor, he is chest pain free, not short of
breath and has no specific complaints.
Past Medical History:
1. Poorly-compliant, poorly-controlled type 2 diabetes mellitus
with polyneuropathy and his most recent A1c was above 9.
2. Endogenous obesity.
3. Coronary artery disease.
4. Hypertension.
5. Bipolar disease.
6. Posttraumatic stress disorder.
7. Homelessness.
8. Anemia.
9. Cellulitis with full-thickness ulcer, plantar right second
toe now with amputation
Social History:
___
Family History:
Almost everyone in his family is dead. Specifically FH
significant for: his mother had a stroke and all his
grandparents had MIs. Only living family member is a half-sister
who is obese.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: temp 98.0 PO 123/77 L Sitting HR 82 RR 18 99% RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Amputated right second tarsal, left
callous well healed on left great toe
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: ___ 97.5 132/86 63 20 98 Ra
Weight: 106.9kg admission weight, today's weight 110.7kg
GENERAL: Sitting in chair eating breakfast. 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 no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Hyperkeratotic area consistent with healing ulcer on L great
toe.
PULSES: 2+ peripheral pulses
Pertinent Results:
Admission Labs:
=============
___ 05:45AM BLOOD WBC-7.1 RBC-4.05* Hgb-12.6* Hct-36.3*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.9 RDWSD-42.3 Plt ___
___ 05:45AM BLOOD Glucose-144* UreaN-37* Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-22 AnGap-16
___ 05:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
___ 05:36PM BLOOD ALT-15 AST-21 AlkPhos-102 TotBili-0.6
___ 11:50PM BLOOD %HbA1c-9.5* eAG-226*
___ 11:50PM BLOOD Triglyc-383* HDL-26* CHOL/HD-8.4
LDLcalc-115
Microbiology:
==============
___ CULTURE-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
Discharge Labs:
==============
___ 05:45AM BLOOD WBC-7.1 RBC-4.05* Hgb-12.6* Hct-36.3*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.9 RDWSD-42.3 Plt ___
___ 05:45AM BLOOD Glucose-144* UreaN-37* Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-22 AnGap-16
___ 11:50PM BLOOD CK-MB-5 cTropnT-0.03* proBNP-159
___ 05:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
___ 11:50PM BLOOD %HbA1c-9.5* eAG-226*
___ 11:50PM BLOOD Triglyc-383* HDL-26* CHOL/HD-8.4
LDLcalc-115
___ 11:50PM BLOOD TSH-2.1
Imaging:
========
TTE ___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal basal
inferior hypokinesis. The remaining segments contract normally.
Quantitative (3D) LVEF = 52%. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Dilated aortic root.
CXR ___
In comparison with study of ___, the cardiac
silhouette is at the
upper limits of normal in size or mildly enlarged. However, no
evidence of
acute pneumonia, vascular congestion, or pleural effusion at
this time.
Brief Hospital Course:
___ with hx CAD s/p CABG x5 (___) presenting with dyspnea,
dizziness, and exertional CP, found to have slightly elevated
troponins (0.04 peak) in setting of prerenal ___.
# stable angina:
Patient reported two episodes of chest pain on exertion. Did not
have a pattern of crescendo symptoms. Troponin elevated to 0.04
with negative CK-MB in setting of prerenal ___, felt most likely
demand ischemia. In view of recent negative nuclear perfusion
study ___, ___, catheterization was deferred. His
symptoms improved following IV hydration and he did not have
chest pain with ambulation. He does not currently follow with a
cardiologist and he was advised to discuss cardiology referral
with his PCP.
# Orthostatic hypotension
Primary symptom was exertional presyncope, most concerning for
volume depletion in the setting of poor PO intake and
hyperglycemia. He received 2.5L NS resolution of presyncope.
However, orthostatics were still positive (systolic
120Lying->100Sit->90Stand) but asymptomatic. ___ be ___
autonomic dysfunction from poorly controlled DM or iatrogenic in
setting of metoprolol. Blood pressures were normotensive and he
does not have strong indication for ACE so this was held on
discharge. Metoprolol continued given CAD/Angina.
# ___: Baseline Cr 0.6-0.7, was 1.0-->1.7-->0.9 after 2.5L
hydration yesterday (___). ___ prerenal in the setting of
dehydration. FENa 0.4% also supports pre-renal etiology. (but
this was calculated with urine and serum levels after he was
hydrated). ACE held.
# PFO w/ right to left shunting
identified during intraoperative TEE in ___
# H/O Diabetic foot ulcer
Left posterior great toe chronic nature followed by podiatry
recently seen with no signs of infection. Amputated ___ right
toe with no sinus tract, no drainage well healing.
# Insulin Dependent Type II diabetes: Patient with FSBG 417 upon
presentation to ___, anion gap of 16. Did not look for
ketones in urine. He received 12U regular insulin. Upon arrival
to ___, glucose on Chem10 330, upon arrival to floor ___ 261.
Continued home lantus/Humalog SS regimen.
# Diabetic neuropathy
# Diabetic retinopathy
Blind in left eye from retinal hemorrhage. Cloud vision in right
eye followed by ophthalmology and vision stable for the past
several months. Patient with diabetic neuropathy of the feet
with pins and needles and reduced sensation. 1+ palpable pluses
and cool to touch.
# Bipolar disorder
Patient states he has episodes of depression and times were he
feels maniac. Right now he states his mood is more on the
depressed end of his spectrum. No suicidal ideation. He follows
with ___ in ___ who prescribes his
mediations. Continued oxcarbazepine, sertraline. Unclear if he
is still taking trazodone as this is not on his fill history.
Transitional Issues:
=====================
[] lisinopril held due to orthostatic hypotension.
[] Recommend cardiology referral
[] A1C 9.5. Uptitrate insulin regimen as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 57 Units Bedtime
2. Lisinopril 20 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. MetFORMIN XR (Glucophage XR) 1000 mg PO QAM
5. TraZODone 150 mg PO QHS
6. Sertraline 100 mg PO DAILY
7. OXcarbazepine 300 mg PO BID
8. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
If still having chest pain after 3 tablets (15 minutes), go to
ED immediately
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually q5min Disp
#*100 Tablet Refills:*0
2. Glargine 57 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. MetFORMIN XR (Glucophage XR) 1000 mg PO QAM
4. Metoprolol Tartrate 25 mg PO BID
5. OXcarbazepine 300 mg PO BID
6. Sertraline 100 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. TraZODone 150 mg PO QHS
9. HELD- Lisinopril 20 mg PO BID This medication was held. Do
not restart Lisinopril until you have your blood pressures
checked by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Orthostatic hypotension
Acute kidney injury
Secondary:
Insulin dependent diabetes mellitus
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because of dizziness, a two episodes of chest pain
while walking uphill. We found that you had low blood pressures
and you appeared dehydrated. We gave you IV fluids for hydration
and your symptoms improved and labwork looked better. We did not
believe you were having a heart attack, but it's important to
follow-up with a cardiologist.
IMPORTANT INSTRUCTIONS:
- Remember to stay well hydrated. Drink 64 oz (8 full glasses)
of fluids per day
- STOP taking your lisinopril until you see your doctor for
follow-up. This may be making your blood pressures too low.
- Have your doctor refer you to a cardiologist for follow-up
We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10706489-DS-17
| 10,706,489 | 29,535,261 |
DS
| 17 |
2154-02-22 00:00:00
|
2154-02-22 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fluent aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ RH F with a PMHx of prior
caudate/ant limb IC hemorrhage ___, evaluated at ___, DVM,
R M1 stenosis, R subclavian subcentimeter aneurysm, HTN, and HL
who presents with waxing/waning expressive aphasia.
She was in her USOH until 9 days ago (___) around 9:00am
at which time her daughter-in-law called her and noted that she
was "jumbling words." The daughter informed her husband, who
called the patient 15 minutes later and noted normal speech.
At midnight between the ___ and ___, the patient fell without
head strike or LOC. She could not get up, so she crawled to her
bed. She denies numbness, paresthesias, weakness, or
disequilibrium, and she was able to take a bath and ambulate
without difficulty the following day.
The patient had no further speech deficits until ___
at 4pm, at which time her son called the patient and noted
"sentences not making sense" and "jumbled speech." On further
clarification, the patient and her son agree that she was having
trouble getting words out; she was also using non-words. She did
not have slurred speech. Her son called her back on a different
phone, because the patient claimed she could not hear her son
and that there was something wrong with the phone; however, the
speech deficits remained. Her son told security at the patient's
___ home, and they called and EMT. At 4:30pm,
the EMT called the son to say the patient's speech was normal.
The EMT checked on the patient again, per the son's request, and
then called EMS at 11:10pm because the patient was having
trouble getting words out.
On arrival to ___, her speech was normal. Subsequently,
she developed word finding difficulty. A ___ did not
demonstrate any acute abnormalities (old left basal ganglia
calcification seen), and she was transferred to ___ for CTA.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus. Denies focal weakness, numbness, and
parasthesiae. 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:
Problems (Last Verified - None on file):
-caudate/ant limb IC hemorrhage (___)
-DVA
-R M1 stenosis found in ___
-R subclavian subcentimeter aneurysm
-HTN
-hypercholesterolemia
-skin cancer (?basocellular)
-L sciatica
-?R eye glaucoma
ACTINIC KERATOSIS
EXCORIATION
SEBORRHEIC KERATOSIS
ACTINIC KERATOSIS
DERMATITIS, ECZEMATOUS
Social History:
___
Family History:
father died of stroke in his ___ he also had HTN
Physical Exam:
========================
Admission Physical Exam:
========================
Vitals: T: 97.9F P: 86 R: 26-->14 BP: 152/63 SaO2: 99%RA
General: Awake, cooperative, NAD, mildly anxious.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple
Pulmonary: no WOB
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: ND
Extremities: No C/C/E bilaterally,
Neurologic:
-Mental Status: Alert, oriented to name, place, month, and date
(but not year versus unable to get year out). Limited
historian--for example, said she had a stroke that presented
with bilateral hand weakness, but this is not true per son and
per ___ records and blamed phone for speech problem. However,
she was aware that her speech was not normal and endorsed
difficulty getting words out. Inattentive (versus word finding),
e.g., able to ___ backwards from ___ to ___ but then
stopped and said "one." Difficulty registering ___ words (vs
repetition problem); recall ___ (even with prompting). Language
with speech latency, impaired repetition (able to repeat "Today
is a sunny day" but not "If I were here, she would go there").
Able to do midline and appendicular but not cross-body commands.
Speech not dysarthric.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
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: Diffusely decreased bulk and normal tone. +RUE
pronation. No adventitious movements, such as tremor, noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5* 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
*Give-way weakness
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
===============
Discharge Exam:
===============
MS: awake and alert. attentive to exam. language is fluent and
clear with very rare phonemic paraphasic errors. repeats well
and names well.
CN: symmetric
Motor: ___ throughout
Pertinent Results:
===============
Admission Labs:
===============
___ 02:15AM BLOOD WBC-9.3 RBC-3.90 Hgb-11.8 Hct-35.9 MCV-92
MCH-30.3 MCHC-32.9 RDW-13.4 RDWSD-45.1 Plt ___
___ 02:15AM BLOOD Neuts-70.6 ___ Monos-5.3 Eos-2.6
Baso-0.5 Im ___ AbsNeut-6.54* AbsLymp-1.91 AbsMono-0.49
AbsEos-0.24 AbsBaso-0.05
___ 02:15AM BLOOD ___ PTT-30.4 ___
___ 02:15AM BLOOD Glucose-114* UreaN-43* Creat-1.4* Na-139
K-5.5* Cl-105 HCO3-19* AnGap-21*
___ 02:15AM BLOOD Albumin-4.5 Calcium-10.1 Phos-3.8 Mg-2.0
___ 02:15AM BLOOD ALT-12 AST-26 AlkPhos-98 TotBili-0.2
___ 02:15AM BLOOD cTropnT-<0.01
___ 02:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
============
Stroke Labs:
============
___ 02:24AM BLOOD %HbA1c-5.5 eAG-111
___ 06:47AM BLOOD Triglyc-91 HDL-65 CHOL/HD-3.0 LDLcalc-115
===============
Discharge Labs:
===============
***
========
Imaging:
========
Non-Contrast CT of Head:
- stable dense left basal ganglia calcification is unchanged
since ___
- intracranial vascular calcifications
- no definite large territorial infarct or hemorrhage
- MRI is more sensitive for the evaluation of acute infarct and
can be considered in the appropriate clinical context
CTA H/N:
Overall similar or examination from ___ with chronic
hip bearing, high-grade stenosis of the M1 segment of the right
MCA without any definite new focal abnormality identified.
MRI Brain:
Multiple punctate left MCA distribution frontoparietal and
frontal
operculum acute to late acute infarcts. Left putamen probable
subacute infarct. Grossly stable right MCA M1 occlusion.
Echocardiogram:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. 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:
1) No specific echocardiographic evidence of cardiac source of
embolus seen.
2) Mild left ventricular hypertrophy with normal biventricular
regional/global systolic function in setting of grade II
diastolic dysfunction.
Brief Hospital Course:
Transition issues:
[ ] The patient should be ASA and Plavix for two months follow
by Plavix alone
[ ] The patient's Cr has been fluctuating during her stay. This
should be trended at rehab to ensure resolution/stability
Ms. ___ was admitted to the neurology stroke service to
further evaluate for stroke.
Her brain MRI showed multiple subacute-to-acute punctate
infarcts in the left MCA region (frontoparietal and frontal
operculum). No definitive source of her infarcts was discovered,
but possible etiologies include atheroembolic (especially given
the presence of intracranial atherosclerotic disease) and
cardioembolic (although no atrial fibrillation picked up on our
telemetry monitoring. She had an echocardiogram which showed no
PFO or source for embolism. She will undergo 4 weeks of cardiac
rhythm monitoring as an outpatient with ___ of Hearts
monitor.
Her LDL is elevated despite treatment with atorvastatin 20 mg,
so this was increased to 40 mg daily.
In discussion with our neuroradiologists and reassessing her
current and prior images, there does not appear to be definitive
data to confirm the prior L basal ganglia hemorrhage from ___
-- there is evidence of calcification but no definitive blood
product. The abnormal vessel in the area of the calcification is
consistent with a DVA (developmental venous anomaly), which
carries a very low risk of bleeding.
Overall, we decided to treat her with two months of dual
antiplatelet therapy (ASA 81 mg + Clopidogrel 75 mg) followed by
indefinite Clopidogrel (75 mg).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Atorvastatin 20 mg PO QPM
6. Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*11
2. Aspirin 81 mg PO DAILY Duration: 2 Months
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet by mouth
daily Disp #*60 Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet by mouth bedtime Disp #*30
Tablet Refills:*11
4. amLODIPine 10 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute ischemic infarctions: left temporal lobe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficulty with finding
words resulting from an ACUTE ISCHEMIC STROKE, a condition where
a blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors.
Your risk factors are:
1. High cholesterol
2. High blood pressure
We are changing your medications as follows:
1. INCREASE atorvastatin to 40 mg daily
2. START clopidogrel (Plavix): 75 mg daily
3. DECREASE aspirin from 325 mg daily to 81 mg daily. Take this
for 2 months and then DISCONTINUE
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Followup Instructions:
___
|
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2154-03-19 20:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Bactrim / Penicillins / Doxycycline /
Clindamycin / Ciprofloxacin / Methotrexate / Arava / Plaquenil
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman with hx of Graves disease s/p
partial thyroidectomy, GERD with ___ esophagus and hiatal
hernia who is presenting with diarrhea since ___ with new
onset bloody diarrhea today.
The patient has felt ill for the past 5 days and has had ___
episodes of watery diarrhea, not associated with meals, occuring
at nights. Reports crampy lower abdominal pain with the
sensation of urgency to go to the bathroom. No fever, chills,
nausea, vomiting. No sick contacts or recent travel. No recent
antibiotic use. She has been taking Tylenol/ibuprofen for her
pain for the past 5 days.
Due to these sxs, she went to ___ ED by ambulance two
days ago and was repleted with hydration and electrolytes and
discharged home. She continued having diarrhea and pain in
abdomen after discharge, worse with PO intake and entirely
unable to tolerate PO without significant diarrhea. Noticed new
red clots in stool tonight (does have known hemorrhoids on
cscope ___. Last colonoscopy was ___ years ago and was normal,
but she was not having symptoms at that time.
She also has a significant GI (Dr ___ and rheum (Dr
___ history with reflux, ___, and a polyarthritis
which is felt to be mixed connective tissue disorder NOS.
Finally, she has a complex endocrine hx with post partum
subacute thyroiditis that was initially managed with
methimazole, however led to significant side effects in ___.
Then in ___, she developed thyrotoxicosis from uncontrolled
Grave's disease leading to subtotal thyroidectomy. Since then
she has had difficulty in maintain normal TSH level on
maintenance levothyroxine, with overshoots and undershoots. Most
recently, her endocrinologist at ___ Dr ___ decreased
her dose from 175 to 88mcg about two weeks ago.
In the ED, initial VS were: 97.7 94 125/75 18 100% RA
ED physical exam was recorded as guiaic positive stool, tender
abdomen in RUQ and epigastrium, no rebound or guarding.
ED labs were unremarkable, including CBC, BMP, LFT, lipase, UA,
lactate, UCG
CT a/p showed diffuse colitis, more prominenet in the ascending
and transverse colon.
Patient was given NS
Transfer VS were 98 81 122/56 14 99% RA
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Inflammatory arthritis vs connective tissue disease
Subacute thyroiditis
Grave's disease on methimazole and s/p sub total thyroidectomy
SVT (now asymptomatic)
Severe reflux with ___
Manometry with low LES pressure
Social History:
___
Family History:
Both parents had colitis, mother had diverticulitis
Sister also has diverticulitis
Physical Exam:
Admission Exam:
==================
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: regular rhythm, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, mild epigastric tenderness to palpation, 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
Discharge exam:
================
___
Well appearing, comfortable sitting in bed eating eggs and toast
MMM, OP clear
RRR, no m/r/g
Lungs ctab with good air movement
Abdomen with hyperactive BS, soft, nontender, mild distention,
improved from prior
no joint swelling
no rashes
Oriented x3, appropriate, moving all extremities
Pertinent Results:
Admission Labs:
================
___ 11:50PM URINE HOURS-RANDOM
___ 11:50PM URINE UCG-NEGATIVE
___ 11:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:04PM LACTATE-1.4
___ 09:00PM GLUCOSE-91 UREA N-<3* CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19
___ 09:00PM estGFR-Using this
___ 09:00PM ALT(SGPT)-19 AST(SGOT)-22 ALK PHOS-38 TOT
BILI-0.2
___ 09:00PM LIPASE-50
___ 09:00PM ALBUMIN-4.1
___ 09:00PM WBC-5.4# RBC-4.55 HGB-12.5 HCT-37.9 MCV-83
MCH-27.5 MCHC-33.0 RDW-14.5 RDWSD-44.0
___ 09:00PM PLT COUNT-239
Interval Labs:
===============
___ 07:48AM BLOOD calTIBC-290 Hapto-241* Ferritn-75 TRF-223
___ 07:48AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.8 Iron-33
___ 07:55AM BLOOD TSH-22*
___ 07:55AM BLOOD CRP-47.4*
Micro:
======
Cdiff: negative
Campylobacter culture: Positive for campylobacter jejuni
O&P negative
Vibrio and Yersenia cultures negative
Ecoli culture negative
Shigella and salmonella negative
Imaging:
=========
CT Abdomen/pelvis with contrast ___
1. Pancolitis, more prominent in the ascending and transverse
colon. This is nonspecific and could be infectious or
inflammatory. Ischemic etiologies are considered much less
likely given the extent of involvement.
2. Mild splenomegaly.
Discharge labs:
=================
___ 07:30AM BLOOD WBC-4.8 RBC-4.12 Hgb-11.3 Hct-33.5*
MCV-81* MCH-27.4 MCHC-33.7 RDW-14.4 RDWSD-42.6 Plt ___
___ 07:30AM BLOOD Glucose-89 UreaN-3* Creat-0.7 Na-141
K-3.6 Cl-104 HCO3-24 AnGap-17
___ 07:30AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ year old woman with hx of Graves disease s/p
subtotal thyroidectomy, GERD with ___ esophagus and hiatal
hernia who is presenting with diarrhea since ___ with new
onset clots in stool on ___.
# Diarrhea
# Pancolitis ___ Campylobacter Jejuni infection
Mrs. ___ presented with large volume watery diarrhea
associated with nocturnal symptoms. She was initially seen at
OSH ED and hydrated on ___ however given persistent abdominal
pain and diarrhea with clots in stool, presented to ___ ED on
___. She reported low grade fevers as well and was found on CT
scan to have pancolitis. Given her symptoms with acute onset,
low grade fevers and sick contacts at work, symptoms felt most
likely due to infectious colitis. GI was consulted and agreed
that this was most likely. She was treated with supportive care
including fluids and pain control and diet was slowly advanced.
Given prolonged symptoms, she was started on levofloxacin on
___ with plan for 5 day course. Prior to discharge, her stool
culture returned positive for campylobacter jejuni infection.
#Anemia: Patient with new mild anemia this admission since
normal CBC in ___. Iron studies notable for mild iron
deficiency (possibly related to bloody stools with this
infection) and reticulocyte count notably low suggesting low
bone marrow production. Will need repeat CBC as outpatient and
consideration of further work-up pending resolution of her
diarrhea.
# Hypothyroidism: In the setting of subtotal thyroidectomy for
Grave's disease. Recent decrease in levothyroxine dose from
175mcg to 88mcg. She had TSH checked this admission and it was
elevated at 22 though this is difficult to interpret in setting
of recent dosage change and acute illness. Patient discussed
with her outpatient endocrinologist prior to discharge who
recommended increasing back to prior dose of 175mcg daily. Will
need repeat TSH in outpatient setting in ___ weeks.
# GERD: Continued home omeprazole and ranitidine.
Transitional Issues:
======================
[]Patient with pancolitis on CT scan this admission, treated
with 5 days levofloxacin. Please consider repeat CT scan or
colonoscopy in ___ weeks to assess resolution
[]Given constellation of symptoms of joint pain with apthous
ulcers, concern for rheumatologic disease, possible Behcet's
syndrome. Please refer to rheumatology in outpatient setting
[]Please repeat CBC in ___ weeks to ___ new anemia
[]F/u final stool cultures
[]f/u lactoferrin from stool
[]Continue levofloxacin through ___
[]Levothyroxine increased to 175mcg daily per patient discussion
with endocrine outpatient given TSH of 0.22
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Omeprazole 20 mg PO BID
3. Ranitidine 150 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
do not take more than 3grams daily
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. Ranitidine 150 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Infectious pancolitis
Hypothyroidism
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 diarrhea and abdominal
pain. You had a CT scan which showed inflammation in the colon.
Given your sudden onset of diarrhea with low grade fevers, your
symptoms were felt to be due to an infection in your colon. You
were treated with fluids, bowel rest and an antibiotic called
levofloxacin with improvement in your symptoms. You were seen by
the GI team who did not feel that there was any need for
additional testing in the hospital. Please continue taking
levofloxacin through ___.
In terms of your overall symptoms over the last several months,
there is concern for an underlying autoimmune disease causing
your symptoms. Please discuss with Dr. ___
rheumatologic ___.
You were found to have an elevated TSH (thyroid level) in the
hospital. While this is difficult to interpret in the setting of
illness, your endocrinologist recommended restarting your prior
levothyroxine dosing of 125mcg daily.
Finally, you were noted to have anemia (low red blood cell
count) on this admission. Your had evidence of mildly low iron
stores. Given your GI symptoms, you were not started on iron
this admission. Please discuss with your primary care physician
regarding starting iron supplements and additional work-up when
you ___ with him.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Bactrim / Penicillins / Doxycycline /
Clindamycin / Ciprofloxacin / Methotrexate / Arava / Plaquenil /
methimazole
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP on ___ (prior to admission)
History of Present Illness:
___ female with history of Behcet's w patient has
had ith associated possible ileitis, ampullary stenosis status
post sphincterotomy who presents with abdominal pain immediately
after an ERCP. several months of persistent abdominal pain. She
was recently found to have possible ileitis for which she was
started on oral budesonide. She also had an ERCP on ___.
Immediately after the ERCP, patient reported epigastric pain
which is sharp and radiates into her back (and at times upwards
and downwards from epigastrum), it is described as aching and
sharp and squeezing. the ache is constant and worse with lying
flat or with p.o. or movement. It is nonpleuritic. She denies
fevers but has some chills. Different from her recent and
chronic abdominal pains in that it is much more severe and the
radiation pattern is atypical for her normal. She has nausea and
vomiting of nonbloody nonbilious emesis. She has had one
episode
of loose stool which was also nonbloody. She denies chest pain
or shortness of breath. She denies facial or arm paresthesias.
She denies dysuria or urinary urgency. She endorses decreased
urinary output. After eating her ERCP, she reported the
symptoms
but was told that it was most likely gas. She went home. She
felt that the pain progressed at home, and she came into the
emergency room on ___ evening.
In the emergency room, her initial vitals were 98.8 85 153/85
100%RA. She was noted to have abdominal pain and appeared
hypovolemic. Her lipase was elevated as below. She had a CT as
below. She was seen by the ERCP team who recommended admission
for post ERCP pancreatitis. She received 4 L IVF (3L of which
were LR), Zofran and opiates.
ROS: Endorses headache which has been going on for a couple days
now, palpitations (which she gets when she is hypovolemic), and
since arrival to the emergency room and hydration some lower
extremity edema and weight gain of approximately 10 pounds. She
denies orthopnea, PND. Her last stress test was about a year
ago
and was normal per her report. Positive or negative as above,
otherwise negative in 12 systems
Past Medical History:
Bechets (recently diagnosed, as has been previously thought to
be
SLE v MCTD v other)
ileitis on MRE, presumed ___ Bechets
GERD
gastritis
gastric polyp
___ esophagus
ampullary site stensosi s/p sphincterotomy ___
Grave's s/p thyroid resection
ovarian dermoid cyst
SVT (rare, occurs only when dehydrated, not on any therapy)
vit D def
tubal ligation
pre-eclampsia
HELLP
Social History:
___
Family History:
Myeloma, prostate cancer, ulcerative colitis, celiac disease,
___ Disease (mother)
Physical Exam:
Admission exam:
=================
Constitutional: VS reviewed, not acutely ill but uncomfortable
HEENT: eyes anicteric, normal hearing, nose unremarkable without
grossly visible ulcers, MMM, slight bruising at site of EGD but
no oral ulcers
CV: RRR no mrg, JVP 9cm
Resp: CTAB
GI: soft, ttp moderately over epigastrum, less so over RUQ and
LUQ, no rebound, very quiet bowel sounds, dullness at ___
but not able to assess spleen properly ___ tenderness
GU: no foley
MSK: no obvious synovitis
Ext: wwp, trace edema in BLEs
Skin: no rash grossly visible
Neuro: A&Ox3, EOMI, PERRL, no droop, ___ BUE/BLE, SILT BUE/BLE
Psych: normal affect, pleasant
.
.
Discharge exam:
================
VS: reviewed
___ 0733 Temp: 97.6 PO BP: 117/78 Lying HR: 61 RR: 17 O2
sat: 97% O2 delivery: Ra
Gen: NAD
HEENT: EOMI, PERRL, anicteric sclera
CV: RR, no mrg
Resp: CTAB
GI: soft, no longer tender to palpation over epigastrum and RUQ,
also not tender to palpation in lower abdomen, no rebound, bowel
sounds present
Ext: WWP, grossly normal strength, trace edema in BLEs
Skin: no jaundice or large rashes
Neuro: A&Ox3, clear speech, conversant, stable gait observed
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS:
===============
___ 08:06PM BLOOD WBC-16.6* RBC-4.62 Hgb-12.1 Hct-37.9
MCV-82 MCH-26.2 MCHC-31.9* RDW-15.0 RDWSD-45.1 Plt ___
___ 08:06PM BLOOD Neuts-85.6* Lymphs-7.1* Monos-6.0
Eos-0.2* Baso-0.3 Im ___ AbsNeut-14.22* AbsLymp-1.18*
AbsMono-1.00* AbsEos-0.03* AbsBaso-0.05
___ 08:06PM BLOOD Glucose-141* UreaN-10 Creat-0.8 Na-141
K-4.3 Cl-101 HCO3-27 AnGap-13
___ 08:06PM BLOOD ALT-134* AST-214* AlkPhos-63 TotBili-1.1
___ 08:06PM BLOOD Lipase-3444*
___ 10:20AM BLOOD cTropnT-<0.01
___ 08:06PM BLOOD Albumin-4.5
___ 08:06PM BLOOD HCG-<5
___ 10:37AM BLOOD Lactate-1.5
.
.
MICRO:
=========
-___ UCx: mixed bacterial flora (final)
.
.
IMAGING:
========
-___ CT a/p w/ contrast:
IMPRESSION:
1. Normal pancreas. Punctate foci of air in the extrahepatic
biliary tree is likely postprocedural.
2. Apparent colonic wall thickening in the descending colon and
at the hepatic flexure without significant surrounding fat
stranding is likely related to collapsed loops of colon.
3. Unchanged mild splenomegaly.
-___ ERCP:
Impression: The scout film showed surgical clips in the RUQ
consistent with the history of cholecystectomy.
Evidence of a previous sphincterotomy was noted at the major
papilla.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with a 0.035in guidewire. Contrast was
injected and there was brisk flow through the ducts. Contrast
extended to the entire biliary tree.
Contrast injection revealed a normal sized biliary tree (9 mm)
with no filling defect, no stricture.
Given the suspicion of ampullary stenosis, a biliary
sphincteroplasty was successfully performed using a 8-10mm CRE
balloon up to 9mm. A waist was seen fluoroscopically.
The biliary tree was then swept with a 9-12mm balloon starting
at the bifurcation. Sludge was successfully removed.
The CBD and CHD were swept repeatedly.
The final occlusion cholangiogram showed a normal appearing
biliary tree.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically. I supervised the acquisition and
interpretation of the fluoroscopic images. The quality of the
fluoroscopic images was good.
.
.
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-5.7 RBC-4.20 Hgb-11.1* Hct-34.5
MCV-82 MCH-26.4 MCHC-32.2 RDW-15.3 RDWSD-45.3 Plt ___
___ 07:35AM BLOOD ___
___ 07:20AM BLOOD Glucose-110* UreaN-3* Creat-0.8 Na-142
K-3.7 Cl-104 HCO3-28 AnGap-10
___ 07:20AM BLOOD ALT-210* AST-28 AlkPhos-67 TotBili-0.4
___ 07:20AM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.4 Mg-1.8
Brief Hospital Course:
# Post-ERCP pancreatitis with:
# n/v: resolved
# abd pain: resolved
# oliguria: resolved
# transaminitis: resolving
Most likely etiology is post ERCP pancreatitis given timing,
lipase, LFT abnormalities. No gallstones, no need to check TGs
and does not drink etoh. Unlikely primary hepatitis given the
timing. Doubt pericarditis given EKG (despite rheum hx and
possible positional nature) or cardiac etiology (given negative
stress, EKG, history) or pulmonary etiology given history and
exam.
- s/p 4L IVF in ED
- ERCP team evaluated the patient daily while she remained
hospitalized
- treated conservatively with gradual improvement
- she was tolerating full liquid diet on day of discharge with
no abdominal pain, nausea, or vomiting, and no tenderness to
palpation on exam
- patient instructed to gradually re-introduce solid foods into
her diet as tolerated
# Anemia: stable
# palpitations
# SVT:
Likely recent sxs are related to hypovolemia per her usual. EKG
was unremarkable. No events on tele.
# Equivocal UA: specimen was very concentrated (sp gr > 1.05)
and only 7 WBCs, not a significantly positive UA. UCx grew MBF.
No abx given.
# GERD
# ___
# hiatal hernia
- was given IV PPI and H2 blocker while she was NPO,
transitioned back to home regimen prior to discharge
# ___'s
# Hx of ileitis
- continued home budesonide, colchicine held while she was NPO
to avoid causing esophagitis/gastritis
- no evidence of ileitis on initial CT abd/pelvis
# vit d deficiency
# grave's s/p resection
- continued home vit d, LT4
# incidental findings: splenomegaly, chronic, likely ___ rheum
condition
.
.
.
Time in care:
[x] Greater than 30 minutes in discharge-related activities on
the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Vitamin D ___ UNIT PO 1X/WEEK (WE)
4. Levoxyl (levothyroxine) 150 mcg oral DAILY
5. Omeprazole 20 mg PO Q12H
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Ranitidine 150 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO DAILY
4. Budesonide 9 mg PO DAILY
5. Colchicine 0.6 mg PO DAILY
6. Levoxyl (levothyroxine) 150 mcg oral DAILY
7. Omeprazole 20 mg PO Q12H
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Ranitidine 150 mg PO BID
10. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
Post-ERCP pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the hospital after a planned procedure
(ERCP) was complicated by inflammation of the pancreas causing
abdominal pain. ___ were treated with bowel rest, IV fluids,
pain medications, and gradual advancement of your diet. At home
___ can continue to advance your diet from full liquids
gradually back to normal.
We wish ___ a full and speedy recovery!
Sincerely,
Dr. ___ the ___ Medicine Team
Followup Instructions:
___
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2156-05-14 18:09:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Bactrim / Penicillins / Doxycycline /
Clindamycin / Ciprofloxacin / Methotrexate / Arava / Plaquenil /
methimazole / Keflex
Attending: ___.
Chief Complaint:
FTT, epigastric pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___ Behcet's, Crohn's disease on
Remicade and steroids presenting with abdominal pain.
The patient has recently had worsening abdominal pain, diarrhea,
and rectal bleeding. She was seen at ___ and reported had a
normal CT scan with stable changes in the distal ileum. She was
subsequently seen by her gastroenterologist on ___, and she was
switched from budesonide to prednisone and planned for
colonoscopy. She underwent the colonoscopy on ___, which showed
normal mucosa in the colon and ileum.
The patient reports that her diarrhea and rectal bleeding have
improved. However, over the past two weeks she has developed
worsening epigastric pain. She describes this as an intermittent
squeezing sensation. The pain lasts minutes to hours and then
abates. However, it has gotten progressively more painful and is
now continuous. The pain awakens her from sleep. No clear
relationship to eating; she placed herself on a clear liquid
diet and this did not help. She feels that this pain is worsened
by movement. No fevers or chills. Nausea but no vomiting. Other
than the prednisone change noted above, no recent medication
changes. She gets intermittent oral and vaginal ulcers but
denies any currently. She endorses a 60 pound weight loss since
___. Given her ongoing symptoms, she presented to the ED for
further evaluation.
In the ED, vitals: 98.2 100 134/99 20 100% RA Exam: Mild to
moderate epigastric tenderness to palpation. Labs notable for:
WBC 14, Hb 12.9, plt 436; BMP, LFTs wnl; trop<0.01x1 Patient
given: morphine 4 mg IVx3, Zofran 4 mg IV x2, omeprazole 20 mg,
prednisone 15 mg, ranitidine 150 mg, Maalox, donnatol 10 mL,
viscous lidocaine, famotidine 20 mg IV
On arrival to the floor, the patient states that her pain is
improved and that hot packs are helping.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Bechet's
Crohn's disease with TI
___ esophagus
Gastritis
Gastric polyp
Ampullary site stensosi s/p sphincterotomy ___
___'s s/p thyroid resection
Ovarian dermoid cyst
SVT (rare, occurs only when dehydrated, not on any therapy)
Vitamin D deficiency
S/p tubal ligation
Pre-eclampsia
HELLP
Social History:
PAST MEDICAL/SURGICAL HISTORY:
Bechet's
Crohn's disease with TI
___ esophagus
Gastritis
Gastric polyp
Ampullary site stensosi s/p sphincterotomy ___
Grave's s/p thyroid resection
Ovarian dermoid cyst
SVT (rare, occurs only when dehydrated, not on any therapy)
Vitamin D deficiency
S/p tubal ligation
Pre-eclampsia
HELLP
SOCIAL HISTORY:
___
Family History:
FAMILY HISTORY: Per OMR:
Myeloma, prostate cancer, ulcerative colitis, celiac disease,
___ Disease (mother)
Physical Exam:
ADMISSION:
=========
VITALS: 97.9 135/87 65 18 96 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; no oral
ulcers
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation in
midepigastrium. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
DISCHARGE:
=========
VS: ___ 0724 Temp: 98.3 PO BP: 117/74 HR: 65 RR: 18 O2 sat:
97% O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB
GI: Abdomen soft, non-distended, mildly tender to palpation in
midepigastrium. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: Very pleasant, appropriate affect
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 12:04PM BLOOD WBC: 14.1* RBC: 5.39* Hgb: 12.9 Hct: 42.3
MCV: 79* MCH: 23.9* MCHC: 30.5* RDW: 16.5* RDWSD: 46.5* Plt Ct:
436*
___ 12:04PM BLOOD Neuts: 79.2* Lymphs: 14.1* Monos: 4.8*
Eos: 0.6* Baso: 0.2 Im ___: 1.1* AbsNeut: 11.11* AbsLymp: 1.98
AbsMono: 0.68 AbsEos: 0.09 AbsBaso: 0.03
___ 12:59PM BLOOD ___: 10.3 PTT: 25.8 ___: 0.9
___ 12:04PM BLOOD Glucose: 104* UreaN: 10 Creat: 0.9 Na:
137
K: 3.8 Cl: 97 HCO3: 24 AnGap: 16
___ 12:04PM BLOOD ALT: 21 AST: 17 AlkPhos: 37 TotBili: 0.4
___ 12:04PM BLOOD Lipase: 41
___ 12:04PM BLOOD cTropnT: <0.01
___ 12:04PM BLOOD proBNP: 45
MICRO:
=====
none
IMAGING/OTHER STUDIES:
======================
- CTA torso (___):
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
Specifically, no evidence of dissection.
2. Few fluid-filled loops of small bowel demonstrate mild wall
enhancement, findings which can be seen in the setting of
gastroenteritis.
3. Enlarged fibroid uterus.
- CXR (___): IMPRESSION: No acute cardiopulmonary process.
LABS AT DISCHARGE:
=================
___ 07:40AM BLOOD WBC-8.8 RBC-4.76 Hgb-11.5 Hct-37.4
MCV-79* MCH-24.2* MCHC-30.7* RDW-16.1* RDWSD-46.4* Plt ___
___ 07:40AM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-139
K-4.6 Cl-99 HCO3-32 AnGap-8*
___ 07:40AM BLOOD Calcium-9.5 Phos-5.0* Mg-2.4
___ 07:40AM BLOOD TSH-0.23*
___ 07:00AM BLOOD Free T4-2.0*
___ 07:00AM BLOOD ___ dsDNA-PND
___ 07:00AM BLOOD SM ANTIBODY-PND
___ 07:00AM BLOOD RNP ANTIBODY-PND
___ 07:00AM BLOOD ANTI-HISTONE ANTIBODY-PND
Brief Hospital Course:
Ms. ___ is a ___ Behcet's, Crohn's disease on
Remicade and steroids presenting with abdominal pain.
# Abdominal pain
# Behcet's
# Crohn disease with TI
Patient presenting with progressively worsening epigastric
abdominal pain. Given therapy with prednisone and Remicade,
esophagitis was a consideration. Patient also with history of
gastritis with metaplasia. However, EGD overall normal and does
not seem to explain her current symptoms. Recent colonoscopy
without evidence of active Crohn disease, so this is also less
likely. Low suspicion for primary cardiac/pulmonary etiology
given lack of risk factors, reproducibility of pain on exam, EKG
without ischemic changes, trop negative, and CTA negative. Given
extensive GI workup, likely significant etiology is function
dyspepsia with visceral hypersensitivity and/or mixed IBS. The
latter is supported with cycles of diarrhea and constipation
with expected relief from defecation. Some symptoms with
features of gastroparesis and emptying could be considered in
the outpatient setting. Patient followed by GI during her stay
who emphasized management of symptoms as the cornerstone of her
care rather than ongoing testing. There was an emphasis on
ensure patient had normal bowel movements. She was reassured
multiple times that no concerning pathology was identified, but
also acknowledging that her symptoms were very distress. She
will require ongoing close management with her outpatient GI
doctor and PCP. She was given 3 tabs of oxycodone 5 mg to use
only for severe abdominal pain. She was also prescribed a trial
of amitriptyline 25 mg qhs for functional abdominal pain. She
was prescribed a bowel regimen for her constipation.
# Chronic arthralgias/myalgias:
Possibly extraintestinal manifestation of IBD. No obvious
synovitis on exam. CRP reassuringly low. Patient correlates
worsening of symptoms to starting remicade for Bechets. While
rare, drug induced lupus has been associated with some TNF-alpha
agents including infliximab. Though considered unlikely basic
rheum workup obtained with ___, dsDNA, and including
anti-histone antibodies (a more specific marker for DIL). These
results were pending on discharge.
# Grave's s/p thyroid resection:
Continued levothyroxine. Repeat TSH slightly low at 0.23 and FT4
slightly high at 2.0. She is not endorsing symptoms of
hyperthyroidism and does not appear hyperthyroid on exam.
# GERD -Continue omeprazole
TRANSITIONAL ISSUES:
=================
[ ] Consider titrating levothyroxine as an outpatient.
[ ] F/u response to amitriptyline
[ ] Rheum workup pending
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Headache
2. DICYCLOMine 20 mg PO BID:PRN Stomach cramps
3. Levoxyl (levothyroxine) 125 mcg oral DAILY
4. Omeprazole 20 mg PO Q12H
5. PredniSONE 15 mg PO BID
6. InFLIXimab 500 mg IV Q8WEEKS
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
RX *amitriptyline 25 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
2. Bisacodyl ___AILY:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 tab rectally once a day Disp #*12
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet(s) by
mouth once a day Disp #*14 Packet 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 650 mg PO Q4H:PRN Headache
8. DICYCLOMine 20 mg PO BID:PRN Stomach cramps
9. InFLIXimab 500 mg IV Q8WEEKS
10. Levoxyl (levothyroxine) 125 mcg oral DAILY
11. Omeprazole 20 mg PO Q12H
12. PredniSONE 15 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
# epigastric abdominal 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 at the ___
___. You were admitted for epigastric abdominal pain.
Due to your Bechet's and immunosuppressive therapy, you
underwent EGD which did not reveal any evidence of ulcers,
infection, or other concerning findings. Your pain is likely due
to functional dyspepsia with visceral hypersensitivity as well
as severe irritable bowel syndrome. The cornerstone of treatment
is focused on relieving symptoms. It is very important that you
have regular bowel movements to prevent flares of pain and bowel
dysmotility. You have a follow up appointment with your
Gastroenterologist on ___ to discuss the plan moving forward.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10706853-DS-7
| 10,706,853 | 24,895,259 |
DS
| 7 |
2135-07-11 00:00:00
|
2135-07-12 07:53:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor-vehicle accident w/ C4-6 c-spine fx, grade 5 splenic lac
s/p embolization, L ___ rib fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with unknown medical history involved in
rollover MVC earlier today. Per medical records, patient was
restrained with airbag deployment and prolonged extrication.
Patient brought to ___ and underwent
emergent ___ embolization of Grade V splenic laceration and
transferred to ___ for continued care and management.
Neurosurgery Spine consulted for cervical spine fractures. Found
to have C4-6 c-spine fx, grade 5 splenic lac s/p embolization, L
___ rib fractures.
Past Medical History:
Some history of opioid abuse, none otherwise
No surgical history
Social History:
___
Family History:
Noncontributory
Physical Exam:
Discharge Physical Exam:
Vitals - T 98.4 / BP 111/62 / HR 108 / RR 18 / 94%RA
HEENT - normocephalic, moist mucous membranes, PERRLA, EOMI
Neck - cervical collar in place
Cardiac - RRR, no M/R/G
Chest - CTAB, left chest wall tenderness
Abdomen - soft, nontender, nondistended
GU - Foley in place
Extremities - sensorimotor function intact in all 4 extremities,
ROM intact
Neuro - A&OX3
Pertinent Results:
Labs Results:
CBC:
___ 06:25AM BLOOD WBC-15.7* RBC-3.11* Hgb-9.7* Hct-29.5*
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.6 RDWSD-48.6* Plt ___
___ 06:35AM BLOOD WBC-13.8* RBC-3.08* Hgb-9.5* Hct-29.0*
MCV-94 MCH-30.8 MCHC-32.8 RDW-14.3 RDWSD-47.0* Plt ___
___ 06:20AM BLOOD WBC-13.5* RBC-2.93* Hgb-9.3* Hct-27.2*
MCV-93 MCH-31.7 MCHC-34.2 RDW-14.0 RDWSD-46.0 Plt ___
___ 06:50AM BLOOD WBC-14.6* RBC-2.82* Hgb-8.8* Hct-26.3*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.7 RDWSD-45.2 Plt ___
___ 07:39AM BLOOD WBC-11.4* RBC-2.77* Hgb-8.8* Hct-26.5*
MCV-96 MCH-31.8 MCHC-33.2 RDW-13.7 RDWSD-46.5* Plt ___
___ 06:40AM BLOOD WBC-10.8* RBC-2.48* Hgb-7.7* Hct-23.5*
MCV-95 MCH-31.0 MCHC-32.8 RDW-13.5 RDWSD-45.8 Plt ___
___ 02:45AM BLOOD WBC-13.0* RBC-2.53* Hgb-7.9* Hct-23.3*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.6 RDWSD-45.8 Plt ___
___ 01:21AM BLOOD WBC-12.4* RBC-2.44* Hgb-7.6* Hct-22.2*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.5 RDWSD-44.4 Plt ___
___ 06:08PM BLOOD WBC-13.7* RBC-2.57* Hgb-8.1* Hct-23.4*
MCV-91 MCH-31.5 MCHC-34.6 RDW-13.4 RDWSD-44.5 Plt ___
___ 02:15PM BLOOD WBC-13.9* RBC-2.55* Hgb-8.1* Hct-23.0*
MCV-90 MCH-31.8 MCHC-35.2 RDW-13.3 RDWSD-43.7 Plt ___
___ 01:53AM BLOOD WBC-15.5* RBC-2.50* Hgb-7.7* Hct-22.7*
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.2 RDWSD-43.7 Plt ___
___ 10:00PM BLOOD WBC-15.2* RBC-2.76* Hgb-8.6* Hct-24.8*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.6 RDWSD-45.0 Plt ___
___ 04:01PM BLOOD WBC-12.9* RBC-3.08* Hgb-9.5* Hct-27.7*
MCV-90 MCH-30.8 MCHC-34.3 RDW-13.6 RDWSD-44.2 Plt ___
___ 10:57PM BLOOD WBC-17.2* RBC-4.11* Hgb-12.7* Hct-37.6*
MCV-92 MCH-30.9 MCHC-33.8 RDW-13.5 RDWSD-45.4 Plt ___
___ 08:15PM BLOOD WBC-17.8* RBC-3.57* Hgb-11.2* Hct-33.6*
MCV-94 MCH-31.4 MCHC-33.3 RDW-13.4 RDWSD-46.1 Plt ___
BMP:
___ 06:35AM BLOOD Glucose-93 UreaN-17 Creat-0.5 Na-138
K-4.3 Cl-100 HCO3-24 AnGap-18
___ 06:40AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-137
K-4.1 Cl-99 HCO3-24 AnGap-18
___ 02:45AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-137 K-4.1
Cl-101 HCO3-25 AnGap-15
___ 01:21AM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-134
K->10.0* Cl-97 HCO3-20*
___ 02:15PM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-134 K-4.0
Cl-100 HCO3-25 AnGap-13
___ 01:53AM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-134
K-3.9 Cl-101 HCO3-26 AnGap-11
___ 03:04AM BLOOD Glucose-124* UreaN-15 Creat-0.9 Na-137
K-5.1 Cl-104 HCO3-21* AnGap-17
___ 10:57PM BLOOD Glucose-125* UreaN-16 Creat-0.9 Na-138
K-5.0 Cl-107 HCO3-21* AnGap-15
Imaging Results:
TRAUMA #3 (PORT CHEST ONLY)Study Date of ___ 8:06 ___
IMPRESSION:
Displaced fractures of at least the left lateral eighth and
ninth ribs.
Subtle left base opacity could be due to atelectasis, but
underlying pulmonary
contusion is difficult to exclude.
Enteric tube courses below the diaphragm, but appears to
terminate in the very
proximal stomach/distal GE junction. Recommend advancement so
that it is well
within the stomach.
Low lung volumes.
KNEE (AP, LAT & OBLIQUE) BILAT PORTStudy Date of ___
8:36 ___
IMPRESSION:
No acute fracture or dislocation of the bilateral knees.
CHEST (PORTABLE AP)Study Date of ___ 3:57 AM
IMPRESSION:
1. Endotracheal tube terminates approximately 4.5 cm above the
carina.
2. Retrocardiac opacity likely represents atelectasis.
MR CERVICAL SPINE W/O CONTRASTStudy Date of ___ 1:13 ___
IMPRESSION:
1. Edema anterior to the posterior longitudinal ligament from C2
through C3
level, is suggestive of underlying ligamentous injury.
2. Edema anterior to the C3 through 5 vertebral bodies may
reflect underlying
anterior longitudinal ligamentous injury.
3. There is no evidence of cervical spinal cord signal
abnormality to indicate
spinal cord edema or cord expansion.
CT CHEST W/O CONTRASTStudy Date of ___ 9:06 AM
IMPRESSION:
1. Status post embolization of grade 5 splenic laceration, no
signs of active
extravasation. Stable hemoperitoneum
2. Stable fractures of left-sided ribs ___ and chest wall
hematoma
3. Hemothorax and bilateral lower lobe collapse, with no
evidence of
pneumothorax.
CHEST (PORTABLE AP)Study Date of ___ 5:16 AM
IMPRESSION:
Compared to chest radiographs ___ through ___.
Patient has been extubated and lungs are low in volume with
substantial
increases in bibasilar atelectasis. Moderate bilateral pleural
effusions are
also larger. Cardiac silhouette is normal but larger and
mediastinal veins
are more engorged, both findings exaggerated by supine
positioning..
Brief Hospital Course:
Mr. ___ is a ___ who suffered a motor-vehicle collision on
___ and brought to the ___ in critical
condition. He was found to have suffered C4-6 c-spine fractures,
grade 5 splenic laceration which was embolized at ___
___, and left ___ rib fractures. He was
initially intubated and cared for in the intensive care unit,
and then successfully extubated. His Hct decreased to 21 and so
he was transfused 1u pRBC and his Hct responded appropriately. A
CTA of his torso was obtained which demonstrated no active
extravasation. He developed some urinary retention which was
treated by Foley placement, he was followed by Urology and
instructed to be discharged with the Foley catheter and then
follow-up with Urology as an outpatient for removal within 1
week. Acute pain service was consulted for advice regarding his
pain management given his prior history of opioid abuse. Social
work was involved to assist with setting him up for treatment
clinic. He has an appointment scheduled with Dr. ___ on
___, office located on ___, ___ to get
set up for opioid treatment. He has follow-up scheduled with
Urology for next week for Foley catheter removal, Neurosurgery
Spine in 4 weeks, and Acute Care Surgery in ___ weeks. He was
instructed to follow-up with his PCP in ___ for weaning of
opioid medication use. The patient expressed understanding and
agreement with the discharge instructions and plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*60 Tablet Refills:*0
2. Calcium Carbonate 500 mg PO QID:PRN heart burn
RX *calcium carbonate [Calcium 600] 600 mg calcium (1,500 mg) 1
tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0
3. 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
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
5. Naloxone 4 mg IN ONCE Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 4 mg IH as needed for
opioid use Disp #*30 Spray Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 15 mg 1 tablet(s) by mouth every 3 hours Disp #*60
Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone 30 mg 1 tablet(s) by mouth every 12 hours Disp
#*20 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*0
10. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
11. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth daily Disp
#*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C4-6 c-spine fractures
Grade 5 splenic laceration s/p embolization at OSH
Left ___ rib fractures
Opioid dependency
Urinary Retention
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 ___ here at ___. ___ suffered
a motor-vehicle collision on ___ and was brought to the
___ in critical condition. ___ were found to
have suffered C4-6 cervical-spine fractures, left ___ rib
fractures, and a splenic laceration. ___ were initially
intubated and cared for in the intensive care unit, and then
successfully extubated. Your blood level decreased slightly and
so ___ were given a transfusion. Imaging was obtained which
demonstrated no new bleeding. ___ developed some urinary
retention which was treated by catheter placement, ___ were
followed by Urology and instructed to be discharged with the
catheter and then follow-up with Urology as an outpatient for
removal within 1 week. Acute pain service was consulted for
advice regarding your pain management. Social work was involved
to assist with setting ___ up for opioid treatment clinic.
___ have an appointment scheduled with Dr. ___ on ___, office located on ___, ___ for opioid
treatment. ___ have follow-up appointments set up with Urology,
Neurosurgery Spine, and Acute Care Surgery at ___. The contact
information is provided below. It is important that ___
follow-up with your Primary Care Physician as well to assist
with weaning your opioid medication use.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ 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.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ 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.
___ 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
___.
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 ___ follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10707442-DS-15
| 10,707,442 | 26,761,736 |
DS
| 15 |
2144-02-29 00:00:00
|
2144-02-29 21:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M hx of COPD, HTN, distant stroke, p/w SAH from OSH.
Family reports that patient started acting odd at 7pm yesterday
evening. He was walking around in his underwear, started trying
to eat dinner prior to being served, and later his speech became
slurred. He complained of a headache, and then became
unresponsive. He was intubated by EMS and taken to ___. Found to have small left posterior parietal
and occipital SAH with significant hypertension with SBPs to
230s. Started on antihypertensives and transferred to ___ for
neurosurgical work-up/intervention. Patient admitted to SICU
with Neurosurg managed using precedex for sedation and ___
drip for blood pressure. Extubated ___ ___. Due to AMS and SAH,
patient had EEG for 24 hours which was negative for seizures or
status. Patient had MRA which showed no vascular abnormality or
evidence of stroke. On ___, patient was noted to be agitated. He
was delirious and weaned off precedex to zyprexa and prn haldol.
Patient was doing well on ___ until he developed significant
urine output to 500cc/hr for at least 7 hours. Given concern for
diabetes insipidus (possibly related to report of prior lithium
use, no longer taking), endocrine was consulted who felt this
was most likely osmotic diuresis given iso-osmolar urine to
serum osms and no clear reason for DI. They recommended UOP
monitoring q4-6 hours, serum sodium q8h and ongoing D51/2NS with
stress dose steroids if decompensating.
Patient's course was also complicated by C diff positive stool
started on flagyl ___. Also with concern for alcohol withdrawal
based on agitation and family report of heavy gin drinking prior
to admission. Patient treated with IV ativan thus far for
withdrawal. Given multiple medical issues, patient transferred
to medicine for further management.
On transfer, vitals were 98.2F, 148/84, 92, 18, 100/ra. Patient
continued to be confused and delirious and endorsed frustration
with Flexiseal and Foley. Difficult to obtain further history
given patient's confused state.
ROS: per HPI, unable to get coherent ROS. Has mild cough.
Past Medical History:
COPD, HTN, BPH, distant stroke (in ___, ___ yrs ago),
Psychiatric history (details unknown)
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam
VS - Temp 98.2 F, BP 148/84, HR 92, R 18, O2-sat 100% RA
___: lying in bed with wrist restraints in place, responds
to questions
HEENT: PERRL. no scleral icterus, OP clear.
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Skin: no rashes.
Neuro: Memory intact. CN II-XII intact. Facial musculature
symmetric. Sensory function intact. ___ ___ strength, unable to
assess for UE strength
Mental Status: A+Ox1.5 (name ___, place ___,
year ___, attentive. Cannot do days of week backwards, serial
7s from 100; poor insight/judgment
Discharge Physical Exam
Pertinent Results:
ADMISSION LABS
=========================
___ 08:35AM GLUCOSE-108* UREA N-17 CREAT-1.1 SODIUM-145
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-25 ANION GAP-16
___ 08:35AM CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-1.9
___ 08:35AM WBC-10.6 RBC-5.13 HGB-13.6* HCT-43.0 MCV-84
MCH-26.5* MCHC-31.7 RDW-14.6
___ 08:35AM PLT COUNT-171
___ 12:29AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-491*
PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 AADO2-190 REQ O2-40
-ASSIST/CON INTUBATED-INTUBATED
___ 12:10AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:10AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:10AM URINE HYALINE-2*
___ 12:10AM URINE MUCOUS-RARE
___ 12:00AM estGFR-Using this
___ 12:00AM estGFR-Using this
___ 12:00AM LIPASE-52
___ 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:00AM WBC-10.8 RBC-5.43 HGB-14.6 HCT-45.6 MCV-84
MCH-26.8* MCHC-31.9 RDW-14.4
___ 12:00AM PLT COUNT-179
___ 12:00AM ___ PTT-27.9 ___
___ 12:00AM ___
PERTINENT LABS
=========================
___ 08:35AM GLUCOSE-108* UREA N-17 CREAT-1.1 SODIUM-145
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-25 ANION GAP-16
___ 08:35AM CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-1.9
___ 08:35AM WBC-10.6 RBC-5.13 HGB-13.6* HCT-43.0 MCV-84
MCH-26.5* MCHC-31.7 RDW-14.6
___ 12:10AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
DISCHARGE LABS
=========================
___ 07:15AM BLOOD WBC-6.7 RBC-4.50* Hgb-12.1* Hct-38.9*
MCV-87 MCH-27.0 MCHC-31.2 RDW-14.3 Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-29* Creat-1.4* Na-139
K-5.2* Cl-105 HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3
___ 07:30AM BLOOD %HbA1c-5.7 eAG-117
___ 07:30AM BLOOD Triglyc-153* HDL-41 CHOL/HD-4.5
LDLcalc-114 LDLmeas-115
MICROBIOLOGY
=========================
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
IMAGING
=========================
___ CXR
The ETT ends 1.4 cm above the carina. The enteric tube projects
with the tip over the mid thoracic spine. Normal heart size.
Opacity at the right lung base may reflect atelectasis or
effusion, but could be artifactual due to patient positioning.
___ CTA head/Neck:
1. No significant interval change in the appearance of the
subarachnoid
Preliminary Reporthemorrhage overlying the right parietal lobe.
2. Occlusion of the cavernous portion of the right internal
carotid artery and occlusion of the left internal carotid artery
just distal to the bifurcation are likely chronic with preserved
flow in the circle ___ are the posterior circulation.
___ CT Head:
No significant interval change in the appearance of subarachnoid
hemorrhage overlying the right parietal lobe compared to the
prior exam. No new foci of hemorrhage are identified.
___ MRI BRAIN:
There is susceptibility artifact in the right parietal lobe from
the
subarachnoid hemorrhage, which is unchanged in extent. There is
no new
hemorrhage. There is no edema or mass effect. There is no
diffusion
abnormality to suggest acute infarction. Periventricular and
subcortical
white matter FLAIR hyperintensities are nonspecific but most
commonly
associated with chronic small vessel ischemic disease in
patients of this age. Prominence of the ventricles and sulci is
consistent with age related involutional changes. There is
absence of the left cavernous carotid flow void.
IMPRESSION:
Unchanged extent of right parietal subarachnoid hemorrhage. No
other acute process.
___ MRA BRAIN:
Vertebral arteries, basilar, and posterior cerebral arteries
appear to be
unremarkable without evidence of stenosis or aneurysm. Anterior
circulation including the middle cerebral arteries are
incompletely evaluated on this exam due to metal artifact.
Brief Hospital Course:
Patient presented to ___ after being found unresponsive by his
wife. he was admitted to the ICU and CTA was done which showed
right pareital/occipital subarachnoid and no vascular anomaly.
BP was initially in the 230's and it improved after sedation and
a nicardipine drip. He was extubated in the afternoon and palced
on a precedex gtt. Neurology was consulted and preliminary
recommendationsn included an EEG and an MRI of the brain without
contrast.
On ___ he was brighter on exam, oriented x 3 and moving all
extremities well with good strength. He continued on EEG and
underwent an MRI scan of the brain which showed stable findings.
On ___, Neurology recommended a MRA vs. angio and reported that
the EEG showed no acute seizures. EEG was discontinued. Patient
had diarrhea and Cdiff was sent which was positive. Patient
was started on Flagyl on ___. O/N on ___ patient had 7 hours of
increase UO >500cc. Urine lytes and UA was obtained. SG was
normal as well as urine lytes. Patient was hypernatremic and
was resuscitated briefly with ___ with mild response to 147.
Medicine was consulted for transfer and patient was transferred
accordingly.
#Iso-osmotic Diuresis: Prior to transfer, pt has had UOP >
500cc/hr for at least 7 hours. Endocrine workup has ruled out DI
and recommended management of iso-osmotic diuresis. Regarding
patient's high urine output, patient was reported to have UOP >
500 cc/hr for at least 7 hours. Endocrine workup ruled out
diabetes insipidus as well as processes secondary to
subarachnoid hemorrhage. Etiology of iso-osmotic diuresis was
unclear but patient's UOP improved spontaneously by day 3 of
transfer (~50 cc/hr by day of discharge).
#Hypernatremia: Pt has had hypernatremia (Na 147), resolved by
time of discharge(Na 135-140). Hypernatremia was likely
secondary to osmotic diuresis and fluid depletion for diuresis
and cdiff colitis. Patient was permitted to free access of po
fluids throughout hospitalization.
#Delirium: Patient with ongoing delirium though seems to be
dramatically less altered than day of admission. AMS initially
thought to be ___ EtOH withdrawal given patient's report of
"Seeing ants on the wall" but wife reports almost never history
of EtOH. Ddx includes: ICU delirium, infection (known c diff),
SAH, withdrawal, hypernatremia (unlikely given low degree). C
diff was treated throughout. Unclear etiology of initial AMS,
but patient's Flexiseal and Foley were discontinued.
Hypernatremia and lyte management were also managed routinely.
Patient did not require haldol or Zyprexa for agitation.
Deliriogenic medications were avoided with the exception of
Ativan on day 1 and 2 of transfer due to unclear h/o possible
EtOH withdrawal. On day of discharge, wife reported that patient
was at baseline mental status (AAOx3 but unable to perform
higher level cognitive functions.)
#COPD: Patient has a known history of COPD per PCP. Patient
reported a mild cough on admission but O2 sats have been stable
at high ___ on room air. Patient was started on albuterol and
ipratropium nebulizers. 4mg methylprednisolone was on patient's
medication list initially, later revealed to be for a COPD
exacerbation in ___. Methylprednisolone was discontinued
and Advair was added to patient's discharge medications. On day
of discharge, patient continued to o2sat in the high ___ on room
air with improved breathing.
#SAH: Pt has recent SAH treated by neurosurgery with control of
blood pressure. SAH puts him at risk for seizure with possible
seizure on admission. Recent EEG shows very low-voltage
background activity without epileptiform activity or seizures.
Pt continues to be confused, delirious. Per neurosurgery
recommendations, patient was started on Keppra for ___nd continued on now 10mg lisinopril and 200mg tid labetalol for
blood pressure control, goal SBP<160 mmHg.
#Depression: Pt has a known history of psychiatric disease,
later reported as depression and remote h/o schizophrenia
diagnosis in the ___. Reportedly on lithium and Thorazine in
past, but not taking for ___ years according to PCP. During his
hospitalization, we continued sertraline, Depakote, and
aripiprazole.
#HTN: Pt has a known history of HTN, now more concerning with
recent ___. Goal SBP <160 during hospitalization in setting of
SAH. During hospitalization, we increased home lisinopril from
5mg to 20mg daily, and added labetalol 200mg tid. While
pressures were controlled, on day of discharge Cr was increased
1.5 (from 1.3 day prior, and 1.1 two days prior), BUN also
increased to 33 (27 day prior) and K at 5.3. Due to concerns of
___, lisinopril was decreased to 10mg daily and labetalol was
continued at 200mg tid. Given controlled BPs, patient was
discharged on this regimen.
#C. diff: Unclear etiology as not sure that patient has had
recent antibiotic use. Will investigate further. Patient was
started on Flagyl 500mg IV q8h for 10 day coruse (start
___. Patient had mild diarrhea on first two days of
admission which resolved throughout hospitalization and on day
of discharge.
#BPH: Pt has a known history of BPH. We continued home
finasteride 5mg daily
#H/o CVA: Patient was ruled out for acute stroke during
admission. Aspirin was held due to ___. Should be restarted in
outpatient setting, particularly given known carotid artery
stenosis. Atorvastatin 40mg PO daily was started per neurology
for LDL>100.
=======================
Transitional Issues
=======================
-Full Code
-Patient should continue 10-day vancomycin course until
___ due to ongoing diarrhea on flagyl
-Please monitor blood pressures. Currently on lisinopril 10mg
and labetalol 100mg. If >160, consider addition of amlodipine
5mg.
-Please consider starting aspirin in the outpatient setting
given significant carotid artery stenosis seen on MRA.
-Please consider referral to vascular surgery as outpatient for
possible carotid end arterectomy given stenosis on imaging
-Please consider neurocognitive evaluation in outpatient setting
given report of ongoing decline in functioning and memory prior
to presentation
- Please repeat chem 7 on ___ and decrease lisinopril if Cr>1.4
or K>5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO BID
2. Senna 8.6 mg PO BID:PRN constipation
3. Finasteride 5 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Divalproex (DELayed Release) 500 mg PO BID
6. Levalbuterol Neb 0.63 mg/3 mL inhalation BID:PRN SOB, wheeze
7. Aripiprazole 5 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, sob
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Sertraline 50 mg PO BID
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, sob
4. Aripiprazole 5 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain, fever
6. Atorvastatin 40 mg PO QHS
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydrocerin 1 Appl TP TID:PRN dry skin, itch
9. Labetalol 200 mg PO TID
10. Lisinopril 10 mg PO DAILY
11. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 10 Days
12. Divalproex (DELayed Release) 500 mg PO BID
13. Levalbuterol Neb 0.63 mg/3 mL inhalation BID:PRN SOB,
wheeze
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___,
Discharge Diagnosis:
Right Parietal/Occipital Subarachnoid Hemorrhage
Hypertension
Seizure like activity
C. diff colitis
Hypernatremia
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure to take care of you while you were admitted to
the ___. You were hospitalized for a seizure due to a head
bleed (right parietal and occipital subarachnoid hemorrhage),
high blood pressure, delirium, high urine output (iso-osmotic
diuresis), high blood sodium (hypernatremia), infection of the
colon (C. diff colitis).
Your subarachnoid hemorrhage was monitored in the ICU and your
symptoms improved. You did not require surgery to fix the bleed.
Please take Tylenol ES as needed for headaches. Symptoms should
improve with time. We recommend that you do not engage in
strenuous activity for 2 weeks upon your injury.
For seizures secondary to your subarachnoid hemorrhage, we
treated you with Keppra. You completed a 7 day course.
Regarding your COPD, we started you on albuterol nebulizers on
___ and discontinued your methylprednisolone. You can
continue your albuterol as needed.
Your medications for high blood pressure have been changed while
you were hospitalized. Please continue lisinopril, now at 10mg,
and labetalol 200mg three times a day for your high blood
pressure since high blood pressure is a risk factor for a
recurrent head bleed.
For your C. difficile infection, you should continue taking
vancomycin, an antibiotic, for a total of 10 days, to be
completed on ___.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10707442-DS-16
| 10,707,442 | 23,962,945 |
DS
| 16 |
2147-06-21 00:00:00
|
2147-06-21 15:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ ___ and dementia presents from ___ s/p fall. CT
notable for small SAH along sylvian fissure and nasal bone
fracture. CT Torso negative. Reportedly no LOC and patient with
GCS 15 on arrival to OSH and 15 currently. Patient reports he
was walking down the stairs when he fell. He struck his head on
the handrail, but denies loss of consciousness. He was taken to
OSH
for evaluation where CT showed a small SAH for which he was
transferred for neurosurgical evaluation. He also has a nasal
fracture with associated laceration which was sutured at OSH. He
complains of pain in the nose and right elbow pain. Difficult
to obtain much more detail regarding events and symptoms given
patient's mental status ___ underlying dementia.
Past Medical History:
COPD, HTN, BPH, distant stroke (in ___, ___ yrs ago),
Psychiatric history (details unknown)
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals-98.8 80 144/59 18 98% RA
GEN: NAD
HEENT: EOMI, nasal laceration c/d/I with sutures
CV: RRR
PULM: non-labored breathing, room air
ABD: soft, NT/ND
EXT: no edema; right elbow with some scrapes involving epidermis
only, no bleeding/bruising noted; intact ROM, no pain with
active/passive motion
NEURO: A&Ox2 (person, situation)
Discharge Physical Exam:
VS: 97.9 PO 106 / 62 R Lying 75 20 99 Ra
GEN: Awake, alert, no acute distress.
HEENT: PERRL, EOMI, left nasal laceration, forehead abrasion.
Bilateral ecchymosis under eyes.
CV: RRR
PULM: Clear bilaterally
ABD: Soft, non-tender, non distended. Active bowel sounds.
EXT: Warm and dry. No edema. Right elbow abrasion.
Pertinent Results:
___ 12:44AM BLOOD WBC-7.9 RBC-3.71* Hgb-10.5* Hct-33.3*
MCV-90 MCH-28.3 MCHC-31.5* RDW-14.5 RDWSD-47.0* Plt ___
___ 01:00PM BLOOD Glucose-152* UreaN-36* Creat-2.0* Na-144
K-4.5 Cl-109* HCO3-23 AnGap-12
___ 06:00PM BLOOD Glucose-152* UreaN-33* Creat-2.0* Na-143
K-4.6 Cl-107 HCO3-22 AnGap-14
___ 12:44AM BLOOD Glucose-106* UreaN-29* Creat-1.8* Na-143
K-4.6 Cl-106 HCO3-25 AnGap-12
___ 12:44AM URINE Color-Straw Appear-Clear Sp ___
___ 12:44AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:44AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-0
___ 12:44AM URINE Mucous-RARE*
___ 12:44 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Mr. ___ is a ___ yo M admitted to the Acute Care Trauma Surgery
Service on ___ after a fall sustaining a nasal bone
fracture, subarachnoid hemorrhage, and an occult right radial
head fracture. He was seen and evaluated by the neurosurgery
team who recommended frequent neurochecked. He is on Depakote at
baseline which was continued. He was seen and evaluated by the
orthopedic surgery team for right radial head fracture who
recommended non-operative management with non-weight bearing a
sling for comfort. The patient was admitted to the floor for
physical therapy assessment, neurological monitoring, and pain
control.
Pain was well controlled on oral medication. Diet advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. Venodyne boots were used during this stay for
DVT prophylaxis. Subcutaneous heparin was started after
neurological exam remained stable.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to rehab for physical
therapy. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
fluticasone 50 bid
proair 90mcg 2 puffs q6 hours PRN
atorvastatin 40'
lisinopril 10'
labetalol 200"
divalproex ___ (1 tab qAM, 2 tab QHS)
cetirizine 10' prn
sertraline 50'
Discharge Medications:
1. Acetaminophen 650 mg PO TID
___ discontinue when no longer needed.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
hold for loose stool
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Heparin 5000 UNIT SC BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Atorvastatin 40 mg PO QPM
9. Cetirizine 10 mg PO DAILY
10. Divalproex (EXTended Release) 500 mg PO QAM
11. Divalproex (EXTended Release) 1000 mg PO QPM
12. Labetalol 200 mg PO TID
13. Lisinopril 10 mg PO DAILY
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
15. Sertraline 50 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
nasal bone fracture
Subarachnoid Hematoma
Right radial head fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care surgery service on ___
after a fall sustaining a nasal bone fracture, small head
bleed/concussion, and a radial head fracture. No intervention is
needed for your nasal bone fracture. You were seen and evaluated
by the neurosurgery team for your head bleed who recommended
follow up with the traumatic brain injury clinic as needed if
you continue to have concussion symptoms.
You were seen and evaluated by the physical therapy team who
recommended discharge to rehab.
You are now doing better, pain is controlled, and you are ready
to be discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10707704-DS-21
| 10,707,704 | 21,360,750 |
DS
| 21 |
2115-05-24 00:00:00
|
2115-05-26 07:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
mechanical ventilation
lumbar puncture
History of Present Illness:
___ yo male with a history of chronic hepatitis C, IV cocaine and
IV heroin use who was found by EMS on the evening of ___
wandering in the streets and agitated after shooting up cocaine
and heroin. He was incoherent, disoriented and spasmic, and
subsequently brought to the ED.
In the ED, he was found to be hyperthermic, hypertensive,
tachycardic and hypoxic. ED labs were notable for WBC 13.6, Hct
54, Na 146, bicarb 16, AG 29, BUN/Cr ___, glucose 90 (low
25), lactate 11.7, K 4.8, CK 266, AST/ALT 67/61, serum tox neg,
Osm 298. UA with lg bld, 10 RBC; utox pos for cocaine and
opiates. EKG showed sinus tachycardia with HR to the 160s but no
ischemic changes. LP was negative for infection. He was
intubated for persistent agitation and became hypotensive after
receiving 8 mg IV Lorazepam. He was initially treated with
phenylephrine, and then given levophed for persistent
hypotension unresponsive to 5 L NS. He was also given vancomycin
and ceftriaxone in the ED due to concerns for sepsis. He was
subsequently transferred to the MICU for continued management of
polysubstance ingestion, complicated by hyperthermia,
hypotension, hypoglycemia, rhabdomyolysis and ___.
Toxicology was consulted, and felt that his presentation was
consistent with sympathomimetic ingestion, and his subsequent
hypotension was caused by a catecholamine depletion via cocaine
washout syndrome vs. large dose of Ativan given in ED. He
self-extubated and eventually weaned from norepinephrine. His
antibiotics were discontinued after Gram stain was determined to
be consistent with respiratory flora and WBC normalized. He
developed a significant transaminitis with AST/ALTs peaking in
the 2000s, with elevated INR to 3.1, rising t.bili and normal
alk phos. N-acetylcysteine was administered on ___. His LFTs
began downtrending in the afternoon of ___. Patient received
large volume of IVF in MICU (LOS + 9.5 L).
Patient arrived to the Medicine floor on ___ for further
management of his liver injury, thrombocytopenia and
rhabdomyolysis.
REVIEW OF SYSTEMS:
General: No fevers, chills, night sweats, or weight changes.
HEENT: No changes in vision or hearing. Has been OOB and feels a
bit unsteady on his feet.
Cardiopulmonary: No cough. Feels mildly SOB, particularly with
exertion. No ___ edema. No chest pain, palpitations.
GI: Nauseous all the time and has no appetite. Able to tolerate
some grapes this morning. Has not vomited. Reports ___ sharp
abdominal pain in the RLQ since being in the hospital. Pain has
not migrated. Does not radiate. Pain worsens with movement.
Constipated - reports no BM since his hospitalization. No
jaundice.
GU: Dysuria and frank blood in urine today. Reports Foley was
just removed this morning. No hematochezia, no melena. No
abnormal genital lesions.
Neuro: No numbness or tingling.
MSK: Generalized muscle weakness and achiness. Pain worsens with
squeezing muscles.
Endocrine: No heat or cold intolerance.
Heme: No easy bruising.
Psychiatric: No S/I. Reports that intoxication was accidental
and not a suicidal gesture.
Past Medical History:
Chronic hepatitis C
Depression
Anxiety
Tonsillectomy
Rotator cuff repair
Wisdom teeth removal
Social History:
___
Family History:
Mother - fibroids
Father - osteoporosis
6 siblings - all alive and well
Maternal grandmother with stroke and "heart disease"
Physical Exam:
ADMISSION PHYSICAL EXAM (MICU)
Vitals- T: 35.9 BP:81/66 P:69 R:21 O2: 100%
GENERAL: intubated, sedated
HEENT: Sclera anicteric, Pupils constricted 2mm, minimally
reactive
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: a few abrasions noted on upper and lower extremities, no
rash
NEURO: sedated, unresponsive to commands, rigid tone, no clonus
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 128/67 p52 R17 97%RA
General: alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD. R IJ central venous
catheter in place.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Soft, mild diffuse tenderness to palpation, worse in
RUQ, +BS
GU: no foley.
Ext: warm, well perfused, 2+ radial pulses, no c/c/e
Pertinent Results:
COMPLETE BLOOD COUNT -
___ 09:15PM BLOOD WBC-13.6* RBC-5.63 Hgb-17.7 Hct-54.2*
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.6 Plt ___
___ 02:44AM BLOOD WBC-26.2*# RBC-4.46* Hgb-14.2# Hct-43.4#
MCV-97 MCH-31.9 MCHC-32.8 RDW-13.7 Plt ___
___ 04:05AM BLOOD WBC-8.5# RBC-4.38* Hgb-13.9* Hct-43.0
MCV-98 MCH-31.8 MCHC-32.4 RDW-15.6* Plt Ct-97*
___ 04:23AM BLOOD WBC-6.2 RBC-4.10* Hgb-13.0* Hct-39.2*
MCV-96 MCH-31.7 MCHC-33.1 RDW-14.0 Plt Ct-81*
___ 03:30AM BLOOD WBC-4.6 RBC-3.89* Hgb-12.2* Hct-37.2*
MCV-96 MCH-31.4 MCHC-32.9 RDW-13.8 Plt Ct-75*
DIFF -
___ 09:15PM BLOOD Neuts-57.1 ___ Monos-3.3 Eos-1.0
Baso-1.1
___ 02:44AM BLOOD Neuts-83.9* Lymphs-7.9* Monos-7.9 Eos-0.1
Baso-0.3
COAGS -
___ 02:44AM BLOOD ___ PTT-42.1* ___
___ 04:05AM BLOOD ___ PTT-65.0* ___
___ 04:44PM BLOOD ___ PTT-51.7* ___
___:23AM BLOOD ___ PTT-71.1* ___
___ 03:30AM BLOOD ___
CHEMISTRIES -
___ 09:15PM BLOOD Glucose-90 UreaN-21* Creat-2.3* Na-146*
K-4.8 Cl-101 HCO3-16* AnGap-34*
___ 02:44AM BLOOD Glucose-87 UreaN-27* Creat-1.7* Na-145
K-3.3 Cl-116* HCO3-22 AnGap-10
___ 09:29AM BLOOD Glucose-139* UreaN-31* Creat-1.9* Na-143
K-3.8 Cl-112* HCO3-22 AnGap-13
___ 02:52PM BLOOD Glucose-141* UreaN-29* Creat-1.8* Na-144
K-3.8 Cl-114* HCO3-21* AnGap-13
___ 06:19AM BLOOD Glucose-93 UreaN-23* Creat-1.4* Na-143
K-3.4 Cl-112* HCO3-22 AnGap-12
___ 04:23AM BLOOD Glucose-84 UreaN-17 Creat-1.1 Na-137
K-3.9 Cl-107 HCO3-24 AnGap-10
___ 03:30AM BLOOD Glucose-86 UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-108 HCO3-26 AnGap-9
LIVER ENZYMES AND BILIRUBIN -
___ 09:15PM BLOOD ALT-61* AST-67* CK(CPK)-266 AlkPhos-87
TotBili-0.6
___ 02:44AM BLOOD ALT-59* AST-148* LD(LDH)-333*
CK(CPK)-5355* AlkPhos-54 TotBili-0.3
___ 09:29AM BLOOD ALT-122* AST-268* LD(LDH)-418*
CK(CPK)-7441* AlkPhos-58 TotBili-0.7
___ 06:19AM BLOOD ___ LD(LDH)-1267*
___ AlkPhos-66 TotBili-1.8* DirBili-1.1* IndBili-0.7
___ 11:57AM BLOOD ALT-2341* AST-___* AlkPhos-69
TotBili-2.1*
___ 04:44PM BLOOD ALT-2215* AST-1710* CK(CPK)-9796*
AlkPhos-62 TotBili-2.2*
___ 10:46PM BLOOD ALT-2063* AST-1490* AlkPhos-67
TotBili-3.0*
___ 04:23AM BLOOD ALT-1799* AST-1198* CK(CPK)-6539*
AlkPhos-66 TotBili-3.4*
___ 03:30AM BLOOD ALT-1228* AST-676* CK(CPK)-4213*
AlkPhos-61 TotBili-3.6*
CPK ISOENZYMES -
___ 09:15PM BLOOD CK-MB-5 cTropnT-0.45*
___ 02:44AM BLOOD CK-MB-91* MB Indx-1.7 cTropnT-0.67*
___ 09:29AM BLOOD CK-MB-132* MB Indx-1.8 cTropnT-0.50*
CHEMISTRIES -
___ 09:15PM BLOOD Albumin-5.8*
___ 02:44AM BLOOD Albumin-3.3* Calcium-6.9* Phos-1.7*
Mg-2.3
___ 09:29AM BLOOD Calcium-7.8* Phos-1.5* Mg-2.2
___ 02:52PM BLOOD Calcium-7.9* Phos-4.5# Mg-2.2
___ 06:19AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.3
___ 04:23AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.9
___ 03:30AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.7
___ 09:15PM BLOOD Osmolal-298
___ 02:44AM BLOOD Cortsol-19.
URINE TOXICIOLOGY -
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
BLOOD GASES -
___ 11:38PM BLOOD Type-ART Temp-36.5 Rates-16/ Tidal V-450
FiO2-100 pO2-168* pCO2-51* pH-7.24* calTCO2-23 Base XS--5
AADO2-497 REQ O2-83 -ASSIST/CON Intubat-INTUBATED
___ 03:05AM BLOOD Type-MIX Temp-37.0 pO2-65* pCO2-58*
pH-7.16* calTCO2-22 Base XS--8
___ 04:47AM BLOOD Type-MIX Temp-36.1 Rates-26/ Tidal V-500
PEEP-5 FiO2-60 pO2-52* pCO2-42 pH-7.25* calTCO2-19* Base XS--8
Intubat-INTUBATED Vent-CONTROLLED
___ 09:44AM BLOOD ___ Temp-37.4 Rates-26/ Tidal V-500
PEEP-5 FiO2-60 pO2-50* pCO2-46* pH-7.25* calTCO2-21 Base XS--6
Intubat-INTUBATED
___ 03:10PM BLOOD ___ Temp-37.2 pO2-45* pCO2-39
pH-7.32* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
OTHER CHEMISTRIES -
___ 09:36PM BLOOD Glucose-81 Lactate-11.7* K-4.5
___ 11:38PM BLOOD Glucose-352* Lactate-2.9* K-3.6
___ 03:05AM BLOOD Lactate-1.1
___ 09:44AM BLOOD Lactate-2.0
___ 03:10PM BLOOD Lactate-1.7
IMAGING:
CT HEAD (___):
FINDINGS:
There is no evidence of fracture chronic hemorrhage, infarction,
mass or
midline shift. There is no hydrocephalus. Visualized paranasal
sinuses and mastoid air cells are clear.
IMPRESSION:
Normal study.
CXR (___):
FINDINGS:
The endotracheal tube is seen with tip between the clavicular
heads, 6.5 cm from the carina. Enteric tube passes below the
field of view with side-port below the GE junction. The lungs
are clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities identified.
IMPRESSION:
Endotracheal tube tip 6.5 cm from the carina.
ECG (___):
Sinus tachycardia. Possible right atrial abnormality.
Indeterminate axis.
Prominent S waves in the early precordial leads. ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical correlation is suggested.
MICRO:
___ 11:50 pm CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
___ 11:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ with h/o drug abuse brought in by EMS agitated wandering the
streets found to have muscle spasms, nystagmus, hyperthermia and
a hyperadrenergic state, intubated for agitation with
polysubstance overdose.
# Overdose/intoxication: Patient had positive tox screen for
cocaine and opioids and presented in a hyperadrenergic state.
Blood pressures were initially markedly elevated in the ED to
systolics in the 240s with pulse in the 170s and marked
reduction in BP over the course of the first few hours. On
arrival the MICU, patient was hypotensive and borderline
bradycardic and on two pressors for support. Toxicology was
consulted who believed that this was secondary to an
intoxication with a sympathomimetic agent, likely cocaine, but
possibly other substances as well. Given his profound
hyperadrenergic state, the hypothesis was that he developed a
catecholamine depletion state and required additional
catecholamine support to improve his pressures. Other etiologies
like infection of the CSF were considered but LP was negative
for infection. Patient was weaned off pressors over the next
___ and remained stable. Patient is in suboxone treatment as
outpatient at ___. His treatment
center was notified of his admission. He will continue to
follow up with them as an outpatient.
# Transaminitis/chronic Hepatitis C: Patient initially had
uptrending LFTs, with concern for shock liver or Tylenol
ingestion. He was started on NAC despite a negative serum
Tylenol level. He was managed with aggressive fluid
resuscitation. Liver enzymes and INR continue to trend down
although still elevated. Likely multifactorial to rhabdo,
cocaine induced injury and shock liver. Per Toxicology
recommendations, suboxone was held in setting of acute liver
injury. Also per their recommendations, he was advised to not
take suboxone until he had follow up labs showing LFTs at his
baseline levels.
# Thrombocytopenia x 3 days - Platelets normal upon admission
and subsequently trended downwards: 97K on ___ --> 81K on ___
--> 75K on ___. Likely combination of dilutional effect from
large volume of IVF received in MICU (~9.5L) and on floor and
toxic insult causing liver injury. Vancomycin and heparin were
discontinued, as both can cause thrombocytopenia, although HIT
is less likely, as his 4T score was 2. He will repeat his labs
at his PCP's office 2 days after discharge. He did not have any
bleeding during this hospitalization.
# AG metabolic acidosis/Lactic acidosis: Patient's initial
lactate was elevated to 11 with AG 29 likely in the setting of
profound vasoconstriction given the his hyperadrenergic state.
His lactate quickly trended down to normal once his blood
pressure normalized over time.
# Respiratory failure: Patient was intubated in the setting of
agitation and altered mental status. He self-extubated the
morning after admission and maintained good saturations.
# ___: Patient's Cr 2.1 which was likely pre-renal given poor
renal perfusion from vasoconstriction from sympathomimetic
intoxication. Maintained continuous fluids (2L at 150 cc/hr) to
prevent further kidney damage in the setting of rhabdomyolysis
___ resolved during admission. ___ resolved upon hospital
discharge.
# Rhabdomyolysis
Likely secondary to vasoconstriction in the setting of cocaine
intoxication. CK increased from 266 on ___, peaking at ___ on
___ and downtrending since that date. Maintained continuous
fluids as stated above. Electrolytes remained normal and Cr
normalized.
# Hypoglycemia: Patient was profoundly hypoglycemic to low of 25
in ED. There was initially much difficulty controlling his
glucose levels and required 3 amps D50, and a D10 drip at
100/hr. Fasting fingersticks were checks q1h for the first
24hrs. Over time, patient's glucoses improved the D10 drip was
weaned. The etiology of the hypoglycemia is unclear although it
may have been related to the catecholamine depletion or a
co-ingestion with some other agent which causes hypoglycemia.
# Nausea: With nausea and poor appetite during hospitalization,
although slightly improved prior to discharge. Likely secondary
to constipation or heroin withdrawal. Provided Zofran PRN.
# Abdominal pain: Noted intermittent sharp RLQ abdominal pain
that worsened with use of his abdominal muscles upon arrival to
the Medicine floor. Also complained of generalized myalgias.
Likely secondary to heroin withdrawal and diffuse muscle injury
causing rhabdo, given active BS, no peritoneal signs, and no
fever or WBC.
#Hematuria: Resolved. Patient with intermittent hematuria and
dysuria during admission. Likely related to foley insertion and
removal while intubated in MICU.
Transitional issues:
[ ] lab check on ___ at ___ to continue to
monitor his liver enzymes, ___, CBC
[ ] f/u with ___ PCP: ___ appointment with Dr. ___
___, at ___ in the ___.
[ ] Advise against restarting any suboxone until his platelet
have normalized
[ ] follow up with PCP regarding his thrombocytopenia -
recommend CBC check and further workup as outpatient as
indicated.
[ ] Follow up hepatitis C with PCP
[ ] Home dose of gabapentin is 600 QID, switched to 600 TID
given recent ___.
[ ] Recommend not restarting citalopram until normalization of
his liver enzymes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. Citalopram 40 mg PO DAILY
3. Gabapentin 800 mg PO QID
Discharge Medications:
1. Gabapentin 600 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Polysubstance intoxication
Secondary Diagnosis:
Acute liver injury
Acute kidney injury
Rhabdomyolysis
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted to the
ICU for management of drug toxicity. You were briefly
intubated. You were noted to have acute liver and kidney
injury, likely related to your drug toxicity. After you were
stabilized, you were transferred the General Medicine floor for
further management. While you were on the Medicine floor, we
gave you IV fluids and monitored your liver and kidney markers,
as well as your markers of muscle breakdown. Your markers
showed steady improvement while you were in the hospital. It was
determined that your levels were low enough that it was safe to
be discharged to home. However it is recommended that you not
resume suboxone until your liver enzymes are completely back to
your baseline. Please go to ___ on ___ to have
your liver enzymes checked. Your PCP in conjunction with your
providers at ___ Horizons will determine when it is safe to
resume suboxone. Your PCP ___ also help to manage your low
platelets that were noted on your labwork.
We hope you continue to feel better.
-Your ___ Team
Followup Instructions:
___
|
10707907-DS-18
| 10,707,907 | 21,829,043 |
DS
| 18 |
2140-10-20 00:00:00
|
2140-10-20 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / azithromycin / nitrofurantoin
Attending: ___.
Chief Complaint:
fall from ladder
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH of PVD s/p L carotid endarterectomy, glaucoma, and
hypertension who presents today after a mechanical fall from 4
feet yesterday while using a
stepladder. + headstrike on the posterior portion of her head,
denies LOC. She also sustained R ___ metatarsal fractures as
well as a right sided clavicle and manubrial fracture. She
states that she initially did not want to go to the ED but after
continued pain from her fractures decided to present to OSH
today
where she received a noncontrast head CT which demonstrated
presence of known bilateral subdural fluid collections from
prior SDH in ___ and new small acute SDH on left side. She is
taking 81mg of aspirin daily but it otherwise healthy. She
states that aside from some pain over her fractures she feels
well. She denies any confusion, dizziness, vertigo, headache,
vision loss, blurred vision, double vision, new difficulty
hearing (she is chronically hard of hearing), tinnitus, focal
numbness, weakness, tingling, bowel incontinence, urinary
incontinence or retention, or difficulty with gait.
Past Medical History:
HTN, osteoporosis, left aptellar fracture, glaucoma, PVD,
recurrent UTIs, tonsillectomy, appendectomy, CEA, cystoscopy,
___ ___
Social History:
___
Family History:
Atherosclerosis- Father
Type 2 diabetes- Mother
Physical Exam:
Gen: NAD, AOx3
Cardiac: regular rate, rhythm
Pulm: non-labored breathing
Skin: extensive bruising over anterior chest wall, TTP
MSK: TTP over dorsal surface of R foot w/ bruising noted, normal
strength
HEENT: Pupils: PERRLA, 3->2 mm bilaterally EOMs intact
Neck: Supple, nontender
Extrem: Warm and well-perfused.
Neuro: Awake and alert, cooperative with exam, normal affect.
Pertinent Results:
CT non-contrast ___ (Outside hospital, performed at 1pm):
Evidence of new small left sided subdural hemorrhage and known
old subdural fluid collections bilaterally. No other acute
intracranial abnormality.
Brief Hospital Course:
Ms. ___ is an ___ who presented to ___ on ___ from an
OSH after falling from a step ladder on ___. At the outside
hospital, imaging showed an acute on chronic subdural hematoma,
a right clavicle fracture, fracture of the ___ metatarsals
of the right foot, and fracture of the manubrium.
Neurosurgery was consulted and after repeat non-contrast head CT
recommended 1 week of Keppra with clinic follow-up in 8 weeks
with repeat head CT. Orthopedic surgery was consulted for the
bone fractures and recommended right-arm sling for comfort,
avoidance of bringing right elbow past midline to avoid
dislocation of fracture and hard-sole shoe for right foot.
Clinic follow-up is recommended in ___ weeks.
A urinalysis was obtained after patient complained of burning
with urination and patient was found to have a urinary tract
infection. She was discharged with a prescription for
ciprofloxacin.
Patient was seen and evaluated by ___ on ___ and was
cleared for discharge home. Tertiary exam was negative for new
findings. Pain was well-controlled with oral medications, she
was tolerating a regular diet, voiding spontaneously, and
ambulating the hallways independently. She was discharged home
on ___ with planned follow-ups with Neurosurgery and
Orthopedics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
Do not exceed 4 grams daily.
2. Ciprofloxacin HCl 500 mg PO Q24H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*3 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID Duration: 6 Days
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*12 Tablet Refills:*0
4. TraMADol 25 mg PO Q6H:PRN pain
Do not drink alcohol or drive while taking this medication.
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-acute on chronic subdural hematoma
-right clavicle fracture
-right ___ impacted metatarsal fractures
-manubrium fracture
-urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
following a fall. You were found to have an acute on chronic
subdural brain bleed, fractured manubrium, fractured right
collar-bone and broken bones in your right foot. A study of your
urine showed that you have a urinary tract infection. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
* You should take your pain medication as directed to stay ahead
of the pain. If the pain medication is too sedating take half
the dose and notify your physician.
* 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.
* 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.
* For your right clavicle fracture, wear a sling for comfort.
Try to avoid moving your elbow past midline to avoid dislocation
of the fracture.
* For your brain bleed, you have been prescribed 1 week of an
anti-seizure medication called Keppra. You should take this as
prescribed.
* For your urinary tract infection, you have been prescribed a 3
day course of antibiotics. Take these as prescribed.
Followup Instructions:
___
|
10707963-DS-22
| 10,707,963 | 22,224,299 |
DS
| 22 |
2179-04-01 00:00:00
|
2179-04-01 15:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female transferred from ___ to ___ ED for
evaluation of hypoxia and dyspnea, found to have bilateral
pulmonary emboli, and is admitted to ICU due to ?right heart
strain. Per, report she had a peripheral saturation of 64% at
her NH. She was put on 4L NC and sats increased to ___.
.
In the ED, initial VS were: 109/69, hr 62, rr20, sat 88 RA. bp
range 102-130/41-64. HR 65-94. 84-95% ___ NC. A CTA confirmed
bilateral pulmonary emboli. Heparin gtt and bolus were started.
She also got a less than full dose of vancomycin (stopped as ct
showed no e/o pna) and a dose of ctx. Also ASA 325mg once. She
was given benadryl due to itching at the iv site during the
vancomycin infusion.
.
Transfer vitals af, hr 72, bp 102/61, rr 18, 94% 3L NC. On
arrival to the MICU, she looked comfortable. She is demented.
Oriented to person only. She has no specific complaints but is
an unreliable historian.
.
Review of systems: unable to obtain
Past Medical History:
-Frontal-temporal dementia: Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in ___.
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low ___ pressure"
treated with Florinef.
-Bilateral cataract surgeries in ___.
-Surgery on both feet foot for bunions. Chronic foot pain.
Social History:
In the past, the patient lived at ___
___ (adult
foster day care) in ___ - currently lives in ___
___, the ___
director at ___., knows the patient well (contact #:
___. Continues to smoke less than one
pack per week. Began
smoking in her ___. Previously drank alcohol, but none
currently.
Patient has a ___ in ___. She has had multiple
occupations in the past, including professional ___ at the
___, ___ and ___, and
___. She is divorced and has no children. Reports that she
attends church regularly and has a community of friends in the
area. Hcp/guardian ___ ___ home,
___ cell
Family History:
NC
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge,
A&Ox1, pleasant
Lungs: CTA anteriorly
CV: RRR, no murmurs
Abd: soft, normoactive bs
Ext: warm and well-perfused, no edema
Neuro: EOMI, full strength in ___ bilaterally
Pertinent Results:
___ 06:29PM ___ PTT-132.4* ___
___ 05:36PM COMMENTS-GREEN TOP
___ 05:36PM LACTATE-1.8
___ 11:25AM D-DIMER-2898*
___ 09:04AM LACTATE-3.8*
___ 09:00AM GLUCOSE-138* UREA N-33* CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
___ 09:00AM estGFR-Using this
___ 09:00AM cTropnT-<0.01
___ 09:00AM CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-1.7
___ 09:00AM WBC-12.8*# RBC-3.50* HGB-11.2* HCT-33.0*
MCV-94# MCH-31.9 MCHC-33.9 RDW-12.6
___ 09:00AM NEUTS-80.9* LYMPHS-11.1* MONOS-5.8 EOS-1.7
BASOS-0.5
___ 09:00AM PLT COUNT-338
___ 09:00AM ___ PTT-27.9 ___
.
INR:
___: 1.1
___: 1.2
___: 1.3
___: 1.7
.
MICROBIOLOGY:
- ___ MRSA screen: No MRSA isolated
- ___ ___ culture: Pending at the time of discahrge (NGTD)
- ___ ___ culture: Pending at the time of discahrge (NGTD)
- ___ Urine culture: Pending at the time of discharge
CTA CHEST ___:
IMPRESSION: 1. Bilateral pulmonary emboli, the largest of which
is in the right main pulmonary artery with findings suggestive
of early right heart strain. Recommended correlation with
echocardiography. 2. Bilateral ground-glass opacities in the
upper lobes are nonspecific. 3. Small hiatal hernia. 4. 12-mm
subcarinal lymph node, likely reactive. 5. 8 mm subcutaneous
nodule within the left anterior chest wall, possibly a sebaceous
cyst, for which clinical correlation is recommended. 6.
Cholelithiasis.
CXR ___:
IMPRESSION: Low lung volumes with blunting of the left
costophrenic angle
suggestive of a small effusion.
TRANSTHORACIC ECHOCARDIOGRAM ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Moderately dilated right
ventricle with moderate systolic dysfunction. Normal global and
regional left ventricular systolic functino. Moderate pulmonary
hypertension.
Brief Hospital Course:
HOSPITAL SUMMARY: Ms. ___ is an ___ who was transferred from
her care facility to ___ for evaluation of hypoxia and
shortness of breath. CTA demonstrated bilateral submassive
pulmonary emboli, and echocardiogram showed evidence of right
heart strain as above, so she was admitted to the medical ICU.
There, she remained hemodynamically stable and was started on
anticoagulation (initially with heparin gtt, then transitioned
to Lovenox therapeutic dosing; she was started on warfarin as
well for planned bridge). She was transferred to the general
medical ward on hospital day 2, where her breathing continued to
improve. She will likely require minimum of 6 months of
anticoagulation. Further work up for prothrombotic state
(malignancy, etc.) will be deferred to the outpatient setting.
She was discharged on a lovenox bridge (70 mg twice per day) to
be continued for 2 days after therapeutic INR. She was
discharged on coumadin 7.5 mg per day with instructions that
this is not a determined stable dose and will note close
monitoring - INR on discharge was 1.7. She did have a new oxygen
requirement upon discharge (84% on RA with ambulation).
.
CHRONIC ISSUES:
.
# DEPRESSION, FRONTOTEMPORAL DEMENTIA: Patient was alert and
pleasant but oriented only to self during this admission. She
was continued on her home doses of citalopram, divalproex,
buspirone, and risperdal.
.
# SLEEP APNEA: Patient unable to tolerate CPAP. No significant
complications were noted during this admission.
.
# HYPERTENSION: Hydrochlorothiazide was held during this
admission given concern for possible hemodynamic instability.
She remained normotensive throughout this admission so
hydrochlorothiazide was discontinued on discharge.
.
#GERD: Continued home dose of omeprazole.
.
TRANSITIONAL CARE:
- Patient will require overlap of warfarin and lovenox (70 mg
BID) for 2 days once an INR goal of ___ (measured twice at least
24 hrs apart) is reached
- Recommend ___ months minimum of anticoagulation therapy
- daily INRs until stable coumadin dose is established
- Thrombophilia workup will be deferred to the outpatient
setting; this may include age-appropriate cancer screening and
smoking cessation counselling depending on goals of care
- 12-mm subcarinal lymph node was noted on CTA imaging (likley
reactive); decision regarding follow up will be deferred to
outpatient providers
- ___ cultures x 2 sets from ___ were pending at the time
of discharge (NGTD) as was urine culture (NGTD)
- Code status: DNR/DNI (confirmed with guardian)
- Guardian: ___ ___ home,
___ cell, fax ___
Medications on Admission:
___ diet pureed foods
omeprazole 20mg daily
citalopram 10mg daily
hctz 12.5mg daily
mv daily
risperidone .5mg daily
glucosamine/chondroitin
ibuprofen 600mg bid
buspirone 10mg bid
divalproex ___ bid
senna
acetaminophen prn
bisacodyl prn
milk of mag prn
.
Allergies: nkda
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. glucosamine-chondroitin Oral
6. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO once a day as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for fever or pain.
11. bisacodyl 5 mg Tablet Sig: ___ Tablets PO once a day as
needed for constipation.
12. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Please give lovenox twice
per day until INR is therapeutic for 2 days. Then discontinue
lovenox. .
13. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 ___: This is not a stable dose of warfarin for this patient.
Please check daily INR until appropriate daily dose is
confirmed. .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Pulmonary emboli
- Right heart strain
SECONDARY:
- Frontotemporal dementia
Discharge Condition:
Mental Status: Confused - always (oriented only to self at
baseline)
Level of Consciousness: Alert and interactive.
Ambulates with a walker.
Discharge Instructions:
It was a pleasure caring for you at the ___
___. You were admitted to ___ with shortness of
breath and low oxygen levels. Imaging studies showed ___ clots
in your lungs (pulmonary emboli) that were affecting your
heart's ability to pump ___. You were treated with ___
thinners and your breathing improved. You will need to continue
to use ___ thinners until directed to stop by your physician.
You will also need oxygen until the ___ clots are stabilized
and absorbed by your body.
We have made the following changes to your medication regimen:
- BEGIN TAKING Lovenox injections (70 mg) twice daily until your
INR ___ test) is > 2 for 2 days. Then discontinue lovenox.
- BEGIN TAKING warfarin 7.5 mg by mouth daily (goal INR is ___.
We have not yet determine what your final dose will be so you
will require frequent ___ tests (INR monitoring) until we know
your proper long-term dose.
- STOP taking hydrochlorathiazide as your ___ pressure was
normal
- STOP taking ibuprofen as this can increase your bleeding risk
while on anticoagulation
.
Please take your medications as prescribed and follow up with
your doctors as recommended below.
Followup Instructions:
___
|
10707963-DS-23
| 10,707,963 | 20,211,608 |
DS
| 23 |
2179-06-16 00:00:00
|
2179-06-17 05:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoxic respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo W w/ end stage frontotemporal dementia, OSA, HTN,
depression and an unprovoked PE dx in ___ on coumadin, who
developed hypoxic respiratory distress, diagnosed with new PEs
on CTA and admitted to MICU for monitoring.
Of note, pt. was admitted to ___ ___ for diagnosis of
submassive PE and dishcarged to ___ on lovenox/coumadin. While
at ___, has done will until the morning of admission,
when patient was found to be SOB, unable to ambulate and weak
while going to the bathroom. HR 110s and O2 sats in ___ on RA
and 84-86% on 6L. Of note last INR was 1.3 on ___, last dose
of coumadin at 4mg. INR was 2.4 on ___, when last checked (on
3mg at that time). No events noted by SNF and they are unsure
as to why INR may have decreased. No medication changes other
decr. of risperidone dose and having been started on ___ on
Carnation instant breakfast 120ml daily.
In the ED, initial VS were: 97.7F 123/83 90 20 96% NRB. She
underwent CTA that showed a new PE in addition to the prior.
ECG was not done. Labs showed 11K, Trop < 0.01, lactate of 1.9.
UA w/ pyuria, bacteriuria, positie nitrates w/ 57 epis. She
received 650mg of APAP, CFTX 1g, Heprain gtt was started at
1300. Pt. is DNR/I from prior admission, family was not
contacted at time of admission.
.
On arrival to the MICU, pt. in NAD on 50% face mask. No acute
complaints. She is unable to provide any reproducible history,
her responses are incongruent.
.
Review of systems: unable to obtain reproducibly.
Past Medical History:
-Pulmonary embolism, Dx ___ on coumadin, 84% on RA with
ambulation on d/c.
-Frontal-temporal dementia: Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in ___.
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low blood pressure"
treated with Florinef.
-Bilateral cataract surgeries in ___.
-Surgery on both feet foot for bunions. Chronic foot pain.
Social History:
___
Family History:
___
Physical Exam:
ADMISSION EXAM
General: Alert, disoriented, inattentive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTA
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Awake, alert, inattentive.
EOMI, VFF, Face symmetric, tongue midline.
UEs and ___.
Toes down.
.
DISCHARGE EXAM
VS - 97.5, BP 119/69 (98/56-135/71) , HR 85, R 20 , O2-sat 95%
4L
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, MMM, OP clear
LUNGS - CTAB on the anterior chest
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND,
EXTREMITIES - WWP,no edema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 10:35AM BLOOD WBC-11.1* RBC-4.22# Hgb-12.9 Hct-40.8#
MCV-97 MCH-30.6 MCHC-31.6 RDW-13.7 Plt ___
___ 10:35AM BLOOD Neuts-76.1* Lymphs-14.6* Monos-6.7
Eos-0.8 Baso-1.8
___ 10:35AM BLOOD ___ PTT-30.8 ___
___ 10:35AM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-137
K-4.8 Cl-103 HCO3-22 AnGap-17
___ 10:35AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9
___ 10:35AM BLOOD cTropnT-<0.01 proBNP-PND
___ 10:54AM BLOOD Lactate-1.9
___ 11:00AM URINE RBC-0 WBC->182* Bacteri-MANY Yeast-NONE
Epi-57
___ 11:00AM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 11:00AM URINE Color-Yellow Appear-Cloudy Sp ___
.
DISCHARGE LABS
___ 07:02AM BLOOD WBC-10.0 RBC-3.95* Hgb-11.8* Hct-38.2
MCV-97 MCH-30.0 MCHC-31.0 RDW-14.2 Plt ___
___ 07:02AM BLOOD ___ PTT-34.9 ___
___ 07:02AM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-144
K-4.4 Cl-110* HCO3-23 AnGap-15
___ 10:35AM BLOOD cTropnT-<0.01 ___
___ 07:02AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
.
MICROBIOLOGY
___ 11:31 am URINE ADDED TO SPECIMEN ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 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
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Blood cultures ___- No growth x 2
.
CTA ___:
FINDINGS: There are curvilinear filling defects in the main
pulmonary artery extending into the right main pulmonary artery
and left main pulmonary artery. The left upper lobe artery
appears patent but just distal to the bifurcation, there appears
to be additional thrombus completely occluding one arterial
branch. There is a large thrombus within the right main
pulmonary artery extending into the right middle lobe artery and
right lower lobe artery, some of which branches appear to be
patent. There is flattening and perhaps mild bowing of the
interventricular septum and reflux of contrast into the hepatic
veins, as seen previously.
The aorta and branch vessels demonstrate calcifications but are
otherwise
unremarkable. Trace pericardial fluid is within physiologic
range and appears unchanged compared to recent prior exam.
Diffuse patchy ground-glass opacity persists and is nonspecific.
No pleural effusion or pneumothorax is detected. A 1-cm
subcarinal lymph node is again noted. No other lymphadenopathy
is detected.
The visualized portion of the thyroid appears homogeneous.
This study is not optimized for evaluation of subdiaphragmatic
structures. Small hiatal hernia is again noted. No acute
subdiaphragmatic process is detected. A 12-mm soft tissue
density subcutaneous nodule in the left anterior chest wall is
again noted. No concerning lytic or sclerotic osseous lesions
are detected.
IMPRESSION: Increased clot burden within the central and
bilateral main
pulmonary arteries.
.
Chest Xray ___
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Borderline size of the cardiac silhouette without
evidence of
pulmonary edema. No pleural effusions. No focal parenchymal
opacity
suggesting pneumonia. Normal hilar and mediastinal structures
.
CTA ___
Extensive pulmonary emboli with increased clot burden in the
left
descending and lower lobe pulmonary artery with associated right
heart strain and enlargement of pulmonary artery.
.
TTE ___
The left atrium is elongated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe pulmonary hypertension. Dilated and
hypertrophied right ventricle with mild global systolic
dysfunction. Normal global and regional left ventricular
systolic function. Moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
estimated pulmonary pressures have further increased.
Brief Hospital Course:
Primary Reason for Admission
___ yo W w/ end stage frontotemporal dementia, OSA, HTN,
depression and an unprovoked PE dx in ___ on coumadin, who
developed hypoxic respiratory distress, diagnosed with new PEs
on CTA and admitted to MICU for monitoring.
.
# Hypoxic respiratory distress/ Submassive Acute Pulmonary
Embolism- As above the patient presented in respiratory distress
from her nursing facility. CTA demonstrated increased clot
burden. which was felt to be the most likely etiology of her
symptoms. Clot burden was significantly increased and appears to
have saddle configuration. Etiology of orignal PE in ___ is
unclear, but this current event is likely due to subtherapeutic
INR in the setting of initiation of a vitamin K containing meal
supplement (carnation instant breakfast). She was currently
hemodynamically stable. Other etiologies such as PNA and
cardiac ischemia were on the differential, but there was
evidence of this clinically and troponins were negative x 2.
During her ICU stay, the patient did not have increasing oxygen
requirements and only required nasal cannula. She was started
on heparin drip, then Lovenox until her INR could reach
therapeutic levels. Lovenox was discontinued when INR was
therapeutic. Her coumadin dose was decreased from her home dose
of 4 mg daily given antibiotic treatment (see below). She
remained hypoxic and had one acute desaturation to an oxygen
saturation of 82% on 4 L NC. Repeat CTA was performed and
showed increased clot burden despite therapeutic INR, in
addition to evidence of right heart strain. She was restarted
on lovenox and coumadin was discontinued. Both pulmonary and
hemetology were consulted and recommended continuation of
lovenox. Though it was felt presentation may be suggestive of
an underlying malignancy. In discussion with her HCP the
decision was made to forgo further work-up given her age and
comorbities. The patient remained hemodynamically stable with
was weaned to 4L nasal cannula. The patient was discharged back
to ___ after discussing her clinical status with the
___ nurse practitioner.
.
# Aspiration risk- There was some some concern for risk of
aspiration raised by nursing. She was evalutated by speech and
swallow who recommended a diet of thin liquids and regular
solids.
.
# UTI- Patient was noted to have a positive UA on admission with
> 182 WBC. Urine culture grew E. coli. She was initally started
on IV ceftriaxone which she received for 3 days. When
sensitivities returned she was transitioned to oral
nitrofurantoin 100 mg twice a day to complete a 7 day course.
The patient was afebrile throughout admission without suprapubic
tenderness on exam. Blood cultures were drawn on admission and
were pending at the time of discharge.
.
STABLE ISSUES
# Frontotemporal dementia- Patient has end state dementia. She
was A+O x1 throughout this hospitalization which per report is
her baseline. The patient was continued on risperdal, valproic
acid.
.
# HTN: She has a documented history of hypertension but was not
on anti-hypertensives as an outpatient. Patient was normotensive
throughout this hospitalization.
.
# OSA. Has not tolerated CPAP in the past, therefore CPAP was
not done while the patient was in ___.
.
# Depression/anxiety- Patient was continued on her home celexa
and buspar.
.
# GERD- Patient was continued on her home PPI
.
TRANSITIONAL ISSUES
- DNR/DNI
Medications on Admission:
- Coumadin 4mg daily
- omeprazole 20mg daily
- citalopram 10mg daily
- MVI
- Risperdal 0.25mg 4PM
- Buspar 10mg BID
- VPA sprinkles 125mg BID
- Docusate 100mg bid
- Senna 8.6mg daily
- aPAP prn
- Ca/D 500/200 tid
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO daily at 4
pm: .
4. divalproex ___ mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO BID (2 times a day).
5. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet
Sig: One (1) Tablet PO three times a day.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain/fever: Do not exceed 4 grams in
24 hours .
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Acute Pulmonary Embolism
Secondary Diagnosis
Frontotemporal Dementia
Depression
Obstructive sleep apnea
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you were having difficulty breathing.
You had a CT scan which showed the clots in your lungs have
gotten worse. This is most likely because the test we use to
monitor your coumadin level was low. The clots continued to
worse and we needed to switch you a new blood thinner. You were
also found to have a urinary tract infection for which you were
given antibiotics.
We made the following changes to your medications
1. STOP Coumadin
2. START lovenox 70 mg twice a day
Followup Instructions:
___
|
10707969-DS-21
| 10,707,969 | 26,323,055 |
DS
| 21 |
2194-12-28 00:00:00
|
2194-12-30 11:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Doxycycline / Bactrim
Attending: ___
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
Liver Biopsy
History of Present Illness:
___ man with drug-induced cholestatsis, d/c'ed from
___ in ___ here with increased nausea since ___. Had
been in ___ until ___ when had decreased appetite and
increased nausea with food. Also noted general decrease in
energy, increased need for sleep, and one episode of word
finding confusion on ___. On day of admission, patient noted
emesis x 1 and development of migraine headache so presented to
ED. Denies fevers, chills, abdominal pain.
.
Of note, patient was treated with Bactrim for a nasal staph
infection in ___ and completed a full seven-day course. On
the final day of the Bactrim, he developed chills, night sweats,
nausea, and headaches and he developed cholestatic hepatitis and
jaundice. LFTs on ___ showed ALT 430, AST 252, ALP 391,
bili 12.3 indicating a drug-induced cholestatic hepatitis
secondary to Bactrim. Viral hepatitis, HIV, CMV, AMA, Smooth
muscle, ceruloplasmin studis were all negative. He was d/c'ed on
___ on ursodiol. His most recent outpt tests showed continued
cholestasis with elevated AP 158 and bili 24.4 though improving
transaminitis. He was maintained on ursodiol TID and
fexofenadine for pruritus. He never developed signs of synthetic
dysfunction or encephalopathy.
.
In the ED, intial vitals were 98.7 53 ___ 100%. Labs
showed bilirubin of 31.8, INR 1.0, ALT 46, AST 62, AP 151. RUQ
U/S was negative for acute biliary pathology.
.
On the floor, patient endorses fatigue. No nausea at present.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, chest pain, abdominal pain,
diarrhea, BRBPR, melena, dysuria, hematuria, peripheral edema.
Endorses headache, constipation, dry cough, 20lbs weight loss
since ___
Past Medical History:
Migraines
Social History:
___
Family History:
No family history of liver disease, parents had HTN, sister just
diagnosed with breast Ca at ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: 98.5 105/59 66 18 100%RA
GENERAL: jaundiced, thin, NAD, appropriate
HEENT: PERRL, EOMI, +scleral icterus, MMM
NECK: no carotid bruits, no JVD
LUNGS: CTAB, no w/r/r
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, no ascites
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, no asterixis
SKIN: scattered excoriations over back, arms, and especially
legs
DISCHARGE PHYSICAL EXAM:
VS - 98, 90/55, 57, 18, 98% RA
GENERAL: jaundiced, thin, NAD, appropriate
HEENT: PERRL, EOMI, +scleral icterus, MMM
NECK: no carotid bruits, no JVD
LUNGS: CTAB, no w/r/r
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, no ascites
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, no asterixis
SKIN: scattered excoriations over back, arms, and especially
legs
Pertinent Results:
PERTINENT LAB RESULTS:
___ 09:50PM BLOOD WBC-6.5 RBC-3.97* Hgb-12.4* Hct-38.2*
MCV-96 MCH-31.2 MCHC-32.5 RDW-16.3* Plt ___
___ 09:50PM BLOOD Neuts-72* Bands-1 Lymphs-12* Monos-7
Eos-2 Baso-0 ___ Metas-2* Myelos-4*
___ 01:49AM BLOOD ___ PTT-29.9 ___
___ 09:50PM BLOOD Glucose-97 UreaN-18 Creat-1.1 Na-136
K-4.5 Cl-100 HCO3-26 AnGap-15
___ 09:50PM BLOOD ALT-46* AST-62* AlkPhos-151*
TotBili-31.8* DirBili-23.7* IndBili-8.1
___ 09:50PM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.2 Mg-2.3
___ 06:10AM BLOOD WBC-5.6 RBC-3.61* Hgb-11.4* Hct-34.7*
MCV-96 MCH-31.7 MCHC-33.0 RDW-16.7* Plt ___
___ 06:10AM BLOOD ___ PTT-32.6 ___
___ 06:10AM BLOOD Glucose-91 UreaN-19 Creat-1.1 Na-137
K-4.0 Cl-100 HCO3-25 AnGap-16
___ 06:10AM BLOOD ALT-44* AST-54* AlkPhos-140*
TotBili-30.1*
___ 06:10AM BLOOD Albumin-3.7 Calcium-9.6 Phos-4.2 Mg-2.3
MICRO:
VRE SWAB PENDING AT TIME OF DISCHARGE
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
12:25 AM
IMPRESSION: Collapsed gallbladder. No intrahepatic bile duct
dilation.
Normal liver echotexture.
BX-NEEDLE LIVER BY RADIOLOGIST Study Date of ___ 3:06 ___
IMPRESSION: Ultrasound-guided non-targeted liver biopsy.
Pathology pending.
PATHOLOGY:
SPECIMEN SUBMITTED: LIVER CORE BIOPSY (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
DIAGNOSIS:
Liver, needle core biopsy:
1. Marked canalicular and hepatocellular cholestasis, most
prominent in zone 3, with associated hepatocyte injury,
apoptosis, and regeneration.
2. Prominent native bile duct injury with associated mixed
inflammation including neutrophils, lymphocytes, and rare plasma
cells and eosinophils.
3. No bile ductular proliferation, steatosis, or ballooning
degeneration.
4. Trichrome stain demonstrates mildly increased portal and
sinusoidal fibrosis.
5. Iron stain shows mild, but diffuse iron deposition, mainly
within hepatocytes.
Note: The features in this biopsy are those of a cholestatic
pattern of injury. The most likely etiology in this clinical
setting is a drug-induced injury as has been well documented
with trimethoprim-sulfamethoxazole. Other causes of cholestatic
injury, such as duct obstruction, are much less likely given the
extent of duct damage, presence of associated mixed
inflammation, and the notable absence of an associated ductular
proliferation.
Clinical: Acute liver failure post- Bactrim.
Gross: The specimen is received in one formalin-filled
container labeled with the patient's name, ___
and the medical record number. It consists of a pale yellow to
focally green liver core measuring 1.8 cm in length that is
entirely submitted in cassette A.
Brief Hospital Course:
___ with presumed drug-induced cholestatic liver injury here
with nausea and vomiting.
.
# drug induced liver injury: Felt to be due to Bactrim
prescribed for recent URI. Recently discharged from the hospital
for this finding. He presents now with worsening jaundice and
nausea. His Bilirubin is elevated though not dramatically higher
than recent baseline. Transaminitis has improved. Viral and
autoimmune studies were negative during last admission. RUQ U/S
remains negative for acute gallbladder pathology and no new
medications to explain continued rise. Patient still without
signs of encephalopathy or synthetic dysfunction. He underwent
liver biopsy which was consistent with Drug induced liver
injury. It appears his LFTs and bilirubin levels have now peaked
which is encouraging that acute injury may have resolved. He
will be followed closely by liver transplant team in clinic. We
continued Ursodiol and Fexofenadine for symptom control.
.
# Nausea: Likely related to underlying liver injury. LFTs are
not dramatically different from recent baseline though bilirubin
has continued to rise. No abdominal pain, fevers, chills, or
ascites on exam to suggest intraabdominal infection, ileus or
SBO. His symptom was controlled with prn Zofran and Compazine.
# Transitional:
1. f/u appointment with liver transplant clinic post discharge
2. pt was instructed to avoid NSAIDs and Tylenol in setting of
acute liver injury
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral unknwon
2. Fexofenadine 60 mg PO BID
3. Propranolol 120 mg PO DAILY
4. Ursodiol 300 mg PO TID
5. Ibuprofen 200 mg PO Q8H:PRN headache
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. traZODONE 50 mg PO HS:PRN insomnia
8. Prochlorperazine 10 mg PO BID:PRN nausea
9. Ranitidine 150 mg PO DAILY:PRN indigestion
Discharge Medications:
1. Ranitidine 150 mg PO DAILY:PRN indigestion
2. Fexofenadine 60 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Ursodiol 300 mg PO TID
5. traZODONE 50 mg PO HS:PRN insomnia
6. Prochlorperazine 10 mg PO BID:PRN nausea
7. Propranolol 120 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Suspected Drug Induced Liver Injury
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 to the hospital with nausea
and lethargy. We have determined these symptoms are related to
your prior liver injury. A liver biopsy was performed during
this admission to help determine the exact cause of your liver
injury.
The following changes have been made to your medications:
STOP: Ibuprofen *** This medication is in the class of
medications called non-steroidal anti-inflammatory medications.
They include Ibuprofen, Aspirin, Naproxen, Aleeve, Motrin,
Indomethacin. These medications should not be taken if you have
liver disease. We also recommend not taking Acetaminophen
(Tylenol) either after acute liver injury. These medications can
make liver failure worse.***
STOP: butalbital-acetaminophen-caff
Followup Instructions:
___
|
10708287-DS-19
| 10,708,287 | 24,728,258 |
DS
| 19 |
2152-06-26 00:00:00
|
2152-06-26 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending: ___.
Chief Complaint:
intractable vomiting, hematemesis
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
___ with history of cyclical vomiting and abdominal migraines
presents with episode of his typical abdominal migraine but more
severe. Unable to tolerate any p.o. for many weeks. Patient has
PICC line for TPN. States that since his last admission he has
had increased fatigue, poor memory, inability to have true BM.
He has been able to take PO meds and eat a little bit of carbs,
and generally has nausea that resolves with sl zofran. The pt
states he was stressed yesterday and started feeling sick. At
3am he started intractably vomiting and noticed vomitus became
brown and with bloody streaks. He was seen at outside hospital,
transferred as his care is provided here. Unable to tolerate his
home Dilaudid and Ativan given intractable nausea and vomiting.
Also received Protonix, Ativan and Zofran.
.
Previous admitted on ___ for similar symptoms, which
have occurred every several months since he was a teenager. Most
recently he was seen at BI with abdominal migraines at top of
the differential. Work-up has included: normal MRCP, normal MRE,
normal EEG, and mildly elevated WBC but no bands and not
febrile. Other considerations have included possible cyclical
vomiting syndrome and he has a daughter with mitochondrial
disease which can be linked to abdominal migraines. He is
treated symptomatically with IV dilaudid, IV zofran, and IV
ativan PRN. Though he had guaiac positive stools, prior stool
studies were all negative for Salmonella, Shigella,
Campylobacter and C. diff toxin with the bleeding felt to be
likely from hemorrhoidal bleeding.
.
He is on chronic TPN since ___ after inability to take PO for
___ weeks ___ abdominal and vomiting. He is undergoing a workup
by neurology at present.
.
In the ED, initial vitals were: 98.9 65 142/88 16 97% RA. CXR
showed no mediastinal widening or air. NG lavage was positive
for red/brown coffee-colored fluid, which began to clear around
500cc NS. The fluid was not guaiac'ed. GI was consulted was
agreed with NG lavage, recommending admission for possible EGD.
He was given ativan 2mg IV x1, zofran, and dilaudid 1mg x1
(which he takes at home). Vitals on transfer: Temp: 98.4po. HR:
65. BP: 137/72. RR: 20 O2: 100RA.
.
On the floor, 99.4 144/70 98 24 99%RA pain ___. He was laying
comfortably in bed feeling improved from admission. Stated this
episode had been similar to prior episodes of cyclic vomiting
and that once he gets too far behind on antiemetics he can only
be controlled with IV medications.
.
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:
Celiac disease on a gluten free diet- diagnosed in ___
Migraine HA
MVA with cervical spine fracture, titanium rods placed at ___ in
___- was referred to pain clinic but not treats his pain
with water exercises.
Borderline diabetic- but then decreased his weight from 260->
220 ___ut 200 per admission H and p from ___
Borderline hypercholesterolemia
Asymptomatic bradycardia
Dudodenal ulcer in ___ s/p cautery when he presented to
___ with similar sx.
History of brain cyst without any neurologic sequellae.
Absent R fourth finger s/p hunting accident
Social History:
___
Family History:
Daughter with mitochondrial type I disease.
MGM cancer in her back.
PGM with liver cancer.
Sister born with ulcers in her stomach. She has recently been
diagnosed with Crohn's but per OSH transfer summary sister has
lupus and another sister with thyroiditis.
Father had MI at age ___.
Physical Exam:
Admission exam:
Vitals: 99.4 144/70 98 24 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: diffuse tenderness but no rebound, no guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, missing ___ digit on R hand
.
VS on day of discharge:
98.7F 120/84 HR ___ - 100s, 18 96% RA
Otherwise unchanged.
Pertinent Results:
Admission labs
___ 12:30PM BLOOD WBC-16.3*# RBC-4.34* Hgb-13.9* Hct-42.6
MCV-98# MCH-32.2* MCHC-32.7 RDW-14.3 Plt ___
___ 12:30PM BLOOD Neuts-95.8* Lymphs-2.1* Monos-1.6*
Eos-0.3 Baso-0.2
___ 12:30PM BLOOD ___ PTT-33.1 ___
___ 12:30PM BLOOD Glucose-1772* UreaN-27* Creat-1.2 Na-125*
K-5.3* Cl-98 HCO3-15* AnGap-17
___ 12:30PM BLOOD ALT-30 AST-21 AlkPhos-68 TotBili-0.5
___ 12:30PM BLOOD Lipase-12
___ 03:09PM BLOOD Calcium-9.3 Phos-1.5*# Mg-1.9
.
Imaging:
.
___ CXR IMPRESSION: No acute cardiopulmonary process. Left
PICC terminates in the proximal right atrium.
.
___ KUB IMPRESSION: Nonspecific bowel gas pattern without
evidence of obstruction or ileus.
.
___ EGD
Impression: Erythema in the duodenal bulb and second part of
the duodenum compatible with duodenitis
Erythema in the antrum compatible with mild gastritis
Grade 5 esophagitis in the middle and lower third of the
esophagus compatible with severe esophagitis (biopsy)
Esophageal candidiasis
Otherwise normal EGD to third part of the duodenum
Recommendations: The cause of the pt's small amount of coffee
ground emesis and hematemesis is likely from his severe erosive
esophagitis
Please start 40mg of pantoprazole or omeprazole twice daily
Follow up biopsy results
Start empiric treatment for ___ esophagitis with Fluconazole
200mg daily for 14 days
Discuss with patient HIV testing given the ___ up per inpatient GI team recommendations
Biopsy results:
DIAGNOSIS: Active (neutrophilic) esophagitis with extensive
coagulative necrosis and ulceration; see note.
Note: No fungal organisms seen on the GMS and PAS-Diastase
stains. Cytomegalovirus and Herpes Simplex Virus (I&II)
immunostains are negative with adequate controls. Additional
stains will be performed. Results will follow as an addendum.
ADDENDUM:
Gram, acid-fast bacilli, and Giemsa stains were performed with
adequate controls. No micro-organisms identified.
RUQ US ___:
IMPRESSION: Normal study without gallstones, gallbladder sludge
or evidence
of cholecystitis.
TTE ___:
The left atrium is mildly dilated. 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) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated ascending aorta.
MRV ___:
The left subclavian vein is markedly attenuated(series 1204b,
image 29),
however, is patent. The visualized left axillary, left
brachiocephalic, right subclavian, right brachiocephalic,
bilateral internal jugular veins, and SVC are patent with no
evidence for a thrombus identified.
The visualized pulmonary artery and arch of the aorta are
unremarkable. There is no mediastinal mass or adenopathy in the
visualized upper abdomen and the lung bases are clear.
The bone marrow signal is normal and no osseous lesions are
identified.
Generated workstation images were essential in demonstrating the
attenuated
left subclavian vein.
IMPRESSION:
Attenuated left subclavian vein; however, it is still patent.
The remainder of the central venous system is patent.
KUB ___:
IMPRESSION: AP supine and erect views of the abdomen show severe
distention
of the colon with stool, and mild dilatation of scattered loops
of small bowel up to diameter of 31 mm. There is no free
subdiaphragmatic gas.
Labs at time of discharge:
___ 06:35AM BLOOD WBC-4.6 RBC-4.18* Hgb-12.6* Hct-36.8*
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.5 Plt ___
___ 06:35AM BLOOD Glucose-114* UreaN-26* Creat-1.2 Na-140
K-3.9 Cl-108 HCO3-26 AnGap-10
___ 06:35AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
___ 05:13PM BLOOD Triglyc-183*
___ 05:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
___ 10:00AM BLOOD HIV Ab-NEGATIVE
___ 05:50AM BLOOD Vanco-14.2
___ 05:21AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
___ yo M with history of recurrent abdominal pain with
nausea/vomiting, prior negative work-up, attributed to abdominal
migraines (Diagnosed by Dr. ___ at ___ and cyclical
vomiting syndrome with question of a mitochondial disorder
(pending a completed evaluation with Dr. ___ at
___, requiring frequent admissions for inability to take POs
and chronic TPN, now admitted for these same symptoms along with
new hematemesis ___ severe esophagitis and candidiasis. His
course was complicated by a CoNS bacteremia from his chronic
PICC line as well as a L subclavian thrombus. He continued to
have abdominal pain/burning/nausea but no emesis throughout his
hospitalization.
# Severe esophagitis/esophageal candidiasis/hematemesis: The pt
presented with intractable vomiting with hematemesis. Endoscopy
was done and pt was found to have severe esophagitis that was
highly friable with candidiasis (visualized on endoscopy).
Unclear etiology, though possibly secondary to signficant
history of vomiting per discussion with GI. No known
immunodeficiency to explain candidiasis, HIV neg. The pt was
started on fluconazole 200mg IV and pantoprazole IV BID. Bx
results showed active (neutrophilic) esophagitis with extensive
coagulative necrosis and ulceration (no evidence of any
organisms, including fungal/viral/bacteria (see report above).
Antifungal regiment was stopped however, he was continued on IV
PPI bid. The abdominal burning sensation he presented with
resolved within one week of tx, however pt stated it had resumed
2 days prior to discharge. His H2 blocker in TPN was restarted
and his abdominal burning resolved.
# Abdominal pain/cyclical vomiting. Pt with hx of intractable
vomiting which was prior to this attributed to cyclical vomiting
syndrome, abdominal migraines, potentially abdominal epilepsy
(EEGs were negative in the past) and/or a mitochondrial disorder
(under consideration). Per discussion with his outpatient
Neurologist, Dr. ___ was felt that abdominal migraine
would be the likely explanation for his symptoms. Patient had
persistent nausea that was moderately controlled with some
breakthrough with PO meds (intermittently treated with IV
Zofran, however mostly with ODT zofran). He was transitioned to
SL ativan and PO dilaudid dissolved in liquids. Mr. ___ was
tolerating liquids (up to 500-600 cc per day). In terms of
evaluation for mitochondrial disorder, he underwent an
evaluation with lactate (wnl), carnitine result was pending at
time of discharge. To help control the migranous component, his
topamax was increased to 75/75mg ___ with a goal of 100mg BID
(can be increased by 25mg every 3 days, while monitoring for
metabolic acidosis and renal stones, last increase on ___.
Amitryptilline was increased to 100mg HS, this can also be
uptightrated as needed. He will require follow up with Dr.
___. His discharge regiment included dilaudid PO, Zofran ODT
and Ativan SL.
Of note, he underwent an an initial medical genetics evaluation
by Dr. ___ at ___ (Office Phone: ___)
on ___. Per verbal discussion with Dr. ___ there is
some concern that he may have a mitochondrial disease (based on
recent findings that some mitochondrial DNA is actually
nuclearly encoded). He is to undergo further testing with
genetics specialists from ___, Dr. ___ will be in contact
with them as well as family. He was empirically started on
Vitamin C, Carnitine, Coenzyme Q10 and Thiamine per Dr.
___. IF HE IS UNABLE TO TOLERATE THESE
MEDICATIONS PO, THEY SHOULD BE ADDED TO HIS TPN IF POSSIBLE OR
CHANGED TO IV. Mr. ___ at this time is awaiting the
delineation of the exact tests that would need to be performed
as well as an ararngement of a muscle biopsy. Dr. ___
___ should be contacted with any further questions.
# Constipation. Patient also had intermittent episodes of lower
quadrant abdominal pain with KUB showing distension of colon
with stool. He was treated with PR bisacodyl and enemas with
improvement in distension. Constipation was felt to be due to
narcotic use. He should continue to receive Bisacodyl and
enemas prn.
# CoNS bacteremia. Developed fevers and ___ BCx coag. neg. staph
bacteremia from PICC line (admitted with PICC line placed at
OSH). Tip Cx was positive. Given left subclavian vein thrombus
was started on IV Vancomycin for a total duration of 4 weeks (to
be completed ___. TTE showed no vegetation.
# L subclavian DVT. Diagnosed at time of attempt to replace PICC
line into Left arm post BCx clearance of above bacteremia. Per
hx had edema, erythema few days after PICC placement at OSH that
eventually resolved. MRV revealed attenuated left subclavian
vein that was still patent with remainder of the central venous
system patent. Started on Lovenox for 3 months (day 1 ___.
On placement of the R PICC line, a small, non-occlusive thrombus
was noted. Given the fact that patient is on anticoagulation, it
is expected to resolve (no signs of sx of DVT on R).
# Migraines (dx in ___. Please see above for treatment.
HAs were pressure like, retroorbital, with no pulsatility,
sigificant photo and phonophobia and well as increasing
tremulousness (though this was not always temporally associated
with HAs). He had an improvement of HA with one dose of
sumatriptan SC. Topamax and Amitryptilline as above. Dilaudid
prn for breakthrough pain. Patient was concerned that his
abdominal pain would worsen with APAP use (prior intolerance)
and he should not be treated with NSAIDs given severe
esophagitis.
# Transaminitis. Normal AST/ALT on admission. Developed after
treatment with Diflucan and improved with discontinuation.
However, was found to have worsening transaminitis w/o alternate
explanation (neg. Hep Serologies, did not correlate with Tylenol
ingestion [one dose of fioricet]) and improved w/o intervention.
At time of discharge ALT and AST were 97/31. RUQ was
unremarkable.
Patient received 1 dose of Hep B vaccine and should receive the
next dose ___ or so and then in ___.
# Nutrition and ACCESS: Pt on chronic TPN and was continued on
home regimen. He was discharged on both, famotidine and IV PPI
given severe esophagitis. Given the PICC associated L
subclavian thrombus and a non-obstructive thrombus and placement
of the R PICC line, patient remains at risk for a recurrent
clot. He was not interested in the J-tube as a means of
nutrition access. After completion of ABx course he will
require repeat BCx at 2 wks post ABx completion and will require
a tunnelled line placement.
#. Celiac disease: Diet-controlled. Prior GI notes indicate that
this is likely not contributing to his current condition. No
prior antibody testing in our system. Will need repeat bx as
outpt.
# Family history of CAD and borderline hyperlipidemia. Given his
strong family history of CAD and LAFB w/ IVCD and prior history
of ? CAD on C. Cath in ___, he will require outpatient
cardiac follow up for risk stratification.
=====================
Transitional issues:
# Hematochezia: pt should have a colonoscopy as an outpatient,
to be discussed with the office of Dr. ___.
# Abdominal migraines: uptightration of topamax as above and f/u
with Dr. ___
# Evaluation of Mitochondrial d/o: f/u with Dr. ___
and follow up of carnitine level (pending at time of discharge).
# Bacteremia: Treatment with vancomycin x 4 wks total with
CBCw/diff, BMP, vanc trough weekly and faxed to Infectious
disease R.Ns. and Dr. ___ at ___.
# Anticoagulation: Lovenox (this will need to be held in
coordination with Access Team prior to placement of Tunelled
line ___ ___ RN ___
He will need a hypercoagulability w/up as OP once he completes 3
months of lovenox given FHx.
# Outpatient cardiology risk stratification evaluation
(preferrably ___ system).
# Completion of Heptatitis B vaccination series: next dose
___ or so and then in ___.
# Continued social work support given progressively worsening
disease and family difficulty coping with his illness and his
daughters (mitochondrial disorder).
# Long term access. After completion of IV antibiotics, he
should undergo blood cultures and if negative tunneled line
placement should be initiated. Please contact Dr. ___
___ and ___ as above.
Medications on Admission:
1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. TPN
Volume(ml/d) 2100 Amino Acid(g/d)110 Dextrose(g/d)410
Fat 46 (g/d)
NO Trace Elements will be added daily
Standard Adult Multivitamins
NaCl 110 NaAc 0 NaPO4 0 KCl 0 KAc 0 KPO4 26 MgS04 12 CaGluc 9
Cycle over 24 hours
7. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO three times a
day for 1 doses: ___ minutes prior to meals.
Disp:*30 Tablet(s)* Refills:*0*
8. Ativan 0.5 mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for nausea or anxiety: do not drive or operate
heavy machinary.
Disp:*30 Tablet(s)* Refills:*1*
9. ranitidine HCl 25 mg/mL Solution Sig: One (1) ml Injection
once a day.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
11. Topamax 37.5mg BID
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q2H (every 2
hours) as needed for pain: give if can tolerate PO, otherwise
give IV. Try crushed in liquids first
.
2. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea:
crush in liquids.
3. lorazepam 1 mg Tablet Sig: ___ Tablet PO every four (4)
hours as needed for nausea: If available, pls provide subligual
formulation, otherwise crush in liquid.
4. topiramate 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. topiramate 25 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
6. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Pantoprazole 40 mg IV Q12H
8. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours): last dose ___.
9. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous DAILY
(Daily) for 3 months: 3 months total, day 1 ___.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
11. Bowel Regimen
Fleets or warm water enema EOD for daily BM
12. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. levocarnitine 330 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO twice a
day: dissolve in liquid.
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. insulin lispro 100 unit/mL Solution Sig: as per sliding
scale units Subcutaneous three times a day.
19. prochlorperazine 25 mg Suppository Sig: One (1) Rectal once
a day as needed for constipation: if unable to take PO.
20. Labs
CBCw/diff, BMP, LFTs and vanc trough
frequency: weekly for ID. In addition will require labs for TPN
monitoring.
21. coenzyme Q10 300 mg Capsule Sig: Three (3) Capsule PO once a
day: Dissolve in liquids.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: severe esophagitis, coagulase negative staph
bacteremia, left subclavian artery thrombus
Secondary: Cyclical vomiting and/or abdominal migraines
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care. You were admitted
for uncontrollable nausea/vomiting with blood in your vomit. You
were treated with IV nausea medications, IV pain medications,
and home TPN with some improvement. You had an endoscopy which
showed severe inflammation and irritation of your esophagus, as
well as suspected fungal infection. You were started on an acid
blocker for your stomach as well as an antifungal, fluconazole.
With this treatment your stomach burning symptoms improved.
Your definitive tests for fungal infection turned out to be
negative.
Your abdominal pain and nausea, though improved, persisted. You
were transitioned to medications by mouth.
Unfortunately you had several complications during this hospital
stay from requiring IV nutrition. You developed a blood
infection from your PICC line and were started on antibiotics.
In ___, due to the chronically indwelling PICC you had a
blood clot in the left subclavian vein. You were treateed with
blood thinner (lovenox).
You have follow-up with your gastroenterologist and neurologist
to help better understand and manage your worsening, chronic
abdominal condition.
Please START the following medications:
- Protonix IV
- Vancomycin IV antibiotics
- Lovenox injection for clot treatment
- Zofran sublingually
- Ativan sublingually
- Dilaudud by mouth to be dissolved in fluids
- Bisacodyl PR
- Daily fleets or warm water enema
- Vitamin C, Thiamine, Carnitine and Coenzyme Q10
CHANGED DOSING:
- Topamax 75mg in AM and 75mg in ___, to be increased to 100mg
twice daily dosing at intervals of 25mg every three days as
tolerated
- Amitryptilline increased to 100mg daily
Please STOP the following medications
- metoclopramide
- omeprazole
- docusate
- oxycodone
- ranitidine (dosed in TPN)
Should you develop any symptoms concerning to you, please call
your doctor at the acute care facility.
Followup Instructions:
___
|
10708287-DS-20
| 10,708,287 | 26,422,298 |
DS
| 20 |
2153-03-20 00:00:00
|
2153-03-23 20:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending: ___.
Chief Complaint:
Abdominal pain with shortness of breath and fleeting chest pain
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
___ yo M with cyclic vomiting syndrome and possible abdominal
migraines admitted with increased chest burning for the past 2
weeks. Mr. ___ was diagnosed with cyclic vomiting syndrome at
age ___ and had been self treating with Reglan for years, but
symptoms have worsened. He had normal EGD/Colonoscopy/gastric
emptying study at ___ but presented to ___ ___ with weight
loss and inability to maintain nutrition and has had a port for
TPN since late ___. MRE and C1 esterase testing were normal in
late ___ as well. Since that time he has been managed with
zofran for nausea and ativan and dilaudid as needed, but had
been doing well for the past few months not needing either
ativan or dilaudid for some time.
He was noted to have severe grade 5 esophagitis along with
gastritis and duodenitis on EGD in ___ that was healed on
follow up endoscopy. Path was notable for chronic inactive and
active duodenitis but he does not have anti-TTG testing in our
system and there was no remark on villous blunting.
He now presents with 2 weeks of burning chest pain radiating to
throat. Worse at night. Worse when lying down. He reports that
the burning causes him to feel short of breath and sometimes he
experiences an attack wherein he cannot breathe for several
seconds. He feels like his throat is closing, and it resolves
without intervention. Shortness of breath improves with
bronchodilator. He reports increased hoarseness. In addition, he
reports fleeting chest pain that is not associated with
shortness of breath or exertion. This pain does not radiate, but
during these pain episode, it hurts to breathe deeply. At
baseline on TPN for nutrition and sometimes eats a small dinner
with his family. However, he recently feels so nauseous after
meals that he administers IV zofran through his TPN port. Has
not been using ativan or pain medication in quite some time as
vomiting not been an issue in the past 1.5 months. The patient
is also complaining of a baseline constipation, often going 11
days without a bowel movement. He feels this is contributing to
his nausea and burning in his chest. His last bowel movement was
5 days prior to admission.
Of note, per the patient and his wife, his daughter has been
diagnosed with an unspecified mitochondrial disease for which
she also receives TPN.
ROS reviewed in 10 other systems, and positive as above,
otherwise negative.
Past Medical History:
Celiac disease on a gluten free diet- diagnosed in ___
Migraine HA
Cyclic vomiting syndrome
MVA with cervical spine fracture, titanium rods placed at ___ in
___- was referred to pain clinic but not treats his pain
with water exercises.
Borderline diabetic- but then decreased his weight from 260->
220 ___ut 200 per admission H and p from ___
Borderline hypercholesterolemia
Asymptomatic bradycardia
Dudodenal ulcer in ___ s/p cautery when he presented to
___ with similar sx.
History of brain cyst without any neurologic sequellae.
Absent R fourth finger s/p hunting accident
Social History:
___
Family History:
Daughter with mitochondrial type I disease.
MGM cancer in her back.
PGM with liver cancer.
Sister born with ulcers in her stomach. She has recently been
diagnosed with Crohn's but per OSH transfer summary sister has
lupus and another sister with thyroiditis.
Father had MI at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 BP 110-120/70s HR ___ RR 18 SaO2 98% RA I/O
GENERAL: NAD. Comfortable
HEENT: No oral lesions, MMM, sclera anicteric, pupils round and
reactice
NECK: Supple, no LAD
___: RRR, nl s1 s2, no MRG, no peripheral edema
LUNGS: CTA in all fields, no rales, wheezes, or ronchi, no
accessory muscle use
ABDOMEN: Soft NT/ND, hypoactive bowel sounds in all four
quadrants, no organomegaly.
SKIN: Warm. Dry. Central line in R chest. c/d/i
NEURO: Alert and oriented x3, strength ___ throughout bilateral
uppers and lowers
DISCHARGE PHYSICAL EXAM:
Unchanged
Pertinent Results:
ADMISSION LABS
___ 03:50PM BLOOD WBC-4.6 RBC-4.43* Hgb-13.1* Hct-38.7*
MCV-87 MCH-29.5 MCHC-33.8 RDW-13.8 Plt ___
___ 03:50PM BLOOD Neuts-75.0* ___ Monos-3.3 Eos-1.3
Baso-0.5
___ 10:32PM BLOOD ___ PTT-35.5 ___
___ 03:50PM BLOOD Glucose-105* UreaN-28* Creat-1.5* Na-142
K-4.1 Cl-109* HCO3-23 AnGap-14
___ 05:19AM BLOOD ALT-42* AST-27 LD(LDH)-157 AlkPhos-90
TotBili-0.3
___ 10:32PM BLOOD CK(CPK)-166
___ 03:50PM BLOOD cTropnT-<0.01
___ 10:32PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:19AM BLOOD cTropnT-<0.01
___ 10:32PM BLOOD Calcium-9.8 Phos-5.7*# Mg-2.5
___ 03:50PM BLOOD D-Dimer-<150
___ 05:19AM BLOOD tTG-IgA-4
STUDIES:
___
CXR: No acute cardiopulmonary process.
___
EGD:
Impression: Severe localized erythema in the stomach body
compatible with local gastritis (biopsy) Atypical peristalsis
and tertiary contractions were noted in the esophagus. Normal
mucosa in the antrum (biopsy). Otherwise normal EGD to third
part of the duodenum
Recommendations:We will follow up biopsy results. Continue high
dose PO PPI.
___ benefit from outpatient manometry study if symptoms persist
to evaluate for esophageal dysmotility as cause of chest pain.
Further plans per inpatient GI team.
___
Pathology Examination
SPECIMEN SUBMITTED: GI BX'S (2 JARS)
DIAGNOSIS:
A. Gastric body biopsy:
Antral type mucosa, no diagnostic abnormalities recognized.
B. Antral biopsy:
No diagnostic abnormalities recognized.
___
KUB
Nonspecific bowel gas pattern with no definite evidence of
obstruction. However, if clinical suspicion exists, serial
radiographs would be indicated on this patient.
Brief Hospital Course:
___ year old male with PMH cyclic vomiting, gastritis and
esophagitis, on TPN, who has been having sudden onset reflux
symptoms, SOB, constipation with nausea, and fleeting chest
pains, with prolonged hospitalization for migraines and chronic
abdominal dysmotility syndrome.
# GERD: The patient has documented chronic gastritis/esophagitis
on past endoscopies, etiology unclear. EGD this admission showed
"severe localized erythema in the stomach body compatible with
local gastritis (biopsied). Aypical peristalsis and tertiary
contractions were noted in the esophagus. Normal mucosa in the
antrum (biopsied). Otherwise normal EGD to third part of the
duodenum. GI to pursue manometry and motility as outpatient.
Biopsies of body and antrum revealed "no diagnostic
abnormalities." The patient and wife endorsed chest burning
refractory to oral PPI, requested home IV PPI. The primary team
transitioned to oral disintegrating lansoprazole, 40mg BID, to
which the patient responded. Fortunately, we were able to send
the patient home on IV PPI as requested by the family.
#Chronic Migraine: Mr. ___ has a history in chronic migraine,
but this did not become an active issue until about 1 week into
the hospitalization. His outpatient regimen included topamax
and amytriptiline. Tramadol did not help abort headaches as a
solo medication. We tried oral sumatriptan but this also did
not work so we transitioned to subcutaneous sumatriptan which
had a very positive benefit to the patient for about 3 hours or
so, and then he would rebound with a migraine. A neurology
consult was placed, and we also discussed his case with his
primary neurologist Dr. ___. It was recommended to maximize
his dose of topamax to 150 mg BID and limit our use of
sumatriptan subq to ___. We were able to keep him
migraines under control with PO lorazepam as needed and tramadol
on top of the topamax/amytriplyline with limited sumatriptan
subq. We obtained prior authorization for sumatriptan subq so
the patient could use this in case of severe migraine at home.
# Constipation/nausea: Etiology unclear, patient attributes to
dysmotility. Patient had regular BM's in house. There was some
atypical peristalsis on EGD, and was believed a candidate for
motility studies as an outpatient. The patient had a variable
adherence to home bowel regimen where he took lactulose as
prescribed but refused colace, senna, and miralax, reporting
that they don't work. The patient and his wife felt strongly
that dysmotility from mitochondrial disorder was responsible for
constipation, nausea, GERD with SOB and cyclic vomiting. The
patient was scheduled for GI followup with Dr. ___ due to
prolonged hospital course this appointment was cancelled. We
controlled his nausea with oral compazine, IV zofran, and oral
lorazepam and reglan. The patient was discharged on oral
lorazepam and reglan.
#. Chest Pain: Fleeting chest pains over past 4 weeks, worse in
recent days, not exertional, not associated with SOB. Considered
ACS vs. PNA vs. PE vs. anxiety. CXR unconcerning for PNA,
remained afebrile without elevated WBC, D-dimer negative,
toponins negative x3. The patient had no episodes of chest pain
in house.
We set up appointments with GI and Neuro for close follow up and
monitoring of these chronic issues. The patient remains on TPN
and presented multiple medical and disposition challenges to the
medicine team. He also carries a diagnosis of mitochondrial
disorder, as does his daughter, and these were major social
stressors that factored into his care. It should be noted to
his primary care physician and others involved in his care the
challenging context to which his medical problems are manifest.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ondansetron 4 mg PO TID:PRN nausea **NOT TAKING**
2. Ondansetron ___ mg IV Q8H:PRN nausea **TAKING**
3. Lactulose 15 mL PO ONCE constipation Duration: 1 Doses
**TAKING**
4. Topiramate (Topamax) 125 mg PO BID **TAKING**
5. Lorazepam 1 mg PO BID:PRN nausea **TAKING**
6. docusate calcium *NF* 240 mg Oral daily **NOT TAKING**
7. Polyethylene Glycol 17 g PO DAILY **NOT TAKING**
8. Senna 1 TAB PO Frequency is Unknown constipation **NOT
TAKING**
not taking
9. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN migraine
10. Omeprazole 40 mg PO BID **TAKING**
11. Albuterol Inhaler 1 PUFF IH Q4H shortness of breath
**TAKING**
12. Amitriptyline 100 mg PO HS **TAKING**
Discharge Medications:
1. Ondansetron ___ mg IV Q8H:PRN nausea
2. Topiramate (Topamax) 150 mg PO BID
RX *topiramate [Topamax] 50 mg 3 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*3
3. Lorazepam 1 mg PO BID:PRN nausea
RX *lorazepam 1 mg 1 by mouth twice a day Disp #*30 Tablet
Refills:*0
4. docusate calcium *NF* 240 mg Oral daily
not taking
5. Ondansetron 4 mg PO TID:PRN nausea
not taking
6. Polyethylene Glycol 17 g PO DAILY
Not taking
7. Senna 1 TAB PO DAILY constipation
not taking
8. Albuterol Inhaler 1 PUFF IH Q4H shortness of breath
9. Amitriptyline 100 mg PO HS
RX *amitriptyline 100 mg 100 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
10. Lactulose 15 mL PO ONCE constipation Duration: 1 Doses
11. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth QIDACHS Disp
#*60 Tablet Refills:*3
12. Sumatriptan Succinate 6 mg SC ONCE Duration: 1 Doses
RX *sumatriptan succinate 6 mg/0.5 mL Inject subcutaneously 6 mg
prn Disp #*18 Cartridge Refills:*3
13. Pantoprazole 40 mg IV Q12H
RX *pantoprazole [Protonix] 40 mg 40 mg twice a day Disp #*60
Vial Refills:*3
RX *pantoprazole [Protonix] 40 mg 40mg IV every twelve (12)
hours Disp #*60 Vial Refills:*3
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN migraine
RX *tramadol 50 mg 1 tablet(s) by mouth q4 hrs Disp #*60 Tablet
Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Laryngospasm secondary to gastritis and acid reflux
Chronic headaches
Gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted due to concern about your difficulty
breathing. It was determined that you were not having a heart
attack and you did not have a blood clot in your lung. In
addition, your upper gastrointestinal tract was visualized, and
there were no major structural abnormalities seen. It was found
to be inflammed, a condition called gastritis, and some biopsies
were taken to determine the cause. These can be discussed during
your ___ clinic visits with your gastroenterologists. To
control your nausea we found a good regimen of lansoprazole,
lorazepam, and reglan.
We also treated your migraines during this admission. We
continued your amitryptiline and topomax while here. We ended
up consulting neurology to help us out and they recommended
increasing your topomax dose to 150 mg BID (from 125 mg BID) and
using sumatriptan sub cutaneously no more than ___. The
combination of tramadol and lorazepam also worked out well.
Medication Changes:
Increase Topomax to 150 mg twice daily
Start intravenous pantoprazole
Start Sumatriptan as needed
Start Metoclopramide for nausea
Start tramadol for headaches
Stop Dilaudid
Stop Omeprazole
Followup Instructions:
___
|
10708431-DS-4
| 10,708,431 | 23,430,883 |
DS
| 4 |
2158-03-02 00:00:00
|
2158-03-03 10:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall, pneumothorax, rib fractures
Major Surgical or Invasive Procedure:
___: Right sided chest tube
History of Present Illness:
___ transfer from OSH after developing progressive subcutaneous
emphysema/facial swelling and subsequent respiratory distress
requiring intubation. He was treated in the OSH ED with
epinephrine, solumedrol, and benadryl with no effect, and
subsequently was intubated for worsening respiratory distress.
Upon arrival to the ED here he had CT scans of the chest,
abdomen, pelvis, and c-spine which revealed extensive
pneumomediastinum, right sided pneumothorax, a smaller
left-sided pneumothorax, and extensive subcutaneous emphysema.
Past Medical History:
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
On admission: Intubated and sedated
Vitals: BP: 123/80 HR 102
Intubated CMV 60% /5 : ABG pH 7.32 pCO2 42 pO2 56 HCO3 23
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bilateral subcutaneus emphysema. Decreased blt respiratory
sounds
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
Vital signs: t=96, bp=90/54, hr=81, resp. rate 20, room air 95%
General: Sitting in chair, NAD, garbled speech related to no
dentures
CV: Ns1, s2, -s3, -s4
LUNGS: decreased bs bases
ABDOMEN: soft, non-tender
EXT: Weak dp bil., ext. cool, mottled, + radial bil. left hand
cool
no calf tendeness, no pedal edema bil
NEURO: alert and oriented x 3, speech garbled, no tremors
SKIN: Crepitus clavicles bil., uppper ant. chest wall, mandible
and neck.
Pertinent Results:
___ 02:18AM BLOOD WBC-8.4 RBC-3.30* Hgb-11.8* Hct-33.0*
MCV-100* MCH-35.7* MCHC-35.7* RDW-12.4 Plt ___
___ 01:14AM BLOOD WBC-11.5* RBC-3.12* Hgb-10.6* Hct-30.6*
MCV-98 MCH-33.9* MCHC-34.6 RDW-12.7 Plt ___
___ 01:53AM BLOOD Neuts-95.3* Lymphs-4.0* Monos-0.6*
Eos-0.1 Baso-0.1
___ 09:46PM BLOOD Neuts-96.9* Lymphs-1.8* Monos-1.1*
Eos-0.1 Baso-0.1
___ 02:18AM BLOOD Plt ___
___ 02:18AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-135 K-4.0
Cl-98 HCO3-28 AnGap-13
___ 05:30PM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-137
K-3.3 Cl-101 HCO3-27 AnGap-12
___ 01:14AM BLOOD ALT-32 AST-51* AlkPhos-95 TotBili-0.3
___ 02:18AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
___ 05:30PM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
___ 01:12PM BLOOD Lactate-0.2*
___ 02:54AM BLOOD Lactate-2.0
___: chest x-ray:
IMPRESSION:
1. Bilateral pneumothoraces and pneumomediastinum not well seen
on this study but are seen on subsequent CT.
2. Endotracheal tube ends 3.7 cm above the carina.
___: cat scan of the head:
IMPRESSION: Extensive subcutaneous air as described above. No
intracranial air. No acute intracranial injury.
___: cat scan of the abdomen:
IMPRESSION:
1. Multiple right-sided rib fractures with bilateral small
pneumothoraces,
extensive pneumomediastinum and tracking of subcutaneous air
along the body wall.
2. Severe pulmonary emphysema with biapical scarring.
3. No solid organ injury in the abdomen or pelvis.
4. Extensive atherosclerosis with abdominal aortic aneurysm to
3.3 cm.
5. ETT and NGT in appropriate position
___: cat scan of the c-spine:
IMPRESSION:
1. No acute fracture or malalignment.
2. Extensive subcutaneous air.
___: chest x-ray:
FINDINGS: Again seen is severe bilateral subcutaneous emphysema
which limits the assessment for small pneumothorax.
Pneumomediastinum is again visualized.
There is a right-sided chest tube. There is mild mediastinal
shift to the
right. A small left basilar pneumothorax is visualized and
probable right
medial pneumothorax.
___: chest x-ray:
Severe widespread subcutaneous emphysema throughout the chest
wall and neck, and severe pneumomediastinum are unchanged over
the past several days. No definite pneumothorax, right pleural
tube in place. Bibasilar atelectasis or aspiration changes,
unchanged since ___ at 12:29 a.m. Heart size is normal
___: chest x-ray:
There is no large right pneumothorax or appreciable pleural
fluid collection following removal of the right pleural tube,
although a small amount of pleural air would be difficult to
detect in the setting of persistent severe subcutaneous
emphysema and pneumomediastinum. Left basal atelectasis has
cleared. Emphysema is severe. There is probably a small to
moderate left pneumothorax, which has remained stable since the
earliest chest radiographs here on ___. Heart is not
enlarged.
Brief Hospital Course:
Mr ___ arrived to ___, s/p fall and developed sudden
onset of right sided facial swelling. He was intubated for
increasing respiratory distress. He was taken to the Trauma ICU
for monitoring. Imaging showed right rib fractures and
bilateral pneumothorax. Soon after arrival a right-sided chest
tube was placed by the thoracic surgery team and he was observed
in the ICU until transfer to the floor on ___.
NEURO: He received acetaminophen and oxycodone with good effect
and adequate pain control.
CV: He exhibited consisent mild-moderate hypertension, so he was
given IV
metoprolol. Once tolerating PO intake, he was transitioned to
oral metoprolol.
PULM: He had a chest tube placed ___ and was extubated on
___, hospital day 2. His chest tube showed a small air leak
the first day it was placed, but no residual pneumothorax was
seen on CXR. The thoracic team removed his chest tube on ___.
Repeat chest x-ray on ___ showed no pneumothorax but increased
subcutaneous air in upper chest. His respiratory status was not
compromised.
GI/GU/FEN: While intubated, he was NPO with IV fluids. He was
hyponatremic on arrival, which improved readily after several
liters of NS followed by ___ NS. His current sodium is 135.
He had a bedside swallow eval performed ___ and he was started
on a regular diet.
ID: He had no infectious issues, no antibiotics were indicated.
Endocrine: His blood sugar was monitored throughout his stay and
was maintained on an insulin sliding scale until his blood
glucose values returned to normal.
Hematology: His complete blood count was examined routinely; no
transfusions were required.
Prophylaxis: He received subcutaneous heparin and venodyne boots
were used during this stay and was encouraged to ambulate as
early as possible.
He is afebrile and his blood pressure is borderline. His
anti-hypertensives have been held today because of a blood
pressure of 90/50. He is able to ambulate without dizziness or
shortness of breath. His blood pressure was monitored
throughtout the day and has increased to 122/70. He is
tolerating a regular diet. His electrolytes have normalized and
his hematocrit is stable.
He is preparing for discharge home with ___ services who will
monitor his blood pressure. He also has instructions to follow
up with the acute care service and with his primary care
provider to ___ his anti-hypertensive agents.
Medications on Admission:
MEDS AT HOME: Amlodipine 10', Atenolol 50', Lisinopril 40',ASA,
Folic Acid, Cyanocobalamin, MVI, Thiamine
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check BP prior to dose: hold for bp <100, hr <60.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Trauma: fall
Blt Pneumo R > L / pneumomediastinum
R Rib fx ___ is displaced.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you had fallen. You
developed swelling of your face, neck and upper chest. You were
also found to have a collapsed lung and rib fractures. You had
an breathing tube placed at the outside hospital and you were
monitored in the intensive care unit. Because of your injuries,
you had swelling of the neck, face and chest. Your vital signs
have stablized and the swelling is decreasing. You are now
preparing for discharge home with the following instructions:
Your injury caused rigth sided ___ 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 antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
___
|
10709096-DS-7
| 10,709,096 | 20,869,326 |
DS
| 7 |
2174-06-17 00:00:00
|
2174-06-17 21:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
trauma with multiple fx
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with early Alzheimer who fell 10 flights of stairs, -LOC
with L S/I pubic rami fractures, left sacral fracture with
associated pre-sacral hematoma, T11 compression fracture. Of
note, patient was accompanied by her son. She has become more
unsteady in recent months. Her son was actually planning on
installing handrails. She was walking down her stairs this pm,
and stepped on her own feet, culminating in fall ___ flights of
stairs, with head strike, but no LOC. Patient complained of left
sided flank pain. She was brought to the ED for further care.
She currently only endorses R thumb pain.
Past Medical History:
Early Alzheimer, Anxiety
Social History:
___
Family History:
NC
Physical Exam:
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Ext: No edema, warm well-perfused
Brief Hospital Course:
(c/s) ___ early Alzheimers s/p mechanical fall ___ stairs with L
sup/inf pubic rami fx, left sacral fx with assoc pre-sacral
hematoma, T11 compression fx. Orthopedics was consulted and
recommended WBAT to LLE, f/u w ortho trauma in 4 weeks Dr.
___. Serial crits were checked and they have been stable.
___ Serial H/H: 00 am. (33.3) 4am (31.8)--> 5pm ( 31.5). On
___, ___ and OT saw patient and recommended rehab.
Neurosurgery was consulted and they rec. TLSO brace worn when
OOB. On ___, the patient was tolerating a regular diet, pain
was controlled, having abdominal function, and was ready for
rehab disposition.
Medications on Admission:
Donepezil 5 mg PO QHS
Sertraline 50 mg PO DAILY
TraZODone 50 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Donepezil 5 mg PO QHS
3. Sertraline 50 mg PO DAILY
4. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left superior and inferior pubic rami fx, left sacral fx with
assoc pre-sacral hematoma, T11 compression fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* Your injury caused pelvic and spine fractures
* 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.
* 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:
___
|
10709102-DS-20
| 10,709,102 | 24,595,337 |
DS
| 20 |
2138-08-26 00:00:00
|
2138-08-28 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Altered mental status and tachycardia
Major Surgical or Invasive Procedure:
Lumbar puncture (___)
History of Present Illness:
Patient is a ___ male with a past medical history of
history of atrial fibrillation (On eliquis, metoprolol), CVA
with
residual aphasia, depression who presents to the emergency
department with concerns for tachycardia and altered mental
status. Per wife, since patient found out that his father is
dying, patient has been acting with erratic behaviors, wanting
to
take his clothes off and speaking things that "do not make
sense". On the day prior to admission, he went to a ___ for rib cage pain, and he has found to have old rib
fractures. He went home, and this morning he woke up refusing to
put clothes on and again per wife, was acting strange. There are
no reports of trauma or falls. He does drink approximately 2
drinks per day, last one this past ___. There was no
reported drug use. No reported cough, fevers or chills.
On arrival, to the ED, he triggered atrial fibrillation with
RVR.
He got IV metoprolol 5mg, and metop tartrate PO 12.5 followed by
metop succinate 12.5. Patient himself denies any symptoms at
this
time but he is confused.
On reassessment in the ED, the patient was following commands
but
thought year was ___, unable to name objects. He states he had
"too many beers" but serum EtOH level is negative and wife
denies
that he had any beer since this past ___. No history of
EtOH
withdrawal per wife.
In the ED, initial VS were:
98.4 76 112/70 16 97% RA
Labs showed:
5.1 > 15.2/44.5 < ___ 16
=============< 110
4.4 18 0.8
Lactate:2.9
UA: Small blood, 20 protein 40 ketones, ___.8 PTT: 26.5 INR: 1.4
Dig: <0.4
ALT: 22 AP: 146 Tbili: 2.4 Alb: 3.5
AST: 32
Imaging showed:
Consults: None
Patient received:
NS 1000 mL
Haloperidol 5 mg
Metoprolol Tartrate 5 mg IV
LORazepam .5 mg IV
Metoprolol Tartrate 12.5 mg
Metoprolol Succinate XL 25 mg
Transfer VS were:
97.8 97 103/70 22 94% RA
On arrival to the floor, patient unable to give any history. Was
somnolent, but arousable to sternal rub. Responding to commands,
but mumbles incoherently. Wife not at bedside and not available
after many attempts to call.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
#Atrial fibrillation
#CVA with residual aphasia, right sided weakness, neck stiffness
(h/o of cervical spine fracture)
#Depression
Social History:
___
Family History:
Father has history of similar presentation about ___ years ago
and was reportedly hospitalized at ___ for 6 months,
diagnosis unclear.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: ___ 0202 Temp: 96.7 Axillary BP: 118/83 HR: 82 RR: 12
O2
sat: 95% O2 delivery: Ra
GENERAL: Lying in bed, arousable but somnolent
HEENT: Left eye crusted over. Pupils 3mm and reactive
bilaterally. No LAD, no thyromegaly.
NECK: supple, no LAD. No JVD.
CV: RRR, S1/S2, ___ holosystolic murmur best heard at apex,
gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Winced on deep palpation of RUQ; appreciated some
hepatomegaly on exam, no splenomegaly. Abd otherwise soft and
non-tender.
EXTREMITIES: no cyanosis, clubbing, or edema. No stigmata of
endocarditis
PULSES: 2+ radial pulses bilaterally
NEURO: Unable to state name, place or time. Responded to
questions but mostly with unintelligible mumbling. Followed
commands such as hand squeeze, raising legs. Sensation and
strength seemed intact though exam limited by
lethargy/somnolence.
DISCHARGE EXAM
==============
VS: 98.2, 125 / 91, 84, 18, 97% RA
General Appearance: Somewhat disheveled looking, in NAD.
HEENT: Atraumatic, normocephalic. Sclera anicteric b/l. MMM. No
oropharyngeal lesions. No LAD.
Lungs: Equal chest rise. Good air movement. No increased work of
breathing. CTAB. No wheezes, rales, or rhonchi.
CV: RRR. Normal S1, S2. ___ non-radiating holosystolic murmur
best heard at the apex. No carotid bruits b/l. +2 carotid pulses
b/l, +2 radial pulses b/l, +2 dorsalis pedis pulses b/l.
Abdomen: Non-distended. Bowel sounds present. Soft, RUQ slightly
tender to palpation. No hepatosplenomegaly.
Extremities: No edema, clubbing, or cyanosis.
Skin: No rashes. 1 cm x 1 cm dark brown nodule right
subclavicular. Warm to touch.
Neuro: A+O x 3 when given choices (has expressive aphasia). Able
to say the days of the week backwards. ___nd RLE.
___ strength LUE and LLE. Sensation to touch intact throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 04:16PM BLOOD WBC-5.1 RBC-4.44* Hgb-15.2 Hct-44.5
MCV-100* MCH-34.2* MCHC-34.2 RDW-13.1 RDWSD-48.3* Plt ___
___ 04:16PM BLOOD Neuts-66.7 Lymphs-17.1* Monos-15.2*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.43 AbsLymp-0.88*
AbsMono-0.78 AbsEos-0.01* AbsBaso-0.03
___ 03:11AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+*
Burr-1+*
___ 03:11AM BLOOD Parst S-NEG
___ 03:11AM BLOOD Ret Aut-1.2 Abs Ret-0.05
___ 04:16PM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-146
K-4.4 Cl-108 HCO3-18* AnGap-20*
___ 04:49PM BLOOD ALT-22 AST-32 AlkPhos-146* TotBili-2.4*
DirBili-0.7* IndBili-1.7
___ 04:49PM BLOOD Lipase-38
___ 04:49PM BLOOD cTropnT-<0.01
___ 03:11AM BLOOD CK-MB-6
___ 03:11AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.2 Mg-1.5*
___ 03:11AM BLOOD Hapto-<10*
___ 03:11AM BLOOD Osmolal-295
___ 03:11AM BLOOD TSH-1.9
___ 04:49PM BLOOD Digoxin-<0.4*
___ 04:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
PERTINENT INTERVAL LABS
=======================
___ 10:13 am CSF;SPINAL FLUID Source: LP.
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
__________________________________________________________
___ 10:13 am CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
__________________________________________________________
___ 10:13 am CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
__________________________________________________________
___ 3:11 am Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
EIA RESULT NOT CONFIRMED BY WESTERN BLOT.
NEGATIVE BY WESTERN BLOT.
Refer to outside lab system for complete Western Blot
results.
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Refer to outside lab system for complete Western Blot
results.
Negative results do not rule out B. ___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
__________________________________________________________
___ 7:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:49 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 03:11AM BLOOD EtGlycl-LESS THAN
___ 03:32AM BLOOD ___ pO2-64* pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Comment-GREEN TOP
___ 05:14PM BLOOD Lactate-2.9*
___ 07:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:15PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-40* Bilirub-SM* Urobiln-4* pH-6.0 Leuks-NEG
___ 07:15PM URINE RBC-15* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-0
___ 07:15PM URINE Mucous-FEW*
___ 07:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 03:11AM BLOOD Ret Aut-1.2 Abs Ret-0.05
___ 03:11AM BLOOD Parst S-NEG
___ 03:11AM BLOOD ALT-19 AST-40 LD(LDH)-331* CK(CPK)-450*
AlkPhos-118 TotBili-2.0*
-Alcohol panel negative.
DISCHARGE LABS
==============
___ 07:36AM BLOOD WBC-3.0* RBC-4.03* Hgb-14.3 Hct-40.0
MCV-99* MCH-35.5* MCHC-35.8 RDW-13.0 RDWSD-46.8* Plt ___
___ 03:11AM BLOOD Neuts-57.2 ___ Monos-17.4*
Eos-2.6 Baso-1.0 Im ___ AbsNeut-2.23 AbsLymp-0.84*
AbsMono-0.68 AbsEos-0.10 AbsBaso-0.04
___ 07:36AM BLOOD Glucose-79 UreaN-6 Creat-0.5 Na-141 K-3.7
Cl-107 HCO3-23 AnGap-11
___ 07:36AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.4*
Brief Hospital Course:
___ male with a past medical history of history of
atrial fibrillation (On eliquis, metoprolol), CVA with residual
aphasia, depression who presents to the emergency department
with concerns for tachycardia and altered mental status.
ACTIVE ISSUES
==============
#Encephalopathy:
When patient presented, we instituted a very broad workup. Tox
screens were negative, alcohol panel was negative, ethylene
glycol was negative, no osmolar gap was present so toxic
ingestion seemed unlikely. VBG was WNL so patient was not
hypercarbic. TSH was WNL so patient was not in thyroid storm.
Folate was normal, vitamin B12 was slightly elevated. Patient
was started on thiamine for three days in case of Wernicke's
encephalopathy. Anaplasma, Babesia, and Lyme serologies were
negative. MRI Brain w/o contrast showed no acute intracranial
abnormalities. Psychiatry did not consider this to be a primary
psychiatric disorder. LP was done following holding of Apixaban,
which showed tube 1: 522 RBCs, 35 WBCs, 52 lymphs, 19 polys,
glucose 62, protein 32. Concerned for meningitis, we initiated
empiric treatment with vancomycin, ampicillin, ceftriaxone,
acyclovir. CSF gram stain negative, culture with preliminary
result of no growth, HSV negative. CSF acid fast culture, fungal
culture, HIV-1, and Lyme still pending. Infectious diseases was
consulted who recommended discharge discharge with doxycycline
100 mg PO BID x14 day total course with PCP follow up given CSF
culture with no growth to date. Sent serum arbovirus antibody
panel, Powassan virus serologies, Borellia miyamotoi serologies,
and anaplasma PCR (pending on discharge). Patient seen and
evaluated by OT, recommended discharge home with 24 hour
supervision. Offered home services, but wife declined.
#Leukopenia:
Patient came in with normal WBC but became leukopenic over the
course of his stay. Neutrophils normal. Could be due to possible
viral infection. Unclear etiology but stable prior to discharge.
Recommend outpatient follow up.
#Hemolysis:
Patient's initial labs showed elevated LDH, decreased
haptoglobin, elevated T. bili. However, his potassium was
normal, he was not anemic, and his reticulocyte count was
normal. A RUQ US was normal. His T. bili subsequently
downtrended. Unclear etiology but stable prior to discharge.
Recommend outpatient follow up.
#Abnormal UA:
Patient's UA showed proteinuria at 30 and hematuria at 15. We
spun the urine, and the urine sediment was unremarkable. Repeat
UA showed proteinuria still at 30 and decreased hematuria at 10.
CHRONIC ISSUES
==============
#Atrial fibrillation
-We continued his metoprolol succinate 25 mg PO QD
-We continued his digoxin 0.125 mg QD
-We held his Elliquis for 3 days for his LP. Restarted after LP.
#Depression
-On no medications at home
-Patient became tearful on ___ while EEG team was about
to place electrodes on patient's head. We consulted spiritual
care/chaplain to see the patient with improvement in patient's
symptoms.
-Psychiatry consulted and does not think patient needs to be on
medication.
#AAA
-Found incidentally
-4.9 cm, as it is less than 5.5 cm, no surgical intervention
recommended
TRANSITIONAL ISSUES
===================
[ ] He will be empirically treated for Lyme disease with oral
doxycycline for 14 days (___).
[ ] Referral to ID PRN.
[ ] WBC 3.0 on discharge, stable. Etiology unclear, possibly in
the setting of unidentified viral infection. Please repeat CBC
on follow up to ensure resolution.
[ ] Please repeat LFTs on follow up to ensure normalization of
tBili.
[ ] OT recommended home w/ 24h supervision. Home services
offered but wife declined. Consider continuing discussion as
needed.
[ ] Consider monitoring Dig levels (low on admission, discharged
on doxycycline).
[ ] Will need monitoring of his AAA (4.9 cm).
CORE ISSUES
===========
#CODE STATUS: Full code (presumed)
#CONTACT: Wife ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Apixaban 5 mg PO BID
3. Digoxin 0.125 mg PO DAILY
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
5. Metoprolol Succinate XL 25 mg PO DAILY Atrial fibrillation
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
Please take at 8am and 8pm daily. Last dose ___ in evening.
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
Disp #*20 Tablet Refills:*0
2. Apixaban 5 mg PO BID
3. Digoxin 0.125 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY Atrial fibrillation
5. Pantoprazole 40 mg PO Q24H
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Encephalopathy
SECONDARY DIAGNOSES
===================
Atrial fibrillation with RVR
Hemolysis
Abdominal aortic aneurysm
Leukopenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were brought to the hospital because you were acting very
strangely, and you were confused.
WHAT WAS DONE WHILE I WAS HERE?
You had a lumbar puncture done, which looked at the fluid in
your spinal column. You also had an EEG done, which analyzed
your brain waves. You were placed on medications to treat a
possible infection and a possible virus in your spinal column
that could have explained your confusion and strange behavior.
WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL?
Please take your medications as prescribed. Specifically,
continue taking doxycycline (the medication to treat your
infection) through ___. Please follow-up with Dr. ___ in
___ weeks.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10709795-DS-19
| 10,709,795 | 29,016,755 |
DS
| 19 |
2181-02-23 00:00:00
|
2181-02-23 22:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
CT-guided biopsy of paravertebral area at L3/L4
History of Present Illness:
___ year old male with a history of prior heroin abuse (sober
since ___, hepatitis C, presenting with subacute low back
pain. About 3 months ago, he developed acute low back pain,
with symptoms of pain radiating down left leg to the level of
the knee. Denied numbness or tingling. He was seen at ___
___ and an MRI was obtained which revealed disc herniation
with impingement of the L5 nerve root. He was referred for
cortisone shots with some improvement. However, about 1 month
ago, the back pain began to worsen. He endorsed sweats but no
significant fevers or chills. His ROS was otherwise negative.
Given the increasing back pain, a repeat MRI was performed 5
days prior to this admission. On that MRI, he was seen to have
new abnormalities at L3-L4 consistent with osteomyelitis. He
presented to the ED today for increasing pain, where he received
ativan and dilaudid. Blood cultures were obtained. He was
transferred to the floor for further management. Other than
above, ROS remained negative.
This is a ___ year old male with a remote history of IV drug
abuse w/ hep c presenting with lower back pain, radiating down
left leg. He also endorses intermittent episodes of bowel or
bladder incontinence. He denies any numbness. He reports he had
some chills last week been no fevers reported the back pain has
been ongoing for the last 3 months and he has received cortisone
shots for them. He reports no headache neck pain chest pain or
shortness of breath.
Past Medical History:
Hepatitis C (untreated - refractory to prior regimens)
Lumbar disc disease (with herniation)
Hypertension
Heroin Abuse (last use ___
Social History:
___
Family History:
Sister had breast cancer, numerous family members with
hypertension
Physical Exam:
VS: temp 97.6, 136/99, 69, 18, 97% RA
Gen: Caucasian male in no apparent distress
HEENT: Anicteric, no oropharyngeal lesions
Neck: supple, no lymphadenopathy
Cardiac: Nl s1/s2 RRR no appreciable murmurs
Pulm: clear bilaterally
Abd: soft NT ND + BS
Ext: No stigmata of endocarditis evident, no edema present
Discharge exam:
afebrile (remained so throughout course), others vitals similar
to above
Gen: Caucasian male in no apparent distress
HEENT: Anicteric, no oropharyngeal lesions
Neck: supple, no lymphadenopathy
Cardiac: Nl s1/s2 RRR no appreciable murmurs
Pulm: clear bilaterally
Abd: soft NT ND + BS
Ext: No stigmata of endocarditis evident, no edema present
Neuro: CNs intact, no ___ motor or sensory deficits
Pertinent Results:
___ 05:45PM GLUCOSE-97 UREA N-7 CREAT-0.6 SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-9
___ 05:45PM ALT(SGPT)-38 AST(SGOT)-45* ALK PHOS-113 TOT
BILI-0.4
MRI from ___
1. There are mostly new abnormalities at L3-4 compared to the
study from
___ most consistent with discitis and
osteomyelitis.
2. Multilevel degenerative changes are again seen including a
left foraminal L5-S1 disc herniation with compression of left L5
nerve root
discharge labs:
___ Ct
___
GlucoseUreaNCreatNaKClHCO3AnGap
___
ESR 49
CRP 21.4
ALTASTAlkPhosTotBili
3845*1130.4
___ 4:00 pm TISSUE paravertebral area of L3/L4.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
blood cultures pending
CXR:
FINDINGS: PA and lateral views of the chest are provided.
Subtle opacity is noted at the left lung base which could
represent pneumonia in the correct clinical setting. Given the
associated volume loss, a component of atelectasis is likely
present. Cardiomediastinal silhouette is normal. No effusion
or pneumothorax is seen. No free air below the right
hemidiaphragm
Brief Hospital Course:
___ year old male presenting with concern for L3/L4
diskitis/osteomyelitis.
.
# Diskitis/Osteomyelitis
No recent heroin use - focus of infection could be secondary
either to hematogenous spread or introduction via recent
cortisone injections. Patient received antibiotics in the ED.
These were stopped after admission to allow highest potential
yield of culture. No neurologic deficits on exam to suggest
progression to epidural abscess, and recent MR spine reassuring,
without evidence of abscess or spinal cord compression.
Underwent CT-guided biopsy of paravertebral area near L3/L4,
which was non-diagnostic. ID was also following patient. Plan
was for repeat CT-guided biopsy on ___, which was delayed
due to more urgent cases. Unfortunately, patient decided to
leave against medical advice on ___, as he did not want to
wait two more days for repeat biopsy. He was counseled
extensively on which symptoms to monitor that could be
suggestive of progressive infection or epidural abscess
developement, and should these develop, he will seek immediate
medical attention. Otherwise, he will work with his outpatient
providers to set up repeat biopsy (this writer will also help
arrange any direct inpatient admission). Antibiotics were not
started at time of discharge, confirmed with ID, given risk of
partially treating an infection and/or promoting antibiotic
resistance that could impair future therapy.
.
# Hypertension - continued home HCTZ, enalapril, amlodipine, and
atenolol
.
# Hepatitis C - not currently treated; was refractory to prior
regimens, consideration for newer agents as outpatient
.
# Hyperlipidemia - not currently treated
.
# History of thyrotoxicosis - was related to hep C treatment -
but resolved upon cessation of treatment
.
# FEN - Regular diet, but NPO after midnight, start IVF at that
time (maintenance)
.
# Pain control - avoiding narcotics, using tramadol for now
.
# Access - peripherals
.
# Code Status - FULL
Dispo- left AMA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO BID
2. Atenolol 100 mg PO BID
3. Amlodipine 5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 100 mg PO BID
3. Enalapril Maleate 20 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
presumed L3/L4 vertebral osteomyelitis/discitis
Secondary diagnoses:
chronic hepatitis C
history of opiate dependence, abstinent since ___ per patient
hypertension
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 subacute lumbar back
pain. A recent MRI showed possible infection in the bone and
discs of the lumbar spine. You underwent a biopsy of the area
that did not show evidence of infection. Given the high
suspicion that you do have a dangerous infection in your spine,
the plan was to perform a repeat biopsy to hopefully correctly
identify the infection.
You did not want to wait for the repeat biopsy, and chose to
leave the hospital against medical advice. You understood that
there was a risk of progressive infection, paralysis, and death
if this infection is untreated.
I will continue to work with your other physicians to help you
with this likely dangerous infection in the coming days.
Please see below for your follow up appointments and
medications.
Followup Instructions:
___
|
10709795-DS-21
| 10,709,795 | 29,124,100 |
DS
| 21 |
2181-03-15 00:00:00
|
2181-03-19 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain, Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of hepatitis C, L3/L4 lumbar disc disease,
hypertension, with recent hospital admission for lower back pain
and concern for vertebral osteomyelitis versus discitis, with
subsequent ___ guided biopsies and cultures which were negative,
presents for evaluation of chills and worsening back pain.
Patient states that his back pain has persisted since his
discharge from the hospital about 2 weeks prior, and in fact his
left lower extremity weakness has actually worsened over the
past week. He denies any sensory alterations in the bilateral
lower extremities. He states that he has had issues with stool
incontinence for about the past month, however has no urinary
incontinence and is able to control the stream of his urine
quite well. He denies any measured fevers, abdominal pain,
colicky pain. He was seen by his outpatient providers yesterday
due to his persistent symptoms and was referred to the emergency
department for repeat MRI imaging and neurosurgery consultation
for potential open biopsy and culture. Concern was regarding
his new LLE hip flexor weakness, worried about epidural abscess
or ongoing discitis/osetomyelitis.
In the ED he was seen by neurosurgery who did not desire
emergent open biopsy, but felt that he needed repeat MRI
imaging. The patient was noted to be hypotensive and felt to be
clinically dry, and was given approximately 4L of IV fluid.
Bedside echo showed normal cardiac squeeze and collapsable IVC.
Noted to be bradycardic, but on a beta blocker. The patient
refused foley catheter and central venous catheter. Labs were
notable for ___, possibly consistent with intravascular volume
depletion.
In consultation with ID, 3 sets of blood cultures were drawn,
and he was given IV Vanco and Cefepime.
In the ED, initial vitals: T97.6, P58, BP80/65, RR18, 91% RA
On arrival to the MICU, Vitals HR53, BP 121/76, SPO2 94% RA.
Feeling fine, states that he may have accidentally taken an
extra dose of his PO dilaudid this AM. Feels like his mental
status is much clearer than this morning in the ED.
Past Medical History:
Hepatitis C (untreated - refractory to prior regimens)
Lumbar disc disease (with herniation) - ? L3-4
discitis/vertebral osteo s/p ___ guided biopsies ___ and ___
both negative by culture
Hypertension
Heroin Abuse (last use ___- pt tells me ___
Social History:
___
Family History:
His father died of ETOH at age ___. His mother died of breast
cancer at age ___. He is ___ of 7 siblings. One of siblings has
HTN.
Physical Exam:
ADMISSION:
Vitals HR53, BP 121/76, SPO2 94% 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: Bradycardic, 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: Normal sensation to light touch bilateral lower
extremities. Denies saddle anesthesia. Strength 5+ bilaterally
for dorsiflexion / plantarflexion / ___. Hip flexion RLE 5+,
LLE 4+ limited by pain.
DISCHARGE:
VITALS: 97.7 155/98 69 18 98% RA
GENERAL: NAD
HEENT: NCAT, OP clear
CARDIAC: RRR
ABDOMEN: nondistended, +BS, nontender
EXTREMITIES: no edema or cyanosis
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. ___ left lower extremity strength.
Sensation intact.
Pertinent Results:
ADMISSION LABS:
___ 07:58AM BLOOD WBC-7.8# RBC-5.24 Hgb-15.2 Hct-45.2
MCV-86 MCH-29.0 MCHC-33.6 RDW-15.6* Plt ___
___ 07:58AM BLOOD Glucose-116* UreaN-52* Creat-1.9*# Na-136
K-3.6 Cl-92* HCO3-30 AnGap-18
___ 07:58AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Lactate-1.6
IMAGING:
___ MRI L-spine w/contrast: There is abnormal enhancement in
the vertebral bodies and intervertebral disc spaces from L2
through L4 levels as described above, consistent with discitis
osteomyelitis, associated with abnormal enhancement in the right
psoas as well as in the anterior paravertebral space, with
minimal improvement since the prior MRI examination dated ___, there is a new area of abnormal enhancement at the
inferior endplate of L2, close followup is recommend.
___ MRI L-spine w/o contrast: Progression of extent of abnormal
signal compared to ___, now involving the inferior
endplate of the L2 vertebra in addition to the L3 and L4
vertebral bodies. No drainable abscess or cord compression is
identified.
___ CXR: Left lung base opacity, not significantly changed from
the prior exam which could represent atelectasis or infection.
Consider PA and lateral of the chest for further evaluation.
MICRO:
urine culture <10,000 organisms/ml
blood culture pending
Brief Hospital Course:
___ with back pain concerning for progressive
osteomyelitis/discitis/epidural abscess initially admitted to
ICU for hypotension and then transferred to medicine floor.
#Hypotension - Etiology unclear. States that he may have taken
an extra dose of dilaudid or his BP pill on morning of
admission. Appeared clinically dry, s/p 4L NS in the ED.
Initially covered for sepsis in the ED with vanc and cefepime,
but had no SIRS criteria, and rapidly improved with fluid
boluses. Held antihypertensive meds during admission. BP was
stable with no fUrther fluids given once in the ICU or on the
floor.
#Back Pain - patient with longstanding back pain, known disc
disease, question epidural abcess / discitis / osteomyeltitis.
Patient denies new fevers, change in urinary or bowel habits,
saddle numbess. Has prior but remote IVDU. No history of
cancer. Endorsed slightly new LLE weakness, but posibily due to
pain. Covered for sepsis in the ED with vanc / cefepime, but
given rapidly improving clinical status will hold further
antibiotics to allow for improved biopsy culture data if
performed. He underwent MRI of the L spine with findings as
above. Has had 2 biopsies in the past which were nondiagnostic
and so new reccommendation were to go for an open biopsy. As
patient was stable, plan was to discharge and return for biopsy
at later date.
___ - Baseline of 0.6, up to 1.9 now. Unclear etiology, likely
volume depleted as resolved with IVF. Cr. of 0.8 on discharge.
#Thrombocytopenia - etiology unclear, no other signs of acute
infection.
Platelets mildly low 144,000 on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Enalapril Maleate 20 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth q4hrs
Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- L2-L4 osteomyelitis (presumptive)
- L3 radiculopathy
- Hypotension NOS
- Acute renal failure
- Thrombocytopenia NOS
- Elevated AST/ALT
Secondary:
- Hepatitis C (untreated - refractory to prior regimens)
- Lumbar disc disease
- 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 Mr ___,
It was a pleasure taking care of you at ___. You were admitted
for back pain, left leg weakness, low blood pressure and concern
for infection in your spine. Hypotension resolved with fluid; it
is unclear what caused this. Imaging showed persistent
inflammatin in your spine suggestive of an infection there. The
plan is to have the surgeon's biopsy your spine to determine if
there is an infection. This will be arraged as an outpatient;
for now you are not on any antibiotics. Many of your blood
pressure meds were held; these will be restarted by your PCP as
an outpatient.
Followup Instructions:
___
|
10710233-DS-7
| 10,710,233 | 21,469,895 |
DS
| 7 |
2138-11-24 00:00:00
|
2138-11-24 10:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo ___ speaking female with dementia, recurrent falls,
dual-chamber permanent pacemaker presents with unwitnessed fall.
Per ___ notes, she was found on the floor near her bed
at 2100 on ___. She was AOX1 (baseline) and could not
recall the details of her fall. VS were T 98.6, HR 66, BP 157/77
RR 20 sat 92% RA.
Pt has h/o syncope that has been attributed to iron deficiency
anemia in the past (per ___ notes). Was admitted to
___ in ___ for syncopal episode that was attributed to
dehydration and metabolic encephalopathy in setting ___ and
recent initiation of benzodiazepine therapy (home trazodone and
alprazolam were discontinued during that admission).
In the ED intial vitals were: T 98.1 BP 176/96 RR 20 SaO2 99% on
RA
- Patient was given levofloxacin, metronidazole, and TDaP
vaccine.
- Labs showed K 3.2 and had CT head and C-spine which were
unremakable on prelim read
- Vitals on transfer to the floor: 98.8 55 169/78 16 100% RA
Upon arrival to the floor the patient is only intermittently
cooperative with the phone interpreter. She denies any pain
currently. She does not recall the circumstances of her fall.
She denies any numbness, tingling, weakness, or neck pain.
Past Medical History:
- Mild Dementia
- Scratching neurosis
- Hypertension
- Recurrent syncope
- atrial fibrillation
- Dual-chamber permanent pacemaker (___)
- depression
- Osteoarthritis
- cataracts
- h/o Herpes Zoster
- h/o L Hip fracture
Social History:
___
Family History:
unable to elicit from pt
Physical Exam:
ADMISSION PHYSICAL:
Vitals- T 98.1 BP 171/90 HR 62 RR 16 SaO2 100% on RA
Weight 47 kg
General- Elderly ___ speaking female
HEENT- EOMI, MMM. L forehead subgaleal hematoma.
Neck- Soft cervical collar in place, no neck tenderness.
Lungs- Bibasilar crackles, otherwise clear.
CV- Bradycardic, regular rhythm. No m/r/g. Device present in
left chest.
Abdomen- Soft, nontender, nondistended
GU- no foley
Ext- R knee with steri strips
Neuro- A&Ox2. Knows own name and "hospital." Otherwise moving
all four extremities spontaneously. Follows commands.
.
DISCHARGE PHYSICAL:
Vitals- T98.6 153/78 59 18 97% RA
General- Sleeping comfortably in bed.
HEENT- Sclera anicteric, MMM. Hematoma over left forehead with
surrounding large ecchymosis.
Neck- supple.
Lungs- Mild bibasilar rales. Poor inspiratory effort.
CV- Normal rate, regular rhythm. Nl S1, S2. No m/r/g.
Abdomen- soft, non-tender, non-distended, nl BS
GU- no foley
Ext- wwp with no c/c/e. Laceration over right knee with
steri-strips in place.
Neuro- CNs2-12 grossly intact, motor function grossly normal.
Pertinent Results:
ADMISSION LABS:
___ 11:30PM BLOOD WBC-5.5 RBC-3.73*# Hgb-10.9*# Hct-33.9*#
MCV-91 MCH-29.3 MCHC-32.2 RDW-16.1* Plt ___
___ 11:30PM BLOOD Neuts-77.4* Lymphs-12.2* Monos-4.9
Eos-5.2* Baso-0.2
___ 11:30PM BLOOD Glucose-103* UreaN-39* Creat-1.6* Na-135
K-3.2* Cl-100 HCO3-25 AnGap-13
___ 11:30PM BLOOD CK(CPK)-250*
___ 11:30PM BLOOD CK-MB-5
___ 11:30PM BLOOD cTropnT-0.03*
___ 11:30PM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.0 Mg-2.3
___ 11:40PM BLOOD Lactate-1.2
.
OTHER PERTINENT LABS:
___ 01:27AM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:27AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:27AM URINE RBC-6* WBC-20* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:27AM URINE CastHy-10*
.
DICHARGE LABS:
___ 06:45AM BLOOD WBC-3.8* RBC-3.21* Hgb-9.2* Hct-29.0*
MCV-90 MCH-28.7 MCHC-31.8 RDW-15.0 Plt ___
___ 06:45AM BLOOD Glucose-82 UreaN-22* Creat-1.1 Na-142
K-4.0 Cl-108 HCO3-28 AnGap-10
___ 06:45AM BLOOD CK(CPK)-155
___ 10:30AM BLOOD CK-MB-6 cTropnT-0.01
___ 06:45AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0.
.
CXR ___: Moderate right pleural effusion with volume loss in
the right lower and middle lobes and opacity at the right base
and left lower lung (better seen on CT)likely atelectasis.
.
XRAY TIB/FIB/RIGHT KNEE ___: No fracture.
.
CT HEAD ___: There is no evidence of hemorrhage, edema, mass
effect or acute large vascular territory infarction. Prominent
ventricles and sulci suggest age-related atrophy.
Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. The basal cisterns
appear patent and there is preservation of gray-white
differentiation. No fracture is identified. There is mucosal
thickening in the right maxillary sinus and left ethmoid air
cells. The remaining visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. Atherosclerotic mural
calcification of the internal carotid arteries is noted. The
globes are unremarkable. There is a large left scalp hematoma.
IMPRESSION: No acute intracranial process. Left scalp hematoma.
.
CT CHEST/ABD/PELVIS ___: CT chest: There is a multinodular
goiter. There is no supraclavicular lymphadenopathy and the
airways are patent to the subsegmental level. Dual chamber
pacemaker leads are noted. There is calcification of the mitral
annulus and coronary arteries. No pericardial effusion. No
mediastinal hematoma. Atherosclerotic calcification of the
aorta. The esophagus is patulous. There is a small right
pleural effusion measuring simple fluid density. There is
opacification in the right lower lobe which likely refelcts
atelectasis; although superimposed infection is possible. There
is the
rounded opacification in the posterior aspect of the left lower
lobe
consistent with rounded atelectasis. No pneumothorax is present
CT abdomen: Evaluation of the solid organs and soft tissues is
limited by lack of intravenous contrast. The liver is normal in
size intrahepatic biliary dilatation. A 7 mm hypodensity in the
right lobe is incompletely characterized. There is
cholelithiasis without evidence of cholecystitis. The pancreas
is atrophic. The spleen and adrenal glands are unremarkable.
The kidneys contain multiple hyper and hypodense cysts. The
small and large bowel are normal in caliber without evidence of
obstruction. The intraabdominal vasculature is demonstrates
atherosclerotic calcifications. There is no mesenteric or
retroperitoneal lymph node enlargement by CT size criteria.
There is a small amount of ascites measuring simple fluid
density
CT pelvis: The bladder is decompressed with a Foley. Ascites
tracks into the pelvis. The uterus is unremarkable. There is
no inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy is present. No fractures identified.
IMPRESSION:
1. Bilateral lower lobe opacifications most likely represting
atelectasis; although infection or aspiration are also possible.
2. Small right pleural effusion.
3. Small amount of simple ascites
4. No evidence of thoracic or abdominal injury.
.
CT C CPINE ___: 1. No evidence of acute fracture or
traumatic malalignment.
2. Unchanged spinal canal stenosis worst at C4-5 and C5-6 with
moderate to severe canal narrowing. This can predispose to cord
injury in the setting of significant trauma.
Brief Hospital Course:
___ ___ speaking female with dementia, recurrent falls,
dual-chamber permanent pacemaker presents with unwitnessed fall.
#) FALL: Mechanical fall is most likely etiology, although
cannot rule out syncope. Differential included cardiovascular
(arrhythmia, hypovolemia, AS), neurological (seizure) and
metabolic (electrolytes, infection) etiologies. CT head showed
no evidence of intracranial hemorrhage. Regarding cardiac
etiologies, pt has only minimal AS per ECHO ___. Pacemaker
interrogation ___ revealed no abnormalities. EKG shows ST
depression in leads V3-V5, new compared to prior, but with
negative troponin X 1, negative CK-MB X 2, no symptoms of chest
pain. No evidence of seizures. CXR shows consolidation that is
likely atelectasis. Pt afebrile, no leukocytosis, no cough -
treatment for PNA was not initiated. Unclear if CXR suggests
aspiration event surrounding episode. U/A shows few bacteria,
20 wbc, negative ___. Pt was treated for presumed UTI
with 3 day course of ciprofloxacin (completed ___.
Orthostatics after 1L volume repletion were as follows: lying-
152/88, 57; sitting- 141/80, 69; standing- 171/105, 81.
.
#) LEFT FOREHEAD HEMATOMA: Sustained in fall that prompted
admission. No evidence of active bleeding, no hemodynamic
instability.
.
#) ACUTE KIDNEY INJURY: Baseline cr 1.0. Improved from 1.6 on
admission (___) to 1.1 on ___ after volume repletion.
.
#) ELEVATED CK: CK 250 on admission. Downtrended to 155 on
___. Likely due to muscle injury from fall.
.
#) DEPRESSION: Continued home sertraline.
.
#) HYPERTENSION: Continued home amlodipine given high BPs in ED
(SBP 170s). Held home metoprolol given bradycardia to mid ___
this admission with resulting BPs 130s-150s/60s-80s.
.
#) IRON-DEFICIENCY ANEMIA: Continued home ferrous sulfate.
.
#) CHRONIC PRURITUS: Continued home prednisone, sarna.
.
## Transitional issues:
- monitor left forehead hematoma
- pt's home metoprolol held this admission for HR ___. HR
does go up to ___ with standing, so can consider restarting
metoprolol at rehab if pt's HR can tolerate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. PredniSONE 2.5 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Hydrocerin 1 Appl TP BID:PRN itchy skin
5. Amlodipine 10 mg PO DAILY
6. Acetaminophen 1000 mg PO TID
7. Vitamin D 800 UNIT PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amlodipine 10 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydrocerin 1 Appl TP BID:PRN itchy skin
5. Polyethylene Glycol 17 g PO DAILY
6. PredniSONE 2.5 mg PO DAILY
7. Sertraline 100 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: unwitnessed fall, likely mechanical
Secondary: acute kidney injury, hypertension, depression, iron
deficiency anemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. You were
admitted for an unwitnessed fall. CT scans of your head and
neck did not show any injury to your brain or spine. Your
pacemaker was evaluated and we did not find any abnormal heart
rhythms that could have caused you to pass out. The most likely
cause of your fall was a loss of balance. You were found to have
a urinary tract infection, which we treated with antibiotics.
Followup Instructions:
___
|
10710475-DS-14
| 10,710,475 | 26,739,660 |
DS
| 14 |
2182-10-04 00:00:00
|
2182-10-06 11:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Darvocet-N 100 / Haldol / Codeine / Latex / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Thorazine / Percocet
Attending: ___
Chief Complaint:
right wrist drop
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
The patient is a ___ year old woman with history of congenital
deafness, cervical spondylosis, chronic pain syndrome, s/p right
ulnar nerve surgery (?___), right ___ digit trigger fingers
s/p steroid injection 11 days ago, who now presents with new
onset right wrist drop.
The history is limited due to absence of in-hour ASL
interpreters and poor connectivity of video interpreter program
causing disconnections within 5 minutes of restarting; pt also
not able to communicate via reading/writing. Thus, the majority
of history is obtained from ED resident and prior urgent care
notes.
The patient has been followed in the orthopedic hand clinic for
symptoms of pain in her right ___ and ___ digits, which was
diagnosed as trigger finger, and for which she recently received
steroid injections on ___. The pain did not improve, and she
wished to discuss potential surgery with her provider. Then
yesterday morning, she reportedly awoke with new onset hand
weakness. She did report global hand pain on the right, but it
is not clear whether this was new pain, or related to the
trigger finger. She also reported feeling subjective sensation
of cold in her hand.
She presented to urgent care ___ in ___ today for the
symptoms, and was told she had a peripheral nerve injury, and
was discharged. Her orthopedic provider was contacted and
recommended transfer to ___. On ED resident's brief history
(prior to connectivity issues), pt denied history of trauma. On
exam, she had wrist and finger extension weakness, but no severe
point tenderness, and good radial pulses. Neurology and Hand
surgery were subsequently consulted.
ROS could not be obtained.
Of note, the patient has been seen in Neurology clinic in ___
by myself and Dr. ___ - her chief complaint at that time had
been pain in her knees and ankles, which were felt more
orthopedic in nature. Her neurologic examination had been
nonfocal, with full and equal strength in all four extremities,
and symmetric sensation and reflexes.
Past Medical History:
Congenital deafness
Meningitis in childhood
Cervical spondylosis and canal narrowing
Bipolar depression s/p ECT in ___
Asthma
Hyperlipidemia
Hypothyroidism
Chronic pain in neck, back, shoulder, and knee
Multiple orthopedic surgeries, including right ulnar nerve
lysis, and L hip replacement
Cirrhosis
Restless legs syndrome
Sleep apnea
Social History:
___
Family History:
Mother passed away at age ___ from alcohol withdrawal. Father
passed away at age ___ from cardiac arrest.
Physical Exam:
Physical Exam:
Vitals: temp 98.2 HR 71 BP 109/46 RR 19 apO2 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: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: awake, alert, attentive. Able to communicate
fluently with video ASL interpreter (prior to disconnections).
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing impaired.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Mildly decreased bulk of upper extremities proximally.
Decreased bulk of right thenar muscles compared to left. 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 4* 0 4- 0 0 5 5 5 5 5 5 5
Other muscles tested on RUE:
brachioradialis 5-*
pronator 4*
supinator 2
flexor carpi ulnaris 5
abductor digiti minimi 0
abductor pollicis brevis 3
*pain limited exam
-Sensory: intact sensation to pinprick (interpreted as pt
nodding after pin) throughout, with exception of distal palmar
surface of ___ phalanges on R.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2+
R 2+ 2+ 2+ 3 2+
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF on the left.
-Gait: Deferred.
Notable findings discharge exam:
___ weakness in right finger extension and wrist extension,
remainder of strength testing was full.
Pertinent Results:
MRI c-spine ___. In comparison to the prior cervical spine MRI of ___,
posterior disc protrusions at C5-6 and C6-7 resulting in
moderate narrowing of the spinal canal have slightly decreased
in size.
2. There is persistent moderate bilateral neural foraminal
narrowing at C6-7.
3. No spinal cord signal abnormality.
MRI brain ___
No evidence of hemorrhage or infarction.
Brief Hospital Course:
The patient is a ___ year old woman with history of congenital
deafness, cervical spondylosis, chronic pain syndrome, s/p right
ulnar nerve surgery (?___), right ___ digit trigger fingers
s/p steroid injection 11 days PTA, who presented with new onset
right wrist drop upon awakening on the day prior to
presentation. On examination the patient has weakness isolated
to the right wrist extensors and finger extensors. Her sensory
examination showed patch sensory deficits which were difficulty
to localize. She underwent an MRI of the C-spine and brain which
confirmed that there were no central lesions to account for her
symptoms. This is most likely a radial neuropathy. She will
follow up with us in clinic to follow for clinical improvement
and consideration of EMG in the future if needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 50 mg PO QHS
2. Baclofen 10 mg PO Q8H:PRN Muscle Spasms
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM knee
6. LORazepam 1 mg PO BID:PRN anxiety
7. Nadolol 20 mg PO BID
8. Pramipexole 1 mg PO QHS
9. Sertraline 25 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*5 Tablet Refills:*0
2. Amitriptyline 50 mg PO QHS
3. Baclofen 10 mg PO Q8H:PRN Muscle Spasms
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM knee
7. LORazepam 1 mg PO BID:PRN anxiety
8. Nadolol 20 mg PO BID
9. Pramipexole 1 mg PO QHS
10. Sertraline 25 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
13.Outpatient Occupational Therapy
right radial neuropathy
Discharge Disposition:
Home
Discharge Diagnosis:
radial neuropathy
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 neurology service because of your
sudden onset right hand/wrist weakness. You underwent an MRI of
your neck which just showed some arthritis but no cause for your
symptoms. You also underwent an MRI of your brain which did not
show an etiology for your symptoms. Based on the pattern of your
weakness and your normal imaging we are confident that your
weakness is the result of injury to a nerve (the radial nerve)
in your arm. These types of injuries get better with time. We
would like to see you in clinic to ensure that things are moving
in the right direction.
It was a pleasure caring for you,
___ neurology
Followup Instructions:
___
|
10710475-DS-17
| 10,710,475 | 22,688,819 |
DS
| 17 |
2184-09-26 00:00:00
|
2184-09-27 22:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Darvocet-N 100 / Haldol / Codeine / Latex / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Thorazine / Percocet /
pantoprazole / adhesive tape
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
CHIEF COMPLAINT: Abdominal pain
HISTORY OF PRESSENT ILLNESS:
Interview obtained by bedside, video ASL interpreter.
Ms. ___ is a ___ year old female with congenital deafness and
pancreatic cancer who presents with abdominal pain 1 day s/p
endoscopy and sigmoidoscopy.
Regarding the patient's pancreatic cancer, she underwent a
Whipple in ___. Neo-adjuvant chemotherapy with gemcitabine was
complicated by colitis and severe pancytopenia so further
chemotherapy was differed and the patient underwent active
surveillance. MRCP on ___ demonstrated a lesion of unclear
significance it was recommended that the patient undergo EUS for
biopsy. The patient underwent sigmoidoscopy and EUS on ___
which demonstrated normal sigmoidoscopy and a pancreatic mass
which was biopsied.
For the past 4 days, the patient has noted stable, left sided
abdominal pain without radiation. She states the pain is sharp,
like a knife. She has had no nausea or vomiting. No fevers or
chills. No chest pain, palpitations or dyspnea. No diarrhea.
Noted increased urinary frequency but no dysuria.
The patient underwent her scheduled sigmoidoscopy and EUS 1 day
prior to admission which was uncomplicated. She then noticed
today that her pain has been exacerbated but otherwise
unchanged.
Past Medical History:
PAST ONCOLOGIC HISTORY:
She was seen in ___ for
routine follow-up with her hepatologist and underwent
surveillance ultrasound ___. The study showed an
ill-defined mass in the head of the pancreas. She was then
referred for MRCP performed ___ which identified a 1.4 cm
mass in the pancreatic head concerning for malignancy. The mass
abutted the SMV and portal vein less than 180°. She underwent
endoscopic ultrasound ___ which confirmed these findings,
and fine-needle biopsy showed adenocarcinoma. Ms. ___
initiated neoadjuvant chemotherapy with
nab-paclitaxel/gemcitabine ___. The dose was interrupted
and
reduced for recurrent thrombocytopenia. She received five doses
in total as of ___.
She underwent pancreaticoduodedenectomy ___ with resection
of a 1.5x1.2x0.8cm grade 2 pancreatic head adenocarcinomoa with
1
of 12 lymph nodes involved, margin negative (nearest margin SMV
2mm), LVI present, perineural invasion absent, pT1cN1Mx stage
IIB
pancreatic head adenocarcinoma.
She resumed adjuvant chemotherapy with gemcitabine 800mg/m2
___. She received two doses, and was then hospitalized
with pancytopenia, colitis, and hypotension. Plans for
additional adjuvant chemotherapy were aborted.
PAST MEDICAL HISTORY:
Pancreatic cancer - as above
Cirrhosis
Congenital deafness
Asthma
Hyperlipidemia
Hypothyroidism
Cervical myelopathy
Osteoarthritis
Chronic pain syndrome
Major depression and PSTD complex
Multiple orthopedic surgeries including left hip replacement
Thyroid disorder
Social History:
___
Family History:
Mother passed away at age ___ from alcohol withdrawal. Father
passed away at age ___ from cardiac arrest.
Physical Exam:
ADMISSION EXAM:
=================
VITALS: T 98.5 BP 99/64 HR 73 R 18 SpO2 94 RA
GENERAL: Tired, NAD
HEENT: Dry OP, no lesions
EYES: PERRL, anicteric
NECK: supple
RESP: CTAB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, diffuse TTP LLQ>RLQ no rebound
EXT: warm, no edema
SKIN: dry, erythematous patch R A/C
NEURO: CN II-XII intact
ACCESS: None
DISCHARGE EXAM:
===============
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1257)
Temp: 98.2 (Tm 98.7), BP: 94/62 (90-105/57-69), HR: 71
(61-77), RR: 18 (___), O2 sat: 96%% (96%-97%), O2 delivery: RA
GENERAL: Tired, NAD
HEENT: Dry OP, no lesions
EYES: PERRL, anicteric
NECK: supple
RESP: CTAB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, diffuse TTP LLQ>RLQ no rebound but improved from
prior
EXT: warm, no edema
SKIN: dry, erythematous patch R A/C
NEURO: CN II-XII grossly intact
ACCESS: None
Pertinent Results:
ADMISSION LABS:
===============
___ 12:43PM BLOOD WBC-7.4 RBC-3.67* Hgb-12.1 Hct-35.8
MCV-98 MCH-33.0* MCHC-33.8 RDW-12.6 RDWSD-44.4 Plt Ct-89*
___ 12:43PM BLOOD Neuts-80.2* Lymphs-10.9* Monos-7.3
Eos-1.1 Baso-0.1 Im ___ AbsNeut-5.97 AbsLymp-0.81*
AbsMono-0.54 AbsEos-0.08 AbsBaso-0.01
___ 12:43PM BLOOD Plt Ct-89*
___ 08:20AM BLOOD ___ PTT-30.9 ___
___ 12:43PM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-130*
K-8.8* Cl-96 HCO3-24 AnGap-10
___ 12:43PM BLOOD ALT-<5 AST-101* AlkPhos-93 TotBili-0.8
___ 12:43PM BLOOD Lipase-103*
___ 12:43PM BLOOD Albumin-3.8
___ 08:20AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
___ 12:43PM BLOOD Lactate-1.8 K-6.4*
___ 02:31PM BLOOD K-3.9
IMAGING:
========
___BD & PELVIS WITH CO
IMPRESSION:
1. No evidence of splenic injury or pneumoperitoneum.
2. Mildly distended loops of proximal jejunum in the left lower
quadrant with mural thickening and mucosal hyperenhancement
adjacent to the gastrojejunal anastomosis appears increased
compared to ___, which is concerning for enteritis.
3. Although better appreciated on the most recent prior MRI and
CTA abdomen
studies, re-demonstrated is a 7 mm hypodensity near the
pancreaticoduodenal
anastomosis with mild dilatation of the pancreatic duct, which
is again
concerning for disease recurrence.
4. Cirrhotic morphology of the liver, similar to prior.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Small consolidation in the left lung base. After review of the
abdominal CT performed in ___, this represents mild
atelectasis. No evidence of current infectious process.
Mild dilation of the main pulmonary artery. Correlation with an
echocardiogram is recommended for assessment of possible
pulmonary
hypertension, if not already performed.
DISCHARGE LABS:
================
___ 07:50AM BLOOD WBC-3.4* RBC-2.92* Hgb-9.5* Hct-28.7*
MCV-98 MCH-32.5* MCHC-33.1 RDW-12.4 RDWSD-45.0 Plt Ct-56*
___ 07:50AM BLOOD Neuts-73.6* Lymphs-14.2* Monos-8.0
Eos-3.6 Baso-0.3 Im ___ AbsNeut-2.48 AbsLymp-0.48*
AbsMono-0.27 AbsEos-0.12 AbsBaso-0.01
___ 07:50AM BLOOD Plt Ct-56*
___ 07:50AM BLOOD Ret Aut-2.9* Abs Ret-0.08
___ 07:50AM BLOOD Glucose-127* UreaN-6 Creat-0.6 Na-141
K-4.1 Cl-105 HCO3-26 AnGap-10
___ 07:50AM BLOOD Albumin-3.5 Calcium-8.0* Phos-2.8 Mg-2.1
Brief Hospital Course:
HOSPITAL COURSE:
========================
___ with pancreatic cancer, congenital deafness and cirrhosis
who presents with abdominal pain 1 day after surveillance
endoscopy/sigmoidoscopy with CT imaging demonstrating enteritis.
ACUTE:
=======
# Hypotension
# C/f Sepsis
There was an initial concern for sepsis in the setting of
enteritis, hypertension (SBP ___, and a low-grade fever on day
of admission. However, while she was initially fluid responsive,
she had repeat episodes of asymptomatic hypertension throughout
her hospital course that was not particularly fluid responsive
or antibiotic responsive. Per chart review this may be
relatively close to her baseline. An a.m. cortisol was checked
which was within normal limits. Other etiologies may be
secondary to narcotic medication side effect, cirrhosis
physiology, or hypothyroidism. Her TSH was checked which was 20
and thus we increased her levothyroxine 200mcg daily (increased
from 175mcg).
# ABDOMINAL PAIN
# ENTERITIS:
Patient presents with abdominal pain 1 day after EUS biopsy and
sigmoidoscopy. CT demonstrates no pneumoperitoneum but does not
jejunal distention concerning for enteritis which may be due to
irritation from recent endoscopy, though given that her pain has
been present prior to the intervention, and with low grade fever
+ asymptomatic hypotension there was concern for infection.
Lactate and exam are not concerning for perforation which again
is reassured by her imaging. Mild lipase elevation is likely due
to pancreatic enzyme leak in setting of recent biopsy. Some of
the pain is likely malignancy related. She was initially on
broad-spectrum antibiotics, but then narrowed to p.o. Flagyl and
ciprofloxacin. D1: ___. She was continued on her
home tramadol and started on HYDROmorphone (Dilaudid) 2 mg PO/NG
Q8H.
# LEUKOPENIA
# ANEMIA
# THROMBOCYTOPENIA:
Her thrombocytopenia is stable and likely from cirrhosis. Acute
change in anemia and leukopenia is likely partially iso of fluid
dilution. Her discharge Platelet: 56 CBC: 3.4 Hb: 9.5.
# PANCREATIC CANCER:
Patient was previously treated with adjuvant gemcitabine but
with was poorly tolerated due to colitis and severe
pancytopenia. Pancreatic mass biopsy from ___ consistent with
adenocarcinoma.
# HYPOTHYROIDISM:
Last TSH 62. TSH on ___ was 20. In setting of hypotension, we
considered a trial a higher dose of levothyroxine as this may be
an alternate etiology. Thus we increased her dose of
levothyroxine to 200mcg daily from her home 175mcg. Please
follow up on her TSH 1 week from discharge and adjust
# Palpitations
On nadolol at home, was initially held iso hypotension but then
restarted prior to discharge.
# CIRRHOSIS: ___ NAFLD
Her LTFs were trended and with normal limits.
# SKIN RASH: likely eczema, stable on steroid cream. She was
continued on home triancinolone
# ASTHMA: stable
She was continued home albuterol and fluticasone inhalers
# CHRONIC PAIN
# ANXIETY:
Recently seen by neurology for multiple complaints of pain in UE
and ___ which is likely c/w prior known disc disease. However,
there was some concern for metastatic disease. Plan for MRI C
and L spine as outpatient. She was continued on her home
bupropion, Ativan, tramadol, and Pramipexole. She was started on
PO Dilaudid with IV for breakthrough.
# HLD: cont home simvastatin
# HYPONATREMIA: -RESOLVED
Likely due to poor PO intake in the setting of pain.
TRANSITIONAL ISSUES:
=====================
[ ] Please get a CBC a week from discharge and follow up ensure
stability of H/H.
[ ] Please follow up her pain and titrate her up/down as needed
[ ] We increased her levothyroxine to 200mcg from 175mcg. Please
recheck levels in ___ weeks and adjust accordingly.
[ ] Please follow up home services, patient has had difficulty
setting them up.
[ ] Alendronate was held on discharge, can restart prn.
[ ] Has had difficulty with irregular BM, can f/u laxative
prescriptions on increased opiate regimen
[ ] Antibiotics (Cipro/Flagyl) for enteritis finish ___
#HCP/CONTACT: Name of health care proxy: ___: friend
Phone number: ___
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. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Alendronate Sodium 70 mg PO QTHUR
3. BuPROPion (Sustained Release) 200 mg PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN msucle spasm
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Levothyroxine Sodium 175 mcg PO DAILY
7. LORazepam 1 mg PO BID:PRN anxiety
8. Nadolol 20 mg PO BID
9. Pramipexole 1 mg PO QHS
10. Simvastatin 40 mg PO QPM
11. TraMADol 50 mg PO BID:PRN Pain - Moderate
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID R arm
13. Calcium Carbonate 500 mg PO DAILY
14. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*4 Tablet Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO QHS:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth at
bedtime Disp #*45 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
6. Levothyroxine Sodium 200 mcg PO DAILY
RX *levothyroxine 200 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
8. BuPROPion (Sustained Release) 200 mg PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. Cyclobenzaprine 5 mg PO TID:PRN msucle spasm
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Loratadine 10 mg PO DAILY
13. LORazepam 1 mg PO BID:PRN anxiety
14. Nadolol 20 mg PO BID
15. Pramipexole 1 mg PO QHS
16. Simvastatin 40 mg PO QPM
17. TraMADol 50 mg PO BID:PRN Pain - Moderate
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID R arm
19. HELD- Alendronate Sodium 70 mg PO QTHUR This medication was
held. Do not restart Alendronate Sodium until restarted by your
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
Hypotension
Enteritis
Hypothyroidism
Hyponatremia
SECONDARY:
===========
Pancreatic Adenocarcinoma
Pancytopenia
Chronic Pain
Cirrhosis ___ NAFLD
Anxiety
Discharge Condition:
Mental Status: Clear and coherent. (Deaf)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because of stomach pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Based on her imaging, it looked like you had an infection of
your intestines. We started you on antibiotics.
- You also had low blood pressure, for which we gave you IV
fluids. This was thought to be caused from your infection and
your liver.
- Your thyroid levels were a bit low, so we increased your
thyroid medication by a tiny bit. This might explain your low
blood pressure as well.
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:
___
|
10710521-DS-20
| 10,710,521 | 26,526,294 |
DS
| 20 |
2175-03-26 00:00:00
|
2175-03-26 21:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Zoloft
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Mesenteric angiogram and celiac stent placement
History of Present Illness:
___ w hx of mesenteric ischemia, s/p celiac artery stent,
also w/ known aortic dissection presents w/ abdominal pain. Pt
has had 1.5 months of abdominal pain that occurs a few hours
after eating. Pain worsened 1 month ago and now happens even
after drinking liquids. He endorses food fear and significant
weight loss. He has also experienced emesis after eating as well
as diarrhea. The celiac artery stent was placed in ___ and a
recent ultrasound confirmed occlusion of his SMA and ___. He
presented to ___ recently and a CTA of his abd was done.
Those images are being uploaded. Last bowel movement two days
ago, nonbloody. + flatus.
Past Medical History:
PMH: CAD s/p stenting ___ yrs ago, DVT's, OSA, CAD, PVD, HTN, HL,
aortic dissection, aortic occlusion w/ reconstitution of iliacs
via collaterals, chronic mesenteric ischemia
PSH: Celiac artery stenting
Social History:
___
Family History:
Diabetes Mellitus, Vascular Disease
Physical Exam:
Admission Physical Exam:
=================================
Vitals 97.9 96 160/89 20 99% RA
Gen: A&Ox3, NAD,
CV: RRR
Pulm: CTAB
Abd: soft, NTND, + BS
Extrem: warm, well perfuse
R: p/p/d/p
L: p/p/d/p
.
.
Discharge Physical Exam:
=================================
Vitals 98.7 73 105/58 18 96% RA
Gen: A&Ox3, NAD
CV: RRR
Pulm: CTAB
Abd: soft, NTND, + BS
Extrem: warm, well perfuse
R: p/p/d/p
L: p/p/d/p
Pertinent Results:
Admission Labs:
==================================
___ 05:53PM BLOOD WBC-12.8*# RBC-4.24* Hgb-13.3* Hct-39.9*
MCV-94 MCH-31.4 MCHC-33.3 RDW-14.4 RDWSD-49.5* Plt ___
___ 05:53PM BLOOD Neuts-78.8* Lymphs-12.7* Monos-6.9
Eos-0.8* Baso-0.4 Im ___ AbsNeut-10.05* AbsLymp-1.62
AbsMono-0.88* AbsEos-0.10 AbsBaso-0.05
___ 05:53PM BLOOD ___ PTT-53.8* ___
___ 05:53PM BLOOD Glucose-91 UreaN-21* Creat-1.0 Na-131*
K-8.5* Cl-100 HCO3-18* AnGap-22*
___ 05:53PM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.4 Mg-2.0
___ 05:53PM BLOOD ALT-59* AST-76* AlkPhos-142* TotBili-0.9
___ 05:53PM BLOOD Lipase-49
___ 07:06PM BLOOD Lactate-2.5* K-4.2
.
.
Discharge Labs:
==================================
___ 07:10AM BLOOD WBC-7.8 RBC-3.87* Hgb-12.1* Hct-36.4*
MCV-94 MCH-31.3 MCHC-33.2 RDW-14.1 RDWSD-47.9* Plt ___
___ 07:10AM BLOOD ___ PTT-78.4* ___
___ 07:10AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-136
K-3.7 Cl-104 HCO3-22 AnGap-14
___ 07:10AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
.
.
Imaging:
==================================
___ CTA:
1. Severe atherosclerosis with patent celiac stent, completely
occluded
proximal SMA, and occluded infrarenal aorta. Attenuated 2 right
renal
arteries. Overall, the appearance is not significantly changed
compared to
previous.
2. Hypodense pancreatic tail mass abutting the splenic hilum,
with associated occlusion of the distal splenic vein, concerning
for primary pancreatic adenocarcinoma.
3. Innumerable hypodense lesions within the liver, concerning
for metastatic disease.
4. Splenic infarct, likely from vascular invasion of the
pancreatic mass.
5. Multiple hazy peritoneal fat stranding particularly in the
right lower
quadrant. Multiple small lymph nodes within the retroperitoneum,
some of
which are irregular in morphology, without necrosis. These
findings are
concerning for peritoneal carcinomatosis and possibly nodal
metastases.
Brief Hospital Course:
Mr. ___ presented to ___ on transfer from ___.
He was started on a heparin gtt and his symptoms improved
quickly. Given the non-operative nature of his aortic dissection
and severe symptoms consistent with worsening mesenteric
ischemia, decision was made to do visceral
angiogram with possible celiac stent placement, which was
completed on HD2, and revealed restenosis of previously placed
celiac artery stent as well as chronic ___ occlusions. The
celiac artery was again stented but attempts to reopen the SMA
were unsuccessful. Please see op report for details.
After a brief and uneventful PACU course, he was transferred to
the floor, where he remained for the rest of his admission.
Patient's coumadin had been held for angio, and was restarted
HD3, while his heparin gtt was continued pending therapeutic
INR. On day of discharge, HD5, he was eating a regular diet,
having bowel movements, voiding, and ambulating independently,
and pain was controlled with tylenol. His INR remained
subtherapeutic, so plan was made for ___ and he
received his first dose while inpatient, 1.5hrs after heparin
gtt was stopped.
On day of discharge patient underwent a follow-up CTA to
reexamine the celiac stent post-procedure. This imaging was
reassuring that the celiac stent was patent, and his known
vascular occlusions and aortic dissection were stable. However,
the CTA also showed a pancreatic mass, multiple hepatic lesions,
as well as retroperitoneal lymphadenopathy and involvement of
the splenic artery with associated infarct. These findings were
immediately discussed with the oncology consult service, who
requested CT chest, LFTs, LDH, CA ___, CEA, and AFP for further
workup of this apparent malignancy, and planned to see the
patient the following day. The patient declined this workup,
strongly desiring to be discharged immediately. The patient
declined to stay to receive discharge instructions, so discharge
paperwork and instructions were given to his wife. The vascular
surgery team will be coordinating with oncology and the
patient's PCP, ___, to arrange close follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN leg pain
4. Warfarin 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Pravastatin 20 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN leg pain
6. Acetaminophen 650 mg PO Q8H:PRN pain or fever
Maximum total dose of acetaminophen (aka Tylenol) per day is 4g
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 8 hrs Disp
#*60 Tablet Refills:*0
7. Clopidogrel 75 mg PO DAILY
Take for 30 days: ___ - ___
RX *clopidogrel 75 mg 1 tablet(s) by mouth every day Disp #*26
Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
9. Enoxaparin Sodium 100 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
Please take until directed to stop by Dr. ___
RX *enoxaparin 100 mg/mL 100 mg SC daily Disp #*15 Syringe
Refills:*0
10. Warfarin 7.5 mg PO DAILY16
Please take on ___ and follow up with Dr. ___ dosing
after that.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chronic mesenteric ischemia with
restenosis of celiac artery stent, Severe malnutrition, Hx of
Recurrent DVT, Abnormal CT Imaging concerning for malignancy
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 Vascular Surgery service after your
mesenteric angiogram and celiac stent placement. Your procedure
went well without complications and you are recovering well. At
this time, you are eating normally, able to use the restroom
without difficulty and have been restarted on all of your home
medications. You will take lovenox/enoxaparin shots until your
INR is therapeutic with your Coumadin. We would like you to get
an INR drawn ___ at ___ and will contact you with what
dose to take when those results are back.
Your cat scan of your abdomen showed abnormalities that are
concerning for cancer. Cancer has not yet been diagnosed, but we
are very concerned. You did not want to stay for further testing
and diagnosis at this time. We will call you tomorrow with
information about who to contact next regarding these cat scan
findings.
You are now ready to continue your recovery from your angiogram
and stenting at home with the following instructions.
MEDICATION:
Take Aspirin 81mg (enteric coated) once daily
Take Plavix (Clopidogrel) 75mg once daily for 30 days
Take Lovenox (enoxaparin) 100mg once daily until INR is
therapeutic
Take Coumadin (warfarin) 7.5mg tomorrow ___ and
have an INR drawn the following day ___ and have
Dr. ___ you what dose to take going forward.
Continue all other medications you were taking before surgery,
unless otherwise directed
You may take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the arm used for the
procedure:
Elevate your arm above the level of your heart with pillows
every ___ hours throughout the day and night
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over arm incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow arm puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking narcotic pain
medications
CALL THE OFFICE at ___ FOR:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from arm puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (at the arm puncture
site):
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office at ___
If bleeding does not stop, call ___ for transfer to the
nearest Emergency Room
Thank you for letting us care for you,
Your ___ Care Team
Followup Instructions:
___
|
10710610-DS-14
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DS
| 14 |
2138-01-14 00:00:00
|
2138-01-14 17:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin base / peanut / shrimp
Attending: ___
Chief Complaint:
poor po intake, ___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PER ___ is a ___ year-old woman with a recent
complex hospital course,in brief,she has a history of Crohns c/b
TI stricture s/p Lap ileocolectomy,s/p RLQ ___ drain for fluid
collection ___ anastomotic leak c/b hematoma s/p ___ drain which
then became infected, s/p ex-lap, washout, ileocolonic
resection, end ileostomy, complicated by SVT and prolonged
hospitalization who now presents with at the recommendation of
her PCP regarding poor PO intake, metabolic acidosis, ___ and
elevated LFTs of unknown etiology.
She reports limited intake for the past two weeks. She notes she
only drinks liquids, mostly water, some soups and mashed
potatoes. She doesn't tolerate solids "just chew and chew but it
doesn't go down". She denies pain with swallowing and denies the
feeling of food getting stuck in her throat. She denies nausea
or vomiting. She continues to empty her ostomy 4 times daily and
takes Imodium approximately 4 times daily. She has recently been
followed closely by her PCP for concern of dehydration leading
to ___ and ___ LFTs of unknown etiology.
Past Medical History:
PMH:
Obesity
Sickle Cell trait
Crohn's disease
Anemia
PSH:
Lap Cholecystectomy
C-section x2
Laparoscopic ileocolectomy ___
Ex-lap, washout, ileocolonic resection, end ileostomy ___
Social History:
___
Family History:
Brother- ___
Father- HTN
Maternal Grandfather- ___ cancer
Mother- CAD/PVD, ___, HTN
Physical Exam:
Gen: NAD, AxOx3
Card: RRR
Pulm: no respiratory distress
Abd: Soft, non-tender, non-distended, no rebound or guarding
Wounds: midline incision clean, dry, no erythema, no
drainage;ostomy with gas and output
Ext: No edema, warm well-perfused
Pertinent Results:
___ 06:00AM BLOOD WBC-9.6 RBC-2.54* Hgb-6.8* Hct-21.1*
MCV-83 MCH-26.8 MCHC-32.2 RDW-16.7* RDWSD-51.2* Plt ___
___ 07:43AM BLOOD WBC-10.7* RBC-2.71* Hgb-7.0* Hct-22.7*
MCV-84 MCH-25.8* MCHC-30.8* RDW-17.0* RDWSD-51.8* Plt ___
___ 08:48AM BLOOD WBC-10.2* RBC-2.88* Hgb-7.5* Hct-23.9*
MCV-83 MCH-26.0 MCHC-31.4* RDW-16.7* RDWSD-50.6* Plt ___
___ 06:45AM BLOOD WBC-10.1* RBC-3.20* Hgb-8.3* Hct-26.2*
MCV-82 MCH-25.9* MCHC-31.7* RDW-16.7* RDWSD-49.8* Plt ___
___ 07:08AM BLOOD WBC-10.4* RBC-3.22* Hgb-8.5* Hct-26.0*
MCV-81* MCH-26.4 MCHC-32.7 RDW-16.1* RDWSD-47.8* Plt ___
___ 03:17PM BLOOD WBC-15.1* RBC-3.84* Hgb-10.1* Hct-31.1*
MCV-81* MCH-26.3 MCHC-32.5 RDW-16.5* RDWSD-48.3* Plt ___
___ 03:17PM BLOOD Neuts-76.0* Lymphs-13.7* Monos-6.7
Eos-0.9* Baso-0.3 Im ___ AbsNeut-11.52* AbsLymp-2.07
AbsMono-1.01* AbsEos-0.13 AbsBaso-0.04
___ 06:00AM BLOOD Glucose-81 UreaN-10 Creat-1.2* Na-138
K-4.0 Cl-108 HCO3-19* AnGap-11
___ 07:43AM BLOOD Glucose-89 UreaN-10 Creat-1.4* Na-136
K-4.0 Cl-107 HCO3-15* AnGap-14
___ 01:15PM BLOOD Glucose-103* UreaN-18 Creat-2.0* Na-129*
K-3.9 Cl-97 HCO3-17* AnGap-15
___ 07:08AM BLOOD Glucose-97 UreaN-21* Creat-2.1* Na-133*
K-4.0 Cl-102 HCO3-15* AnGap-16
___ 03:17PM BLOOD Glucose-117* UreaN-27* Creat-2.8*#
Na-129* K-4.2 Cl-99 HCO3-13* AnGap-17
___ 07:43AM BLOOD ALT-48* AST-33 AlkPhos-133* TotBili-0.2
___ 06:45AM BLOOD ALT-50* AST-26 AlkPhos-132* TotBili-0.2
___ 03:17PM BLOOD ALT-82* AST-43* AlkPhos-188* TotBili-0.3
___ 06:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2
___ 07:08AM BLOOD Albumin-3.6 Calcium-9.7 Phos-4.0 Mg-2.2
___ 03:17PM BLOOD Albumin-4.2 Calcium-10.3 Phos-4.2 Mg-1.4*
___ 06:19AM BLOOD ___ pO2-81* pCO2-39 pH-7.33*
calTCO2-21 Base XS--4 Comment-GREEN TOP
___ 05:13PM BLOOD ___ pO2-123* pCO2-43 pH-7.24*
calTCO2-19* Base XS--8 Comment-GREEN TOP
___ 03:22PM BLOOD ___ pO2-34* pCO2-36 pH-7.26*
calTCO2-17* Base XS--10 Comment-GREEN TOP
Brief Hospital Course:
___ female with history of Crohn's disease c/b TI
stricture s/p Laparoscopic ileocolectomy, s/p RLQ ___ drain for
fluid collection ___ anastomotic leak c/b hematoma s/p ___ drain
s/p ex-lap, washout, ileocolonic resection, end
ileostomy, who presents to ED with poor PO intake, metabolic
acidosis, ___ & elevated LFTs of unknown etiology. She was
admitted to colorectal service for IV fluid hydration.Nephrology
consulted for assistance in medical management. Hospital course
as follows:
___
After initial operation, developed ___ in the setting of ATN
from IV contrast. Creatinine improved down to 1.4. This
admission , creatinine up to 2.8. She has a history of poor
oral intake and high output from ostomy. Also low blood
pressures prior to this presentation. Per nephrology, this is
prerenal ___, improving with IV fluids. There were very few
granular casts on urine sediment which might represent very mild
ATN. Nephrology Recs as followed:
-Continue IV fluids
-Encourage oral hydration
-maintain MAP >65 at all times.
-Avoid all nephrotoxic medications, NSAIDS and contrast if
possible.
-Monitor UOP closely and Cr daily.
-Renally dose all medications
#Metabolic acidosis
She has high anion gap metabolic acidosis which is a combination
___ and lactic acidosis. Has a UTI though would continue to
look for source of infection. ___ started on sodium
bicarbonate 1300 mg PO TID- stopped at discharge.
#Hyponatremia
She has hypovolemic hyponatremia in the setting of volume
depletion. Sodium improving with normal saline. Home IV
infusion arranged at discharge as follows: NS 125 cc/hr 1 Liter
daily for 2 weeks. Weekly labs for Chem 10 to be sent to Dr.
___.
# UTI
Urine cultures growing gram-negative rods, treat asymptomatic E
coli bacteruria- Macrobid.
#Anemia
Hematocrit 21.1 on ___, transfused with 1 Unit RBC.
At time of discharge, patient with satisfactory gas/ostomy
output and psyllium wafers/loperamide titrated
accordingly.(c-diff culture negative).Patient is tolerating a
diet,voiding, and ambulating independently. She will follow-up
in the clinic in 2 weeks. This information was communicated to
the patient directly prior to discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. FoLIC Acid 1 mg PO DAILY
3. Ondansetron ODT 4 mg PO DAILY:PRN Nausea/Vomiting - First
Line
4. Ranitidine 150 mg PO QHS
5. TraZODone 50 mg PO QHS:PRN insomnia
6. Vitamin D ___ UNIT PO 1X/WEEK (SA)
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma sx/shortness of
breath
8. amLODIPine 10 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
11. NPH 12 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline
Insertion
2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
3. LOPERamide 4 mg PO QID
4. Nitrofurantoin (Macrodantin) 100 mg PO BID
RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1
capsule(s) by mouth twice a day Disp #*4 Capsule Refills:*0
5. Psyllium Wafer 2 WAF PO BID
6. NPH 12 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using REG Insulin
7. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma sx/shortness of
breath
9. amLODIPine 10 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Ondansetron ODT 4 mg PO DAILY:PRN Nausea/Vomiting - First
Line
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
14. Ranitidine 150 mg PO QHS
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___
Metabolic acidosis
Poor PO intake
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You presented to ED with decrease oral intake and had abnormal
lab findings concerning for kidney injury and treated with IV
fluids and responded well. You were also found to have a UTI and
started on antibiotics; please take as prescribed. You were also
evaluated by Nephrology. During your hospital stay you received
a blood transfusion for a low hematocrit and had stable vital
signs. You are now ready for discharge home with ___ services
for wound and ostomy teaching. You are being discharged home
with IV fluids for 2 weeks and will have weekly lab draws to
monitor your electrolytes.
Ostomy output: The most common complication from an ileostomy is
dehydration. You must measure your ileostomy output for the next
few weeks- please bring your I&O sheet to your post-op
appointment. The output should be no less than 500cc or greater
than 1200cc per day. If you find that your output has become too
much or too little, please call the office. Please monitor for
signs and symptoms of dehydration. If you notice these symptoms,
please call the office or go to the emergency room. You will
need to keep yourself well hydrated, if you notice your
ileostomy output increasing, drink liquids with electrolytes
such as Gatorade.
Please monitor the appearance of your stoma and care for it as
instructed by the ostomy nurses. ___ you notice that the stoma is
turning darker blue or purple please call the office or go to
the emergency room. The stoma may ooze small amounts of blood at
times when touched which will improve over time. Monitor the
skin around the stoma for any bulging or signs of infection. You
will follow up with the ostomy nurses in the clinic as
scheduled. You will also have a visiting nurse at home for the
next few weeks to help to monitor your ostomy (until you are
comfortable caring for it on your own).
Monitor your abdominal wound for signs and symptoms of
infection including: increasing redness of the incision lines,
white/green/yellow/foul smelling drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area.
Pain is expected after surgery. This will gradually improve
over the first week or so you are home. You should continue to
take 2 Extra Strength Tylenol (___) for pain every 8 hours
around the clock. Please do not take more than 3000mg of Tylenol
in 24 hours or any other medications that contain Tylenol such
as cold medication. Do not drink alcohol while taking Tylenol.
You may also take Advil (Ibuprofen) 600mg every 8 hours for 7
days. Please take Advil with food. If these medications are not
controlling your pain to a point where you can ambulate and
perform minor tasks, you should take a dose of the narcotic pain
medication Oxycodone. Please do not take sedating medications,
drink alcohol, or drive while taking the narcotic pain
medication.
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs, and
go outside and walk. Please avoid traveling long distances until
you speak with your surgical team at your post-op visit.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
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