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10710772-DS-3
| 10,710,772 | 20,585,735 |
DS
| 3 |
2161-02-19 00:00:00
|
2161-02-19 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
transient visual loss in right visual field
Major Surgical or Invasive Procedure:
none
History of Present Illness:
NEUROLOGY STROKE ADMISSION
** Not Code Stroke **
Time/Date the patient was last known well: 16:45 ___
___ Stroke Scale Score: 0
t-PA administered:
[x] No - Reason t-PA was not given or considered: Symptoms
resolved
Thrombectomy performed:
[x] No - Reason not performed or considered: NIHSS 0,
asymptomatic
NIHSS Performed within 6 hours of presentation at: 18:00
NIHSS Total: 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: Right visual field loss
HPI:
___ is a healthy ___ right-handed woman who
presents with transient right visual field loss today.
She works in a lab at ___ and was working at her
computer
at ~4:45PM when she suddenly developed difficulty reading and
noticed she could not see her right hand on the keyboard. When
she closed either eye, she did not "go blind" and realized she
could not see the right side through either eye. She told her
coworkers in the lab where she works and an MD quickly evaluated
her finding no other deficits. She was able to walk and use her
limbs, though she is not aware of anything she did with her
right
hand. She would have to move her right hand into her left field
to see it. These symptoms lasted maximally for 15 minutes. One
of
her coworkers accompanied her walking across the street to the
___ ED, and she says her symptoms began to improve as they
walked and were resolved by the time she was seen here in triage
at 5:10PM.
She did not develop any subsequent headache. There were no other
associated symptoms.
She reports a history of 1x/monthtly migraine headaches, though
these are characterized as a bifrontal steady pain with
photophobia, but no nausea or other migrainous features. They
resolve after ___ hours without treatment, or after sleep. She
typically sequesters herself in a dark room during these.
ROS: Positive as noted above.
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
ALLERGIES:
Aspirin -- epistaxis but last when she was ___ years old.
- Modified Rankin Scale:
[x] 0: No symptoms
Past Medical History:
none
Social History:
___
Family History:
Father with epilepsy.
No family history of bleeding/clotting disorders.
No strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.2 HR:96 BP:170/90 RR:16 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
No neck tenderness.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRLA, EOMI. VFF to confrontation, no
extinction.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 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
-Sensory: No deficits to light touch. Graphesthesia intact.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: Deferred.
===================================================
DISCHARGE PHYSICAL EXAM:
Vitals: T:97.4 HR:92 BP:128/86 RR:16 SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
No neck tenderness.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRLA, EOMI. VFF to confrontation, no
extinction.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 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
-Sensory: No deficits to light touch. No extinction
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: normal
===================================================
Pertinent Results:
___ 05:47PM BLOOD WBC-8.1 RBC-4.23 Hgb-12.6 Hct-37.7 MCV-89
MCH-29.8 MCHC-33.4 RDW-12.8 RDWSD-41.7 Plt ___
___ 05:47PM BLOOD Neuts-61.4 ___ Monos-5.9 Eos-2.1
Baso-0.7 Im ___ AbsNeut-4.94 AbsLymp-2.40 AbsMono-0.48
AbsEos-0.17 AbsBaso-0.06
___ 09:29AM BLOOD ___ PTT-31.6 ___
___ 09:29AM BLOOD D-Dimer-225
___ 09:29AM BLOOD Lupus-PND dRVVT-S-PND
___ 05:47PM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-138 K-3.9
Cl-98 HCO3-22 AnGap-18
___ 05:47PM BLOOD ALT-10 AST-18 AlkPhos-51 TotBili-0.4
___ 05:47PM BLOOD Lipase-32
___ 05:47PM BLOOD cTropnT-<0.01
___ 05:47PM BLOOD Albumin-4.7 Calcium-9.8 Phos-4.1 Mg-2.0
Cholest-265*
___ 05:47PM BLOOD %HbA1c-5.2 eAG-103
___ 05:47PM BLOOD Triglyc-277* HDL-73 CHOL/HD-3.6
LDLcalc-137*
___ 05:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:47PM BLOOD GreenHd-HOLD
___ 09:29AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 09:29AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
=====================================
PERTINENT IMAGING RESULTS:
MRI Brain:
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles and sulci are normal in caliber
and
configuration. 2.0 x 1.8 cm structure in the anterior right
posterior fossa
with signal characteristics equivalent to CSF is likely an
arachnoid cyst (9: 5). Bilateral orbits are unremarkable.
Paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute infarct is identified.
CTA head and neck:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air
cells,and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation. The dural
venous sinuses are patent. A 7 mm density at the right
cerebellopontine angle
did not have restricted diffusion on the prior MRI and is
consistent with a
benign arachnoid granulation.
CTA NECK:
The carotidandvertebral arteries and their major branches appear
normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. There is a likely
1.0 cm
nodule in the right thyroid lobe, recommend correlation with
prior thyroid
ultrasound if available, otherwise recommend routine thyroid
ultrasound for further characterization, which is amenable to be
obtained in the ambulatory setting.
Echo:
The left atrial volume index is normal. There is no evidence of
an atrial septal defect or patent foramen
ovale by 2D/color Doppler or agitated saline at rest and with
maneuvers. The estimated right atrial
pressure is ___ mmHg. There is normal left ventricular wall
thickness with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 56 % (normal
54-73%). Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests a normal left ventricular
filling pressure (PCWP less than 12mmHg). There is normal
diastolic function. Normal right ventricular cavity size with
normal free wall motion. Tricuspid annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is physiologic tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: 1) Normal study. Normal biventricular cavity sizes
and regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure. 2) No structural cardiac
source of embolism (e.g.patent foramen ovale/atrial septal
defect, intracardiac thrombus, or vegetation) seen. 3) A liver
echo-density was noted on subcostal views of unclear
significance. Consider dedicated imaging to further evaluate
structural change. No prior abdominal imaging in OMR.
Brief Hospital Course:
BRIEF SUMMARY and Hospital course:
___ is a healthy ___ woman who presented
with
___ minutes of right visual field loss of abrupt onset. There
were
no associated symptoms. Her history is notable for
estrogen-containing oral contraceptive use, and possible
migraine but without aura. She is not a smoker. Her neurological
exam was normal at admission and throughout hospitalization,
without recurrence of her symptoms.
She was admitted for TIA workup, with primary risk factor being
female gender and OCP use. Migraine aura with Acephalgic
migraine was considered as the most likely possibility, but it
was felt that patient warranted a full TIA work up before making
this diagnosis. Seizure was considered less likely based on the
symptoms and course described by patient. Pt's brain imaging was
reassuring (MRI brain, CTA head and neck). Transthoracic echo
was negative for thrombus or PFO. Hypercoagulability labs were
sent and some were pending at discharge. D-Dimer 225, and no
signs and symptoms of DVT, no PFO on echo therefore we did not
obtain LENIs/pelvis MRV.
Patient's lipid profile was abnormal with Cholesterol of 265,
Triglycerides 277, HDL 73, LDL 137. She was started on low dose
Atorvastatin to be taken for 3 months f/b repeat Lipid profile
testing. Her HbA1c was 5.2, TSH 1.4.
Pending Labs:
LUPUS anticoagulant
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
CARDIOLIPIN ANTIBODIES (IGG, IGM)
==============================================
TRANSITIONAL ISSUES:
[ ] Stop taking estrogen containing OCP, discuss non-estrogen
contraceptive options with your PCP/Gynecologist
[ ] Start taking baby aspirin (Aspirin 81 mg)
[ ] Take Atorvastatin (20 mg, to lower cholesterol) for 3
months, then get repeat lipid profile at your PCP's office and
consider stopping the Atorvastatin medicine
[ ] We also placed a heart rhythm monitor, called Ziopatch,
prior to discharge. Results of this will be sent to Dr.
___.
[ ] Please follow up with your PCP.
[ ] Please follow up with Neurology. We have emailed the
scheduler, if you do not hear about this appointment or have any
questions regarding this hospitalization, please call
___ and leave a message for Dr. ___.
[ ] Transthoracic echo with liver echo-density was noted on
subcostal views. Consider dedicated imaging to further evaluate
structural change.
[ ] CT showed a likely 1.0 cm nodule in the right thyroid lobe,
recommend correlation with prior thyroid ultrasound if
available, otherwise recommend routine thyroid ultrasound for
further characterization, which is amenable to be obtained in
the ambulatory setting.
=================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why: pt at baseline
status
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 137) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - Gave
Atorvastatin 20 mg for 3 months, pt is young and mechanism of
TIA was not atheroembolic () No [if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
___/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No- patient at baseline functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
=================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ (___) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack
?Migraine Aura
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 transient loss of
vision in your right visual field.
We obtained brain imaging and found no evidence of stroke on
your MRI. Since you have a history of migraines, it is possible
that the transient visual field loss was caused by a migraine
aura. However, as this can also happen due to a TRANSIENT
ISCHEMIC ATTACK (TIA), therefore we admitted you. A TIA is a
condition where a blood vessel providing oxygen and nutrients to
the brain is transiently 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.
TIA/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:
[ ] Taking estrogen containing contraceptives
[ ] High cholesterol
------
We are changing your medications as follows:
[ ] Stop taking estrogen containing OCP, discuss non-estrogen
contraceptive options with your PCP/Gynecologist
[ ] Start taking baby aspirin (Aspirin 81 mg)
[ ] Take Atorvastatin (20 mg, to lower cholesterol) for 3
months, then get repeat lipid profile at your PCP's office and
consider stopping the Atorvastatin medicine
------
[ ] We also placed a heart rhythm monitor, called Ziopatch,
prior to discharge. Results of this will be sent to Dr.
___.
[ ] Please follow up with your PCP.
[ ] Please follow up with Neurology. We have emailed the
scheduler, if you do not hear about this appointment or have any
questions regarding this hospitalization, please call
___ and leave a message for Dr. ___.
[ ] Transthoracic echo with liver echo-density was noted on
subcostal views. Consider dedicated imaging to further evaluate
structural change.
If you experience similar symptom again and have a migraine
headache with it, we will reconsider the diagnosis of migraine
aura. We have therefore set up an appointment with a
Neurologist, Dr. ___. If you do not hear about this
appointment or have any questions regarding this
hospitalization, please call ___ and leave a message
for Dr. ___.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below. [ ] Please discuss with your PCP regarding
liver imaging as discussed. ___ echo with liver
echo-density was noted on subcostal views. Consider dedicated
imaging to further evaluate structural change."
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
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10710902-DS-22
| 10,710,902 | 22,217,269 |
DS
| 22 |
2176-07-15 00:00:00
|
2176-07-15 17:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Verapamil / Atenolol
Attending: ___.
Chief Complaint:
Anemia, weakness
Major Surgical or Invasive Procedure:
There were no major surgical and invasive procedures.
History of Present Illness:
___ with pmh of coronary artery disease, hypertension,
hypercholesterolemia and a diagnosis of SIADH without a known
etiology, as well as irritable bowel syndrome who presents with
worsening anemia over the last three months. Labs drawn at
___ showed low Hct and was transferred to ___
ED. She was noted to have pallor with no clear cause (no bloody
bm, no hematemesis, hemopotysis), no changes in mentation. She
complained of abdominal pain for the last three days as well as
weakness and shortness of breath for 3 days. No other somatic
complaints save for chronic arthritis in the knees.
Per records from ___, her H/H in ___ was
8.3/26.0 and was 8.3/25.6 on ___.
In the ED, initial vital signs were 97.7 56 174/77 20 98%RA
- Labs were notable for: H/H of 5.9/19.8; LDH 238,
- Imaging:CXR (my read) prominent pulm vasculature,
cardiomegaly, and an anterior mediastinal mass. A CT
abdomen/pelvis is being obtained to evaluate for abdominal pain.
- Consults: None
- Patient was given:2 units PRBCs, magnesium sulfate, and 1L NS
On transfer, vital signs were 98.0 61 197/54 20 98% Nasal
Cannula
Upon arrival to the unit pt reports her abdominal pain has
improved. She has mild back pain consistent with her baseline.
Please refer to nightfloat note for PMH, meds, allergies, and
social history, and family history.
REVIEW OF SYSTEMS: As per HPI
___ with pmh of coronary artery disease, hypertension,
hypercholesterolemia and a diagnosis of SIADH without a known
etiology, as well as irritable bowel syndrome who presents with
worsening anemia over the last three months. Labs drawn at
___ showed low Hct and was transferred to ___
ED. She was noted to have pallor with no clear cause (no bloody
bm, no hematemesis, hemopotysis), no changes in mentation. She
complained of abdominal pain for the last three days as well as
weakness and shortness of breath for 3 days. No other somatic
complaints save for chronic arthritis in the knees.
Per records from ___, her H/H in ___ was
8.3/26.0 and was 8.3/25.6 on ___.
In the ED, initial vital signs were 97.7 56 174/77 20 98%RA
- Labs were notable for: H/H of 5.9/19.8; LDH 238,
- Imaging:CXR (my read) prominent pulm vasculature,
cardiomegaly, and an anterior mediastinal mass. A CT
abdomen/pelvis is being obtained to evaluate for abdominal pain.
- Consults: None
- Patient was given:2 units PRBCs, magnesium sulfate, and 1L NS
On transfer, vital signs were 98.0 61 197/54 20 98% Nasal
Cannula
Upon arrival to the unit pt reports her abdominal pain has
improved. She has mild back pain consistent with her baseline.
REVIEW OF SYSTEMS: As per HPI
Past Medical History:
-coronary artery disease, status post catheterization in ___
with single vessel disease.
-Hypertension
-hypercholesterolemia.
-Osteoarthritis
-Urinary incontinence, secondary to pelvic floor prolapse.
-GERD
-iron deficiency anemia
-SIADH (unknown etiology, has been present since at least ___
-IBS
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.9 217/51 (improved to 135/74 with home medications)
71 18 97% on 2L
General: pleasant elderly ___ woman in no distress
HEENT: pale conjunctiva, MMM, oropharynx clear
Neck: Supple
Lungs: CTAB anteriorly
CV: RRR, ___ systolic murmur radiating to the carotids
Abdomen: Soft, NTND, normoactive bowel sounds
GU: Foley in place
Ext: Warm, well-perfused, trace edema w/ TEDS stockings, 2+
pulses
Neuro: AAOx3, CN II-XII grossly intact, diffusely weak
DISCHARGE EXAM
==============
Vitals: 98.4 98.1 157/36 61 18 92%RA
General: pleasant elderly ___ woman in no distress
HEENT: pale conjunctiva, MMM, oropharynx clear
Neck: Supple
Lungs: CTAB anteriorly
CV: RRR, ___ systolic murmur radiating to the carotids
Abdomen: Soft, NTND, normoactive bowel sounds
GU: Foley in place
Ext: Warm, well-perfused, trace edema w/ TEDS stockings, 2+
pulses
Neuro: AAOx3, CN II-XII grossly intact, diffusely weak
Pertinent Results:
ADMISSION LABS
==============
___ 05:00PM BLOOD Glucose-104* UreaN-30* Creat-1.1 Na-132*
K-4.8 Cl-99 HCO3-23 AnGap-15
___ 05:00PM BLOOD WBC-6.8 RBC-2.56*# Hgb-5.9*# Hct-19.8*#
MCV-77*# MCH-23.0*# MCHC-29.8*# RDW-16.9* RDWSD-47.8* Plt
___
___ 05:00PM BLOOD Neuts-69.4 Lymphs-16.3* Monos-12.6
Eos-1.0 Baso-0.4 Im ___ AbsNeut-4.69 AbsLymp-1.10*
AbsMono-0.85* AbsEos-0.07 AbsBaso-0.03
___ 05:00PM BLOOD ___ PTT-28.3 ___
___ 05:00PM BLOOD ALT-15 AST-19 AlkPhos-92 TotBili-0.2
___ 05:00PM BLOOD Lipase-47
___ 05:00PM BLOOD cTropnT-0.02*
___ 05:00PM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.3# Mg-2.2
___ 09:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS
==============
___ 07:17AM BLOOD Glucose-80 UreaN-27* Creat-1.2* Na-133
K-4.7 Cl-97 HCO3-23 AnGap-18
___ 02:05PM BLOOD WBC-7.0 RBC-3.27* Hgb-8.2* Hct-25.8*
MCV-79* MCH-25.1* MCHC-31.8* RDW-17.6* RDWSD-50.5* Plt ___
___ 07:17AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
ANEMIA WORK-UP
==============
___ 02:05PM BLOOD Ret Aut-1.6 Abs Ret-0.05
___ 05:50PM BLOOD LD(LDH)-238
___ 05:50PM BLOOD calTIBC-428 ___ Ferritn-10* TRF-329
IMAGING
=======
CXR: Scattered atelectasis with mild congestion and
cardiomegaly.
CT ABD/PELVIS W/ CONTRAST:
1. No evidence of acute intra-abdominal process. Nonvisualized
appendix.
2. Colonic diverticulosis without evidence for acute
diverticulitis.
3. 1.1 cm left complex renal cyst, unchanged from ___. If
clinically
indicated, and nonurgent for renal ultrasound could be obtained
for further evaluation.
4. Right adrenal soft tissue nodule, unchanged in ___ and
likely
representing an adrenal adenoma.
5. Stable, moderate cardiomegaly.
Brief Hospital Course:
___ with past medical history of coronary artery disease,
hypertension, hypercholesterolemia and a diagnosis of SIADH
without a known etiology, as well as irritable bowel syndrome
who presents with anemia and pallor and abdominal pain.
#Anemia: She was transferred from ___
for a H/H of 5.9/19.8 without obvious source of bleeding. Her
labs are consistent with an iron deficient anemia LDH was
normal. She received two units pRBCs. Her H/H appropriately
responded and was 8.0/25.9. Per discussion with patient, she
last had a colonoscopy many years ago which was unremarkable. We
discussed whether she would want to have another to evaluate for
bleeding and possible malignancy. She clearly stated that she
does not want another colonoscopy even if she might have colon
cancer. She knew that she needed to take iron supplements but
stopped because of constipation. For this reason, a stool guaiac
was also not done. Her H/H on discharge was stable at 8.2/25.8.
#Abdominal pain:
The differential here is broad including gastritis or PUD
causing an upper GI bleed causing the anemia. There may be an
upper GI malignancy as well. CT Abdomen/pelvis was unremarkable
for acute intra-abdominal process and only had colonic
diverticulosis. She was initially started on a PPI but given
this risks of a PPI, her age, and that we suspect a lower GI
bleed this was discontinued. She had no pain or discomfort on
discharge.
#Hypertension: She had some SBPs in the low 200s while on
hydralazine, furosemide, and lisinopril. Repeat was in the 170s.
Blood pressure fluctuated in the 110s-170s but she remained
asymptomatic.
TRANSITIONAL ISSUES
===================
Discharge vitals: 98.4 157/36 61 18 92%RA
Vital signs per routine
Care as prior to current admission
-Anemia: Restarted on iron supplements and bowel regimen. Needs
Senna, Colace, and Miralax PRN to avoid constipation while on
iron.
-Hypertension: Elevated BPs correlated with agitation and BP was
stable with SBPs 150-170s.
-Goals of care: She stated that she did not want a colonoscopy
to evaluate for bleeding or colon cancer.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aluminum Hydroxide Suspension 15 mL PO Q6H:PRN GI upset
2. OxycoDONE (Immediate Release) 2.5 mg PO BID
3. Zolpidem Tartrate 10 mg PO QHS
4. Lisinopril 10 mg PO DAILY
5. HydrALAzine 75 mg PO TID
6. Gabapentin 100 mg PO TID
7. Acetaminophen 650 mg PO Q6H:PRN Pain
8. Furosemide 20 mg PO 4X/WEEK (___)
9. Vitamin D 50,000 UNIT PO Q21D
10. Bisacodyl 15 mg PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 15 mg PO DAILY
4. Furosemide 20 mg PO 4X/WEEK (___)
5. Gabapentin 100 mg PO TID
6. HydrALAzine 75 mg PO TID
7. Lisinopril 10 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO BID
9. Zolpidem Tartrate 10 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. Ferrous Sulfate 325 mg PO TID
12. Senna 17.2 mg PO HS
13. Aluminum Hydroxide Suspension 15 mL PO Q6H:PRN GI upset
14. Vitamin D 50,000 UNIT PO Q21D
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Iron-deficiency anemia
SECONDARY DIAGNOSIS
====================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
You were admitted to the ___
for anemia. It was noted that your blood levels were low and you
were transferred here. Laboratory results showed that you were
deficient in iron. We started you on iron supplements. You
should be aware that iron supplementation can cause you to be
constipated and can take the stool softeners to help with this.
Iron may also make your stool darker.
It was a pleasure to take care of you and we wish you the very
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10711229-DS-20
| 10,711,229 | 24,016,097 |
DS
| 20 |
2204-11-02 00:00:00
|
2204-11-02 15:18:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex
Attending: ___.
Chief Complaint:
Ms. ___ is a ___ year old female s/p CABG ___ ___
presenting with RLE swelling and tenderness s/p cardiac
catheterization.
Major Surgical or Invasive Procedure:
Wash-out of knee ___
History of Present Illness:
Pt initially presented to her cardiologist several weeks prior
to admission ___ reports of chest tightness/pressure with
associated dyspnea with
exertion and at rest that started about 6 months prior. She had
a persantine stress test on ___ that showed a moderate
partially reversible defect involving the apex. She was referred
for catheterization, which occured via right femoral access on
___. This demonstrated a very tight LAD and LCX lesion. No
intervention was performed given complexity of LAD lesion. Pt
was evaluated by ___, who deemed her high risk for CABG
revision so pt underwent repeat cath via RRA on ___, s/p DES to
LCx.
From a cardiac perspective, pt has done well post cath with no
recurrent of her dyspnea. However, she has noted increased
swelling and erythema of her right leg. She was seen ___ the ED
on ___ and had an ultrasound demonstrating a hematoma, but no
fistula or aneurysm. She was evaluated by ___ ___ the ED, was
ambulating with walker and discharged home. She called the
cardiology office on the day of admission reporting worsening of
her pain, inability to ambulate, severe tenderness so she was
referred back to the ED.
___ the ED, initial vitals were 10 99.6 71 138/52 18 98%. She
received morphine 2 mg IV x 2 for the pain with mild
improvement. She had right ___ with no evidence of DVT, femoral
ultrasound done but pending at time of admission. She was
admitted to cardiology for work up of post-procedural
complications.
Past Medical History:
- DM2
- HTN
- CAD
- s/p CABG ___ LIMA-->LAD, SVG--> D1, SVG--> PDA
- hypercholesterolemia
- s/p laminectomy ___
- spondylosis
- Lumbar Spinal Stenosis S/P L1-L3 Laminectomy and Fusion of
L2-L3 ___ ___
- s/p bilateral carpal tunnel release ___
- cataracts
- GERD
- dysphagia: esophageal manometry (___) shows evidence of
ineffective esophageal peristalsis ___ just under 50% of wet
swallows with a borderline low ___ pressure
- 6mm lung nodule ___ RML two year stability ___ ___
- adenomatous polyps on colonoscopy ___. 2 Polypectomys ___
ascending colon on ___
- ___ gastritis and doudenitis on EGD (NSIAD induced?)
- esophogeal ring ___ egd
Social History:
___
Family History:
mother: DM1, deceased from MI age ___
father: lung cancer, deceased
Brother renal cancer
Physical Exam:
Admission exam:
VS: T= 98.3 BP= 143/69 HR= 83 RR= 20 O2 sat= 96 RA
General: Elderly woman ___ no acute distress lying ___ bed
HEENT: AT/NC, good color, sclera anicteric
Neck: Supple, no JVP distention
CV: RRR, harsh holosystolic murmur best heard at LUSB, radiating
to carotids
Lungs: Comfortable on RA, CTAB
Abdomen: Flat, soft, non tender, non distended
GU: No foley
Groin: Right groin medial yellow ecchymosis, and lateral purple
echymosis, no palpable induration ___ groin
Ext: Right leg significantly larger than right, warm, tender,
edematous, soft, distal pulses intact
Neuro: Alert, oriented although intermittently tangential (since
morphine per her son)
Skin: dry, intact with bruising as noted above
PULSES: ___, femoral, radial 2+
Discharge exam:
98.6 152/63 HR 71 RR12 97% RA
General: Elderly woman, comfortable, NAD
HEENT: AT/NC, MMM, conjunctival pallor
Neck: Supple, no JVP distention
CV: RRR, harsh holosystolic murmur best heard at LUSB, radiating
to carotids
Lungs: Diffuse wheezing, crackles ___ bases bilaterally
Abdomen: Flat, soft, non tender, non distended
Ext: Mildly tender right knee, much improved. No edema
bilaterally.
Neuro: Alert, intermittently tangential
Skin: New rash on chest that was pruritic, improving and no
longer symptomatic
PULSES: ___, femoral, radial 2+
Pertinent Results:
___ 04:01PM K+-4.9
___ 02:15PM GLUCOSE-259* UREA N-33* CREAT-1.3* SODIUM-136
POTASSIUM-6.4* CHLORIDE-99 TOTAL CO2-21* ANION GAP-22*
___ 02:15PM estGFR-Using this
___ 02:15PM WBC-8.0# RBC-3.53* HGB-10.5* HCT-32.3* MCV-92
MCH-29.6 MCHC-32.3 RDW-13.4
___ 02:15PM NEUTS-79.3* LYMPHS-14.2* MONOS-5.7 EOS-0.5
BASOS-0.3
___ 02:15PM PLT COUNT-216
___ 02:15PM ___ PTT-28.0 ___
___ 06:15AM BLOOD WBC-8.4 RBC-2.83* Hgb-7.9* Hct-26.3*
MCV-93 MCH-27.9 MCHC-30.1* RDW-15.1 Plt ___
___ 06:15AM BLOOD Glucose-183* UreaN-63* Creat-2.5* Na-148*
K-4.6 Cl-115* HCO3-19* AnGap-19
___ 10:40AM BLOOD ALT-55* AST-86* LD(LDH)-281* AlkPhos-166*
TotBili-1.2
___ 05:58AM BLOOD ESR-140*
___ 06:15AM BLOOD CRP-GREATER TH
___ 05:58AM BLOOD CRP-GREATER TH
___ 07:15PM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01
___ 10:40AM BLOOD ALT-55* AST-86* LD(LDH)-281* AlkPhos-166*
TotBili-1.2
___ 07:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:20AM URINE Blood-TR Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 07:20AM URINE RBC-24* WBC-142* Bacteri-MOD Yeast-NONE
Epi-2 TransE-5
___ 11:58AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:58AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-70 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:58AM URINE RBC-5* WBC-98* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-2
___ 11:58AM URINE CastGr-17* CastHy-3* CastCel-3*
___ 11:58AM URINE Hours-RANDOM UreaN-396 Creat-62 Na-43
K-42 Cl-43
___ 07:00PM JOINT FLUID ___ RBC-1725* Polys-89*
___ Macro-6
___ 07:00PM JOINT FLUID Crystal-NONE
Micro:
Blood cultures ___ and ___ NEGATIVE
Blood cultures ___ NGTD
___ 7:00 pm JOINT FLUID Source: Knee.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ ___.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 2:43 pm TISSUE RIGHT KNEE SYNOVIUM.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 6:49 am URINE Source: ___.
WORKUP REQUESTED BY ___ ___ (___) ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ ___ (___) REQUESTED TO R/O S. AUREUS ___ CULTURE
___.
NO STAPHYLOCOCCUS AUREUS ISOLATED.
___ 5:32 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ Right leg U/S: No evidence of deep venous thrombosis ___
the right lower extremity. Unchanged superficial fluid
collection ___ the right groin likely representing a seroma or
hematoma.
___ FEMORAL VASCULAR US RIG: No evidence of pseudoaneurysm
or fistula. Small right groin hematoma or
seroma.
___ CHEST (PORTABLE AP): Mild cardiomegaly and pulmonary and
mediastinal vasculature engorgement are
new, but there is no pulmonary edema, focal consolidation or
appreciable
pleural effusion.
___ Right knee x-ray
IMPRESSION: Large joint effusion. No evidence for
osteomyelitis; however, is
there is concern for septic arthritis, aspiration would be
recommended.
___ ECG
Sinus rhythm. Poor R wave progression. Consider prior anterior
myocardial
infarction, age undetermined. Non-specific inferior and lateral
ST-T wave
changes. Compared to the previous tracing of ___
non-specific inferior and lateral T wave changes are seen on the
current tracing.
___ CT groin:
2.3 x 1.1 cm collection within the subcutaneous fat of the right
groin which
is consistent with a small hematoma related to the previous
right common
femoral artery access. No drainable collections identified.
___ Chest xray:
FINDINGS: As compared to the previous radiograph, the lung
volumes have
decreased, but the diameter of the vascular structures have
increased. This
could reflect mild fluid overload. However, no evidence of
pneumonia is
present on the current image. No pleural effusions. Unchanged
moderate
cardiomegaly, the alignment of the sternal wires is constant.
___ Chest xray:
Moderately severe pulmonary edema has improved ___ the left lung
since ___. More pronounced consolidation at the base of the right lung
could be
residual edema and atelectasis but pneumonia, particularly
aspiration needs to
be considered. Mild-to-moderate cardiomegaly and mediastinal
venous
engorgement unchanged, pulmonary vascular cephalization more
pronounced.
Pleural effusion is presumed but not substantial.
___ Renal U/S
Both kidneys are normal ___ size and position. The right kidney
measures 10.7
cm and the left kidney measures 11.1 cm. There is trace
perinephric fluid
surrounding both kidneys greater on the right than the left
without associated
mass effect. The renal cortical thickness, echogenicity and
corticomedullary
differentiation is within normal limits. No hydronephrosis,
stones or masses
are identified ___ either kidney.
___ Chest xray:
FINDINGS: Slightly worsening pulmonary edema. Worsening right
infrahilar
opacity, potentially reflecting aspiration or infection, minimal
cardiomegaly.
No pneumothorax. The left PICC line is ___ unchanged position.
Brief Hospital Course:
___ year old woman with recent right groin access catheterization
presenting ___ for right leg pain, likely from transient
bacteremia, found to have a septic knee. Treated for septic
arthirits and pain, developed AIN, then ATN. Pain improving,
participating ___ physical therapy, creatinine improving.
Occassionally delirious but redirectable.
#MSSA Septic Knee arthritis with septic shock: Patient presented
with right leg pain, and was noted to have a swollen knee and
fever. Tap revealed white cells and MSSA, no crystals. She
underwent washout of the knee on ___ with drain ___ place then
removed. Was initially covered with vancomycin, but on day 3 of
vancomycin (___) spiked a fever, was hypoxic, and had altered
mental status, so was broadened with cefepime. Transitioned to
nafcillin, had AIN shortly after (likely due to toradol),
started cefazolin ___. Had chest rash concerning for reaction
to cefazolin, however improving, likely . Sepsis appears to be
improving, knee is much more benign, with last fever on ___.
- Cefazolin x 4 weeks at minimum, will be followed by Infectious
Disease Team at ___.
-Will need weekly labs sent to BI ID as per below
- PICC placed on ___ and confirmed with x ray
-Staples to be removed week of ___
-followup with Orthopedics week of ___
#Pain control: Patient has intermittent pain ___ the right knee
that is improving, responding well to standing tylenol and PRN
oxycodone. Family is concerned oxycodone is worsening delirium,
so have been using sparingly
-Continue tylenol, oxycodone for breakthrough pain
-No toradol given acute interstitial nephritis
# Anemia: Patient found to have hematocrit of 32 on admission
from baseline of 37, downtrending initially. Now stable at 26.3
for many days.Unclear source but no source of active bleeding
# Acute tubular necrosis: Cr on admission 1.2 and increased to
4.6 ___ setting of sepsis, possible drug reation and urinary
retention. Is downtrending at the time of dischrage with post
ATN diuresis and Cr of 1.8
-Avoid nephrotoxic agents
-No toradol
-trend Chem 7 on ___
#Hypernatremia- secondary to post ATN diuresis and wasting of
free water. Calculated free water deficit to 2L and replaced
with encourageing po intake and 12NS x 2L.
-repeat Chem 7 on ___
#Rash: patient had 2 rashes during this hospitalization. ___ was
on the recumbent surfaces and asymptomatic. This resolved and
likely secondary to heat rash. ___ rash appeared on the chest
and was puritic, likely drug reaction and question of nafcillin
(which she had had one dose of) and resolved making nafcillin
more likely than cefazolin given that cefazolin was continued.
-monitor and use sarna for symptoms and disucss with ID if
concerning rash appears
# HTN: Hypertensive at baseline on amlodipine, metoprolol XL,
losartan. ___ the setting of sepsis, had been hypotensive to
systolic of ___. All anti-hypertensives were temporarily
discontinued. Pressures are trending back up.
- Metoprolol restarted on home dose of 50mg
-repeat Blood pressure if she is more hypertensive can add
losartan 25 mg titrating to SBP <125
- All other antihypertensives have been discontinued
# DM2: has been mostly euglycemic here
-Continue home glargine, metformin
#Delirium: Mild cognitive impairments at baseline, occassionally
delirious but redirectable. Has not required medications here.
Will likely improve after discharge.
-Redirection, quiet at night, frequent family visits
# CAD: Stable, asymptomatic during this admission
- continue aspirin
- continue plavix
- on pravastatin while inhouse and to continue her fluvastatin
on discharge
#Goals of care: Patient had previously expressed a desire to be
DNR/DNI. This was reversed here ___ the hospital by her family as
her course was worsening.
-Should be readdressed as an outpatient now that she is
stabilizing
Transitional Issues:
CBC with differential (weekly) ( X )
BUN/Cr (weekly) ( X )
AST/ALT (weekly) ( X )
ESR/CRP (weekly) ( X )
Drug Level Monitoring: None
Please fax above labs to the ___ R.N.s at
___.
Other transitional issues:
[]Staples need to be removed week of ___
[]f/u with Orthopedics as per above
[]Voiding trial to be performed at rehab
[]Monitor blood pressure and start losartan at low dose and
uptitrate to goal blood pressure <130
[]Repeat electrolytes on ___ and give ___ x 1L for Na of
145-148
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluvastatin Sodium 40 mg oral daily
4. Furosemide 20 mg PO ___ AND ___
5. Glargine 24 Units Bedtime
6. Losartan Potassium 100 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral daily
15. Acetaminophen 500 mg PO BID:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Acetaminophen 500 mg PO BID:PRN pain
4. Ferrous Sulfate 325 mg PO DAILY
5. Glargine 24 Units Bedtime
6. Multivitamins 1 TAB PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. CefazoLIN 1 g IV Q12H
9. Docusate Sodium 100 mg PO BID
Hold if patient refuses or loose stools
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Hold for sleep or sedation
11. Sarna Lotion 1 Appl TP TID:PRN Rash
12. Senna 17.2 mg PO HS
13. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral daily
14. Fish Oil (Omega 3) 1000 mg PO BID
15. Fluvastatin Sodium 40 mg oral daily
16. Furosemide 20 mg PO ___ AND ___
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Omeprazole 40 mg PO BID
19. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic knee
Right groin hematoma
ATN
Discharge Condition:
Alert and oriented to person and place,
Discharge Instructions:
Dear Ms. ___, it was a pleasure taking care of you ___ the
hospital. You were admitted to the hospital because of leg pain.
We did a tap of your knee and found that it was infected. We
also did an ultrasound of your leg and saw that you had a
hematoma. We started you on antibiotics and stopped your blood
pressure medications while your body fought the infection. You
had a bad reaction to one of your medications, probably toradol,
and got a kidney injury. Your infection has been improving over
the last couple of days and your knee is looking better. Your
kidneys are also starting to improve
Followup Instructions:
___
|
10711229-DS-21
| 10,711,229 | 20,496,508 |
DS
| 21 |
2208-09-22 00:00:00
|
2208-09-23 11:04:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex
Attending: ___.
Chief Complaint:
Fever, altered mental status, malodorous urine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH cad s/p cabg, dm2, Alzheimer's disease, prior UTI's p/w
AMS and fever.
Per her son, in the last 3 days the patient had developed a
cough
and was becoming less talkative. She was found this morning in
bed to be more confused with weakness, fever, and malodourous
urine. Her family was concerned and called EMS for transport to
___.
At ___ ED she was found to have fever to 102.8F and developed
hypotension with SBP in the high 90's, below her normal
baseline.
Flu PCR was positive. UA concerning for UTI in context of
patient history and condition. She was started on oseltamivir,
initiated on ceftriaxone for her UTI, and bolused 500 ml of NS
while in the ED with improvement in her pressures.
Son denies trauma or focal neurologic signs.
Past Medical History:
- DM2
- HTN
- CAD
- s/p CABG ___ LIMA-->LAD, SVG--> D1, SVG--> PDA
- hypercholesterolemia
- s/p laminectomy ___
- spondylosis
- Lumbar Spinal Stenosis S/P L1-L3 Laminectomy and Fusion of
L2-L3 in ___
- s/p bilateral carpal tunnel release ___
- cataracts
- GERD
- dysphagia: esophageal manometry (___) shows evidence of
ineffective esophageal peristalsis in just under 50% of wet
swallows with a borderline low ___ pressure
- 6mm lung nodule in RML two year stability in ___
- adenomatous polyps on colonoscopy ___. 2 Polypectomys in
ascending colon on ___
- ___ gastritis and doudenitis on EGD (NSIAD induced?)
- esophogeal ring ___ egd
Social History:
___
Family History:
mother: DM1, deceased from MI age ___
father: lung cancer, deceased
Brother renal cancer
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 99.5F, 78 ,133/65, 18, 95% on RA
GENERAL: AOx1 to self, NAD
HEENT: PERRLA, non-erythematous oropharynx.
NECK: No cervical lymphadenopathy.
CARDIAC: ___ SEM across precordium, RRR.
LUNGS: CTAB with no w/c/r.
ABDOMEN: Soft, non-tender, non-distended. No suprapubic
tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: Moving all four extremities spontaneously against
gravity
DISCHARGE EXAM:
===============
VITALS: ___ 0804 Temp: 98.6 PO BP: 167/79 HR: 65 RR: 18 O2
sat: 93% O2 delivery: Ra FSBG: 183
GENERAL: Pleasant, well-appearing elderly woman, laying in bed
comfortably in NAD, speaks in short sentences with long pauses
HEENT: NC/AT, EOMI, anicteric sclera, dry MM
CARDIAC: RRR, normal S1/S2, harsh IV/VI systolic ejection murmur
appreciated across precordium, loudest at LUSB
LUNGS: CTAB, breathing comfortably on RA without use of
accessory
muscles
ABDOMEN: Soft, non-tender to palpation, non-distended, no
suprapubic tenderness
BACK: No CVA tenderness
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: Warm and well-perfused
NEUROLOGIC: A&Ox0 today (but per nursing was oriented to person
a
few minutes prior to my interview), moving all four extremities
spontaneously, no facial asymmetry
Pertinent Results:
ADMISSION LABS:
===============
___ 11:00AM ___ PTT-26.1 ___
___ 11:00AM PLT COUNT-159
___ 11:00AM NEUTS-79.4* LYMPHS-11.5* MONOS-8.1 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-5.46 AbsLymp-0.79* AbsMono-0.56
AbsEos-0.03* AbsBaso-0.02
___ 11:00AM WBC-6.9 RBC-4.11 HGB-11.9 HCT-36.5 MCV-89
MCH-29.0 MCHC-32.6 RDW-13.3 RDWSD-43.7
___ 11:00AM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-1.6
___ 11:00AM CK-MB-<1
___ 11:00AM cTropnT-0.02*
___ 11:00AM estGFR-Using this
___ 11:00AM GLUCOSE-148* UREA N-27* CREAT-1.4* SODIUM-139
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
___ 11:19AM LACTATE-1.6
___ 11:21AM URINE MUCOUS-RARE*
___ 11:21AM URINE RBC-1 WBC-15* BACTERIA-MANY* YEAST-NONE
EPI-1 TRANS EPI-<1
___ 11:21AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 11:21AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:21AM URINE UHOLD-HOLD
___ 11:21AM URINE HOURS-RANDOM
___ 01:41PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
___ 09:25PM WBC-7.4 RBC-3.65* HGB-10.6* HCT-33.1* MCV-91
MCH-29.0 MCHC-32.0 RDW-13.3 RDWSD-43.9
___ 09:25PM WBC-7.4 RBC-3.65* HGB-10.6* HCT-33.1* MCV-91
MCH-29.0 MCHC-32.0 RDW-13.3 RDWSD-43.9
___ 09:25PM CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-1.6
___ 09:25PM CK-MB-4 cTropnT-0.01
___ 09:25PM GLUCOSE-168* UREA N-26* CREAT-1.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-18
MICROBIOLOGY:
=============
___ BLOOD CX: Pending
___ 11:21 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
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--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/DIAGNOSTICS:
====================
___ CXR:
No evidence of pneumonia or cardiac decompensation.
DISCHARGE LABS:
===============
___ 07:40AM BLOOD WBC-6.4 RBC-3.65* Hgb-10.6* Hct-32.6*
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.4 RDWSD-43.9 Plt ___
___ 07:40AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-141
K-4.2 Cl-102 HCO3-21* AnGap-18
Brief Hospital Course:
Ms. ___ is an ___ with PMH of CAD s/p CABG and DES,
Alzheimer's dementia, and multiple UTI's this year presenting
with cough, AMS, and foul smelling urine, found to have
influenza and sepsis secondary to UTI.
ACUTE ISSUES:
=============
# Complicated urinary tract infection
# Altered mental status / acute toxic metabolic encephalopathy
# Sepsis
# Hypotension
Patient presented with altered mental status, fever, malodorous
urine and hypotension responsive to fluids. Her initial
urinalysis was concerning for a urinary tract infection. She had
a prior urine culture from ___ growing pan-sensitive
E.coli and was initially started on ceftriaxone with improvement
in her blood pressure and mental status. She has no signs or
symptoms suggestive of pyelonephritis. On ___, patient was
converted from IV ceftriaxone to PO augmentin for a 7-day course
of treatment given complicated UTI. Her urine cultures
ultimately grew pan-sensitive E.coli and she was continued on PO
augmentin, course through ___. Augmentin was chosen due to its
sensitivity. Bactrim was not initiated due to ___ and
nitrofurantoin was not started due to her age and ciprofloxacin
was not used due to its intermediate sensitivity.
# ___
Patient presented with creatinine of 1.4 from baseline of
1.0-1.1. Etiology likely hypovolemia in the setting of urinary
tract infection with sepsis and poor PO intake. Her creatinine
improved with fluids and was 1.1 prior to discharge. Patient's
home losartan was initially held in the setting of her ___ and
was ___ on ___.
# Influenza A
Patient presented after one day history of cough, fever, and
altered mental status. She tested positive for influenza in the
ED and was initially started on Oseltamavir. This was
discontinued on ___ in the setting of poor side effect profile
in the elderly and given that symptoms were past 48 hour window
and symptoms improved. Patient was treated supportively with
Tylenol as needed and tessalon perles, but had minimal
respiratory symptoms during her hospital course.
# Troponemia
# Elevated lactate
Patient presented with mild troponin elevation to 0.02, likely
secondary to decreased renal clearance in setting of acute
kidney injury. Not thought to be secondary to demand from sepsis
given only minimal elevation. No evidence of ischemia on ECG and
patient was without chest pain to suggest ischemia. Repeat
troponins negative.
CHRONIC ISSUES:
===============
# Alzheimer's dementia
Does not take any pharmacotherapy at home. Baseline mental
status is alert and oriented to person only.
# HTN
Patient takes amlodipine, losartan, and metoprolol at home which
were initially held in the setting of initial presentation with
hypotension. After resolution of hypotension, patient's home
metoprolol was ___. Given her normal blood pressures, her
home losartan was ___. Her home amlodipine was held on
discharge.
# CAD
Continued home Plavix, fluvastatin, and aspirin. Initially held
home metoprolol in the setting of her hypotension/sepsis, but
was ___ on ___ after medically stable. Initially held
home losartan in the setting of hypotension and ___ and
___ on ___ after resolution of symptoms.
# Type II DM
Held home metformin given ___ and treated with reduced dose of
home glargine and SSI. Metformin was ___ on day of
discharge given resolution of kidney injury.
# Lower extremity edema
Patient reportedly takes Lasix 20mg daily for chronic lower
extremity edema. No history of CHF so home Lasix was held.
# Depression
Continued home sertraline 125 mg daily
TRANSITIONAL ISSUES:
====================
[] New medications: Augmentin 875mg PO BID through ___
[] Held medications: Lasix 20mg daily, amlodipine 2.5mg PO daily
[] Patient's home amlodipine was initially held in the setting
of hypotension from sepsis. Please follow-up blood pressures and
re-start this medication if persistently hypertensive.
[] Unclear why patient is taking Lasix 20mg daily for lower
extremity edema, as she does not have a history of congestive
heart failure. This medication was discontinued during
admission.
[] **Please repeat electrolytes, including BUN/Cr at follow-up
appointment with PCP.**
[] Patient was discharged home with home physical therapy
services
#Code status: Full
#Health care proxy/emergency contact: HCP: ___ (son)
___ and ___ (daughter): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Pantoprazole 20 mg PO Q24H
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Fluvastatin Sodium 40 mg oral DAILY
5. Sertraline 125 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. amLODIPine 2.5 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Losartan Potassium 100 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral DAILY
12. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
13. Glucerna Shake (nut.tx.gluc.intol,lac-free,soy) 1 btl oral
DAILY
14. Metamucil (psyllium husk) 0.52 gram oral DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Cyanocobalamin 1500 mcg PO DAILY
17. melatonin 5 mg oral QHS
18. Fish Oil (Omega 3) 1000 mg PO DAILY
19. Cranberry Plus Vitamin C (cranberry conc-ascorbic acid)
140-100 mg oral DAILY
20. Glargine 30 Units Bedtime
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
2. Glargine 30 Units Bedtime
3. Aspirin 81 mg PO DAILY
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral DAILY
5. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
6. Clopidogrel 75 mg PO DAILY
7. Cranberry Plus Vitamin C (cranberry conc-ascorbic acid)
140-100 mg oral DAILY
8. Cyanocobalamin 1500 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Fluvastatin Sodium 40 mg oral DAILY
12. Glucerna Shake (nut.tx.gluc.intol,lac-free,soy) 1 btl oral
DAILY
13. Losartan Potassium 100 mg PO DAILY
14. melatonin 5 mg oral QHS
15. Metamucil (psyllium husk) 0.52 gram oral DAILY
16. MetFORMIN (Glucophage) 500 mg PO BID
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Pantoprazole 20 mg PO Q24H
19. Sertraline 125 mg PO DAILY
20. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until following up with your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- Sepsis
- Complicated urinary tract infection
- Acute kidney injury
- Influenza
Secondary diagnosis:
- Alzheimer's dementia
- Type II diabetes mellitus
- Coronary artery disease
- Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
fevers and were confused.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You were found to have an infection in your urine and were
treated with antibiotics.
- You were given fluids through your vein.
- You were found to have the flu and were treated supportively
with Tylenol and cough medicine.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should continue taking your medications, as prescribed.
You were started on augmentin, which is an antibiotic to treat
your urinary tract infection. You should continue taking this
medication through ___.
- You should follow up with your primary care doctor.
It was a pleasure taking care of you, and we wish you well!
Sincerely,
Your ___ Team
MEDICATION CHANGES:
[] New medications: Augmentin 875mg PO twice per day through
___
[] Held medications: Lasix 20mg daily, amlodipine 2.5mg PO daily
Followup Instructions:
___
|
10711408-DS-4
| 10,711,408 | 26,848,821 |
DS
| 4 |
2116-08-29 00:00:00
|
2116-08-30 21:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, headache
Major Surgical or Invasive Procedure:
J-Tube Placement ___
Chest Tube ___
EGD and bronch s/p tracheal stent placement ___
L subclavian line ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with locoregional esophageal SCC s/p chemoradiation with
plans for possible esophagectomy, DVT, atrial fibrillation who
is
admitted for management of chest pain, headache and concern for
infection.
The patient was hospitalized at ___ from /___. His
hospital course was notable for newly diagnosed atrial
fibrillation (not discharged on rate control, but dosing of
lovenox changed to 70 q12), severe protein-calorie malnutrition
(started on TPN via L arm PICC), severe chest pain associated
with malignancy and back pain associated with muscle spasm and
history of kidney stones (fentanyl patch increased to 100
mcg/hr,
discharged also on 15 mg oxycodone q4 with 4 mg dilaudid PO as
breakthrough), constipation (required enemas and laxatives), and
low TSH (.19) with normal fT4.
Since discharge he has been at ___, where he feels
that his pain control has not been adequate. He feels
dehydrated.
His chronic chest pain, attributed to disease, has changed only
in that he does not feel like he is getting his pain medications
as frequently as needed. No pleuritic chest pain or dyspnea. He
has been constipated, no BM in three days. His back spasms are
symptomatically worse as well, such that he is having difficulty
walking. Because of these issues, he was referred to the ___
ED.
On arrival to the ED, initial vitals were 98.4 105 106/67 18 97%
RA
- exam notable for tachycardia, wheezes and rales on R lung
- labs: INR 1.2, WBC 17 with 82%N, Hgb 11.8, PLT 503, Na 133, K
4.1, lactate 2.3, AST and ALT normal, ALP 135, Tbili 0.7
- CXR: unchanged positioning of esophageal stent, no acute
cardiopulmonary abnormality
- EKG with no ischemic changes
- the patient received 1gm vanco, 2g cefepime, 0.5 mg IV
dilaudid
x 2, 1L NS
- patient was admitted over concern for infection (Tachycardia,
elevated WBC count) as well as for symptomatic management
Prior to transfer vitals were stable.
On arrival to the floor, patient endorses the above story and
denies any other complaints on review of systems. He has not
smoked cigarettes in 2 weeks.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY: h/o heavy smoking and heavy alcohol use
who presented in ___ with DVT in the right lower
extremity and then dysphagia in ___ and was found to
have a 2.9 x 2.3 cm mid esophageal mass which was positive for
squamous cell carcinoma, superficially invasive. Mr. ___
underwent placement of a Merit covered esophageal stent from
25-35 cm. PET/CT showed no distant metastases. On ___ Dr.
___ EGD/EUS and noted a stent in the esophagus
from 34-39 cm; the gastroesophageal junction was at 43 cm and
appeared normal; Dr. ___ not get an ultrasound T-stage
because of the stent; there were two lymph nodes at 20 cm, the
largest measuring 6.3 mm and suspicious; the stomach and
duodenum appeared normal, clinical stage TXN2M0. We recommended
chemotherapy and radiation therapy on the CROSS regimen with
plan for esophagectomy if 0.7 cm indeterminate lingular nodule
is stable.
PAST MEDICAL HISTORY:
-HTN, HLD
-Tobacco Abuse
-EtOH Abuse
Social History:
___
Family History:
Father died at age ___ from gastric cancer. Mother died at age ___
from a CVA.
Physical Exam:
ADMISSION ADMISSION PHYSICAL EXAM:
===============================
VS: tachycardic, afebrile, normal O2 sat and respiration
GENERAL: Pleasant man, in no apparent distress, lying in bed
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: tachycardic but regular, normal s1/s2
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, Strength full
throughout. Sensation to light touch intact.
SKIN: No significant rashes.
ACCESS: L arm PICC c/d/i
DISCHARGE PHYSICAL EXAM:
=======================
VS: ___ 0722 Temp: 98.3 PO BP: 100/56 HR: 75 RR: 18 O2 sat:
95% O2 delivery: RA, Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: appears older than stated age, no apparent distress,
lying on side in bed spitting and coughing up clear mucus
HEENT: sclera anicteric, OP clear, MMM, right lower front teeth
broken, poor dentition, mallampati 3
CARDIAC: irregularly irregular, distant heart sounds, normal
s1/s2, no m/r/g
LUNG: dry cough, Diffuse rhonchi in all fields, no wheezes or
rales
ABD: Soft, mildly distended, mildly ttp over incision sites,
nonerythematous, no guarding or rebound. normal bowel sounds,
J-tube site clean, nonerythematous, or indurated.
EXT: Warm, well perfused, no edema.
NEURO: A&Ox3, gross motor intact, face symmetric
SKIN: No significant rashes.
ACCESS: R arm PICC c/d/I, no tenderness or erythema. LUE PIV
Pertinent Results:
ADMISSION LABS:
===============
___ 04:06PM BLOOD WBC-17.0* RBC-3.63* Hgb-11.8* Hct-35.1*
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.6 RDWSD-51.4* Plt ___
___ 04:06PM BLOOD Neuts-82.4* Lymphs-6.0* Monos-9.0
Eos-0.9* Baso-0.4 Im ___ AbsNeut-13.97* AbsLymp-1.02*
AbsMono-1.52* AbsEos-0.16 AbsBaso-0.07
___ 04:06PM BLOOD ___ PTT-34.5 ___
___ 04:06PM BLOOD Glucose-96 UreaN-34* Creat-0.9 Na-133*
K-5.5* Cl-97 HCO3-22 AnGap-14
___ 04:06PM BLOOD ALT-17 AST-29 AlkPhos-135* TotBili-0.7
___ 04:06PM BLOOD Albumin-3.2*
___ 05:27PM BLOOD K-4.1
___ 05:39PM BLOOD Lactate-2.3*
STUDIES:
=======
___ CXR
IMPRESSION:
Left-sided central line and the esophageal stent remain
unchanged. There is subsegmental atelectasis in the left lung
base. There are new small
bilateral pleural effusions. Lungs are low volume with
worsening interstitial prominence. Cardiomediastinal silhouette
is unremarkable. No pneumothorax is seen.
___ TTE
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
63 %. Left ventricular cardiac index is normal (>2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with low normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (?#) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is moderate [2+] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a very
small circumferential pericardial effusion.
There are no 2D or Doppler echocardiographic evidence of
tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
the rhythm is sinus and the heart rate is slower; the
echocardiographic findings are similar. Moderate tricuspid
regurgitaiton was present on the priorecho (not noted) and the
PASP was likely underestimated.
___ Abdomen XR
IMPRESSION:
Within limits of a supine radiograph, grossly, there is no
intra-abdominal free air.
___ ESOPHAGUS
IMPRESSION:
No evidence of leak. No contrast is seen in the airway. The
stent lumen is
narrowed, which could be related to debris as seen on CT ___.
___ Pulmonary/General Pulmonary Bronchoscopy
TEF with esophageal stent protruding through into trachea, a
___ 16x40 covered stent was deployed
___ CHEST (PORTABLE AP)
IMPRESSION:
The proximal portion of esophageal stent projects adjacent to
the posterior
fourth rib, unchanged since prior.
___ EGD
metal stent noted in ___ below UES extending to ___
Bx were taken of above and below stent
___ Tissue: GASTROINTESTINAL MUCOSAL BIOPSY
1. Proximal stent, biopsy:
-Squamous epithelium with mild active esophagitis with
predominant neutrophils. Additional levels
were examined.
2. Distal stent, biopsy:
-Squamous mucosa with ulceration and granulation tissue, and
stromal atypia consistent with
radiation effect. Additional levels were examined.
- GMS and PAS stains show fungal forms consistent with ___
within the fibropurulent exudate.
- Cytokeratin cocktail highlights scattered benign-appearing
squamous epithelial cells in the ulcer.
Factor VIII highlights endothelial cells.
- Immunostain for CMV is negative. No viral cytopathic changes
are seen.
___ VIDEO OROPHARYNGEAL SWA
IMPRESSION:
Aspiration with thin liquids. Contrast was noted refluxing up
the trachea
with thin liquids. This may be related to additional aspiration
events beyond
what was observed on this study and refux while coughing.The
metal esophageal
stent is patent, imaged on a single frontal view. Consider
endoscopic
evaluation as clinically indicated.
___ PORTABLE CXR
IMPRESSION:
1. Stable cardiomediastinal silhouette with no pulmonary
vascular congestion
or pulmonary edema.
___ G/GJ/GI TUBE CHECK
IMPRESSION:
Jejunostomy tube in situe without evidence of leak, dislodgement
or fracture.
Free passage of oral contrast into the jejunum. No bowel
obstruction.
___ CTA CHEST AND CT ABDOME
IMPRESSION:
1. No pulmonary embolism or acute aortic syndrome.
2. Bilateral moderate-sized pleural effusions and bibasilar
relaxation
atelectasis. Mild decrease in anteroposterior caliber of the
bilateral main
bronchi may reflect presence of bronchomalacia.
3. An esophageal stent is noted in place with presence of orally
ingested
contrast within it, but otherwise patent. Enlarged distal
esophageal lymph
nodes as before remains suspicious for metastatic involvement.
4. No metastatic disease seen in the abdomen or pelvis. A
percutaneous
jejunostomy tube is in appropriate position.
5. Mild urothelial enhancement within the left renal pelvis and
proximal
ureter may reflect presence of urinary tract infection,
correlation with
urinalysis is recommended.
___ CXR PORTABLE:
IMPRESSION:
Compared to chest radiographs ___ through ___.
No pneumothorax or pleural effusion following removal of the
left pigtail
pleural drainage catheter.
Pulmonary vascular engorgement has worsened, moderate right
pleural effusion
has increased highlighting the right major fissure and mild
pulmonary edema is
new. Heart size mildly enlarged, increased since ___. No
right
pneumothorax.
___ TTE
CONCLUSION:
The left atrial volume index is normal. The interatrial septum
is aneurysmal. There is a possible atrial septal defect. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional left ventricular systolic function. Overall
left ventricular systolic function is normal. Quantitative
biplane left ventricular ejection fraction is 70 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2). Diastolic
function could not be assessed. Normal right ventricular cavity
size with normal free wall motion. The aortic sinus is mildly
dilated with normal ascending aorta diameter for gender. The
aortic arch is mildly dilated. The aortic valve leafletS (3)
appear structurally normal. There is no aortic valve stenosis.
There is trace aortic regurgitation. The mitral valve leaflets
are mildly thickened with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is trivial tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is borderline elevated. There is a very small circumferential
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
IMPRESSION: 1) Very small serous circumferential pericardial
effusion without specific
echocardiographic signs of tamponade. 2) Normal biventricular
regional/global systolic function.
Normal cardiac index.
___ CXR PORTABLE
IMPRESSION:
Evacuation of the large majority of large left pleural effusion
with chest
tube in place at the base of the left pleural space. Poorly
visualized stent
corresponding to the course of the esophagus, which seems to
terminate at the
level of the lower mediastinum, although not well visualized;
correlation with
clinical circumstances is suggested. Findings suggest mild
pulmonary edema.
___ ECG
AFIB W/ RVR
___ PORTABLE CXR
IMPRESSION:
New hazy opacity at the right lung base, may represent
infection, aspiration
or atelectasis.
___ CHEST (PA & LAT)
IMPRESSION:
Unchanged positioning of esophageal stent. No acute
cardiopulmonary
abnormality.
MICRO:
=======
___ c diff PCR and toxin positive
___ BCx no growth
___ UCx No Growth
___ BCx ENTEROBACTER CLOACAE COMPLEX
___ MRSA swab positive
DISCHRAGE LABS:
===============
___ 07:00AM BLOOD WBC: 11.7* RBC: 3.21* Hgb: 9.6* Hct:
31.7* MCV: 99* MCH: 29.9 MCHC: 30.3* RDW: 17.7* RDWSD: 63.7* Plt
Ct: 503*
___ 07:00AM BLOOD Glucose: 96 UreaN: 14 Creat: 0.7 Na: 140
K: 4.7 Cl: 97 HCO3: 33* AnGap: 10
___ 07:00AM BLOOD Calcium: 9.5 Phos: 3.2 Mg: 1.6
Brief Hospital Course:
Mr. ___ is a ___ year old male with locoregional esophageal SCC
s/p chemoradiation, with stent in place, a-fib with history of
DVT (___) on lovenox, chronic cancer associated pain, who
initially admitted with chest pain and nutrition optimization.
Was initiated on j-tube feeds with J-tube placement. Hospital
course was initially complicated by J-tube leaks. Also was found
to have TE fistula on video swallow and with candidal
esophagitis. He was evaluated by IP and CT surgery, underwent
EGD and bronch with tracheal stent placed ___. TEF resolved
after repeat esophagram. Regarding his pain control, he was
initially started on a PCA pump, however subsequently
transitioned to PO dialudid and fentanyl patch. His hospital
course was also complicated by worsening sepsis including
enterobacter bacteremia thought to be from gut translocation
requiring ICU transfer, HAP, and C. diff colitis. He was
initially started on broad spectrum antibiotics however
subsequently narrowed to levofloxacin, fluconazole, and PO
vancomycin at time of discharge. Additionally, patient developed
severe right sided retro-orbital headaches for which he was
evaluated by neurology, with unclear etiology which subsequently
improved with flexeril. At time of discharge arranged for
follow-up with IP for tracheal stent follow-up. cardiothoracic
surgery for ongoing consideration of esophagectomy versus active
surveillance, and with palliative care for complex pain
syndrome.
ACUTE ISSUES:
==================
# Esophageal SCC
# Esophageal stent
# TE Fistula s/p tracheal stent - Patient with esophageal SCC
diagnosed ___, who presented with odynophagia and chest
pain, thought to be secondary to underlying esophageal SCC and
esophagitis from previous chemoradiation. He previous had
esophageal stent placement. During early hospitalization, had
persistent odynophagia and choking sensation, had video swallow
showing TE fistula. TEF likely due to esophageal carcinoma,
radiation, and esophageal stent. Patient underwent EGD and
subsequent bronchoscopy with tracheal stent placement. Patient
had a repeat esophagram which demonstrated resolution of TEF. He
was initiated on J-tube feeds advanced to goal with symptoms
improving on pain regimen per below, on PO dialudid and fentanyl
patch. Per IP, was continued on nebulized mucomyst, albuterol,
and normal saline for 7 days. Follow-up was arranged with IP
with Dr. ___ and with CTS with Dr. ___ ongoing
consideration of future esophagectomy vs. active surveillance
post-discharge.
#Enterobacter blood stream infection - ___ course was
complicated by sepsis requiring ICU transfer found to have
enterobacter bacteremia though to be from gut translocation,
possibly esophageal given above history. He was initially
started on broad spectrum antibiotics including IV Vancomycin,
cefepime, and flagyl. Blood cultures were subsequently clear on
___ and he was narrowed to levofloxacin with plan 14 day
total course of antibiotics, levofloxacin to end on ___.
# Hospital Acquired Pneumonia - ___ course was complicated
by two HAPs, The first occurred during the first weeks of
hospitalization. The patient was found to be febrile with CXR
showing new RLL opacity with sputum culture growing GNRs,
although finalized as respiratory flora. Finalized sputum
cultures without identification of GNR though completed course
of antibiotics. He was initially started on vanc/cefepime/flagyl
and narrowed to CTX/flagyl (___). The second HAP occurred in
the weeks leading up to discharge. Though multiple CXRs were
taken, no pneumonia was seen, though had significant pulmonary
exam findings which included rhonchi throughout the posterior
lung fields and productive cough. These symptoms resolved after
being started on vanc/cefepime/flagyl, and then transitioning to
levofloxacin. In the days leading up to discharge the patient's
pulmonary exam findings resolved and the patient was discharged
with with clear lung fields, and minimal cough that was mildly
productive of clear sputum. As levofloxacin is the same
antibiotic as that use for the septic blood infection, will
continue the course until ___.
#Esophageal Candidiasis - EGD with biopsy showed evidence of
___ with fibropurulent exudate of distal stent. He was
treated with fluconazole 200mg QD plan for 14 day total course
to end on ___.
# C Difficile colitis - Was found to have worsening leukocytosis
with diarrhea, was C. diff positive. Given his ongoing mild
diarrhea within 72 hours prior to discharge, decision was made
to continue PO vancomycin 12mg PO QID for 14 days after last
dose of PO antibiotics. Plan to continue PO vancomycin through
___.
# Severe Protein Calorie Malnutrition
# Failure to thrive
# J-tube placement - Patient had evidence of severe malnutrition
related to odynophagia and poor PO intake. He was initially
started on TPN. Subsequently had J-tube placement given long
term nutrition goals. Finding of ET fistula on ___ necessitated
full nutrition via tube feeds. Prior to discharge was tolerating
J tube Osmolite 105cc/hr cycled 16 hours well. His J tube
intermittently became clogged, was evaluated by ___ with
fluorogram however J tube was found to be functioning well
without kinks.
# Pain control - Patient initially presented with chest pain and
severe odynophagia per above. Likely multifactorial given known
esophageal SCC and prolonged complicated hospital course. Was
initially on PCA pump. Was eventually weaned to dilaudid 4mg PO
Q4H:PRN and fentanyl patch 150 mcg/h TD Q72H. He will require
palliative care follow-up for complex pain management.
# Right sided, retro orbital headaches - Patient began having
severe right sided, retro orbital headaches. It was initially
felt that these could have been due to metastatic disease vs
opioid overuse. Workup included MR head, CT head and sinuses,
ophthalmologic evaluation, neurologic evaluation. Head imaging
was largely unrevealing, without trigeminal neuralgia. Headaches
initially did not improve with acetaminophen, fioricet, ativan,
or cyclobenzaprine. They improved with intermittent flexeril PRN
and patient was discharged with short course of flexeril PRN.
# Acute Hypoxemic Respiratory Failure
# Presumed ___ course was complicated by ___
developed post-op ___. CXR showed L pleural effusion in the
setting of Afib with RVR and mIVF for surgery and TPN. Pleural
effusion was transudative in etiology and underwent chest tube
placement ___. Was also intermittently diuresed to good
therapeutic effect and subsequently weaned to RA. Also started
Tiotropium Bromide 1 CAP IH DAILY for presumed COPD.
# Atrial fibrillation
# Atrial Flutter - A-fib diagnosed ___ in setting of
dehydration on lovenox BID and rate control with metoprolol 50
BID and digoxin 0.125mg QD. In the presence of dehydration at
___ in ___. Patient remains high risk for thrombosis
given active malignancy and limited mobility with history of
DVT. Early in hospitalization patient experienced several
episodes of afib w/ RVR to 160s. Metoprolol Tartrate 50 mg PO/NG
BID was initiated and due to persistent soft BPs was dose
limited leading to initiation of digoxin in consultation with
cardiology. Subsequent EKGs showing A flutter and given
persistent orthostatic hypotension, metoprolol was decreased to
25mg PO BID.
# Orthostatic Hypotension - Pt was admitted with a baseline
hypotension, with SBP's ___ throughout hospitalization
though MAP >60. At times of poor PO intake, patient developed
dizziness, though remained responsive to fluids, and was largely
asymptomatic. Per above, was started on Metoprolol Tartrate 50
mg PO/NG for afib rate control which was later down-titrated to
Metoprolol Tartrate 25 mg PO/NG BID. Was asymptomatic on
ambulation prior to discharge.
# Leukocytosis
# Thrombocytosis - Was thought to be multifactorial in setting
of underlying malignancy and infectious etiologies including HAP
and esophagitis per above.
# Macrocytic Anemia - Baseline Hb ___ remained stable during
hospitalization, likely mixed in setting of underlying
malignancy with anemia of chronic disease, on going phlebotomy,
and iron deficiency.
# History of DVT/Venous thrombosis (___) - History of lower
extremity DVT was continued on therapeutic Enoxaparin Sodium 70
mg SC Q12H.
TRANSITIONAL ISSUES:
====================
NEW/CHANGED MEDS
[ ] Started Levofloxacin 750 mg PO DAILY x ___ntibiotics for enterobacter bacteremia and HAP (ends
___
[ ] Started fluconazole 200mg PO QD x 14 days (ends ___
[ ] Started Vancomycin Oral Liquid ___ mg PO QID (ends
___
[ ] Started metoprolol tartrate 25mg PO BID for AF
[ ] Started digoxin 0.125mg PO QD for AF
[ ] Started tiotropium bromide 1 IH QD for COPD
[ ] Increased fentanyl patch from 100 to 150mcg/h TD Q72H
[ ] Discontinued oxycodone 15mg PO Q4H and replaced with
dilaudid 4mg PO Q4H:PRN discharged with 30 tablets
[ ] Increased cyclobenzaprine from 5mg to 10 mg PO TID:PRN
headache discharged 20 tablets
[ ] Ongoing assessment with primary oncologist Dr. ___ CTS
Dr. ___ for esophagectomy vs. ongoing surveillance
as indicated
[ ] Follow-up arranged with IP for tracheal stent care
[ ] Dr. ___ to coordinate palliative care follow-up for complex
pain syndrome
[ ] Titrate optimal pain regimen as indicated given esophageal
carcinoma and complex pain syndrome managed by Dr. ___
___ care
[ ] Consider repeat CBC check at oncology follow-up to ensure
continues to down-trend
[ ] Discharged on Osmolite 105cc/hr cycled 16 hours via J-tube
feeds nutrition contacted to set up follow-up appointment
[ ] Of note, the MRI report comments on a 2 mm outpouching at
the origin of the left posterior communicating artery favored to
represent an infundibulum. Can consider repeat MRA or CTA in ___
year to ensure stability.
[ ] If recurrent headache, consider Headache Clinic referral
#CODE: Full Code, confirmed
#EMERGENCY CONTACT HCP: ___ Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN BREAKTHROUGH PAIN
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nicotine Patch 14 mg TD DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain from heart
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Tamsulosin 0.4 mg PO QHS
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY
13. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
14. Fentanyl Patch 100 mcg/h TD Q72H
15. OxyCODONE (Immediate Release) 15 mg PO Q4H
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily:PRN Disp #*30
Tablet Refills:*0
2. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Doxazosin 1 mg PO HS
RX *doxazosin [Cardura] 1 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
4. Fluconazole 200 mg PO Q24H Duration: 14 Days
RX *fluconazole 200 mg 1 tablet(s) by mouth Daily Disp #*5
Tablet Refills:*0
5. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet(s) by
mouth BID:PRN Disp #*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 Daily
Disp #*1 Capsule Refills:*0
9. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*80 Capsule Refills:*0
10. Cyclobenzaprine 10 mg PO TID:PRN headache
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID:PRN Disp #*20
Tablet Refills:*0
11. Fentanyl Patch 150 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour 1 Patches Q72H Disp #*10 Patch
Refills:*0
RX *fentanyl 50 mcg/hour Apply transdermal for 72 hours Disp
#*10 Patch Refills:*0
12. Aspirin 81 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
15. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth Q4H:PRN
Disp #*30 Tablet Refills:*0
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Nicotine Patch 14 mg TD DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain from heart
20. Ondansetron 8 mg PO Q8H:PRN nausea
21. Polyethylene Glycol 17 g PO DAILY
22. HELD- Prochlorperazine 10 mg PO Q6H:PRN nausea This
medication was held. Do not restart Prochlorperazine until you
see your primary physician
23. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until you see your primary physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Esophageal SCC with TE fistula
Secondary Diagnosis:
- Enterococcal bacteremia
- Esophageal ___ acquired pneumonia
- C. Diff Colitis
- Severe Malnutrition
- Atrial Flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the Hospital because you were having
chest pain related to your esophageal cancer
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your chest pain was thought to be related to your esophageal
cancer and was treated with pain medications
- You were found to have a fistula or connection between your
esophagus (eating tube) and trachea (breathing tube) which
subsequently closed
- You had an upper endoscopy procedure and also a bronchoscopy
and a stent was placed in your trachea
- You had a J feeding tube placed for nutriition
- You were treated for several different infections requiring
ICU transfers including a blood stream infection, pneumonias,
fungal infection in your esophagus, and also for diarrhea
- You were diagnosed with atrial flutter and evaluated by the
cardiologists and started on 2 separate new medications in order
to better control your heart rates
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medications as prescribed and keep
your appointments as listed below
- Your primary oncologist Dr. ___ will reach out to your
about scheduling your next follow-up appointment with her
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10711408-DS-5
| 10,711,408 | 20,252,281 |
DS
| 5 |
2116-10-05 00:00:00
|
2116-10-05 10:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea/Vomiting
Major Surgical or Invasive Procedure:
___
Three-hole ___ near total esophagectomy with gastric
conduit, repair of tracheoesophageal fistula via partial
tracheal resection in the right chest, intercostal muscle flap
buttress to the tracheal repair.
___
Bronchoscopy
___
Fiberoptic laryngoscopy
___
J tube replaced
History of Present Illness:
Mr. ___ is a ___ male with history of
locoregional esophageal ___ s/p neoadjuvant chemo-XRT with plans
for possible esophagectomy, DVT on lovenox, atrial fibrillation,
and recent prolonged hospitalization complicated by malnutrition
s/p J-tube, TE fistula s/p tracheal stent, enterobacter
bacteremia, hospital-acquired pneumonia, and C. diff colitis on
PO vancomycin who presents with abdominal pain and
nausea/vomiting.
Patient with recent prolonged 2 month hospitalization from
___ to ___. He had a J-tubed placed and was started on
tube feeds with J-tube placement. Hospital course was initially
complicated by J-tube leaks. Also was found to have TE fistula
on
video swallow and with candidal esophagitis. He was evaluated by
IP and CT surgery, underwent EGD and bronch with tracheal stent
placement on ___. TEF resolved after repeat esophagram.
Regarding his pain control, he was initially started on a PCA
pump, however subsequently transitioned to PO dialudid and
fentanyl patch. His hospital course was also complicated by
worsening sepsis including enterobacter bacteremia thought to be
from gut translocation requiring ICU transfer, HAP, and C. diff
colitis. He was initially started on broad spectrum antibiotics
however subsequently narrowed to levofloxacin, fluconazole, and
PO vancomycin at time of discharge. Additionally, patient
developed severe right sided retro-orbital headaches for which
he
was evaluated by neurology, with unclear etiology which
subsequently improved with flexeril. He was ultimately
discharged
home with services.
Since discharge patient was seen by thoracic surgery for
discussing regarding possible surgery but was told there would
be
high risk of morbidity and mortality. He has felt very weak and
fatigued and has been sleeping most of the day. He was seen at
the ___ on ___ for his clogged J-tube which
successfully unclogged. He then developed sudden onset severe
diffuse abdominal pain last night. There was no known trigger.
Pain was constant and associated with nausea and multiple
episodes of non-bloody emesis. He also reports coughing up lots
of sputum. He has not been able to tolerate any of his oral
medications.
He initially presented to ___. Labs were notable
for
WBC 18.4, H/H 12.5//31.7, Plt 584, trop I < 0.04, BNP 164,
lipase
106, digoxin 0.6, LFTs wnl, calcium 10.5, Na 142, K 3.9, BUN/Cr
33/1.1. He was in afib with RVR in the 130s and was given
metoprolol 5mg IV. He was also given dilaudid 0.5mg IV x 2,
dilaudid 2mg IV, Zofran 4mg IV, and 1L NS. CXR was negative for
acute process. He was transferred to ___ for further
evaluation.
On arrival to the ___, initial vitals were 97.9 114 124/83 14 94%
RA. Exam was notable for abdominal pain out of proportion to the
exam and G-tube in site without warmth, erythema, or drainage.
Labs were notable for WBC 22.2, H/H 12.4/38.4, Plt 556, Na 137,
K
4.9, BUN/Cr ___, LFTs/lipase wnl, digoxin 0.6, lactate 2.4,
VBG 7.49/32/201, and UA negative. Blood and urine cultures were
done. CTA abdomen did not reveal mesenteric ischemia or other
acute process. Patient was given Zosyn 4.5g IV, morphine 4mg IV,
dilaudid 1mg IV x 2, Zofran 4mg IV x 2, and 1L NS. Discussed
with
___ resident prior to transfer who was unsure of etiology of
abdominal pain but reported that patient now appeared more
comfortable with improved abdominal pain. Prior to transfer
vitals were 98.0 98 120/65 16 96% RA.
On arrival to the floor, patient reports ___ abdominal pain
which is improved from this morning. He last episode was early
this morning while in an ambulance. He feels dizzy with
transfers. He feels very weak. He has continued diarrhea. He
denies fevers/chills, night sweats, headache, vision changes,
shortness of breath, hemoptysis, chest pain, palpitations,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Presented in ___ with DVT in the right lower extremity
and then dysphagia in ___ and was found to have a 2.9
x
2.3 cm mid esophageal mass which was positive for squamous cell
carcinoma, superficially invasive. Mr. ___ underwent placement
of a Merit covered esophageal stent from 25-35 cm. PET/CT showed
no distant metastases. On ___ Dr. ___ EGD/EUS
and noted a stent in the esophagus from 34-39 cm; the
gastroesophageal junction was at 43 cm and appeared normal; Dr.
___ not get an ultrasound T-stage because of the
stent;
there were two lymph nodes at 20 cm, the largest measuring 6.3
mm
and suspicious; the stomach and duodenum appeared normal,
clinical stage TXN2M0. We recommended chemotherapy and radiation
therapy on the CROSS regimen with plan for esophagectomy if 0.7
cm indeterminate lingular nodule is stable.
PAST MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- Tobacco Abuse
- EtOH Abuse
Social History:
___
Family History:
Father died at age ___ from gastric cancer. Mother
died at age ___ from a CVA.
Physical Exam:
VS: Temp 99.4, BP 123/75, HR 95, RR 18, O2 sat 96% RA.
GENERAL: Pleasant fatigued-appearing man, lying in bed in mild
distress.
HEENT: Anicteric, PERLL, poor dentition, white streaks on
tongue.
CARDIAC: Irregularly irregular, distant heart sounds, normal
s1/s2, no m/r/g.
LUNG: Rhonchi on right side.
ABD: Soft, right-sided tenderness to palpation, non-distended,
normal bowel sounds, J-tube site clean.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:55AM BLOOD WBC-22.2* RBC-4.17* Hgb-12.4* Hct-38.4*
MCV-92 MCH-29.7 MCHC-32.3 RDW-17.7* RDWSD-58.4* Plt ___
___ 10:55AM BLOOD Neuts-91.2* Lymphs-2.4* Monos-5.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-20.24* AbsLymp-0.53*
AbsMono-1.23* AbsEos-0.00* AbsBaso-0.07
___ 06:25AM BLOOD ___ PTT-27.3 ___
___ 10:55AM BLOOD Glucose-132* UreaN-30* Creat-0.8 Na-137
K-7.8* Cl-99 HCO3-24 AnGap-14
___ 10:55AM BLOOD ALT-32 AST-116* AlkPhos-103 TotBili-0.4
___ 06:25AM BLOOD Calcium-9.6 Phos-3.2 Mg-1.6
___ 11:04AM BLOOD Lactate-2.4* K-9.8*
___ 02:41PM BLOOD K-4.9
Chemistry
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:50 106*1 30* 0.9 1382 ___ 102
___ 16:55 891 32* 1.0 1382 ___ 132
___ 13:11 861 31* 0.9 1362 ___ 9*2
___ 06:35 110*1 30* 1.0 1402 ___ 122
___ 00:44 5.13
___ 14:28 5.13
___ 05:14 109*1 22* 0.9 1372 ___ 8*2
___ 21:15 941 23* 0.8 1362 ___ 142
___ 05:58 114*1 24* 0.8 1402 ___ 132
___ 05:40 129*1 22* 0.9 1392 ___ 102
___ 04:36 871 18 0.8 1412 ___ 132
___ 05:56 ___ 1392 5.5*3 100 28 112
___ 05:05 ___ 1392 ___ 132
___ 17:10 ___ ___ 122
___ 05:03 ___ 1382 ___ 9*2
___ 06:18 ___ 1412 5.43 102 31 8*2
___ 05:33 991 16 0.7 1382 ___ 122
___ 05:39 138*1 25* 0.7 1422 5.03 ___
___ 04:58 851 15 0.6 1422 5.03 ___
IMAGING:
========
___ Carotid ultrasound :
Greater than 70% stenosis of the right internal carotid artery.
50-69% stenosis of the left internal carotid artery.
___ Head CT :
No evidence of acute intracranial process. No mass effect. MR
with
gadolinium would be the best way to assess for metastatic
disease. If MR
cannot be performed, and further evaluation is needed, then
contrast enhanced CT could be alternatively considered.
___ Video swallow :
1. Aspiration with thin liquids.
2. Laryngeal penetration with nectar thickened liquids with no
gross
aspiration.
3. No evidence of esophageal leak.
___ CXR :
Right-sided chest tube is unchanged. Patient is status post
esophagectomy and gastric pull-up. Left lung is clear.
Cardiomediastinal silhouette is stable. No pneumothorax is seen.
Small right pleural effusion stable.
___ CXR :
There are stable postsurgical changes following esophagectomy
and gastric
pull-up. Small right pleural effusion and small right
pneumothorax with a
basilar component is unchanged. Subcutaneous emphysema seen in
the right
lateral chest wall. There is subsegmental atelectasis in the
left lung base
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ Imaging BILAT UP EXT VEINS US
No evidence of deep vein thrombosis in the bilateral upper
extremity veins.
___HEST W/CONTRAST
1. No pulmonary embolism or acute aortic injury. There is trace
amount of pericardial effusion.
2. Esophageal mass status post stenting in the mid esophagus. A
3.2 x 2.1 x 1.4 cm polypoid soft tissue mass arising from the
posterior wall of the esophagus seems project into the superior
segment of the stent nearly completely occluding the lumen.
These
could represent superior extension of the esophageal mass or
mass
in conjunction with debris. Trachea is patent however appears
involved.
3. Interval improvement of bilateral pleural effusions.
4. Bilateral nonobstructing renal calculi.
___ Imaging CTA ABD & PELVIS
1. Moderate calcified and noncalcified atherosclerotic plaque
throughout the abdominal aorta without high-grade stenosis or
evidence of mesenteric ischemia.
2. Right lower lobe ___ nodular opacities are suggestive
of small airways disease or aspiration.
3. Increased circumferential wall thickening, edema, and mucosal
hyperemia of the distal esophagus with prominent paraesophageal
lymph nodes, findings which could reflect esophagitis, though
extension of known malignancy is not excluded.
4. Persistent fullness and mild wall thickening of the left
renal
pelvis and proximal ureter without obstructing lesion.
Correlation with urine cytology is recommended and consider
urology consultation.
5. Prostatomegaly.
6. Apparent bladder wall thickening may be due to
underdistention
or an element of chronic outlet obstruction. Correlation with
urinalysis is recommended to exclude underlying infection.
7. Trace bilateral pleural effusions improved compared to prior.
Brief Hospital Course:
PRINICIPLE REASON FOR ADMISSION:
___ yo M with locoregional esophageal SCC s/p neoadjuvant
chemo-XRT with plans for possible resection, DVT on lovenox,
atrial fibrillation, and recent prolonged hospitalization
complicated by malnutrition s/p J-tube, TE fistula s/p tracheal
stent, enterobacter bacteremia, HCAP, and C. diff colitis on PO
vancomycin who presented with abdominal pain and
nausea/vomiting. Ultimately thought likely viral gastroenteritis
and resolved with supportive care.
After extensive discussion with thoracic surgery team,, he
elected to proceed with esophagectomy. He underwent esophageal
stent removal on ___ with advanced endoscopy in preparation for
OR on ___.
# Esophageal SCC complicated by TE Fistula s/p Tracheal Stent:
Patient with esophageal SCC diagnosed ___. Diagnosed with TE
fistula likely due to esophageal carcinoma, radiation, and
esophageal stent. Now s/p bronchoscopy with tracheal stent
placement. After extensive discussion with thoracic surgery
team,
he has elected to proceed with esophagectomy. He was maintained
on full liquid diet with J-tube feeds. He underwent esophageal
stent removal on ___ prior to transfer to thoracic surgery team.
# Abdominal Pain:
# Nausea with Vomiting: Suspected viral gastroenteritis.
Abdominal CT without acute pathology. CT A/P suggestive of
possible esophagitis, but location of pain not classic. Symptoms
resolved now with supportive care.
- Pain control with home fentanyl patch and PO dilaudid plus IV
dilaudid for breakthrough
- Palliative Care consult, well known to service from last
hospitalization
# History of DVT: RLE DVT diagnosed at OSH in ___. Most
recently on lovenox ___ SC daily. Repeat Doppler US show no
DVT in upper or lower extremities, and anticoagulation was held
in ___ period. Will need to discuss risks and
benefits of resuming anticoagulation following surgery.
# Severe Protein Calorie Malnutrition:
# Cancer-Related Fatigue: Patient had J-tube placed during
recent admission for tube feeds. Clogged multiple times and had
difficulty at home administering TF. Nutrition was consulted and
recommended switching TF to day time feeds to see if better
tolerated. Started on ___, and were tolerated, but he does not
like being connected during the day. Also increased free water
flushes given poor po intake
# Aspiration pneumonitis- Developed likely in s/o N/V. Has
stable
respiratory exam and no sx or signs concerning PNA.
#Left renal pelvis fullness, bladder wall thickening- U/A not
c/w
UTI. No RBCs seen on U/A. Cr stable. Recommend nonurgent
outpatient urology consult
# Cancer-Related Pain: Continued home pain medications.
# C. Diff Colitis: Continued PO vancomycin with planned end date
___. A repeat culture was sent on ___ and was negative.
# Atrial Fibrillation: Patient was in afib with RVR as OSH.
Continued home digoxin and metoprolol. Initially anticoagulated
on lovenox before holding for surgery and he is currently
receiving it. He'll transition to Coumadin once his surgical
issues have resolved.
# Esophageal Candidiasis: Diagnosed on EGD cultures. Completed
course of fluconazole.
# History of Enterobacter Bacteremia: Completed course of
levaquin.
# Headache- Continue flexeril PRN
# COPD- Continue spiriva
# Anemia: Chronic and stable.
# BPH- Continue home doxazosin
# HTN- Continue home metoprolol and aspirin
SURGICAL COURSE:
Mr. ___ was taken to the Operating Room on ___ and
underwent a Three-hole ___ near total esophagectomy with
gastric conduit, repair of tracheoesophageal fistula via partial
tracheal resection in the right chest and intercostal muscle
flap buttress to the tracheal repair. He tolerated the procedure
well and returned to the TSICU extubated and in stable
condition. Over the next ___ hours his pain got worse and he was
placed on a Ketamine drip along with his other chronic pain
medications and it was effective. He also became more congested
and had trouble clearing his secretions. A bronchoscopy was done
on ___ which improved his respiratory status. He was
treated with Nebulizers, chest ___ and incentive spirometry with
effect and his BAL was clean. He was tolerating J tube feedings
and was going to have a barium swallow on ___. The ENT
service evaluated him first to assess his swallowing ability and
his left vocal fold was hypomobile. The right vocal fold was
normal. Based on the findings, the Speech and Swallow service
also evaluated him and recommended postponing his barium
swallow. He remained NPO and his tube feedings were gradually
advanced to goal.
He was followed closely by the Palliative Care service post op
as they knew him well and helped manage his pain issues. Once
his Ketamine was weaned off he was on a Dilaudid PCA and
eventually had liquid Oxycodone via his J tube. His pre op
Fentanyl patch was also resumed at 150 mg daily but that was
eventually increased to 200 mg daily with effect. Their plan was
to wean his Oxycodone down over the next week or two and then
begin to wean his Fentanyl patch.
He was followed closely by the SLP service and ENT and was able
to undergo a video/barium swallow on ___ which showed no
anastomotic leak and no gross aspiration. He was then placed on
a diet of pureed solids and honey thick liquids which he took in
modest amounts. His tube feedings continued however he began to
have trouble with hyperkalemia and his tube feedings preparation
was changed to Nepro. His medicatiuons were reviewed, none of
which would cause hyperkalemia. His Nepro ran at 55 cc's/hr over
24 hours which was his goal. He had problems intermittently with
clogging of the J tube and in light of his modest oral intake,
the tube was replaced and upsized in ___ on ___ and is
working well. His potassium ran in the low 5 range following the
change but his whole blood potassium was 4.4.
The Medical service was consulted post op in light of some
complaints of dizziness as well as his hyperkalemia. They felt
that the dizziness was maybe in light of general deconditioning
as he was not orthostatic. A head CT was done which was negative
for metastatic disease and he also had a carotid duplex scan
which showed > 70% occlusion of his ___ and 50-69% of his LICA.
The hyperkalemia may have been due to post op thrombocytosis
from stress and malignancy. These issues will need follow up by
his PCP.
The Physical Therapy service evaluated him on numerous occasions
and recommended that he return home with home physical therapy
to help improve his mobility and endurance. He will need to
have an ENT/SLP appointment arranged for as an out patient
closer to home as he prefers not to return here for outpatient
visits. He was instructed to take all of his medications
crushed, mixed in applesauce and followed by honey thick
liquids.
After a long hospital stay he was discharged to home on
___ will follow up with Dr. ___ in ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
4. Fentanyl Patch 150 mcg/h TD Q72H
5. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN BREAKTHROUGH PAIN
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Nicotine Patch 14 mg TD DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Digoxin 0.125 mg PO DAILY
11. Doxazosin 1 mg PO HS
12. Metoprolol Tartrate 25 mg PO BID
13. Senna 8.6 mg PO BID
14. Tiotropium Bromide 1 CAP IH DAILY
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Polyethylene Glycol 17 g PO DAILY
18. Vancomycin Oral Liquid ___ mg PO QID
19. Cyclobenzaprine 10 mg PO TID:PRN headache
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Crush well, mix in applesauce and follow with honey thick liquid
RX *acetaminophen 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*1
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch once a day Disp #*30 Patch Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: using tabs
Crush well, mix in applesauce and follow with honey thick liquid
RX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
4. Fentanyl Patch 200 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour 2 patches every 72 hours Disp #*25
Patch Refills:*0
5. Aspirin 81 mg PO DAILY
Crush well, mix with applesauce and follow up with honey thick
liquids
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Cyclobenzaprine 10 mg PO TID:PRN headache
8. Digoxin 0.125 mg PO DAILY
Crush well, mix in applesauce and follow with honey thick liquid
9. Docusate Sodium 100 mg PO BID
10. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
Crush well, mix in applesauce and follow with honey thick liquid
13. Multivitamins 1 TAB PO DAILY
Crush well, mix in applesauce and follow with honey thick liquid
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Senna 8.6 mg PO BID
Crush well, mix in applesauce and follow with honey thick liquid
16. Tiotropium Bromide 1 CAP IH DAILY
17.Nutrition
Nepro at 55 cc's/hr over 24 hrs (5.2 cans per day)
Disp: one month supply
Refills for 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral gastroenteritis
Severe malnutrition
Esophageal cancer and tracheoesophageal fistula.
Left vocal cord hypomobile
Oropharyngeal dysphagia
Hyperkalemia
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:
Call Dr. ___ ___ if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting
-Increased abdominal pain
-Drainage or redness from your incisions
Medication
-See medication discharge sheet
-Use pill crusher to crush all medications
-Take stool softners to prevent constipation
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen in follow up
-Walk ___ times a day for ___ minutes increase to a Goal of
30 minutes daily as tolerated
Diet:
Pureed solids, honey thickened liquids
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for ___ minutes after meals
J tube feedings: Nepro at 55 cc's/hr over 24 hours. You can
begin to cycle your feedings over 18 hours so that you have some
freedom during the day. The rate would be 75 cc's/hr from 4PM to
10AM. Continue to flush the tube with 100 cc's water every 6
hrs.
Daily weights: keep a log of weights and oral intake and bring
it with you to your appointment so that your caloric intake can
be assessed.
NO CARBONATED DRINKS
Followup Instructions:
___
|
10711408-DS-6
| 10,711,408 | 28,492,404 |
DS
| 6 |
2116-12-19 00:00:00
|
2116-12-19 18:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough/emesis
Major Surgical or Invasive Procedure:
___
EGD with stent placement
___
Flexible and rigid bronchoscopy with stent placement
___
Flexible bronchoscopy
___
Flexible bronchoscopy
___
Flexible and rigid bronchoscopy with stent removal and stent
replacement
___
EGD with stent removal
___
PICC line
___
Bronch
___
Colonoscopy
___ EGD
___ Rigid bronchoscopy
History of Present Illness:
___ man with a past medical
history notable for DVT, esophageal cancer, A. fib, status post
three-hole ___ near total esophagectomy with
gastric conduit, repair of tracheoesophageal fistula via
partial tracheal resection in the right chest, intercostal
muscle flap buttress to the tracheal repair on ___.
Had post op course complicated by L recurrent laryngeal nerve
palsy, chronic pain, continued malnutrition, C diff, aspiration
pneumonitis. Discharged home with services on ___.
Since discharge, pt has been doing reasonably well. States that
he has been tolerating his tube feeds, having loose regular
bowel
movements, and having small amounts of thickened liquids.
Receiving ___ services without concern. This morning around 9
am,
started experiencing sudden nausea with emesis that he describes
as thin mostly clear liquid. Presented to ___ where
he was transferred to ___ for further care. Otherwise denies
any fever, chills, abdominal pain, dysuria, headache, chest
pain,
SOB. Does endorse continued productive cough that has been
present since discharge. Thoracic surgery consulted for
continued
management post-operatively.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Presented in ___ with DVT in the right lower extremity
and then dysphagia in ___ and was found to have a 2.9
x
2.3 cm mid esophageal mass which was positive for squamous cell
carcinoma, superficially invasive. Mr. ___ underwent placement
of a Merit covered esophageal stent from 25-35 cm. PET/CT showed
no distant metastases. On ___ Dr. ___ EGD/EUS
and noted a stent in the esophagus from 34-39 cm; the
gastroesophageal junction was at 43 cm and appeared normal; Dr.
___ not get an ultrasound T-stage because of the
stent;
there were two lymph nodes at 20 cm, the largest measuring 6.3
mm
and suspicious; the stomach and duodenum appeared normal,
clinical stage TXN2M0. We recommended chemotherapy and radiation
therapy on the CROSS regimen with plan for esophagectomy if 0.7
cm indeterminate lingular nodule is stable.
PAST MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- Tobacco Abuse
- EtOH Abuse
Social History:
___
Family History:
Father died at age ___ from gastric cancer. Mother
died at age ___ from a CVA.
Physical Exam:
Temp: T 99.5 HR: 108 BP: 115/60 RR: 20 O2 Sat: 90% ___ mask
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings: cervical incision well healed
RESPIRATORY
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings: Mild resp distress, coarse breath sounds
bilat
CARDIOVASCULAR
[ ] RRR [ ] No m/r/g [x] No JVD [ ] PMI nl [ ] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings: regular rate, sinus tachycardia
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings: J tube in place, mild distension
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ CTA Chest/abd:
1. There is a fistulous connection between the trachea and the
gastric
conduit approximately the level of T3-4.
2. Scattered patchy opacities throughout the lung fields, most
pronounced in the bilateral lower lobes and right upper lobe,
likely represent aspirated gastric contents. Superimposed
infection cannot be excluded.
___ Ba swallow :
Findings consistent with tracheoesophageal fistula. No evidence
of
obstruction.
___ CXR :
Comparison to ___. Stable examination of the
thorax. Stable
position of the new tracheal stent. The left PICC line is in
stable correct position.
___ CT Chest/abd/pelvis :
1. Residual fistula between gastric pull-through and trachea at
level of
tracheal stent.
2. Significant interval improvement in multifocal airspace
disease with
residual bronchial wall thickening and ___
opacities
compatible with bronchitis, bronchiolitis, and pneumonitis which
could be
secondary to aspiration in the setting of a fistula.
Superimposed infection cannot be entirely excluded.
3. No acute findings identified within the abdomen or pelvis.
4. Additional chronic changes as detailed above.
___ CT abd/pelvis :
New cecal wall thickening and inflammation centered about the
cecum,
concerning for colitis either due to infection or inflammation.
Bubbly
lucencies in the wall suggest coinciding pneumatosis of the
cecum.
___ CT Chest :
1. New, small left pneumothorax.
2. Unchanged possible communication between, at least the
external surface of the tracheal stent and the gastric lumen.
3. Bilateral ___ and ground-glass opacities, are
improved from prior, again possibly representing infection or
inflammation.
4. Partial resection of the posterior right sixth rib.
Sclerotic right
lateral rib lesions could be postsurgical, but underlying
malignancy can't be excluded.
___ CT Chest/abd/pelvis :
1. Persistent small left apical pneumothorax.
2. Patchy airspace consolidation in the left lung, likely
representing
aspiration and/or pneumonia.
3. No acute intra-abdominal process identified. A soft tissue
nodule
associated with pancreatic tail is favored to be an accessory
spleen as
opposed to a pancreatic lesion. This could likely be
re-evaluated at next
follow-up, or if it would affect short term management it could
be confirmed with MRI or denatured RBC scan.
4. A 1.9 cm right lower pole renal lesion is similar to ___ and
could be a cyst with an enhancing septation versus 2 adjacent
cysts.
Attention on follow-up is suggested. Otherwise, this could also
be further evaluated with MRI if felt clinically indicated.
5. Multiple nonobstructing bilateral renal calculi.
___ Ba swallow :
Findings consistent with persistent tracheoesophageal fistula.
___ CXR :
The tip of a left PICC line projects over the upper right
atrium, unchanged.
A tracheal stent is present. Patchy opacities within the
periphery of the
left mid lower lung are unchanged. There is no pleural effusion
or
pneumothorax. The size and appearance of the cardiomediastinal
silhouette is unchanged.
MICRO :
___ 2:36 pm BRONCHOALVEOLAR LAVAGE TRACHEAL WASH.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM NEGATIVE ROD #2. ~5000 CFU/mL.
FURTHER WORKUP ON REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
GRAM NEGATIVE ROD #3. ~1000 CFU/mL.
FURTHER WORKUP ON REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
YEAST.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service I the
Emergency Room and admitted to the hospital for further
management of his nausea and emesis. A CTA of the chest and
abdomen revealed a fistulous connection between the trachea and
the gastric connection. He was made NPO, hydrated with IV
fluids and admitted to the ICU for airway protection. He was
also placed on broad spectrum antibiotics. He underwent an EGD
on ___ and an esophageal stent was placed. He subsequebtly
developed rapid atrial fibrillation and was placed on a
diltiazem drip. The following day a bronchoscopy was done and a
tracheal stent was placed. He remained intubated and lightly
sedated post procedure. A chest CT was done on ___ which
showed a persistent fistulous tract and he underwent another
bronchoscopy and his endotracheal tube was advanced so that the
balloon was within the stent overlaying the defect. He was
finally weaned and extubated on ___. He remained NPO and
had a nasogastric tube in place to keep any bile acids away from
the stent. He was transferred to the Surgical floor and given
time for the tract to heal.
A barium swallow was done on ___ which showed some barium
going through the trachea. On ___ the Interventional
Pulmonary service repeated a bronchoscopy and replaced the
tracheal stent. Plans were for replacement of his esophageal
stent on ___ but unfortunately he had an EGD which showed
the esophageal stent had migrated into the stomach and it was
removed but the esophageal anastomosis was ulcerated, likely
from the stent therefore it could not be replaced. Plans were
for a repeat EGD in ___ weeks to assess the site. In the
interim he had persistent diarrhea. Despite changing his tube
feeding preparation on multiple occasions his problem persisted.
The nutrition service felt that it was attributed to the use of
antibiotics but his antibiotics stopped on ___ and the
problem persisted. The GI service evaluated him and recommended
multiple stool testing which was all negative but he persisted
with multiple loose stools ___ per day. They were a bit less
when his tube feeding was stopped but never resolved.
On ___trial fibrillation as high as
180 bpm associated with hypotension and received 2 liters of
fluid during resuscitation. His WBC was up to 25K and a CT of
the chest/abdomen and pelvis was done which showed new cecal
wall thickening and inflammation centered about the cecum,
concerning for colitis either due to infection or inflammation.
There was also possibly some pneumotosis on the scan. The ACS
service was consultrd and recommended serial abdominal exams and
conservative treatment as he had no RUQ tenderness, his lactate
was normal and his nonbloody diarrhea was chronic. He was placed
on Cipro and Flagyl and watched closely. TPN was started to try
to improve his nutritional status. Gradually his WBC downtrended
and he remained afebrile. The GI service was reconsulted after
his tube feedings were stopped for 7 days and his diarrhea
persisted. A colonoscopy was done on ___ which was
significant for a right cecal mass. Pathology results eventually
returned tubulovillous adenoma. Colorectal surgery was consulted
given that the mass could not be removed endoscopically. The
decision was made to pursue outpatient follow up.
After the colonoscopy, a brief ICU stay (___) occurred
due to hypotension and leukocytosis. Broad spectrum antibiotics
were started as part of this. Blood cultures were negative and
his blood pressures improved so antibiotics were discontinued
per the recommendation of our Infectious Disease colleagues. His
tube feeds continued to be held and he remained on TPN.
During the next week he had a repeat EGD on ___ with no
fistula. Unfortunately a barium swallow study later that day did
reveal evidence of a persisted TEF. His tube feeds were
restarted and his TPN was discontinued on ___ at which point
his feeds were advanced to goal.
Unfortunately his liquid bowel movements increased in frequency
with restarting the tube feeds. A Clostridium Difficile assay
was resent which returned negative. After consultation with
Nutrition and extensive discussion with specialists the disease
was made to switch to Promote with banana flakes and additional
protein supplementation. This finally resulted in an acceptable
amount of liquid stools that would not cause hypotension or
alteration in hemodynamics. The rate was increased to 100. A
repeat bronchoscopy on ___ revealed that the stent was in good
position. On ___ he developed persistent hyperkalemia and the
decision was made in conjunction with nutrition to reduce the
tube feeds back to 80cc. During this time his tube feeds were
briefly held until the hyperkalemia resolved and he required
normal saline boluses for hypotension and dizziness. After
restarting his tube feeds his blood pressure ultimately improved
and his symptoms of dizziness resolved (___). He was
ultimately discharged home on ___ in stable condition with
appropriate hemodynamics and plan for outpatient follow up with
Thoracic Surgery and Interventional Pulmonology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
5. Fentanyl Patch 200 mcg/h TD Q72H
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: using tabs
8. Cyclobenzaprine 10 mg PO TID:PRN headache
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Acetaminophen 1000 mg PO Q8H
12. Tiotropium Bromide 1 CAP IH DAILY
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Metoprolol Tartrate 25 mg PO BID
15. Digoxin 0.125 mg PO DAILY
16. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg NG Q6H:PRN headache or pain
Give via J tube and flush with 10 mls water
RX *acetaminophen 160 mg/5 mL 20 mls via J tube every six (6)
hours Disp #*473 Milliliter Milliliter Refills:*2
2. Acetylcysteine 20% ___ mL NEB BID
RX *acetylcysteine 200 mg/mL (20 %) 5 mls twice a day Disp #*30
Milliliter Refills:*5
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb INH four times
a day Disp #*60 Vial Refills:*5
4. Citalopram 30 mg NG DAILY
Please use suspension and give via J tube, flush with 10 mls
water
RX *citalopram 10 mg/5 mL 15 mls via J tube once a day Disp
#*480 Milliliter Milliliter Refills:*4
5. GuaiFENesin 10 mL NG Q6H
Give via J tube and flush with 10 mls water
RX *guaifenesin 100 mg/5 mL 10 mls via J tube four times a day
Disp #*946 Milliliter Milliliter Refills:*5
6. LOPERamide 2 mg NG QID:PRN loose stools
Please use suspension and give via J tube, flush with 10 mls
water
RX *loperamide 1 mg/5 mL 10 mls via J tube four times a day
Refills:*5
7. Omeprazole 40 mg PO BID
give via J tube and flush with 10 mls water
RX *omeprazole 40 mg 40 mg via J tube twice a day Disp #*600
Milliliter Refills:*5
8. OxycoDONE Liquid ___ mg PO Q8H:PRN Pain - Moderate
Please use elixir and give via J tube, flush with 10 mls water
RX *oxycodone 5 mg/5 mL 20 mls via J tube every eight (8) hours
Disp #*300 Milliliter Refills:*0
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
RX *sodium chloride 3 % 15 mls INH twice a day Disp #*14 Vial
Refills:*5
10. Digoxin 0.25 mg NG DAILY
Please use suspension or elixir and give via J tube, flush with
10 mls water
RX *digoxin 50 mcg/mL 5 mls via J tube once a day Refills:*5
11. Enoxaparin Sodium 100 mg SC QD
RX *enoxaparin 100 mg/mL 100 mg sc once a day Disp #*30 Syringe
Refills:*2
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Metoprolol Tartrate 12.5 mg NG Q6H
Please use suspension and give via J tube...flush with 10 mls
water
RX *metoprolol tartrate 25 mg 12.5 mg via J tube four times a
day Disp #*2 Bottle Refills:*5
14. Fentanyl Patch 200 mcg/h TD Q72H
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until taking by mouth
17.Respiratory Therapy
Nebulizer machine with appropriate tubing/mask
Dx tracheoesophageal fistula post esophagectomy
1. Acetaminophen (Liquid) 650 mg NG Q6H:PRN headache or pain
Give via J tube and flush with 10 mls water
RX *acetaminophen 160 mg/5 mL 20 mls via J tube every six (6)
hours Disp #*473 Milliliter Milliliter Refills:*2
2. Acetylcysteine 20% ___ mL NEB BID
RX *acetylcysteine 200 mg/mL (20 %) 5 mls twice a day Disp #*30
Milliliter Refills:*5
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb INH four times
a day Disp #*60 Vial Refills:*5
4. Citalopram 30 mg NG DAILY
Please use suspension and give via J tube, flush with 10 mls
water
RX *citalopram 10 mg/5 mL 15 mls via J tube once a day Disp
#*480 Milliliter Milliliter Refills:*4
5. GuaiFENesin 10 mL NG Q6H
Give via J tube and flush with 10 mls water
RX *guaifenesin 100 mg/5 mL 10 mls via J tube four times a day
Disp #*946 Milliliter Milliliter Refills:*5
6. LOPERamide 2 mg NG QID:PRN loose stools
Please use suspension and give via J tube, flush with 10 mls
water
RX *loperamide 1 mg/5 mL 10 mls via J tube four times a day
Refills:*5
7. Omeprazole 40 mg PO BID
give via J tube and flush with 10 mls water
RX *omeprazole 40 mg 40 mg via J tube twice a day Disp #*600
Milliliter Refills:*5
8. OxycoDONE Liquid ___ mg PO Q8H:PRN Pain - Moderate
Please use elixir and give via J tube, flush with 10 mls water
RX *oxycodone 5 mg/5 mL 20 mls via J tube every eight (8) hours
Disp #*300 Milliliter Refills:*0
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
RX *sodium chloride 3 % 15 mls INH twice a day Disp #*14 Vial
Refills:*5
10. Enoxaparin Sodium 100 mg SC QD
RX *enoxaparin 100 mg/mL 100 mg sc once a day Disp #*30 Syringe
Refills:*2
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Metoprolol Tartrate 12.5 mg NG Q6H
Please use suspension and give via J tube...flush with 10 mls
water
RX *metoprolol tartrate 25 mg 12.5 mg via J tube four times a
day Disp #*2 Bottle Refills:*5
13. Digoxin 0.125 mg NG DAILY
RX *digoxin 50 mcg/mL 0.125 mg via J tube once a day Refills:*5
14. Fentanyl Patch 200 mcg/h TD Q72H
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until taking by mouth
17.Respiratory Therapy
Nebulizer machine with appropriate tubing/mask
Dx tracheoesophageal fistula post esophagectomy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Tracheoesophageal fistula
Pneumonia
Osmotic diarrhea
Cecal mass
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for evaluation after having
a cough and emesis at home. The multiple scans and endoscopies
that were done revealed a hole between the trachea and the
esophagus. Multiple attempts have been made to cover the area
with a stent/stents and at this point you are unable to eat
anything by mouth. All of your nutrition and medications go
through your feeding tube. You are being discharged to home
while you continue to recooperate and heal and will need to come
back to BI for
bronchoscopy, endoscopy and follow up with Dr. ___. You
will eventually need to see a colorectal surgeon to deal with
your cecal mass but that will be at a later date.
* Continue to cough up all of your secretions to clear your
airway. Use the nebulizer machine and medications as ordered.
The flutter valve and incentive spirometer will also help. If
you develop any fevers > 101, chills or any new symptoms that
concern you call Dr. ___ at ___.
* Continue your J tube feedings. Its important that you receive
100% of your calories so that you can heal. Please call Dr.
___ your stitches come out. The tube needs to stay
secured at all times.
* Increase your activity daily to improve your strength and
mobility.
* Please call us with any questions or concerns at ___
Followup Instructions:
___
|
10711408-DS-7
| 10,711,408 | 26,548,145 |
DS
| 7 |
2117-04-24 00:00:00
|
2117-04-24 16:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
septic shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with extensive history including
A. fib on Lovenox, esophageal cancer (P63+, CK7 negative) s/p
esophagectomy, kidney stones, complex pain syndrome who
presented
to OSH with N/V and ultimately transferred for septic shock ___
pneumonia.
In brief his oncologic history is:
___: Found to have RLE DVT
___: Dysphagia in ___ and was found to have a 2.9 x
2.3 cm mid esophageal mass which was positive for squamous cell
carcinoma, superficially invasive. S/p placement of Merit
covered
esophageal stent from 25-35 cm. (Dr. ___ at ___
___)
___: Referred to ___ for PET/CT which showed avid
mid-esophageal mass measuring 2.9x2.3cm no distant metastases
___: EUS revealed 2 suspicious lymph nodes but his T stage
was indeterminate due to the presence of the esophageal stent.
EGD stent in the esophagus from 34-39 cm; the gastroesophageal
junction was at 43 cm and appeared normal; clinical stage
TXN2M0.
___: Started chemotherapy (Taxol/ ___ with Zometa) and
radiation therapy on the CROSS regimen with plan but ultimately
only completed 3 of the 5 chemotherapy treatments (day 1, 8 and
15) because of infection/bacteremia.
___: lap J tube placement
___: EGD and bronch with tracheal stent placed ___: near total esophagectomy with gastric conduit, repair
of
tracheoesophageal fistula via partial tracheal resection in the
right chest, intercostal muscle flap buttress to the tracheal
repair
Recently he had a prolonged hospitalization at ___
(___) for trachea-esophageal fistula requiring stent
placement and intubation (5 days total). Course complicated by
symptomatic afib with RVR (hypotensive, dizzy). Tracheal stent
was placed, and esophageal stent was removed as it had migrated
to stomach. Esophageal stent could not be replaced due to
ulcerations. Also was treated for colitis with cipro/flagyl
based
on imaging diagnosis. On further work-up, colonscopy found right
cecal mass (tubulovillous adenoma). Course also complicated by
difficulty managing tube feeds and nutrition. He was discharged
with plans to follow-up with Thoracic Surgery and Interventional
Pulmonology. Outpatient follow-up showed initially TEF
persisting, with recent stent replacement on ___. Stent was
removed on ___ as bronch found no discernible fistula. Most
recent outpatient appointment was with CRS for preop assessment
laparoscopic possible open ileocolectomy with primary
anastomosis
for 3cm cecum polyp.
On ___, he presented to ___ ED J-tube site redness and
discomfort
with yellowish thick discharge. At that time, he denied fevers,
chills, change in bowel habits ___ BMs per day), vomiting or
other symptoms. Ultrasound and laboratory values were
unremarkable and he was discharged home from the ED.
On the morning of ___, he noted that he was began coughing more
when trying to take his medications. He felt as if he was
coughing up secretions from his stomach. He did not think
anything was coming from his lungs and stated that it did not
feel like previous times when he had a fistula. With the
coughing, he had notable nausea and mild abdominal discomfort
but
did not vomit. He then started developing chills for about an
hour. He also endorsed SOB and lightheadedness. He then called
his sister who took him to an OSH. He also endorsed a week of
intermittent dysuria. At the OSH, he was noted to be hypotensive
to the ___, improved somewhat with IV fluids, however ultimately
requiring levo fed. Chest x-ray was concerning for pneumonia and
patient was given vancomycin and cefepime. CT of the chest,
abdomen, and pelvis was concerning for pneumonia as well as
possible colitis. Patient was transferred here for further
treatment.
Past Medical History:
PAST MEDICAL HISTORY:
=====================
-esophageal SCC (diagnosed ___, s/p esophageal stenting
___
& 3 cycles of carboplatin-paclitaxel + XRT [total 4140 cGy],
complicated by TEF ___ requiring tracheal stenting ___
w/ persistent complications, subsequently s/p Open ___
esophagectomy + partial tracheal resection ___ complicated
by anastomotic leak requiring double barrel [tracheal and
neo-esophageal] stents)
-atrial fibrillation
-carotid stenosis
-chronic pain
-DVT
-ETOH use disorder
-HLD
-HTN
-malnutrition
-prior C. difficile colitis (___)
-tobacco use disorder (not active, 90-pack-year history)
-unresectable cecal polyp (tentatively to be removed ___
PAST SURGICAL HISTORY:
======================
-esophageal stenting (___)
-tracheal stenting (___)
-Open ___ esophagectomy + partial tracheal resection
(___)
PAST ONCOLOGIC HISTORY:
=======================
___: Found to have RLE DVT
___: Dysphagia in ___ and was found to have a 2.9 x
2.3 cm mid esophageal mass which was positive for squamous cell
carcinoma, superficially invasive. S/p placement of Merit
covered
esophageal stent from 25-35 cm. (Dr. ___ at ___
___)
___: Referred to ___ for PET/CT which showed avid
mid-esophageal mass measuring 2.9x2.3cm no distant metastases
___: EUS revealed 2 suspicious lymph nodes but his T stage
was indeterminate due to the presence of the esophageal stent.
EGD stent in the esophagus from 34-39 cm; the gastroesophageal
junction was at 43 cm and appeared normal; clinical stage
TXN2M0.
___: Started chemotherapy (Taxol/ ___ with Zometa) and
radiation therapy on the CROSS regimen with plan but ultimately
only completed 3 of the 5 chemotherapy treatments (day 1, 8 and
15) because of infection/bacteremia.
___: lap J tube placement
___: EGD and bronch with tracheal stent placed ___: near total esophagectomy with gastric conduit, repair
of
tracheoesophageal fistula via partial tracheal resection in the
right chest, intercostal muscle flap buttress to the tracheal
repair
Social History:
___
Family History:
Notable for a father who died at age ___ from gastric cancer and
a
mother who died at age ___ from a CVA.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals reviewed.
GENERAL: Calm, comfortable in NAD. Answering questions
appropriately
HEAD: Atraumatic, conjunctiva clear, EOMI, pupils reactive,
sclera anicteric, oral mucosa w/o lesions
NECK: Supple, no LAD, no thyromegaly.
CARDIAC: RRR, S1S2 w/o m/r/g.
RESPIRATORY: Speaking in full sentences. Diffuse rhonchi
bilaterally with coarse crackles L>R. No wheezes
ABDOMEN: No distension. J-tube site without purulence or
erythema. soft, NT, +BS. No palpable organomegaly.
EXTREMITIES: Warm, no edema, peripheral pulses are strong and
full.
SKIN: No obvious lesions over the face, thorax, abdomen,
extremities.
NEUROLOGIC: Grossly intact, face symmetric, speech fluent,
stands
from seated position, gait normal.
PSYCHIATRIC: Pleasant and cooperative.
ACCESS: RIJ in place with no bleeding
DISCHARGE EXAM:
VS: ___ 0848 Temp: 97.9 PO BP: 114/61 HR: 93 RR: 19 O2 sat:
97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
Gen - sitting up in bed, appears comfortable, speaking in full
sentences; hoarse voice
Eyes - EOMI, no scleral icterus
ENT - OP clear, MMM
Heart - NR/RR, no m/r/g
Lungs - CTAB, no wheezes, crackles or rhonchi
Abd - soft nontender, normal bowel sounds, G tube with
surrounding erythema
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION LABS:
===============
___ 09:55PM BLOOD WBC-38.1* RBC-2.84* Hgb-8.9* Hct-28.3*
MCV-100* MCH-31.3 MCHC-31.4* RDW-13.4 RDWSD-49.0* Plt ___
___ 09:55PM BLOOD Neuts-90.3* Lymphs-2.9* Monos-5.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-34.40* AbsLymp-1.10*
AbsMono-1.89* AbsEos-0.00* AbsBaso-0.09*
___ 09:55PM BLOOD Plt ___
___ 10:13PM BLOOD ___ PTT-29.1 ___
___ 09:55PM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-139
K-4.3 Cl-107 HCO3-23 AnGap-9*
___ 09:55PM BLOOD ALT-14 AST-13 AlkPhos-63 TotBili-0.3
___ 09:55PM BLOOD Lipase-6
___ 09:55PM BLOOD Albumin-3.0*
___ 01:48AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.6
___ 01:48AM BLOOD Digoxin-0.5*
___ 10:13PM BLOOD ___ pO2-32* pCO2-45 pH-7.35
calTCO2-26 Base XS--1
___ 10:13PM BLOOD Lactate-1.2
___ 10:13PM BLOOD O2 Sat-56
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-11.6* RBC-2.82* Hgb-8.5* Hct-28.2*
MCV-100* MCH-30.1 MCHC-30.1* RDW-13.1 RDWSD-48.0* Plt ___
___ 06:40AM BLOOD Glucose-95 UreaN-24* Creat-1.1 Na-140
K-5.5* Cl-99 HCO3-32 AnGap-9*
___ 06:40AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.0
___ 10:38AM BLOOD K-4.6
MICRO:
BCx (___): STAPHYLOCOCCUS, COAGULASE NEGATIVE.
UCx (___): NO GROWTH.
Sputum cx (___): TEST CANCELLED, PATIENT CREDITED.
MRSA screen (___): No MRSA isolated.
Sputum cx (___): GRAM STAIN (Final ___:
___ 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.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final ___:
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
PENICILLIUM SPECIES.
C.diff (___): PCR positive, toxin antigen negative
Sputum cx (___):
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final ___: YEAST.
BCx (___): No growth
BCx (___): No growth x2
UCx (___): NO GROWTH.
C.diff PCR (___): negative
MRSA screen (___): No MRSA isolated.
IMAGING:
========
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
1. New right IJ CV catheter appears well positioned.
2. Lower lung opacities, left greater than right, remain
concerning for
pneumonia.
3. Status post esophagectomy with gastric pull-through accounts
for
prominence of the cardiomediastinal silhouette.
___ Imaging BARIUM SWALLOW/ESOPHAGU
FINDINGS:
Re-demonstrated are postsurgical changes related to prior
esophagectomy. A
right-sided central line and multiple leads project over the
chest. There is no evidence of a fistulous connection between
the esophagus and trachea. Contrast passed freely through the
neo esophagus without evidence of obstruction. The patient
tolerated the procedure well without signs of gross aspiration.
IMPRESSION:
Postsurgical changes related to prior esophagectomy. No evidence
of a
tracheoesophageal fistula.
Video swallow study (___):
IMPRESSION:
1. Gross aspiration with thin liquids which was limited with
left head turn.
2. Mild aspiration with nectar thick liquids.
3. Penetration with pudding.
Please note that a detailed description of dynamic swallowing as
well as a
summative assessment and recommendations are reported separately
in a
standalone note by the Speech-Language Pathologist (OMR, Notes,
Rehabilitation Services).
CXR (___):
IMPRESSION:
Interval improvement in bibasilar pneumonia.
CXR (___):
IMPRESSION:
Compared to chest radiographs since ___ most recently
and ___.
Bilateral broncho pneumonia in the lower lungs stable on the
left, improved on the right since ___. Broncho pneumonia
was present in the left lower lung on ___. It is new or
substantially increased since than on the right. Mild
cardiomegaly is chronic. No evidence of cardiac decompensation.
Pleural effusion minimal on the right if any. No pneumothorax.
The upper portion of the neo esophagus is stable in appearance
since at least ___ and has not become distended.
Brief Hospital Course:
___ year old male with past medical history of atrial
fibrillation Lovenox, esophageal cancer s/p esophagectomy
complicated by tracheoesophageal fistula and partial tracheal
resection, status post prior glue/alloderm and metal stenting,
complex pain syndrome on fentanyl + oxycodone, cecal mass with
upcoming planned surgical intervention, admitted on ___ with
septic shock secondary to acute bacterial pneumonia, initially
in the ICU on broad spectrum antibiotics, subsequently with
improving respiratory status, course complicated by ___ and
dysphagia.
# Septic shock secondary to
# Acute bacterial Pneumonia, suspected aspiration
# Acute hypoxic respiratory failure
Patient with complex history notable for prior esophagectomy and
partial tracheal resection complicated by tracheoesophageal
fistula s/p prior closure, on modified diet and supplemental
tube feeds at home who presented with leukocytosis and hypoxia.
Workup notable for lung imaging with multifocal pneumonia. He
was treated with broad spectrum antibiotics with subsequent
ability to wean oxgen. Workup notable for barium swallow which
showed no evidence of a fistula. He clinically improved and
completed a 7 day course of antibiotics while in the hospital.
The patient then had a recurrent episode of aspiration. He was
started on broad spectrum antibiotics and completed a course
while hospitalized. Work up of dysphagia below.
# Dysphagia
Secondary to prior operative interventions. He was made NPO and
started on tube feeds. He was seen by SLP and video swallow
showed hypomobility of L vocal cord. Patient seen by ENT who
recommended outpatient follow-up for planning for L vocal cord
injection.
# GERD
Given concern that his severe reflux (result of his prior
esophagectomy) was contributing to his aspiration risk, ENT
recommended increasing his home PPI to BID dosing. Given
recurrent reflux and aspiration, patient also started on
ranitidine BID. He was seen by thoracic surgery who
recommended, in addition to above therapy, to also trial reglan.
Reflux improved and he was restarted on trial of PO diet which
he tolerated well with continued improvement in his reflux.
# Positive blood culture, coag negative staph
1 set of admission blood culture grew coag neg staph. Thought
to more likely be contaminant, but given his severe sepsis on
presentation requiring pressors, ID recommended completion of 7
day course of vancomycin. He completed this.
# ___
Course complicated by rising Cr from 0.8 to 1.3. Treated with
IV fluids without improvement. Was evaluated by renal consult
who felt most likely related to his presenting
sepsis/hypotension and contrast. Cr stabilized at 1.1. Renal
advised this might take ___ weeks to resolve. If does not,
could consider additional workup at that time.
# Depression
Continued Citalopram
# Complex pain syndrome
Continued Fentanyl + prn oxycodone
# Paroxysmal Atrial fibrillation
# Chronic DVT lower extremity
Initially continued on home Enoxaparin; this was held in setting
___ above, and then restarted once GFR stable. Continued
metoprolol, digoxin
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
2. Citalopram 10 mg PO DAILY
3. Fentanyl Patch 200 mcg/h TD Q72H
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. OxyCODONE Liquid 20 mg PO Q8H:PRN Pain - Moderate
7. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
9. Digoxin 0.125 mg PO DAILY
10. GuaiFENesin 10 mL PO Q6H:PRN cough
11. Omeprazole 40 mg PO DAILY
12. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heartburn
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth four times a day Disp #*120 Tablet Refills:*0
2. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl [Reglan] 5 mg 2 tablet(s) by mouth four
times a day; before meals and before bedtime Disp #*240 Tablet
Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
4. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
8. Citalopram 10 mg PO DAILY
9. Digoxin 0.125 mg PO DAILY
10. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
11. Fentanyl Patch 200 mcg/h TD Q72H
12. GuaiFENesin 10 mL PO Q6H:PRN cough
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. LOPERamide 2 mg PO QID:PRN diarrhea
15. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) via J
tube twice a day Disp #*30 Tablet Refills:*0
16. OxyCODONE Liquid 20 mg PO Q8H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 20 mg by mouth every eight (8) hours
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Septic shock secondary to
# Acute bacterial pneumonia, concern for aspiration
# Dysphagia
# ___
# Positive blood culture, coag negative staph
# Depression
# Complex pain syndrome
# Paroxysmal Atrial fibrillation
# Chronic DVT lower extremity
# GERD
# Esophageal cancer
# Chronic pain
#decreased mobility of left vocal cord
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 at ___. You were admitted
with a severe pneumonia. You were treated with antibiotics and
improved.
We think this pneumonia was caused by difficulty swallowing.
You were seen by swallow specialists and a video swallow study
was performed and showed decreased mobility of your left vocal
cord. You were advised to turn your head to the left when you
eat/swallow.
You should follow up in ___ clinic to have an injection in your
vocal cord that will improve your swallowing.
Followup Instructions:
___
|
10712105-DS-3
| 10,712,105 | 23,647,930 |
DS
| 3 |
2135-05-01 00:00:00
|
2135-05-01 21:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / codeine / ketoconazole
Attending: ___.
Chief Complaint:
cough, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a very pleasant ___ male with HIV/AIDs,
last CD4 ct ___ who presents with headache, n/v/d and productive
cough without hemoptysis x 4 days. He also endorses subjective
fever/chills/sweats and 6 lb wt loss over the last 2 wks and
pleuritic CP. He measured his temp on one occasion and reports
it was 100.1. Pt states that he is recently homeless, living in
the ___ but has an apartment arranged that will be
available in 2 wks. In this setting, his belongings, including
medications, have been stolen and he has therefore been unable
to take his HIV meds and bactrim.
In the ED, initial vitals were: 97.0 77 121/83 16 100% RA UA was
negative, labs were unremarkable. He was given 2 L of NS. Head
CT was performed and showed no acute intracranial process. EKG
showed sinus with RBBB (old). Chest xray showed no acute
cardiopulmonary process. He was given 2 L NS.
On the floor, pt states he feels dehydrated and weak. His last
episode of diarrhea was earlier this AM. No recent N/v. He c/o
pain in his rectum as well as blood in his stool as well as pain
down his legs which he attributes to his neuropathy.
Review of systems:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath. Denies palpitations. Denies abdominal pain.
No dysuria or frequency. Denies arthralgias or myalgias.
Past Medical History:
HIV/AIDS on Norvir truvada, prezista, Bactrim
Anal dysplasia, ? anorectal cancer
Chronic pain on methadone/gabapentin
Anxiety on clonidine
Hep C
? Bipolar vs depression
Social History:
___
Family History:
Cardiac disease in mother and father.
Physical Exam:
ADMISSION
Vitals: 97.4 136/72 46 17 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, small amt of white plaques on
tongue
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coughing. 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, strength and sensation grossly intact.
DISCHARGE
VS: 97.0 102/65 47 18 99%RA
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:40AM BLOOD WBC-7.2 RBC-4.52* Hgb-13.9 Hct-41.3
MCV-91 MCH-30.8 MCHC-33.7 RDW-13.2 RDWSD-44.3 Plt ___
___ 11:40AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-138
K-3.8 Cl-97 HCO3-29 AnGap-16
___ 11:40AM BLOOD ALT-29 AST-36 AlkPhos-59 TotBili-1.0
DISCHARGE
___ 07:30AM BLOOD WBC-4.9 RBC-3.96* Hgb-12.4* Hct-37.8*
MCV-96 MCH-31.3 MCHC-32.8 RDW-13.6 RDWSD-47.8* Plt ___
___ 07:30AM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-141
K-4.9 Cl-107 HCO3-31 AnGap-8
CXR
No acute cardiopulmonary process.
EKG - Qtc 482ms
Brief Hospital Course:
This is a ___ year old homeless male with past medical history of
AIDS (last CD4 108) on ART, but noncompliant with outpatient
follow-up, admitted ___ with vague complaints, workup
without remarkable findings able to be discharged home.
# Prolonged QT - admission EKG notable for Qtc 500--repeat once
on floor was 480ms; review of medications showed multiple Qt
prolonging agents; discussed with patient re: stopping
promethazine, with plan for outpatient reassessment by PCP to
see if QTc improved. Other potential meds that may be playing a
role included methadone.
# Loose stools - admitted reporting recent diarrhea, but on
further questioning, he reported that he was having one loose
stool per day, 30 minutes after eating breakfast; no concerning
signs for infection on labs or exam; discussed with patient that
this likely represented normal variation in setting of
gastrocolic reflex; no infection workup was sent as patient had
1 bowel movement during his admission. Recommended he discuss
further this his longitudinal providers.
# Cough - reported several days of cough leading up to
admission, but lungs were clear on exam, chest xray clear as
well; he was not hypoxic and had no focal respiratory findings;
flu negative; may have represented self-resolving viral
infection.
# Peripheral Neuropathy / Chronic Pain - initially reported
severe pain in legs; he was soon seen ambulating comfortably
around the unit; exam without notable abnormalities; pain may
have related to recent theft of his medications (had not taken
his home gabapentin x 4 days); restarted home meds, including
methadone and gabapentin. Patient initially reported that he
was on oxycodone, but this was a one-time prescription from a
provider other than his PCP--this was not continued
# HIV/AIDS - has not been compliant with follow-up for more than
a year; I spoke with PCP who was very concerned about him from
this respect; I spoke with his appointed ID fellow, who met with
him and encouraged him to come to scheduled follow-up within 2
weeks of discharge. Continued home Truvada, Darunavir,
Ritonavir, Bactrim prophylaxis. At time of discharge toxo IgG,
CMV serology were pending--to be followed-up by discharging
attending.
# Rectal pain / Anal Dysplasia - continued home pain regimen as
above; he had not been compliant with prior outpatient
follow-up; encouraged him to follow-up with appointment with Dr.
___ 1 day after discharge.
# Anxiety/depression - Continued clonidine, buspirone
# Chronic Nausea - stopped promethazine as above
Transitional Issues
- Discharge to ___
- Reminded regarding outpatient follow-up appointments with PCP
and ID
- Instructed patient to stop promethazine given concern for
borderline prolonged Qtc--would consider rechecking EKG at
follow-up visit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO DAILY:PRN HA
2. Gabapentin 800 mg PO TID
3. BusPIRone 15 mg PO BID
4. CloniDINE 0.2 mg PO BID
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Darunavir 800 mg PO DAILY
7. RiTONAvir 100 mg PO DAILY
8. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
9. Methadone 80 mg PO DAILY
10. Ibuprofen 400 mg PO DAILY:PRN ha
11. Promethazine 25 mg PO Q8H:PRN nausea
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN TID
Discharge Medications:
1. Acetaminophen 500 mg PO DAILY:PRN headache
2. BusPIRone 15 mg PO BID
3. CloniDINE 0.2 mg PO BID
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Gabapentin 800 mg PO TID
7. Ibuprofen 400 mg PO DAILY:PRN headache
8. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
9. RiTONAvir 100 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Methadone 90 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Prolonged QT
# Loose stools
# Peripheral Neuropathy / Chronic Leg Pain
# HIV/AIDS
# Rectal pain / Anal Dysplasia
# Anxiety/depression
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 at ___. You were admitted
with leg pain and cough. Your pain improved with restarting
your home medications. Your chest xray was reassuring that you
did not have a serious infection.
It is very important that you take your medications and
follow-up with your scheduled visits.
While you were in the hospital, we noted that you had an
abnormal electrical finding in your heart (slightly prolonged
Qt). This may be a result of some of your medications
(methadone, promethazine). We recommend holding off on taking
additional promethazine until you speak with your primary care
doctor to help prevent problems with your heart.
Followup Instructions:
___
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2135-07-21 10:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / codeine / ketoconazole
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a past medical history notable for HIV on
antiretroviral therapy (Last VL ___: 5,960 copies/ml CD4:
108) and prophylactic Bactrim, recently admitted to Medicine
service in ___ presents four days of fever, chills,
drenching night sweats and cough. Pt states that Tmax at home of
~102. Around this time, he complains of new onset headache,
frontal, +photophobia and asso nausea, no emesis, worsened with
lying supine. States that headache can be "paralyzing" it is so
severe. Denies rash. As these symptoms began, he states that he
stopped taking his ART therapy, thinking that they were
contributing to his nausea. Denies any chest pain, abdominal
pain, nausea, vomiting, dysuria, bowel changes. His cough is
productive of scant yellow sputum. His last CD4 count was 108 in
___.
In the ED: Initial VS 97.2 65 107/66 20 98% RA
Physical examination in ED: Unremarkable
Labs notable for: WBC 17.3, lytes WNL
Imaging: Right middle lobe linear opacity appears to have been
present on prior examinations, slightly more conspicuous, may
reflect atelectasis or post inflammatory/infectious changes. An
acute process is difficult to exclude.
Consults called: non
Pt given IV Ketorolac 30 mg; 1000 mL; cloniDINE .2 mg Gabapentin
800 mg x 2, Promethazine 25 mg
On the floor, pt endorses ___ headache with photophobia.
Stating that Toradol and gabapentin did not work for pain,
requesting home dose methadone. Pt endorses above history as
above.
Past Medical History:
HIV/AIDS on Norvir truvada, prezista, Bactrim
Anal dysplasia, ? anorectal cancer
Chronic pain on methadone/gabapentin
Anxiety on clonidine
Hep C
? Bipolar vs depression
Recurrent pneumonoccal pneumonia
Social History:
___
Family History:
Cardiac disease in mother and father.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL - pleasant, well-appearing gentleman, with mild head
discomfort. Able to keep eyes open in lit room, speaking full
sentences
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII fully tested and intact; strength
___ throughout. Gait assessment deferred. Negative Kernig and
Brudzinki
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T: 98.6/98.5 49-56 ___ 20 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear, no
thrush, no leukoplakia, dentures in place
Neck: supple, full ROM, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no edema
Skin: No evidence of rash
Neuro: A&Ox3, CNIII-XII intact and symmetric, strength ___ in
UE and ___ bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 03:08PM BLOOD WBC-17.3*# RBC-4.47* Hgb-13.9 Hct-41.8
MCV-94 MCH-31.1 MCHC-33.3 RDW-12.7 RDWSD-43.3 Plt ___
___ 03:08PM BLOOD Neuts-66.5 ___ Monos-6.4 Eos-0.1*
Baso-0.3 Im ___ AbsNeut-11.51*# AbsLymp-4.39* AbsMono-1.11*
AbsEos-0.02* AbsBaso-0.05
___ 03:08PM BLOOD Glucose-80 UreaN-19 Creat-1.0 Na-137
K-3.7 Cl-97 HCO3-29 AnGap-15
___ 03:13PM BLOOD Lactate-1.2
DISCHARGE AND PERTINENT LABS
============================
___ 05:40AM BLOOD WBC-6.5 RBC-4.24* Hgb-13.0* Hct-39.8*
MCV-94 MCH-30.7 MCHC-32.7 RDW-13.0 RDWSD-44.6 Plt ___
___ 11:00AM BLOOD Neuts-55.3 ___ Monos-9.3 Eos-0.8*
Baso-0.2 Im ___ AbsNeut-4.96# AbsLymp-2.91 AbsMono-0.83*
AbsEos-0.07 AbsBaso-0.02
___ 06:34AM BLOOD ___ PTT-28.7 ___
___ 11:00AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 05:40AM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-139
K-5.0 Cl-101 HCO3-30 AnGap-13
___ 06:34AM BLOOD ALT-15 AST-22 LD(LDH)-155 AlkPhos-50
TotBili-0.3
___ 05:40AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
MICROBIOLOGY
============
___ 3:07 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:00 am SEROLOGY/BLOOD
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
___ 6:15 am SEROLOGY/BLOOD
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
IMAGING
=======
___ CXR PA&L
FINDINGS:
PA and lateral chest radiograph obscuration of the right heart
border which on the lateral radiograph corresponds to a linear
opacity. This appears to have been present on examination dated
___, may be post infectious/inflammatory in etiology
or atelectasis, slightly more conspicuous. Retrocardiac is
slightly more conspicuous relative to prior study, may reflect a
small hiatal hernia or confluence of shadows. There is no
pleural effusion or pneumothorax. Cardiomediastinal and hilar
contours are within normal limits. No evidence of pulmonary
edema.
IMPRESSION:
Right middle lobe linear opacity appears to have been present on
prior
examinations, slightly more conspicuous, may reflect atelectasis
or post
inflammatory/infectious changes. An acute process is difficult
to exclude.
___ CT Head w/o contrast
FINDINGS:
There is no evidence of acute infarct,hemorrhage, edema, or mass
effect. The ventricles and sulci are normal in size and
configuration.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Please note that MR is more sensitive in the detection of
intracranial mass or infection.
Brief Hospital Course:
___ is a ___ with a h/o HIV/AIDS on antiretroviral
therapy (Last VL ___: 5,960 copies/ml CD4: 108) and
prophylactic Bactrim who presented with four days of fever,
chills, drenching night sweats, cough and new severe headaches,
concerning for meningitis.
# Fever/chills/headaches: Symptoms concerning for meningitis
although other viral illnesses a possibility. Unlikely bacterial
meningitis given duration of symptoms. Patient presented with
leukocytosis, new onset fever to 102, headache, and cough in the
setting of immunosuppression due to HIV. Patient had recent
admission to ___ d/t viral syndrome and has a h/o of recurrent
pneumonia and PCP ___ given equivocal CXR and productive
cough, PNA including PCP possible although LDH is normal. CT
head unremarkable, and without meningismus on exam. He continued
to refuse an LP but was started on empiric treatment with
vancomycin, ceftriaxone, ampicillin, and acyclovir (day ___ =
___ until he left AMA on ___. After discussion with
infectious disease, he was written for PO acyclovir and
cefpodoxime to complete a 10 day course (day 10 = ___. On
the day of AMA discharge, his fevers, chills, and sweats, and
headaches had resolved. He did complain of a productive cough
with scant bloody sputum. His blood cultures showed no growth to
date. A urine culture was negative and a serum cryptococcal
antigen was negative. An RPR was negative, and CD4 count 146.
Patient discharged AMA despite numerous conversations explaining
the risks of leaving, including seizure, permanent neurologic
injury, and death. He expressed understanding of these risks and
was deemed to have capacity. His PCP was notified by email of
these events.
# HIV/AIDS: Has a history of struggling to take his medications
as prescribed. Admitted to having occasionally taken ARVs while
at ___ a month ago given negative stigma associated with
them. Was continued on home truvada, darunavir, ritonavir,
Bactrim ppx. CD4 count 146 as above.
# Prolonged QTc: has a longstanding history with QTc 495. Was
continued on home methadone given stability on this medication.
Other QTc prolonging agents were avoided.
Transitional issues:
====================
[] Patient discharged AMA despite numerous conversations
explaining the risks of leaving, including seizure, permanent
neurologic injury, and death. He expressed understanding of
these risks and was deemed to have capacity.
[]Patient discharged on PO acyclovir 800 mg TID, 400 mg q12h
cefpodoxime (through ___
[]Needs ID and PCP follow up within the next few days
-Code: full
-Contact: HCP: ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO DAILY:PRN headache
2. BusPIRone 15 mg PO BID
3. CloniDINE 0.2 mg PO BID
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (___) 1 TAB PO DAILY
6. Gabapentin 800 mg PO TID
7. Ibuprofen 400 mg PO DAILY:PRN headache
8. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
9. RiTONAvir 100 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Methadone 90 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO DAILY:PRN headache
2. BusPIRone 15 mg PO BID
3. CloniDINE 0.2 mg PO BID
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Gabapentin 800 mg PO TID
7. Methadone 90 mg PO DAILY
8. RiTONAvir 100 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Ibuprofen 400 mg PO DAILY:PRN headache
11. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
12. Acyclovir 800 mg PO Q8H Duration: 8 Days
RX *acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp
#*24 Tablet Refills:*0
13. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 8 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*32 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
==================
Meningitis
HIV/AIDS
Secondary diagnoses:
====================
Hepatitis C
Anxiety
Prolonged QTc
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were in the hospital because you were having fevers and
headaches. We believe that your symptoms are due to an infection
around your brain called meningitis. We started treating you
with multiple strong antibiotics through an IV in your arm.
You wanted to leave the hospital because you felt better and
that you wanted to rest at home. We explained to you that
leaving is very dangerous because you will be unable to receive
these strong IV antibiotics. We will give you antibiotics you
can take by mouth but these are unlikely to work because pill
antibiotics do not work against brain infections.
We explained that if you leave the hospital, you would be
leaving against medical advice. You would be at risk of
worsening infection, seizure, permanent neurologic injury, and
death. You said that you understood these risks.
You should return to the hospital if you experience worsening
headache, seizures, fevers, chills, night sweats, or other
concerning symptoms.
It was a pleasure participating in your care.
Sincerely,
Your ___ team
Followup Instructions:
___
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2137-05-20 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / codeine / ketoconazole / promethazine / hair
dye
Attending: ___.
Chief Complaint:
Productive Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past medical history of HIV on HAART and prophylactic
bactrim with poor compliance ___: 50,119 (4.7 log10)
copies/ml and absolute CD4 count 63), rectal cancer, HCV+, and
on
methadone p/w 1 week of intermittent cough, fevers, and
worsening
neuropathic and rectal pain. He notes that he was recently seen
at ___ and diagnosed with a pneumonia however he left AGAINST
MEDICAL ADVICE, because he says that there are too many
dangerous
and trauma cases there despite the doctor there telling him that
he really needs antibiotics. He has felt significantly more
fatigued with intermittent sweats. He was sent here by his PCP
whom she saw this AM.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals: 98.7 45 101/60 18 100% RA
- Labs: WBC 4.8, Flu negative.
- CXR: Low lung volumes. Left base opacity could be due to
atelectasis or pneumonia.
- he was given: CTX 1g at 1200, doxycycline 100mg at 1147,
gabapentin 800mg at 1200
- exam notable for:
Bilateral clear lungs with frequent intermittent
cough. Rectal exam with moderate amount of surrounding friable
skin, no gross blood
Past Medical History:
HIV/AIDS
HCV
Recurrent pneumonoccal pneumonia
Opiate dependence on methadone
Anal dysplasia, ? anorectal cancer
Chronic pain - suspected to be HIV neuropathy
Anxiety on clonidine
Bipolar disorder vs cluster B personality disorder
Social History:
___
Family History:
Cardiac disease in mother and father.
Colitis brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 PO 113/74 56 16 93 Ra
GENERAL - well-appearing man walking around in room, tearful at
times.
HEENT - NCAT, no conjunctival pallor or scleral icterus,
PERRLA,
EOMI, OP clear
NECK - supple
CARDIAC - RRR, normal S1/S2, no m/r/g
PULMONARY - CTAB, without wheezes or rhonchi
ABDOMEN - +BS, soft, non-tender, non-distended, no organomegaly
EXTREMITIES - wwp, no cce
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly intact; moving all
extremities spontaneously. Gait normal.
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant, not responding to internal stimuli
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1043)
Temp: 98.1 (Tm 98.1), BP: 111/74 (111-115/68-74), HR: 58
(52-58), RR: 20 (___), O2 sat: 95% (93-95), O2 delivery: Ra
GENERAL - comfortable, sitting in chair.
HEENT - NCAT, no conjunctival pallor or scleral icterus
NECK - refused
CARDIAC - refused
PULMONARY - breathing comfortably on room air, refused
auscultation
ABDOMEN - refused
EXTREMITIES - no edema
SKIN - refused
NEUROLOGIC - A&Ox3, moving all extremities spontaneously. Gait
normal.
Pertinent Results:
ADMISSION LABS
___ 10:55AM BLOOD WBC-4.8 RBC-4.83 Hgb-14.7 Hct-43.8 MCV-91
MCH-30.4 MCHC-33.6 RDW-12.9 RDWSD-43.0 Plt ___
___ 10:55AM BLOOD Neuts-45.5 ___ Monos-13.0 Eos-4.8
Baso-0.4 Im ___ AbsNeut-2.17 AbsLymp-1.67 AbsMono-0.62
AbsEos-0.23 AbsBaso-0.02
___ 10:55AM BLOOD WBC-4.8 Lymph-35 Abs ___ CD3%-85
Abs CD3-1434 CD4%-4 Abs CD4-62* CD8%-75 Abs CD8-1260*
CD4/CD8-0.05*
___ 10:55AM BLOOD Glucose-85 UreaN-17 Creat-1.1 Na-139
K-5.0 Cl-98 HCO3-31 AnGap-10
___ 08:10AM BLOOD ALT-25 AST-38 LD(LDH)-226 AlkPhos-67
TotBili-0.6
___ 08:10AM BLOOD Albumin-4.0 Calcium-9.2 Phos-8.1* Mg-2.2
___ 11:03AM BLOOD Lactate-1.3
DISCHARGE LABS
___ 08:00AM BLOOD WBC-3.6* RBC-4.61 Hgb-14.2 Hct-42.9
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.3 RDWSD-45.3 Plt ___
___ 08:10AM BLOOD Neuts-17.9* Lymphs-62.2* Monos-13.8*
Eos-5.1 Baso-0.5 Im ___ AbsNeut-0.66*# AbsLymp-2.30
AbsMono-0.51 AbsEos-0.19 AbsBaso-0.02
___ 08:00AM BLOOD Glucose-68* UreaN-18 Creat-0.9 Na-142
K-4.9 Cl-106 HCO3-30 AnGap-6*
___ 08:00AM BLOOD Calcium-9.4 Phos-8.6* Mg-1.9
STUDIES
___ 10:50 am BLOOD CULTURES
Blood Culture, Routine (Pending): no growth two days
Blood Culture, Routine (Pending): no growth two days
_________________
___ 10:40 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___________________
___ CXR
Low lung volumes. Left base opacity could be due to atelectasis
or pneumonia.
___ CT A/P
No evidence of rectal abscess.
Brief Hospital Course:
** Patient eloped after refusing medication prescriptions or
discharge instructions.
___ with past medical history of HIV on HAART and prophylactic
bactrim with poor compliance ___: 50,119 (4.7 log10)
copies/ml and absolute CD4 count 63), rectal cancer, and opiate
dependence on methadone p/w 1 week of intermittent cough,
subjective fevers, and worsening neuropathic and rectal pain.
ACTIVE ISSUES
==============
#Cough
The patient reports cough and also constitutional symptoms
including fevers and malaise prior to admission. He was briefly
started on Ceftriaxone and doxycycline in the emergency
department for possible pneumonia. However, these were
subsequently discontinued in the absence of any signs or
symptoms indicative of an infection, and when CT abdomen/pelvis
showed that the streaky abnormnality in his lung base was just
atelectasis. He remained afebrile. PCP was unlikely despite CD4
of 64 given normal oxygen saturation, normal LDH and CXR without
ground glass opacification. Stable at discharge.
#HIV/AIDS
#Psychosocial barriers to adherence
Diagnosed in ___ and poorly controlled with viral load of
50,119 (4.7 log10) and CD4 count of 63 most recently from ___.
He was on HAART (Truvada, Darunavir, Ritonavir) therapy, but
stopped all his antiviral meds 5 weeks ago.
A previous clinic note states that patient has been
noncompliant because he feels that medications "don't work."
When I spoke with Mr. ___ felt that he quite liked
dwelling dramatically on the notion that he is "dying of AIDS"
and seemed to selectively disengage when I told him he could
improve medically and have a near normal life expectancy if he
were to be adherent to HAART and attend outpatient medical
appointments. His prioritization of attention-seeking and
dramatic behavior even over his own health and survival seems
most consistent with HPD, although my therapeutic relationship
with the patient has of course been too short to diagnose a
personality disorder with any confidence. Regardless of the
specific diagnosis, he does not seem to have sufficient insight
or interest to make progress on psychological barriers to
adherence at this time.
ID was consulted and recommended switching his regimen from
Truvada and Tivicay to Descovy and Tivicay, given better
long-term side effect profile. The patient had his first dose of
this new regimen on ___. Unfortunately he then eloped,
refusing all medication prescriptions.
#Anal squamous cell carcinoma in situ s/p excision
#Anal pain
He presented with rectal pain for which surgery was consulted.
However, he refused a physical exam. A CT scan was negative for
any acute abnormalities or deep complications. Follow-up in
clinic with Dr. ___ on discharge for further evaluation was
recommended.
Chronic issues
==============
#Chronic pain
#Neuropathy
He likely has HIV-associated neuropathy that manifests as severe
burning in feet and legs. Recent MRI L spine negative for acute
process. He is on gabapentin at home. He repeatedly requested
Percocet and became angry when told it was not indicated for
chronic neuropathic pain.
#Opiate dependence
He has prolonged QTc and ___ clinic outpatient has been
trying to wean down the methadone. QTc was 445 on admission and
methadone was continued. Outpatient follow up for further
adjustment of his pain regimen is recommended. Last dose letter
provided.
#Hepatitis C infection: viral load last checked was 1,900,000.
But patient has failed to follow up with ID . Patient has also
declined to receive hepatitis A and B vaccination. Follow up
with infectious disease as above is recommended.
#Anxiety
Stable during hospital stay. Home clonazepam 0.5 mg BID and
clonidine were continued.
#Tobacco abuse
On nicotine patch, stable during hospital stay.
Transitional issues
===================
[] started on Descovy and Tivicay ___. Unfortunately,
patient eloped after refusing medication prescriptions
[] CD4 62. If CD4<50, will consider MAC ppx, though will need
further hx from pt as he has listed allergy to erythromycin
[] please ensure follow up with ID (appointment with Dr. ___
[] rectal pain of unclear etiology with negative CT scan, will
follow up with Dr. ___ as outpatient
[] Please ensure that patient has follow-up with Dr. ___
anal cancer per colorectal surgery
[] Recommend connecting with outpatient psychiatry
[] Recommend continued follow-up with community resource
specialist given housing concerns (he is behind on rent and may
soon face eviction).
[] Recommend outpatient podiatry to help with calluses on feet
[] F/u HIV genotype
#CODE: Full (confirmed)
#COMMUNICATION: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO DAILY:PRN headache
2. CloniDINE 0.2 mg PO BID
3. Darunavir 800 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Gabapentin 800 mg PO QID
6. Methadone 86 mg PO DAILY
7. RiTONAvir 100 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Ibuprofen 600 mg PO Q6H:PRN headache
10. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
11. Acyclovir 800 mg PO Q8H
12. Ensure Plus (food supplemt, lactose-reduced) 0.05-1.5
gram-kcal/mL oral TID W/MEALS
13. Multivitamins 1 TAB PO DAILY
14. ClonazePAM 0.5 mg PO BID
Discharge Medications:
1. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
RX *emtricitabine-tenofovir alafen [Descovy] 200 mg-25 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Acetaminophen 500 mg PO DAILY:PRN headache
4. Acyclovir 800 mg PO Q8H
5. ClonazePAM 0.5 mg PO BID
6. CloniDINE 0.2 mg PO BID
7. Ensure Plus (food supplemt, lactose-reduced) 0.05-1.5
gram-kcal/mL oral TID W/MEALS
8. Gabapentin 800 mg PO QID
9. Ibuprofen 600 mg PO Q6H:PRN headache
10. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
11. Methadone 86 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
#HIV
Secondary diagnoses
===================
#Anal squamous cell carcinoma in situ s/p excision
#Chronic pain
#Neuropathy
#Hepatitis C infection
#Anxiety
#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 to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because we were concerned you
had pneumonia.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had a CT scan that did not
show evidence of infection
- You were seen by our colorectal surgeons but declined an exam.
They will follow up with you as an outpatient.
- You were started on a new medication for your HIV. If you have
trouble obtaining this medication, please call your PCP ___.
WHAT SHOULD I DO WHEN I GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10712178-DS-9
| 10,712,178 | 25,840,911 |
DS
| 9 |
2156-05-04 00:00:00
|
2156-05-04 21:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ w/ hx of hypothyroidism, gastritis (seen on EGD in ___,
and
chronic GERD w/ hiatal hernia s/p ___ fundoplication, who
presents with persistent epigastric abdominal pain.
Patient's epigastric pain began suddenly 9 days ago. She
describes this pain as a "flame" that radiates from her
epigastrium up her chest. She reports that the pain has been
___ at its worst and constant over the past 9 days. She denies
the pain being worsened with food, but adds that she has had
very
little to eat over the past 9 days (few tablespoons at a time).
Additionally, she reports that she has lost 8lbs over since this
pain began. The pain is not worsened by exercise or position.
Additionally, the patient reports nausea, no appetite,
suprapubic
pain. Patient denies fevers, chills, chest pain, shortness of
breath, cough, vomiting, melena, or bloody stools.
She initially presented to ___ emergency department
on ___ and was diagnosed with peptic ulcer disease and was
prescribed sulcralfate, which has not helped. She has stopped
taking ASA 81 mg two days ago. Today, ___, she presented to
Dr. ___ referred her to the ___ emergency department
because he was concerned for possible cholecystitis or peptic
ulcer disease. Of note patient has had recent macrobid for a UTI
and augmentin for laryngitis, found later to be most likely
fungal laryngitis.
- In the ED, initial vitals were:
Temp: 98.2 HR: 65 BP: 122/70 RR: 16 O2 Sat: 96% RA
- Exam was notable for:
Tender to palpation in epigastrium
- Labs were notable for:
___ 01:50PM BLOOD WBC: 5.4 RBC: 4.54 Hgb: 13.2 Hct: 41.8
MCV: 92 MCH: 29.1 MCHC: 31.6* RDW: 15.5 RDWSD: 52.3* Plt Ct: 214
___ 01:50PM BLOOD Neuts: 51.5 Lymphs: ___ Monos: 10.5 Eos:
0.7* Baso: 0.9 Im ___: 0.4 AbsNeut: 2.78 AbsLymp: 1.95 AbsMono:
0.57 AbsEos: 0.04 AbsBaso: 0.05
___ 01:50PM BLOOD Plt Ct: 214
___ 01:50PM BLOOD ___: 11.5 PTT: 23.6* ___: 1.1
___ 01:50PM BLOOD Glucose: 101* UreaN: 12 Creat: 0.9 Na:
147
K: 4.5 Cl: 108 HCO3: 26 AnGap: 13
___ 01:50PM BLOOD ALT: 11 AST: 13 AlkPhos: 73 TotBili: 0.3
___ 01:50PM BLOOD Lipase: 13
___ 01:50PM BLOOD cTropnT: <0.01
___ 01:50PM BLOOD Albumin: 4.1
- Studies were notable for:
CT Scan, ___. ___ ___: per patient, report not
available, inflammation due to gastric ulcer
Right upper quadrant ultrasound:
1. Cholelithiasis without specific findings for acute
cholecystitis. However,given the degree of gallbladder
distension, acute cholecystitis is not excluded in the
appropriate clinical setting. HIDA can be considered for further
assessment if there is continued concern for acute
cholecystitis.
2. No biliary dilatation.
- The patient was given:
Morphine sulfate 4 mg IV
Ceftriaxone 1 g IV
EKG ___: sinus bradycardia, abnormal R wave progression
(early transition)
- GI was consulted
Make NPO, if RUQ pain call ACS for possible cholecystitis. If no
pain, plan for EGD tomorrow morning.
On arrival to the floor, the patient reports that since
receiving
morphine in the ED, her pain has gone down significantly.
Past Medical History:
PMHx:
Depression
Hypercholesterolemia
Hypothyroidism
GERD
Hiatal hernia
H/o H pylori (treated in ___
Paraesophageal hernia
Surgical Hx:
Laproscopic paraesophageal hernia repair, fundoplication, ___
gastroplasty, and graft placement ___
Ventral herniorrhaphy w/ marlex mesh ___
Bilateral apron ___ reduction mammoplasty ___
Left spigelian hernia repair ___
Social History:
___
Family History:
Mother with breast ca and colon ca, lived into her ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 97.9 PO BP: 135/71 HR: 58 RR: 18 O2
sat: 93% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mildly-tender to
deep palpation in epigastrium and suprapubic area. Negative
___ sign. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:24 HR Data (last updated ___ @ 557)
Temp: 98.0 (Tm 98.0), BP: 112/69 (112-137/64-85), HR: 71
(59-71), RR: 18, O2 sat: 95% (94-95), O2 delivery: Ra
GENERAL: Alert and interactive.
HEENT: MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mildly-tender to
deep palpation in epigastrium and LUQ. Negative ___ sign.
No
organomegaly. No visible skin rashes
GU: No suprapubic tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Gait wnl
Pertinent Results:
ADMISSION LABS
===============
___ 01:50PM BLOOD WBC-5.4 RBC-4.54 Hgb-13.2 Hct-41.8 MCV-92
MCH-29.1 MCHC-31.6* RDW-15.5 RDWSD-52.3* Plt ___
___ 01:50PM BLOOD Neuts-51.5 ___ Monos-10.5
Eos-0.7* Baso-0.9 Im ___ AbsNeut-2.78 AbsLymp-1.95
AbsMono-0.57 AbsEos-0.04 AbsBaso-0.05
___ 01:50PM BLOOD ___ PTT-23.6* ___
___ 01:50PM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-147
K-4.5 Cl-108 HCO3-26 AnGap-13
___ 01:50PM BLOOD ALT-11 AST-13 AlkPhos-73 TotBili-0.3
___ 01:50PM BLOOD cTropnT-<0.01
___ 01:50PM BLOOD Albumin-4.1
DISCHARGE LABS
===============
___ 06:44AM BLOOD WBC-5.1 RBC-4.40 Hgb-12.9 Hct-40.0 MCV-91
MCH-29.3 MCHC-32.3 RDW-15.4 RDWSD-50.5* Plt ___
___ 06:44AM BLOOD Plt ___
___ 06:44AM BLOOD ___ PTT-23.1* ___
___ 06:44AM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-144
K-4.3 Cl-105 HCO3-22 AnGap-17
___ 06:44AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.2
OTHER PERTINENT LABS
=====================
___ 09:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:54PM BLOOD pO2-151* pCO2-41 pH-7.38 calTCO2-25 Base
XS-0
___ 09:54PM BLOOD Lactate-1.3
IMAGING/STUDIES
===============
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
1. Cholelithiasis without specific findings for acute
cholecystitis. However,
given the degree of gallbladder distension, acute cholecystitis
is not
excluded in the appropriate clinical setting. HIDA can be
considered for
further assessment if there is continued concern for acute
cholecystitis.
2. No biliary dilatation.
___ Gastroenterology EGD
Normal mucosa in the esophagus, stomach, and duodenum. Biopsy
with normal histology. ___ fundoplication intact and in
place endoscopically.
___ HIDA
IMPRESSION: Normal hepatobiliary scan. No evidence of acute
cholecystitis.
Brief Hospital Course:
SUMMARY STATEMENT
==================
___ w/ hx of gastritis s/p fundoplication, hypothyroidism, who
presented with persistent epigastric abdominal pain. She
underwent a through evaluation which demonstrated cholelitiasis
and no evidence of acute causes of her abdominal pain.
ACUTE/ACTIVE ISSUES:
====================
# Epigastric pain
# H/o GERD, H. pylori
Patient presented with epigastric pain for 9 days, with normal
CT
AP at OSH (notable for diverticulosis without diverticulitis,
cholelithiasis without evidence of cholecystitis, fatty liver
infiltrates, bilateral inguinal hernias. No mention of aortic
disease or pyelonephritis.) This was thought most likely to
represent peptic ulcer disease/gastritis by EGD here on ___ was
completely unremarkable. Presentation was unlikely cardiac
related given normal EKG, neg trop x2. RUQ US with evidence of
cholelithiasis and distended GB, but otherwise no clear other
signs of cholecystitis. However given the normal endoscopy and
ongoing epigastric pain with unclear findings on RUQ ultrasound,
the GI team recommended HIDA scan. This showed no obstruction.
Patient was given high dose PPI twice daily, ranitidine,
sucralfate, calcium carbonate as needed which was narrowed to
just H2 blocker and PPI at the time of discharge.
# Suprapubic Tenderness
# UTI
Patient described developing suprapubic pain and dysuria 3 days
prior to admission, stating that this presentation was similar
to her prior UTI pain which she had 3 weeks ago. UA demonstrated
WBC 22, protein 30, ketones 10. Patient was started on
ceftriaxone in ED which was continued for 3 days until urine
culture showed mixed bacterial flora with no predominant
organism. Symptoms resolved after 3 day course of CTX.
# Depression/Anxiety
Patient stated that she has been feeling more depressed lately,
and was stressed by the current dynamics of her relationship
with
her daughter. She stated that she doesn't have many friends or
family to watch after her. She also endorsed significant
anxiety. It was speculated that at least part
of her worsening abdominal pain may have been anxiety and
stress-related. She was continued on the home escitalopram 10 mg
daily, buspirone 10 mg twice daily, lorazepam nightly. Social
work was consulted for psychosocial distress and depression.
CHRONIC/STABLE ISSUES:
======================
# Chronic MSK pain
- continue home gabapentin 100mg AM, noon
- continue home gabapentin 300mg QHS
# Hypothyroidism
- home levothyroxine 112mcg
# Chronic Constipation
- home bisacodyl
- home docusate sodium 100mg
# Hypercholesterolemia
- Continue home atorvastatin 10mg
- Recently stopped taking ASA 81 mg due to likely PUD, continue
to hold
# Fungal Laryngitis
- s/p 3 wk tx with clotrimazole troche, started ___,
additionally has completed a tx of amoxicillin clavulanate
- Follow-up with Dr. ___, in ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. BusPIRone 10 mg PO BID
3. Diclofenac Sodium ___ 50 mg PO BID:PRN Knee Pain
4. Escitalopram Oxalate 10 mg PO DAILY
5. Esomeprazole 40 mg Other DAILY
6. Gabapentin 300 mg PO QHS
7. Gabapentin 100 mg PO BID
8. Levothyroxine Sodium 112 mcg PO DAILY
9. LORazepam 1 mg PO QHS
10. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Ranitidine 150 mg PO QHS
13. Sucralfate 1 gm PO QID
14. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever
15. Bisacodyl ___ mg PR QHS:PRN Constipation - Second Line
16. Calcium Carbonate 300 mg PO QID:PRN Heartburn
17. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
18. Cyanocobalamin 1000 mcg PO DAILY
19. Docusate Sodium 100 mg PO BID
20. Lactobacillus acidophilus 460 mg (20 billion cell) oral
DAILY
21. Magnesium Oxide 400 mg PO DAILY
22. Multivitamins 1 TAB PO DAILY
23. Simethicone 80 mg PO QID:PRN Gas Pain
Discharge Medications:
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever
2. Atorvastatin 10 mg PO QPM
3. Bisacodyl ___ mg PR QHS:PRN Constipation - Second Line
4. BusPIRone 10 mg PO BID
5. Calcium Carbonate 300 mg PO QID:PRN Heartburn
6. Cyanocobalamin 1000 mcg PO DAILY
7. Diclofenac Sodium ___ 50 mg PO BID:PRN Knee Pain
8. Docusate Sodium 100 mg PO BID
9. Escitalopram Oxalate 10 mg PO DAILY
10. Esomeprazole 40 mg Other DAILY
11. Gabapentin 300 mg PO QHS
12. Gabapentin 100 mg PO BID
13. Lactobacillus acidophilus 460 mg (20 billion cell) oral
DAILY
14. Levothyroxine Sodium 112 mcg PO DAILY
15. LORazepam 1 mg PO QHS
16. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
17. Magnesium Oxide 400 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
20. Ranitidine 150 mg PO QHS
21. Simethicone 80 mg PO QID:PRN Gas Pain
22. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
23. HELD- Sucralfate 1 gm PO QID This medication was held. Do
not restart Sucralfate until you see your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Epigastric Discomfort
UTI
SECONDARY DIAGNOSES:
=====================
Anxiety
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
upper abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
-We performed an ultrasound which showed you had slight
swelling of your gallbladder.
-You underwent a procedure called endoscopy (EGD) which was
completely normal. There was no evidence of ulcers, reflux or
inflammation.
-You received a scan called and HIDA scan to evaluate her
gallbladder. This demonstrated no blockages.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Please maintain a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10712190-DS-16
| 10,712,190 | 22,325,794 |
DS
| 16 |
2139-07-05 00:00:00
|
2139-07-05 23:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / ACE Inhibitors
Attending: ___
Chief Complaint:
Acute on Chronic Systolic Congestive Heart Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with a history of HTN, CHF, presenting
for worsening lower extremity edema. Patient was in his usual
state of health when over the last 4 days he noted worsening ___
edema. He usually gets his cardiology care at ___. He had an
echo which he states was abnormal, and he was started on
furosemide, which was recently uptitrated to 60mg daily. He
states that despite the increase in lasix, his edema is
worsening.
In the ED intial vitals were:98.2 ___ 18 100%. patient
was noted to have mod leuk, few bacteria on UA (asymptomatic)
and received Ceftriaxone. Patient had BNP>3400, Patient was also
given PO lasix and admitted to ___.
On the floor patient's only complaint is that he has a lot of
saliva, and he is unsure why. He states he is scheduled to see
his PCP to figure this out. Denies any current dyspnea. States
the furosemide in the ED did not result in significant
urination.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Patient gets most of his care at ___
Nonischemic Cardiomyopathy (LVEF 15%, moderate-to-severe mitral
regurgitation, ___ investigation negative)
Hypertension
Chronic Kidney Disease (baseline Cr 1.2)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Multiple
relatives with hypertension but no family history of CHF/CAD.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.5 139/99 86 16 98RA
GENERAL: NAD
HEENT: NCAT.
NECK: Supple with JVP 3cm above clavicle at 45 degrees.
CARDIAC: ___ SEM @ LLSB, regular
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: 3+ ___ edema to mid femur
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98, Tmax 98.2, 60s-70s, 105-124/70s-90s, 99% on RA, 68.4
from 71.5kg, Ins 1380, Outs 6325 (net -4.9L), Tele = 7-beat run
of NSVT and rare PVCs
GENERAL: No acute distress
HEENT: NCAT, EOMI/PERRL, MMM
NECK: Supple, did not appreciate JVP
CARDIAC: Regular rhythm, soft ___ mitral regurg murmur best
appreciated in left axilla.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS:
==========
___ 06:45PM BLOOD WBC-8.3 RBC-5.02 Hgb-14.6 Hct-46.8 MCV-93
MCH-29.1 MCHC-31.3 RDW-15.6* Plt ___
___ 05:10AM BLOOD WBC-6.8 RBC-4.77 Hgb-14.2 Hct-44.4 MCV-93
MCH-29.8 MCHC-32.0 RDW-15.7* Plt ___
___ 06:00AM BLOOD WBC-6.0 RBC-4.51* Hgb-13.8* Hct-41.6
MCV-92 MCH-30.7 MCHC-33.2 RDW-15.8* Plt ___
___ 11:00AM BLOOD WBC-6.4 RBC-4.89 Hgb-14.3 Hct-45.2 MCV-93
MCH-29.2 MCHC-31.6 RDW-15.9* Plt ___
___ 05:50AM BLOOD WBC-5.9 RBC-4.73 Hgb-14.4 Hct-44.0 MCV-93
MCH-30.4 MCHC-32.7 RDW-15.7* Plt ___
___ 06:45PM BLOOD ___ PTT-37.9* ___
___ 06:00AM BLOOD ___ PTT-39.9* ___
___ 05:50AM BLOOD ___
___ 06:45PM BLOOD Glucose-78 UreaN-27* Creat-1.5* Na-138
K-3.8 Cl-102 HCO3-25 AnGap-15
___ 01:05PM BLOOD Glucose-86 UreaN-23* Creat-1.3* Na-140
K-3.5 Cl-102 HCO3-29 AnGap-13
___ 11:00AM BLOOD Glucose-176* UreaN-32* Creat-1.3* Na-136
K-3.8 Cl-99 HCO3-29 AnGap-12
___ 05:50AM BLOOD Glucose-68* UreaN-30* Creat-1.2 Na-141
K-3.6 Cl-99 HCO3-33* AnGap-13
___ 06:45PM BLOOD ALT-28 AST-35 AlkPhos-113 TotBili-1.2
___ 06:00AM BLOOD ALT-19 AST-26 LD(LDH)-311* AlkPhos-102
TotBili-1.2
___ 06:45PM BLOOD Lipase-19
___ 06:00AM BLOOD Lipase-23
___ 06:45PM BLOOD proBNP-3486*
___ 05:10AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
___ 06:00AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.7 Mg-1.7
___ 05:50AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
___ 12:45PM BLOOD TSH-0.47
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
___ 09:00PM URINE RBC-2 WBC-34* Bacteri-FEW Yeast-NONE
Epi-0
___ 09:00PM URINE CastHy-135*
___ 09:00PM URINE Mucous-RARE
IMAGING:
===============
ECG ___: Sinus rhythm. Left ventricular hypertrophy with
secondary repolarization
abnormalities. No previous tracing available for comparison.
CHEST X-RAY ___ =
Cardiomegaly with minimal pulmonary vascular congestion.
TRANSTHORACIC ECHOCARDIOGRAM ___ =
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. There is SEVERE
GLOBAL LEFT VENTRICULAR HYPOKINESIS (LVEF = 15 %). The estimated
cardiac index is depressed (<2.0L/min/m2). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. 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. An eccentric,
posteriorly directed jet of moderate to severe (3+) MITRAL
REGURGITATION is seen. The posterior mitral leaflet is markedly
tethered due to posterolateral displacement of the papillary
muscles. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. [In the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
ABDOMINAL ULTRASOUND ___
IMPRESSION:
1. Pulsatile portal venous waveform can be seen with severe
right heart
failure or tricuspid regurgitation.
2. Gallbladder wall thickening and moderate amount of ascites
is likely third
spacing from volume overload.
MICRO:
===============
URINE CULTURE:
___ 9:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old male with a history of CHF and HTN cared for at ___,
presented with worsening lower extremity edema and elevated BNP
secondary to acute on chronic systolic congestive heart failure.
# Acute on Chronic Systolic Congestive Heart Failure: Presented
with ___ edema, elevated JVD, elevated BNP,
cardiomegaly/pulmonary edema on CXR, LVEF15% with MR on
echocardiogram. Per ___ records, ___, ESR, UPEP/SPEP, HIV, TSH
levels all within normal limits. Right and left heart
catheterization revealed no coronary artery disease. Diuresed
well to furosemide IV boluses and was transitioned to Torsemide.
Was discharged on 40 mg daily of Torsemide. Was also treated
with home dose 100 mg metoprolol succinate. Losartan dose was
decreased to 25 mg daily (from 50 mg) given ___ as noted below.
Previously had been on spironolactone 12.5 mg daily. This was
held during admission, recommend consideration of restarting
this on follow up cardiology appointment. Admission weight was
79.4 kgs. (175.04 lbs). Discharge weight was 68.4 kg on
___.
#Abdominal Pain: Complained of severe bilateral lower abdominal
pain radiating to back on ___ AM. Claims not happened before
but would be better with BM. Remainder of exam unremarkable
aside from murmur and leg edema. LFTs/Lipase normal. Ddx
electrolyte abnormality from large diuresis versus constipation
versus hepatic congestion. Abdominal ultrasound showed:
pulsatile portal venous waveform consistent with severe right
heart
failure or tricuspid regurgitation. Also noted was gallbladder
wall thickening and moderate amount of ascites likely from third
spacing from volume overload. Abdominal pain resolved with
simethicone, polyethylene glycol, oxycodone 5mg x1, and
magnesium oxide x1.
# Coagulopathy: INR 1.4-1.5 not on any known anticoagulation
with albumin 3.1 and LDH 311. Transaminases/lipase normal.
Likely related to congestive hepatopathy vs lack of dietary
vitamin K. Abdominal ultrasound showed moderate ascites, likely
related to volume overload. Recommend continued monitoring of
abdominal exam on discharge follow up.
# Acute Kidney Injury: Creatinine elevated to 1.5 on admission
from unknown baseline. ___ be related to poor forward flow given
low ejection fraction. Patient was diuresed and creatinine
normalized to 1.2 on day of discharge. His electrolytes were
monitored throughout his hospital course. Recommend rechecking
electrolytes at discharge follow up appointment.
# Asymptomatic Bacteruria: UA with few bacteria with moderate
leuks, in setting of having hyaline casts on UA. Patient
received ceftriaxone in the ED. This was discontinued on the
medical ward. Urine culture was negative.
# Hypertension: Chronic stable issue on metoprolol and losartan.
TRANSITIONAL ISSUES:
=================
- CHF: discharged on 25 mg Losartan (decrease from prior dose of
50 mg), Metoprolol succinate 100 mg XL, and Torsemide 40 mg
daily. Previously was on Spironolactone 12.5 mg daily, would
recommend restarting this on outpatient follow up. Has follow up
with Dr. ___ at ___ clinic on ___, recommend
checking chem-10 at follow up appointment. Patient should have
chemistries drawn on discharge follow up. Discharge weight was
68.4 kg.
- Ascites: Abdominal ultrasound showed: pulsatile portal venous
waveform consistent with severe right heart
failure or tricuspid regurgitation. Also noted was gallbladder
wall thickening and moderate amount of ascites likely from third
spacing from volume overload. Recommend continued monitoring of
abdominal exam on discharge follow up.
# Full Code: Full Code confirmed with patient. Contact is
___ (sister) ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
Unclear if patient is very compliant with medication or diet.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Spironolactone 12.5 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
2. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having leg
swelling because of worsening heart failure. You were given
diuretics ("water pills") to urinate the excess fluid away. You
were discharged when you were at a dry weight of 68.4 kg (~151
pounds).
Please weight yourself every day; if you gain more than 3
pounds, please call the ___ heart failure clinic at
___ as you may need to adjust your medications. In
addition, you should have your blood chemistries checked this at
your discharge follow up appointment with Dr. ___ on ___. Please take all medications as prescribed, attend all
appointments as directed, follow a low-salt heart healthy diet,
and call a physician if you have any questions.
Take Care
- Your ___ Team
Followup Instructions:
___
|
10712217-DS-11
| 10,712,217 | 21,561,906 |
DS
| 11 |
2177-12-03 00:00:00
|
2177-12-04 21:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending: ___.
Chief Complaint:
leg swelling, DOE
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
Tracheostomy
PICC line placement
Arterial line placement
Trauma line placement
History of Present Illness:
___ M with a PMH of afib on coumadin, diabetes, HIV, HTN and
CHF BIBA after calling 911 for several months of increasing ___
edema x2months and concerns that he was not doing well at home
w/ lightheadness, DOEx4days, disorientation. Upon further
questioning he does note DOE x4days and several weeks of dark
malodorous loose stool with intermittent BRBPR in the toilet
bowl. Does recall some mild abdominal pain 4 days ago that has
resolved. States he has had a colonoscopy and EGD previously at
___, does not know why, states he does not remember being told
anything was wrong. Denies ETOH use, occasional Aleve use. Of
note, he states his ___ stopped checking his blood levels about
1 month ago. He continued to take his coumadin as previously
instructed (1.5pills/day, unknown dose). Denies F/C/CP/SOB at
rest/N/V/hematemesis, diaphoresis. Noted ___ edema has worsened
over the last 2 days.
In the ED, initial VS were Temp 98 HR 148 BP 98/58 RR 15 sat
100% 3LNC. He was noted to be pale appearing and tachycardic
with guaiac positive black stool on rectal exam. Labs were
significant for a hct of 12.8 (last noted to be 37.4 in ___,
hgb 3.6, INR 14.2, plts 216, Cr 2.7 (last noted to be 1.2 in
___ with a BUN of 73, Bicarb 20, glucose 216, trop 0.07,
lactate 1.3, LFTs normal, Alb 3.6. Repeat Hct 1.5hrs later was
stable at 12.4 prior to ___ transfusions. Blood cultures were
sent. ECG showed afib with RVR (HR120s) and poor baseline. CXR
showed mild cardiomegaly, clear lungs without acute process.
Patient received 1 liter NS with improvement in his SBP from ___
to 100s and HR from 140s to 120s. Patient was ordered for 4PRBCs
ad 3 units FFP, however only the first unit of FFP had been
completed prior to transfer. Patient was receiving the second
unit of FFP on arrival and had not received any PRBCs. He
received pantoprazole 40mg IV and vitamin K 10mg IV. GI was
consulted and plans to do EGD and colonoscopy early this week,
when hct is >25 and INR is therapeutic. Admitted with a presumed
diagnosis of subacute lower GI bleed. VS on transfer HR 120-130
BP94/60 rr16 100% RA.
On arrival to the MICU, he is comfortable lying in bed without
chest pain, SOB, lightheadedness. C/o trembling.
Past Medical History:
afib on coumadin (CHADS 3, denies h/o strokes)
diabetes on oral hypoglycemics
HTN
HL
CHF
CAD s/p MI ___ ago (denies PCI or CABG)
CKD (unknown baseline)
HIV, pt reports undetectable viral load
s/p right hernia repair
Social History:
___
Family History:
Mother w/ HTN. Father w/ HTN and h/o MI. Denies DM, CVA, cancers
including stomach and colon cancer.
Physical Exam:
Admission Exam:
Vitals: T: 98.4 BP: 117/66 P: 133 R: 18 O2: 100%2LNC
General: Alert, oriented, no acute distress, pleasant and
interactive
HEENT: Sclera anicteric, MMM, oropharynx clear w/ dentures,
EOMI, PERRL
Neck: supple, JVP could not be assessed ___ large neck, no LAD,
trauma line in right JVP with moderate hematoma posteriorly
CV: rapid irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Lungs: Clear to auscultation bilaterally with mild rales at the
bases bilaterally, no wheezes, rhonchi
Abdomen: Obese, soft, non-tender, mildly distended, bowel sounds
present- normoactive, unable to assess for organomegaly. healed
scar to the right of the umbilicus
GU: no foley
Ext: ___ symmetric edema to knees bilaterally, warm, well
perfused, 1+ pulses, no clubbing, cyanosis, verucous lesions on
anterior shins bilaterally
Neuro: A&Ox3, CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred
Discharge Exam:
General: Awake, sitting in chair, interactive, following
commands.
HEENT: PERRL, anicteric sclera.
CV: S1S2 RRR w/o m/r/gs.
Lungs: CTA bilaterally w/o crackles or wheezing.
Ab: Positive BSs, NT/ND, no HSM.
Ext: Brawny ___ skin changes.
Neuro: Alert and interactive. Moving all extremities. No focal
motor deficits noted.
Pertinent Results:
Admission Labs:
___ 11:10PM BLOOD WBC-6.2# RBC-1.33*# Hgb-3.6*# Hct-12.8*#
MCV-97 MCH-27.3# MCHC-28.3*# RDW-17.4* Plt ___
___ 11:10PM BLOOD Neuts-75.1* ___ Monos-6.1 Eos-0.3
Baso-0.2
___ 11:10PM BLOOD ___ PTT-45.9* ___
___ 03:06AM BLOOD ___ 11:10PM BLOOD Glucose-216* UreaN-73* Creat-2.7*# Na-143
K-4.5 Cl-114* HCO3-20* AnGap-14
___ 11:10PM BLOOD ALT-11 AST-8 AlkPhos-114 TotBili-0.1
___ 11:10PM BLOOD cTropnT-0.07*
___ 03:06AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.2
___ 11:10PM BLOOD Albumin-3.6
___ 03:17AM BLOOD ___ pH-7.30*
___ 11:25PM BLOOD Lactate-1.3
___ 11:25PM BLOOD Hgb-3.9* calcHCT-12
___ 03:17AM BLOOD freeCa-1.02*
___ 05:59AM URINE Color-Straw Appear-Clear Sp ___
___ 05:59AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 05:59AM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:59AM URINE Hours-RANDOM UreaN-616 Creat-84 Na-43
K-27 Cl-33
___ 03:51AM BLOOD WBC-8.0 RBC-2.80* Hgb-7.9* Hct-25.0*
MCV-89 MCH-28.1 MCHC-31.5 RDW-16.4* Plt ___
___ 05:39AM BLOOD WBC-7.8 RBC-2.75* Hgb-7.9* Hct-24.5*
MCV-89 MCH-28.7 MCHC-32.1 RDW-16.6* Plt ___
___ 03:15AM BLOOD ___ PTT-24.4* ___
___ 12:58AM BLOOD ___ PTT-26.7 ___
___ 04:01AM BLOOD ___ PTT-25.0 ___
___ 03:51AM BLOOD ___ PTT-29.2 ___
___ 12:58AM BLOOD Glucose-153* UreaN-36* Creat-1.8* Na-150*
K-3.0* Cl-112* HCO3-28 AnGap-13
___ 12:00PM BLOOD Na-149* K-3.5 Cl-114*
___ 11:13PM BLOOD Glucose-180* UreaN-31* Creat-1.7* Na-145
K-3.4 Cl-110* HCO3-25 AnGap-13
___ 04:01AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-145
K-3.7 Cl-111* HCO3-27 AnGap-11
___ 03:51AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-146*
K-3.8 Cl-110* HCO3-26 AnGap-14
___ 10:04PM BLOOD Glucose-120* UreaN-18 Creat-1.5* Na-147*
K-3.6 Cl-112* HCO3-24 AnGap-15
___ 05:39AM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-147*
K-4.0 Cl-112* HCO3-27 AnGap-12
___ 05:39AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0
___ 05:35AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND
___ 05:35AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND
___ 03:56PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:56PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 03:56PM URINE RBC-1 WBC-12* Bacteri-NONE Yeast-NONE
Epi-0
___ 3:56 pm URINE Site: NOT SPECIFIED
Source: Line-PICC line.
URINE CULTURE (Preliminary):
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.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:00 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).
ECG Study Date of ___ 11:12:34 ___
Atrial fibrillation with rapid ventricular response rate of 126
beats per
minute. Multifocal premature ventricular complexes. Delayed R
wave
transition. Non-specific ST segment changes in the lateral and
high lateral leads. No previous tracing available for
comparison.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 10:29 AM
FINDINGS:
CT OF THE ABDOMEN WITHOUT CONTRAST: Although this study is not
tailored for
the evaluation of supradiaphragmatic contents, the visualized
lung bases show
bilateral consolidations/collapse on the right greater than the
left with air
bronchograms and trace bilateral pleural effusions on the right
greater than
the left. Diffuse ground-glass opacification in the aerated
portions of the
lung bases is also noted. No pulmonary nodules are seen.
Limited imaging of
the heart shows moderately enlarged size without pericardial
effusion. The
visualized portion of the descending thoracic aorta is slightly
tortuous in
its course. The esophagus contains an enteric tube and
otherwise appears
unremarkable.
Evaluation of the solid organs is limited without intravenous
contrast.
Within these limitations, no gross abnormality is detected
within the liver.
There is trace perihepatic fluid. No intrahepatic or
extrahepatic biliary
ductal dilatation is seen. The gallbladder contains several
calcified
gallstones in the dependent portion measuring up to 6 mm in
size. No
gallbladder wall thickening, edema, or pericholecystic fluid is
seen. The
pancreas is unremarkable. The spleen contains a 2.1-cm
hypodensity with
internal fluid density of 19 Hounsfield units, likely
representing a splenic
cyst. The spleen is otherwise unremarkable. The bilateral
adrenal glands and
kidneys are within normal limits.
The stomach contains an enteric tube in the distal body. The
intra-abdominal
loops of small and large bowel are unremarkable without evidence
of wall
thickening or obstruction. The appendix is normal in
appearance. Minimal
fluid is noted tracking along the left paracolic gutter. There
is no large
volume abdominal ascites or retroperitoneal fluid collection.
No free air is
present. No mesenteric or retroperitoneal lymphadenopathy is
noted, although
there are scattered small retroperitoneal and iliac lymph nodes
which do not
meet CT size criteria for lymphadenopathy.
The abdominal aorta is normal in caliber throughout.
CT OF THE PELVIS WITHOUT CONTRAST: The urinary bladder is
decompressed by
Foley catheter in appropriate position. The prostate and
seminal vesicles are
unremarkable. A small amount of simple free fluid is noted
superior to the
urinary bladder, within the superior pelvis. The rectum and
sigmoid colon are
unremarkable. Several prominent pelvic side wall and inguinal
lymph nodes are
noted measuring up to 12 mm in short axis.
OSSEOUS STRUCTURES AND SOFT TISSUES: There is a compression
fracture
deformity at the L5 vertebral body which is indeterminate in
age. No
suspicious lytic or sclerotic lesions are detected in the bone.
There is mild
generalized anasarca. No focal fluid collections are noted
within the soft
tissue to suggest hematoma.
IMPRESSION:
1. No evidence of retroperitoneal or subcutaneous fluid
collection to suggest
hematoma. Mild generalized anasarca and minimal perihepatic and
pelvic
ascites is noted.
2. Bibasilar consolidation/collapse of the lungs, on the right
greater than
the left, with trace pleural effusions.
3. Cholelithiasis.
4. Nonspecific prominent pelvic side wall and inguinal lymph
nodes.
TTE (Complete) Done ___ at 10:56:45 AM FINAL
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately 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 diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild-moderate mitral regurgitation. Pulmonary artery
hypertension.
PORTABLE ABDOMEN Study Date of ___ 11:51 AM
*** UNAPPROVED (PRELIMINARY) REPORT *** !! WET READ !!
Preliminary report has not yet been released for viewing.
CHEST (PORTABLE AP) Study Date of ___ 2:50 ___
NG tube tip is in the stomach. Tracheostomy tube is in the
standard position. Left PICC tip is in the mid-to-lower SVC.
Moderate cardiomegaly is stable. There is mild vascular
congestion. Bibasilar opacities, larger on the left side are
unchanged, could be due to atelectasis and/or pneumonia. There
are no new lung abnormalities.
EGD ___
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
General anesthesia. A physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The vocal cords were visualized. The procedure was
not difficult. The patient tolerated the procedure well. There
were no complications.
Findings: Esophagus:
Mucosa: Esophagitis with no bleeding was seen in the GE
junctoin, compatible with mild esophagitis.
Stomach:
Mucosa: Erythema of the mucosa with no bleeding was noted in
the antrum. These findings are compatible with mild gastritis.
Other linear erosion on the greater curvature of the stomach
consistent with NG tube trauma
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Esophagitis in the GE junctoin compatible with mild
esophagitis
Linear erosion on the greater curvature of the stomach
consistent with NG tube trauma
Erythema in the antrum compatible with mild gastritis
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: No clear explanation for the patient's GI bleed
from this EGD.
Will need colonoscopy when more stable
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSIS are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology.
Bronchoscopy ___
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
standard time out was performed as per protocol. The procedure
was performed for diagnostic and therapeutic purposes at the
operating room. A physical exam was performed. The bronchoscope
was introduced through an endotracheal tube and advanced under
direct visualization until the tracheobronchial tree was
reached.The procedure was not difficult. The quality of the
preparation was good. The patient tolerated the procedure well.
There were no complications.
Recommendations: Admit to ICU
Additional notes: Patient medication list was reconciled.
Attending was present for the entire procedure. FINAL DIAGNOSES
are listed in the impression section above. Estimated blood loss
= 25 ml. No specimens were taken for pathology.
Colonoscopy ___
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
efficiency of a colonoscopy in detecting lesions was discussed
with the patient and it was pointed out that a small percentage
of polyps and other lesions can be missed with the test. A
physical exam was performed. The patient was administered
moderate sedation. The physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position.The
digital exam was normal. The colonoscope was introduced through
the rectum and advanced under direct visualization until the
cecum was reached. The appendiceal orifice and ileo-cecal valve
were identified. Careful visualization of the colon was
performed as the colonoscope was withdrawn. The colonoscope was
retroflexed within the rectum. The procedure was not difficult.
The quality of the preparation was fair. The patient tolerated
the procedure well. There were no complications.
Findings:
Protruding Lesions Three sessile non-bleeding polyps of benign
appearance and ranging in size from 5 mm to 6 mm were found in
the ascending, descending, sigmoid.
Excavated Lesions A single circular ulcer was found in the
rectum. A single linear ulcer was found in the rectum.
Impression: Polyps in the ascending, descending, sigmoid
Ulcer in the rectum
Ulcer in the rectum
Otherwise normal colonoscopy to cecum
Recommendations: Colonoscopy in 6 mos.
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure. Degree of difficulty 1 (5 most difficult) FINAL
DIAGNOSES are listed in the impression section above. Estimated
blood loss = zero. No specimens were taken for pathology
Brief Hospital Course:
___ M with a PMH of afib on coumadin, diabetes, HIV, HTN, and
CHF admitted to the ICU with likely subacute GIB, with hct 12.8
in the context of supratherapeutic INR at 14.2. Originally he
was hypotensive secondary to significant blood loss. Patient was
noted to have SBPs in the ___ on admission, was responsive to
IVF bolus. He then receivied 6 units PRBCs and FFP with a
massive transfusion protocol with SBPs in the 100s with a trauma
line that was placed. All his at home antihypertensives were
held clonidine, monixidil, isosorbide dinitrate. His atrial
fibrillation normally treated with coumadin and diltiazem at
home became Afib with RVR likely 2ndary to anemia (rates in the
120s to 140s). Patient then became agitiated and went into flash
pulmonary edema. he was intubated and then was stablaized. He
failed 3 extubation attmepts, 1 planned and 2 self attmepts. He
then got a tracheosomty placed. He improved afterwards and was
able to breath off of the ventilator without hemodynamic
compromise.
# Anemia ___ gastrointestinal bleeding: Patient reports a
history of weeks of dark stools and was noted to have dark
guaiac positive stool on rectal exam. He does not carry a
diagnosis of liver disease or known GI pathology, however he has
also not seen a GI physician and has not had an EGD or
colonoscopy previously. LFTs are normal, MCV normal. Hcts
stabilized, then dropped again and he was transfused another 2
more units. His EGD showed esophagitis in the GE junctoin
compatible with mild esophagitis, linear erosion on the greater
curvature of the stomach consistent with NG tube trauma,
erythema in the antrum compatible with mild gastritis. He had a
colonoscopy that showed several rectal ulcers and polyps in the
ascending, descending, and sigmoid colon. No clear explanation
of the GI bleed was discovered and a colonscopy was recommened
in 6 months.
# Supratherapeutic INR: patient is on coumadin for atrial
fibrillation. It is currently unclear how or for how long his
INR has been supratherapeutic. He was given vitamin K 10mg IV
and multiple units of FFP. Patient is a poor historian and may
have inadvertantly taken more than recommended. He was continued
without anticoagulation due to the GIB. At the end of the
hospitalization his coumadin was restarted at his home dose and
will be continued to be montiored and managed as an outpatient.
#A. fib. with RVR on multiple occasion led to flashing during
the extubation attempts. He was managed as above for coumadin
and rate controlled with diltiazem and metoprolol.
#CHF Pt required large doses of iv lasix and lasix drips to
treat vol overload and lost over 19 kilograms during the
hospitalization likely due to a fluid overloaded state and ___
edema that resolved by the time of discharge.
#Hypertension: History of htn he was treated before with
clonidine, Isosorbide Dinitrate, Lisinopril, Diltiazem ER,
Metoprolol, and Minoxidil. He was treated with clonidine,
diltiazem, metoprolol mainly, but several medicines were used on
a prn basis including hydralazine and a nitroglycerin drip. We
discharged him with lisinopril, metoprolol, clonidine, and
isosorbide dinitrate.
# ___: It is unknown whether the patient carries a diagnosis
of CKD, however he does related that he has been told his
kidneys do not work well. States he does not urinate a lot as
well. Admission Cr is 2.7. Last known Cr is 1.2 from ___. ___
could be due to renal hypoperfusion ___ acute/subacute blood
loss. Final Cr during hospitalization 1.5.
# Elevated troponin: Likely due to demand ischemia ___
tachycardia and significant anemia. Following trops flat.
Outpatient management should be continued.
# Diabetes: Blood glucose 216 on admission. Patient managed on
oral hypoglycemics as an outpatient. Managed with 10 units of
glargine and a sliding scale, may be continued as an outpatient
or transitioned to oral medications.
# HIV: patient reports an undetectable viral load. Inactive
issue during this hospitalization.
-continued home meds and needs to continue outpt followup
Hypernatremia -Pt required free water flushes to resolve his
hypernatremia. This issue resolved in the hospitalization.
UTI- He was found to have a E.Coli UTI and we decided to treat
for 7 days with ceftriaxone staring on ___. End dat ___.
Transitional issues:
Colonoscopy with GI within 6 months
Gi says the flexiseal- would be best to avoid, but can continue
for patient comfort/ skin issues.
___ start glipizide when taking PO, now discharging on insulin
per regimen in the hospital
Diet per Page 1: pureed and nectar thick with cuff deflated, no
PMV
Discharged on subq heparin for dvt prophylaxis will read address
the issue of anticoagulation as an outpatient
Pt was send out on 7 days on ceftriaxone for a UTI end on
___.
PICC line
Hypertension medications may need uptitration
Holding lasix as patient diuresed during hospitalization over 20
pounds and was borderline hypernatremic at time of discharge,
during cardiology appointment, reconsideration of restarting
lasix.
Blood cultures pending
Emergency contact ___ ___
Sister ___ ___, not official
emergency contact.
Full code during this admission
Medications on Admission:
Unable to obtain information regarding preadmission medication
at this time. Information was obtained from dc list from ___
in ___.
1. Abacavir Sulfate 600 mg PO HS
2. Efavirenz 600 mg PO HS
3. LaMIVudine 150 mg PO HS
4. Azithromycin 250 mg PO Q24H
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Isosorbide Dinitrate 20 mg PO TID
9. Minoxidil 5 mg PO BID
10. CloniDINE 0.4 mg PO BID
11. Furosemide 40 mg PO DAILY
12. Furosemide 20 mg PO PRN lower extremity edema
13. Pravastatin 40 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Warfarin 5 mg PO DAILY16
16. GlipiZIDE 5 mg PO DAILY
take 30 minutes before a meal
17. traZODONE 25 mg PO HS
18. Calcitriol 0.25 mcg PO MWF
19. Cyanocobalamin 1000 mcg PO DAILY
20. Doxazosin 8 mg PO HS
21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
22. Omeprazole 40 mg PO DAILY
23. Docusate Sodium 100 mg PO BID
24. Polyethylene Glycol 17 g PO DAILY:PRN constipation
25. Lactulose 15 mL PO Q8H:PRN constipation
26. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Abacavir Sulfate 600 mg PO HS
2. CloniDINE 0.4 mg PO BID
3. Efavirenz 600 mg PO HS
4. Isosorbide Dinitrate 40 mg PO TID
HOLD for SBP<100
5. LaMIVudine 150 mg PO HS
6. Senna 1 TAB PO BID:PRN constipation
7. Warfarin 5 mg PO DAILY16
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Lisinopril 20 mg PO DAILY
12. Glargine 10 Units Dinner
Insulin SC Sliding Scale using REG Insulin
13. Omeprazole 40 mg PO DAILY
14. Metoprolol Tartrate 100 mg PO TID
hold for SBP < 100, HR < 60
15. Aspirin 81 mg PO DAILY
16. Calcitriol 0.25 mcg PO MWF
17. Cyanocobalamin 1000 mcg PO DAILY
18. Lactulose 15 mL PO Q8H:PRN constipation
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Pravastatin 40 mg PO DAILY
21. traZODONE 25 mg PO HS:PRN Sleep aide
22. Quetiapine Fumarate 50 mg PO Q12H:PRN agitation
23. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower gastrointestinal bleed
Congestive heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___.
You were treated in the hospital for low blood pressures likely
from a gastrointestinal bleed in the setting of a high INR,
which is a measure of the thinness of your blood on coumadin.
You received several blood transfusions. You were also seen by
the gastroenterology doctors who recommended a colonoscopy that
showed rectal ulcers, which may be where the bleed was coming
from. You should have another colonoscopy in 6 months. Because
you stopped bleeding your coumadin was restarted on discharge.
Because you were critically ill, you were treated in the
intensive care unit and were intubated for several days due to
fluid in your lungs. Since you had the breathing tube in for
several days and it had been replaced several times, we changed
your tube to a tracheostomy, which is the breathing tube that
was placed in your neck. As you improve this may be able to be
removed in the future. Since you cannot eat safely right now,
you have a feeding tube in as well which can be removed when you
can safely swallow.
Changes to your medications:
STOP taking minoxidil
STOP taking doxazosin.
STOP taking glipizide
STOP taking azithromycin
STOP taking Lasix
CHANGE dose of lisinopril to 20 mg daily
CHANGE dose of isosorbide dinitrate to 40 mg three times a day
CHANGE metoprolol to three times daily
START taking heparin shots three times a day. This can help
prevent blood clots.
START taking lantus insulin 10 units at night and insulin
sliding scale with meals.
START taking seroquel 50 mg twice a day as needed
START taking ceftriaxone 1 g daily x 7 days, starting ___,
given in the ICU.
Followup Instructions:
___
|
10712276-DS-6
| 10,712,276 | 25,926,677 |
DS
| 6 |
2143-02-20 00:00:00
|
2143-02-21 17:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of COPD on intermittent home 2L, pAF, EF 55% in
___, HTN, CKD stage 3 and aortic arch aneurysm presenting
with
dyspnea and chest tightness/pressure x 4 days.
He was referred after seeing PCP and ___, was found to
have new bilateral pleural effusions on CXR. He reports the
chest
pressure is similar to prior episodes when he has dyspnea. He
reports whitish yellow sputum and baseline fatigue, though his
son notes he has been more somnolent at home. He denies fever,
chills, cough, cold symptoms, nausea/vomiting.
In the ED...
- Initial vitals:
Yest 15:28 97.6 78 151/96 16 94% 3L NC
- Exam:
"Gen: well appearing
HEENT: NCAT, dry MM (baseline after radiation therapy)
CV: rrr
Pulm: diffuse soft wheezes, mildly decreased BS at bases,
minimal
rales, no rhonchi
Ext: no edema"
- EKG: sinus, multiple PVCs, RBBB,
- Labs/studies notable for: BNP 6138, trop neg x2, flu neg, Cr
1.0
-CTA chest with aortic arch aneurysm. "per Rads the innominate
takes off from the proximal aneurysm and left common carotid and
subclavian arteries take off from the aneurysm." was discussed
with patient and family, surgery was again declined (declined in
___. report below
- Patient was given:
___ 17:29 NEB Ipratropium-Albuterol Neb 1 NEB
___
___ 18:56 PO Azithromycin 500 mg ___
___ 18:56 IH Albuterol 0.083% Neb Soln 1 NEB ___
___ 18:56 IV MethylPREDNISolone Sodium Succ 125 mg
___
___ 23:30 NEB Ipratropium-Albuterol Neb ___
Not Given
___ 01:07 IV Furosemide 40 mg ___
___ 01:07 IV Labetalol 10 mg ___
___ 02:08 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 02:08 IH Ipratropium Bromide Neb 1 NEB ___
- Vitals on transfer: Today 02:27 98.0 80 139/83 25 97% 4L NC
On the floor, history obtained with ___ speaking staff
member. Was not able to communicate effectively using language
line. He confirms the above history. Also notes no cough, fever,
sick contacts, edema, weight change. He started to feel better
hours ago in the ED (got Lasix a few hours before hitting floor,
steroids about 9 hours before). He does not want to stay in the
hospital. Says he has filled out DNR/DNI documentation in the
past.
Past Medical History:
aortic arch aneurysm (declined surgery in ___
abdominal aortic aneurysm s/p open repair
COPD on intermittent home 2L O2
pAF diagnosed via Holter monitor
HTN
T2DM
CKD stage 3
carotid stenosis
HLD
BPH
nasopharyngeal CA
amblyopia
Social History:
___
Family History:
NC
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VS: 96.9 AdultAxillary 152 / 82 R Lying 78 22 94 3L
GENERAL: NAD
HEENT: anicteric sclera, dry oral mucosa
NECK: ___ at earlobe at 45 degrees
CV: RRR, PVCs, S1/S2, no murmurs
PULM: crackles at bases. mild diffuse expiratory wheezing,
prolonged expiratory phase
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: trace ___ edema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm, no rashes
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: 24 HR Data (last updated ___ @ 924)
Temp: 97.7 (Tm 99.0), BP: 147/73 (137-161/58-91), HR: 70
(65-80), RR: 16 (___), O2 sat: 91% (91-97), O2 delivery: 2L
Nc,
Wt: 152.4 lb/69.13 kg
Fluid Balance (last updated ___ @ 845)
Last 8 hours Total cumulative 50ml
IN: Total 300ml, PO Amt 300ml
OUT: Total 250ml, Urine Amt 250ml
Last 24 hours Total cumulative 100ml
IN: Total 1400ml, PO Amt 1400ml
OUT: Total 1300ml, Urine Amt 1300ml
Weight: 72.2kg -> 69.13kg
Telemetry: NSR
General: WDWN elderly male
HEENT: MMM
Neck: ___ barely visible just below clavicle at close to 90
degrees (~9-10cm)
Lungs: Mild bibasilar rales, improved air movement bilaterally
CV: Irregular rhythm. Normal S1, S2. No murmur appreciated.
Abdomen: Soft, nontender, nondistended.
Ext: Warm, well perfused, no peripheral edema.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:22PM BLOOD WBC-8.5 RBC-3.82* Hgb-12.4* Hct-38.9*
MCV-102* MCH-32.5* MCHC-31.9* RDW-15.1 RDWSD-55.8* Plt ___
___ 04:22PM BLOOD Neuts-78.1* Lymphs-11.7* Monos-7.1
Eos-2.2 Baso-0.4 Im ___ AbsNeut-6.64* AbsLymp-0.99*
AbsMono-0.60 AbsEos-0.19 AbsBaso-0.03
___ 04:22PM BLOOD Plt ___
___ 04:22PM BLOOD Glucose-107* UreaN-23* Creat-1.0 Na-140
K-4.1 Cl-97 HCO3-28 AnGap-15
___ 04:22PM BLOOD proBNP-6138*
___ 04:22PM BLOOD cTropnT-<0.01
___ 11:38PM BLOOD cTropnT-<0.01
==============
DISCHARGE LABS
==============
___ 08:33AM BLOOD WBC-11.2* RBC-3.85* Hgb-12.6* Hct-39.3*
MCV-102* MCH-32.7* MCHC-32.1 RDW-15.2 RDWSD-56.8* Plt ___
___ 08:33AM BLOOD Glucose-192* UreaN-30* Creat-1.2 Na-142
K-4.0 Cl-96 HCO3-33* AnGap-13
===================
IMAGING/PROCEDURES
===================
CTA Chest
1. Large fusiform aneurysm at the aortic arch measuring up to
6.8 cm in
diameter, involving the arch branches, and spanning a segment of
approximately
11 cm of the aorta. No associated dissection or signs of
perforation.
Recommend consultation with cardiothoracic surgery regarding
further
management.
2. Dilated main pulmonary artery, correlate for pulmonary
arterial
hypertension.
3. No evidence of pulmonary embolism.
4. Small right and trace left pleural effusions.
5. Severe emphysema.
6. Hepatic steatosis.
CXR
Thoracic aortic aneurysm involving the arch is again visualized
and overall stable in size compared to the recent chest CT dated
___. No pleural effusions. Mild pulmonary vascular
congestion in both lower lobes, nonspecific.
TTE:
Severely dilated aortic arch. Mildly dilated ascending aorta.
Preserved global left ventricular systolic function with the
suggestion of possible mild basal inferior and inferolateral
hypokinesis in limited views. Mildly dilated right ventricle
with low-normal systolic function. Mild mitral and tricsupid
regurgitation. Moderate pulmonary hypertension.
Brief Hospital Course:
=======
SUMMARY
=======
Mr. ___ is a ___ with history of COPD on intermittent home 2L,
pAF, EF 55% in ___, HTN, CKD stage 3 and aortic arch aneurysm
presenting with dyspnea and chest tightness/pressure x 4 days
and found to have a COPD exacerbation and heart failure
exacerbation.
# CORONARIES: unknown
# PUMP: LVEF 60%
# RHYTHM: pAF, currently NSR
======================
ACTIVE MEDICAL ISSUES
======================
#Hypoxemic respiratory failure
#Worsening dyspnea
Believe multifactorial, but more likely related to COPD
exacerbation rather than HF exacerbation as not particulary
fluid overloaded on exam and did not diurese much to Lasix.
Patient improved after some Lasix and also with treatment of
COPD exacerbation with prednisone, azithromycin, and duonebs.
Per family, patient has been requiring O2 at home while
ambulating and does not have portable O2 prescribed. Plan to
email patient's PCP at discharge to arrange coordination of
portable O2 as outpatient.
#Suspected HFpEF Exacerbation
Patient presented with 4 days of worsening dyspnea and chest
pressure and found to have a mildly elevated BNP and slightly
elevated ___ consistent with a mild heart failure exacerbation.
He received 40mg IV Lasix ___ and improved symptomatically.
Since not particularly volume overloaded, suspect resp symptoms
largely due to COPD exacerbation. Not on home Lasix but given
slightly elevated ___ start PO Lasix 40mg and patient to
follow-up with Atrius PCP and cardiologist as outpatient.
Patient to continue on home metoprolol and ACE inhibitor and to
f/u with Dr. ___ in ___ weeks.
#Suspected COPD exacerbation
Has severe emphysema at baseline and is on intermittent home O2.
Did have increased sputum production and with bilateral wheezes
consistent with COPD exacerbation. Patient was started on
prednisone 40 mg daily and azithromycin daily to complete a
5-day course. Symptoms improved after 1 day of treatment and
patient to complete rest of treatment for COPD exacerbation as
outpatient. He should follow-up with his PCP ___ 1 week to
ensure symptoms continue to resolve.
#pAF
Per outpatient notes, diagnosed on Holter. CHADS-VASC of 5. Had
discussed AC with OP cards but not yet initiated. After
discussing with patient and his son, decision was made to
initiate apixaban 2.5 mg twice daily.
#Aortic Arch Aneurysm given findings on CT scan in the ED,:
Cardiac surgery was consulted but patient and family declined
surgery as risk was too great. Cardiac surgery recommended goal
SBP of less than 140. Patient underwent a TTE on ___ which
again showed a severely dilated aortic arch with no appreciable
aortic regurgitation.
#HTN:
Continued on home lisinopril, amlodipine, metop. As above, goal
SBP <140.
#Goals
Confirmed code status is DNR/DNI with son and patient.
===================
TRANSITIONAL ISSUES
===================
DISCHARGE WEIGHT: 69.13kg (152.4 lb)
DISCHARGE CREATININE: 1.2
[ ] HFpEF: Given the patient remains slightly volume up on exam,
he was discharged on Lasix 40 mg daily. Please follow-up Lyme
exam and weights as outpatient and titrate Lasix as needed.
[ ] COPD Exacerbation: Patient to be discharged on prednisone 40
mg daily for total of 5 days and azithromycin for a 5-day
course. Patient should be evaluated early next week to ensure
symptoms resolve.
[ ] Aortic root aneurysm: had a previously known severely
dilated aortic root aneurysm that was again noted on CT and TTE
on this hospitalization. Cardiac surgery was consulted in the ED
but son and patient declined surgery. Will manage medically by
ensuring systolic blood pressures are less than 140
[ ] Confirmed with patient and son that he has a DNR/DNI on this
admission.
# CODE: DNR/DNI
# CONTACT: HCP: son ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. GlipiZIDE 10 mg PO BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Pravastatin 60 mg PO QPM
8. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once daily Disp #*3
Tablet Refills:*0
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 4 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth once daily Disp #*6
Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
6. GlipiZIDE 10 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 30 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 60 mg PO QPM
13.Outpatient Lab Work
ICD-10: I50
LAB TEST: Basic metabolic profile
DATE: ___
PLEASE FAX RESULTS TO: ___ ATTN: Dr. ___
Discharge Disposition:
Home
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS
==================
- COPD exacerbation
- Heart failure exacerbation
====================
SECONDARY DIAGNOSIS
====================
Severely dilated aortic arch aneurysm
Paroxysmal A. fib
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 the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having shortness of breath
and were found to have a exacerbation of your COPD and heart
failure.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were started on steroids and antibiotics for your COPD
exacerbation.
- You were given Lasix (water pill) through your IV because you
were thought to have some extra fluid on.
- After a day on the COPD and heart failure treatment, your
breathing improved and you were felt to be safe for discharge
home.
-You had an echocardiogram of your heart (ultrasound), which
showed that you have a very enlarged aorta. You were seen by
the cardiac surgeons and after discussion with you and your
family, it was decided that surgery would be risky and would not
be something you would like to pursue.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You will be discharged on a new medication called furosemide
(water pill) that you should take every day to prevent fluid
from accumulating in your lungs.
- You will need to continue taking the steroids and antibiotics
for a total of 5 days to treat your COPD exacerbation. (last day
___
- You are being discharged on a blood thinning medication. This
can make it harder for you to stop bleeding. If you fall and hit
your head, please go to the nearest emergency room as you are at
increased risk of head bleeding.
- We will notify your PCP about your recent admission and
arrange for follow-up. Should receive a call from their office
in ___ days for follow-up appointment. We will also let your
PCP know about her increased need for oxygen so that you can be
arranged for portable oxygen as an outpatient.
- You will need to have your labs checked next week on ___ to
make sure your kidney function and electrolytes are stable on
the new medication. These results will be faxed to Dr. ___.
- We will also notify your cardiologist of your recent admission
and will arrange for follow-up.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10713098-DS-13
| 10,713,098 | 23,973,526 |
DS
| 13 |
2139-06-25 00:00:00
|
2139-06-25 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine
Attending: ___.
Chief Complaint:
Positive blood culture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMHx of recently diagnosed pancreatic CA currently
on cycle 1 of chemotherapy, who was referred to the ED for blood
cx positive for GNRs. Pt reports that she initially presented
yesterday for low grade fevers (Tm 100) and sore throat.
However, she was then called back to ED at ___ after
blood cx drawn returned positive for GNRs.
In the ED at ___, pt was noted to have RUQ TTP. She underwent
RUQ US in the ED at ___ which showed cholelithiasis without
clear evidence of cholecystitis. She received a dose of Zosyn
prior to transfer.
White blood cell count was not elevated, urinalysis negative.
LFTs from the outside hospital: AST 178, ALT 166, alkaline
phosphatase 229 total bilirubin 2.2, direct bilirubin 1.4.
ED Course:
Initial VS: 98.8 83 107/60 18 98% RA
Imaging: no new imaging
Meds given: zosyn, zofran
VS prior to transfer: 98.6 97 103/59 16 98% RA
On arrival to the floor, the patient endorsed RUQ pain only on
palpation. Otherwise, she denies any current pain. Her sore
throat has resolved.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea, urinary
symptoms, muscle or joint pains, focal numbness or tingling,
skin rash. The remainder of the ROS was negative.
Past Medical History:
adenocarcinoma of the pancreas
Social History:
___
Family History:
Brother died of prostate CA at age ___
Sister died of either ovarian or uterine CA at age ___
Sister alive and well at age ___, had breast CA
Father died of bleeding ulcer and PNA at age ___
Mother died of CHF at age ___
Physical Exam:
Admission Exam:
VS - 98.4 98/60 89 20 98%RA
GEN - Alert, NAD
HEENT - NC/AT, no thrush noted
NECK - Supple, no cervical LAD
CV - RRR, no m/r/g
RESP - CTA B
ABD - S/ND, BS present, TTP on deep palpation of RUQ
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - Non-focal
PSYCH - Calm, appropriate
Discharge Exam:
VS: 97.9 100/58 72 18 99% RA
GEN: NAD
HEENT: no thrush noted, no erythema noted
NECK: Supple, no cervical LAD
CV: RR, nl R, no murmurs
RESP: CTAB
ABD: soft, minimal RUQ tenderness, no distension. +BS.
Ext: No edema, WWP.
Skin: No rashses.
Pertinent Results:
Admission Labs:
___ 05:22AM BLOOD WBC-0.9*# RBC-2.59*# Hgb-7.4*# Hct-22.7*#
MCV-88 MCH-28.6 MCHC-32.6 RDW-12.9 Plt Ct-79*#
___ 05:22AM BLOOD Neuts-32* Bands-0 Lymphs-66* Monos-0
Eos-1 Baso-0 Atyps-1* ___ Myelos-0
___ 05:22AM BLOOD ___ PTT-30.4 ___
___ 05:22AM BLOOD Glucose-76 UreaN-7 Creat-0.4 Na-135 K-3.9
Cl-102 HCO3-25 AnGap-12
___ 05:22AM BLOOD ALT-123* AST-80* AlkPhos-151* TotBili-0.7
___ 05:22AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.7
Discharge Labs:
___ 05:24AM BLOOD WBC-5.7# RBC-2.62* Hgb-7.3* Hct-22.5*
MCV-86 MCH-27.7 MCHC-32.2 RDW-13.1 Plt Ct-58*
___ 05:24AM BLOOD Neuts-77.5* ___ Monos-1.7*
Eos-0.3 Baso-0.2
___ 05:24AM BLOOD Glucose-75 UreaN-3* Creat-0.5 Na-135
K-3.5 Cl-99 HCO3-27 AnGap-13
___ 05:24AM BLOOD ALT-115* AST-113* AlkPhos-119*
TotBili-0.3
___ MICRO:
___ Blood cultures: NGTD
CTAP: IMPRESSION: 1. Mass in the body of the pancreas
consistent with pancreatic adenocarcinoma. 2. Left adrenal mass
concerning for metastasis. 3. 1.6cm left renal mass in the
lower pole may repreesent a second primary. Retroperitoneal
lymphadenopathy can be from renal mass versus pancreatic mass.
4. Small bowel wall thickening over 13 cm most likely
represents tumor infilltration which then raises the possibility
of lymphoma (Oncologist and Patient notified of results).
Brief Hospital Course:
___ with recently diagnosed pancreatic cancer on cycle 1 of
chemotherapy who was transferred from an OSH with positive blood
culture.
# Klebsiella Pneumoniae bacteremia:
She had a klebsiella pneumonia bacteremia in ___ bottles drawn
from her port-a-cath. Final sensitivities were obtained and ID
was consulted. She was initially treated with
Piperacillin/Tazobactam until final sensitivities returned and
she was changed to ceftriaxone. She will be treated for a total
fo 14 days of antibiotics (11 more days from discharge). IV
infusion was arranged for her to receive these antibiotics at
home. There was no evidence of port infection but this will need
to be monitored closely after antibiotics are discontinued.
- 14 days of IV antibiotics
# Pancytopenia, secondary to chemotherapy:
Given her neutropenia (ANC nadir of 288) and bacteremia, she was
given a dose of neupogen. Her WBC responded appropriately. Her
Hct and platelets were also low. She did not require
transfusion. She will get follow up labs with her oncology the
day after discharge for further monitoring. No symptoms of
anemia.
# Pancreatic cancer:
Further chemotherapy per primary oncologist.
# Transaminitis:
She underwent evaluation of her gallbladder which was without
evidence of infection. The likely etiology of her transaminitis
was secondary to chemotherapy. She will follow up with her
oncology for further evaluation.
# CTAP findings:
Communicated to patient and Dr. ___. Very unlikely that three
separate primary cancers exist. Much more likely that she has a
single cancer. However, Dr. ___ will follow her and is aware
of these findings. The patient is also aware of the findings.
# Tobacco Abuse:
Continue with nicotine patch per the patients request.
# CODE STATUS: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q8H:PRN nausea or anxiety
2. Docusate Sodium 100 mg PO BID
3. Pantoprazole 40 mg PO Q24H
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Fentanyl Patch 25 mcg/h TD Q72H
6. Senna 8.6 mg PO BID:PRN constipation
7. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lorazepam 0.5 mg PO Q8H:PRN nausea or anxiety
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
she has not been using this at home
4. Pantoprazole 40 mg PO Q24H
5. Prochlorperazine 10 mg PO Q8H:PRN nausea
6. Senna 8.6 mg PO BID:PRN constipation
7. Fentanyl Patch 25 mcg/h TD Q72H
She has not been using this at home
8. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV daily Disp #*11 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacteremia
Pancytopenia secondary to chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for bacteria in your blood. You were treated
with IV antibiotics and will need to continue IV antibiotics for
another 11 days after discharge.
You will follow up with your oncologist tomorrow for repeat labs
and assessment.
Followup Instructions:
___
|
10713110-DS-10
| 10,713,110 | 27,537,458 |
DS
| 10 |
2169-01-23 00:00:00
|
2169-01-23 16:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Thigh pain
Major Surgical or Invasive Procedure:
Left hip joint aspiration ___
History of Present Illness:
___ yo male s/p left Hip sx ___ removal of medicated spacer and
reimplantation of hip.
Of note he had complications including bacteremia and underwent
washout in
___ with six-week course of vancomycin and
increase
in inflammatory markers in late ___. He had ongoing
bony destruction and persistent infection there and underwent
resection arthroplasty with irrigation and debridement and
placement of antibiotic spacer on ___. He
completed
over eight weeks of IV antibiotics with improvement in his
inflammatory markers. Recently, he underwent re-aspiration of
the hip on ___ with Interventional Radiology.
On ___ patient underwent left hip removal of antibiotic
spacer and reimplantation total hip arthroplasty with ___
___. During this hospitalization he was started on lovenox
for post-op ppx and was given RBCs as needed for post-op anemia.
He had LENIs for calf swelling that were negative for blood
clot. Geriatrics also followed the patient. He was discharged to
rehab on ___ in stable condition.
He was recovering at rehab when he had sudden onset left hip
pain as well as nausea and vomiting (LLQ pain as he was being
rolled). He denied chest pain, SOB, dysuria although he reported
diarrhea yesterday. He was found to be tachycardic and
hypotensive and was brought to ___ where he had a WBC of 19.9
and lactate of 5.1. hgb 10.1. FAST negative. Green diarrhea that
was guaiac positive. He was transferred to ___ for further
evaluation. He was brought to the ED. Per documentation CT A/P
was done that showed a large fluid collection around the left
hip as well as ?prostatitis.
On arrival, he was afebrile, hypotensive to 84/54, HR 120's.
Lactate 5.3 WBC 19.9. Urine negative. CT abd pelvis was negative
for acute intraabdominal pathology but showed a left hip
effusion. A f/u bedside u/s showed a hematoma anterior to the
hip effusion. He received 1 g vancomycin, zosyn, and 2 L IVF. He
had 2 18 gauge IVs and a 20.
In the ED, initial vitals: 99.6 F, HR 100s, BP 90/50s, RR 18,
99% RA.
On arrival to the MICU, patient is A/OX3 and c/o left hip pain.
His hip is tender to palpation, swollen with tense skin, not
erythematous. Steri strips are present along surgical site,
appears c/d/I with some crusting. He reports things were going
well at rehab until yesterday.
Past Medical History:
HTN
HL
CKD III
spinal stenosis
osteoarthritis
L hip/femur osteomyelitis and septic joint with septic
trochanteric bursitis complicated by Staph epidermidis
bacteremia, s/p washout and 6+ week course Daptomycin->
Vancomycin
Social History:
___
Family History:
Non-contributory
Physical Exam:
===========================
ADMISSION PHYSICAL EXAM
===========================
Vitals: T: 98.2 F BP: 110/60s P: 100s R: 18 O2: 100% RA
GENERAL: Alert, oriented, pale
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
NECK: supple, difficult to appreciate JVP
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic with soft systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: left hip is tender to palpation, swollen with tense skin,
not erythematous. Steri strips are present along surgical site,
appears c/d/I with some crusting. 2+ peripheral DP pulses, able
to wiggle toes, good strength with RLE, unable to move LLE d/t
pain
SKIN: surgical site as noted above, wounds per RN
NEURO: non-focal
DISCHARGE PHYSICAL EXAM:
AVSS
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM. JVD below clavicle
LUNGS: Mild crackles at bases of lungs bilaterally, otherwise no
w/r
HEART: RRR, S1, S2, soft systolic murmur at RUSB
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP. L thigh with well healing surgical incision,
no
erythema, ecchymosis, or drainage. Non-tender to palpation. Firm
to palpation surrounding surgical incision. 1+ edema LLE
NEURO: awake, A&Ox2
Pertinent Results:
===========================
LABS
===========================
ADMISSION
---------------
___ 10:40PM BLOOD WBC-23.9*# RBC-2.19* Hgb-6.9* Hct-22.5*
MCV-103*# MCH-31.5 MCHC-30.7* RDW-14.6 RDWSD-54.4* Plt ___
___ 10:40PM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-3*
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-22.23*
AbsLymp-0.72* AbsMono-0.72 AbsEos-0.00* AbsBaso-0.00*
___ 10:40PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL
___ 10:40PM BLOOD ___ PTT-29.4 ___
___ 10:40PM BLOOD Glucose-159* UreaN-20 Creat-1.0 Na-137
K-4.0 Cl-100 HCO3-22 AnGap-19
___ 10:40PM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.4 Mg-1.6
___ 04:02AM BLOOD ___ Temp-37.1 pO2-17* pCO2-42
pH-7.39 calTCO2-26 Base XS--2 Intubat-NOT INTUBA
___ 10:46PM BLOOD Lactate-3.8*
===================
IMAGING
===================
Left Hip XR ___: There is irregularity of that acetabulum
adjacent to the acetabular cup component of the hip prosthesis.
Large heterogeneous abnormality of mixed attenuation extending
from gluteal musculature along the proximal left femur, likely
represents hematoma.
Linear, serpiginous abnormality within it may represent
calcification,
hypervascularity or area of contrast extravasation. Close
Clinical or imaging follow-up recommended to exclude mass, or
superimposed infection.
Irregularity of the lateral acetabulum, difficult to compared to
the prior MRI which was markedly abnormal, and assess whether
this is from infection or chronic finding.
There is edema, and enlargement of the left lower extremity.
Multiple hepatic lesions, indeterminate, possibly benign.
Mildly prominent bile duct, may be from prior cholecystectomy,
correlate with LFTs if clinically indicated.
Thickening of the rectum, may be inflammatory/infectious,
neoplasm cannot be excluded. 3.4 cm infrarenal aortic aneurysm.
Brief Hospital Course:
___ year old male with a history of Chronic Kidney Disease III,
Hypertension, septic left hip complicated by osteomyelitis s/p 6
week course of antibiotics and removal of spacer/total hip
arthroplasty hip presenting with left hip pain found to have
hematoma.
# Acute Blood Loss Anemia: Hemoglobin at OSH was 10.1, down to
6.9 here, likely due to bleeding into the left thigh given CT
findings and ___ joint aspiration significant for bloody fluid.
He did not have any other obvious sources of bleeding during his
MICU stay. He was transfused 4uPRBC with a hemoglobin increase
to 9.3 and a repeat hemoglobin of 9.5 before transfer out of the
MICU. Hemoglobin stable since transfer from ICU. Discharge Hgb
is 8.7.
# Shock: Originally he presented with an elevated WBC count and
lactate with hypotension. Source was initially felt to be septic
arthritis/osteoarthritis of the left hip, however left joint
aspiration was underwhelming with 1000 WBCs. His C.diff was
positive with signs of colitis on CT. He was transfused with
IVF, 4U pRBCs, and initially treated with broad spectrum
antibiotics using Vancomycin and Cefepime. Improvement in WBC
count and lactate were seen prior to transfer out of the MICU
and he remained stable on the floor.
# Sepsis due to
# C.diff infection: C. diff stool assay was positive at an
outside hospital with colitis seen on CT and an initial WBC
elevated to 20. He was started on po vancomycin q6h on ___ for
a 14 day course. Last day is ___.
# HTN: Home anti-hypertensive medications were initially held in
the setting of shock, quinapril resumed prior to discharge.
# CKD III: Maintained at his baseline creatinine of 0.7-1.0 in
the MICU.
TRANSITIONAL ISSUES:
[] Follow-up appt. with ___ ortho scheduled ___
[] Needs to wear abduction brace on L leg when out of bed
[] CT A/P findings: consider further workup as indicated =>
Letter was sent to PCP to notify of the findings for possible
outpatient follow-up.
[] multiple indeterminate hepatic lesions
[] Thickening of rectum- neoplasm cannot be excluded
[] 3.4 cm infrarenal aortic aneurysm
[] Patient diagnosed with c. diff colitis and initiated on 14
day course of PO vancomycin. Last day is ___
[] discharge Hgb 8.7. Stable between 8.3 and 9.5.
[] Patient being discharged with foley catheter. Please consider
removal in the next ___ days.
[] Patient has left knee pain on day of discharge. Evaluated by
orthopedics and cleared to continue rehab. Please reevaluate if
signs of infection.
# Communication/HCP: sister ___ (HCP) ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal BID PRN
2. Docusate Sodium 100 mg PO BID
3. Fleet Enema ___ID PRN constipation
4. Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
13. Quinapril 20 mg PO DAILY
14. Senna 17.2 mg PO DAILY constipation
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal BID PRN
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Fleet Enema ___ID PRN constipation
8. Furosemide 20 mg PO DAILY
9. Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
14. Quinapril 20 mg PO DAILY
15. Senna 17.2 mg PO DAILY constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Left thigh hematoma
Secondary diagnoses:
Clostridium difficile colitis
Hypotension
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___!
Why was I admitted to the hospital?
-You were admitted to the hospital because there was bleeding in
your hip
What happened while I was in the hospital?
-You received blood transfusions because your blood counts were
low
What should I do after leaving the hospital?
-Continue to work with physical therapy
-Follow-up with Dr. ___ scheduled appointment below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Followup Instructions:
___
|
10713499-DS-11
| 10,713,499 | 22,962,332 |
DS
| 11 |
2125-06-10 00:00:00
|
2125-06-10 17:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine / morphine
Attending: ___.
Chief Complaint:
___ yo M s/p 4 foot mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ who was on his usual state of health when
he fell from a 3 feet ladder. He believes it was a mechanical
fall related to stretching too far in one direction. He landed
on his right side of the body. He hit his right head. He does
not remember experiencing any dizziness or lightheadedness
before the fall. No loss of consciousness after the fall. He
remembers
experiencing excruciating pain localized to the right
hemithorax, back and forehead, as well as blood trickling down
from his forehead. He was experiencing trouble breathing
immediately after the incident, which has currently improved.
His family member called an ambulance, which brought him in to
___. He is not experiencing any headaches, dizziness, or
vision changes
currently. He did complain of nausea but attributes it to
fentanyl he received in the ED. He has vomited bilious brown
material twice since receiving the pain medication. On further
review of systems, he denies any palpitations, abdominal pain,
changes in bowel movements. He denies any gross hematuria,
however blood-tinged urine is noted in the urinal at bedside.
Past Medical History:
HTN
IBS
Asthma
Bilateral renal cysts
Nephrolithiasis
BPH
CKD
Social History:
Currently retired. He used to work for a ___. He
lives with his daughter who is disabled and he takes care of
her. He is a widower. He has two children, a son and a
daughter. He does not drink, smoke or use recreational drugs.
Physical Exam:
Admission Physical Exam:
Vitals: Temp: 98.4; BP: 136 / 61; HR: 64; RR: 16; SpO2: 94 Ra
General: appears to be experiencing pain and seems uncomfortable
HEENT: 2 cm laceration on the forehead on his right side and a
small laceration on the right pinna. Both have been stitched and
look clean. PERLA.
CV: RRR, no murmurs, gallops or rubs
Pulm: Pain palpation of the right side of the back. Diminished
breath sound on the right side. No crackles, wheezes or rhonchi.
Abd: Soft, nontender but mild to moderately distended. No masses
or hernias appreciated. +Right CVA tenderness
Ext: No pain in the ___ or ___. ___ and ___ are well perfused.
Palpable radial pulses, feet wwp.
Neuro: AAOx3. Gross sensation intact in the ___ and ___. Face
symmetric. Strength is ___ in the lower extremities, ___ on the
right ___ (chronic per pt) and ___ on the left ___
Discharge Physical Exam:
VS: T: 97.9 PO BP: 146/67 L Lying HR: 69 RR: 18 O2: 95% RA
GEN: A+Ox3, NAD
HEENT: right forehead laceration, closed with dermabond,
well-approximated, no s/s infection. Right superior pinna
laceration with dissolvable sutures, right ear lobe laceration
with dermabond, well approximated, no s/s infection
CV: RRR
PULM: CTA b/l
ABD: soft, distended per baseline, non-tender to palpation
EXT: no edema b/l
Pertinent Results:
___ 06:45PM WBC-8.1 RBC-3.05* HGB-9.7* HCT-28.0* MCV-92
MCH-31.8 MCHC-34.6 RDW-12.8 RDWSD-42.5
___ 06:45PM PLT COUNT-106*
___ 01:19PM WBC-8.7 RBC-3.33* HGB-10.3* HCT-31.0* MCV-93
MCH-30.9 MCHC-33.2 RDW-12.8 RDWSD-43.6
___ 01:19PM PLT COUNT-104*
___ 12:28PM URINE HOURS-RANDOM
___ 12:28PM URINE UHOLD-HOLD
___ 12:28PM URINE COLOR-Red* APPEAR-Hazy* SP ___
___ 12:28PM URINE BLOOD-LG* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR*
___ 12:28PM URINE RBC->182* WBC-10* BACTERIA-NONE
YEAST-NONE EPI-0
___ 12:28PM URINE MUCOUS-RARE*
___ 09:40AM GLUCOSE-137* CREAT-1.4* NA+-145 K+-3.3
___ 09:40AM estGFR-Using this
___ 09:40AM HGB-10.8* calcHCT-32
___ 09:29AM GLUCOSE-139* UREA N-22* CREAT-1.5*
SODIUM-149* POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-21* ANION
GAP-15
___ 09:29AM estGFR-Using this
___ 09:29AM WBC-6.8 RBC-3.40* HGB-10.8* HCT-31.7* MCV-93
MCH-31.8 MCHC-34.1 RDW-12.7 RDWSD-43.8
___ 09:29AM NEUTS-67.1 ___ MONOS-4.7* EOS-1.0
BASOS-0.3 IM ___ AbsNeut-4.54 AbsLymp-1.68 AbsMono-0.32
AbsEos-0.07 AbsBaso-0.02
___ 09:29AM PLT COUNT-149*
___ 09:29AM ___ PTT-20.0* ___
Imaging:
CT C-spine w/o contrast
There is apparent widening of the C4/C5 disc space, which is
likely related to adjacent disc space narrowing at C3/C4 and
C5/C6 from degenerative changes, but underlying ligamentous
injury is not excluded in the appropriate clinical setting. No
prior available for comparison. There is very minimal
anterolisthesis of C4 over C5.No acute fracture is seen.6 mm
sclerotic focus in the T1 vertebral body may represent a bone
island.There is no prevertebral soft tissue swelling. Partially
imaged lung apices are grossly clear. The imaged thyroid gland
dd
demonstrates a 4 mm hypodensity in the left lobe, no further
follow-up is warranted by size criteria.
CT ABD/ Pelvis with contrast
1. Several foci of right nephric and perinephric active
extravasation; active extravasation within a renal cyst as well
as in the right perinephric region, underlying injury of the
renal parenchyma may be present. Probable subcapsular hematoma
along the superolateral aspect of the right kidney measures
approximately 1.5 cm in width. Right perinephric stranding.
Small
amount of free fluid tracking along the right lateral abdomen
and
small amount of free fluid in the pelvis.
2. Interval collapse of a dominant right lobe liver cyst with
adjacent fat stranding and small amount of perihepatic fluid.
3. Mildly displaced fracture of the anterior right fourth rib
and
nondisplaced fractures of the anterolateral right sixth and
seventh ribs and lateral right eighth rib.
4. Severe compression deformity of the T7 vertebral body of
indeterminate age given lack of priors for comparison, but acute
component not excluded. Minimal 2 mm of retropulsion at this
level, which mildly narrows the central canal.
5. Mild loss of height of the inferior L2 vertebral body is new
since ___, but otherwise most likely not acute.
6. Small right pleural effusion and trace left pleural effusion
with overlying atelectasis.
7. Cholelithiasis.
CT head w/o contrast
There is no evidence of acute intracranial hemorrhage, midline
shift, mass effect, or acute large vascular territorial infarct.
Mild prominence of the ventricles and sulci is consistent with
involutional change. Periventricular and subcortical white
matter
hypodensities are likely sequelae of chronic small vessel
disease. The visualized paranasal sinuses demonstrate partially
imaged mucous retention cysts and mild mucosal thickening in the
bilateral maxillary sinuses. The mastoid air cells are clear.
No acute fracture is seen.
Brief Hospital Course:
Mr. ___ is an ___ who presented to ___ s/p 4 foot
mechanical fall off a ladder. Imaging revealed fractures of his
ribs 4, 6, 7 and 8 and a laceration of his right kidney. On
examination, he had chest pain localized to the right hemithorax
and lacerations of his forehead and right ear. Gross hematuria
was also present after he urinated. He also had a C-collar
placed.
At the ED, Mr. ___ was given fentanyl and this resulted in
multiple episodes of bilious vomiting. The patient reported
sensitivity to narcotic medication. Later that day, his
C-collar was cleared by the Neurosurgery spine service. Lab work
was trended to monitor both his hematocrit (remained stable) and
creatinine (mildly increased on arrival but decreased overtime).
He was transferred to the floor. Overnight, he slept well but
had a transient RBBB on EKG. Follow up with his PCP revealed
that he had chronic RBBB. At night, he was given low dose
oxycodone, but complained of mild nausea in the morning of
___. His pain medicine was therefore switched to tramidol,
which helped control his pain. The patient worked with physical
therapy and was cleared for discharge home.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
1. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
2. Furosemide 10 mg PO DAILY
3. LORazepam 0.5 mg PO QHS:PRN insomnia
4. Metoprolol Succinate XL 50 mg PO BID
5. Lisinopril 20 mg PO QAM
6. Lisinopril 10 mg PO LUNCH
7. HydrALAZINE 10 mg PO Q6H
8. Terazosin 4 mg PO QHS
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Terazosin 4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
-Right ___ & ___ rib fractures
-Right kidney laceration
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 after falling off a ladder and
you sustained multiple right-sided rib fractures as well as a
right kidney laceration. For your rib fractures, you received
pain medication and your breathing has remained stable. For
your kidney laceration, your blood counts were monitored and
have remained stable. You worked with physical therapy and were
cleared to be discharged home.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
* Your injury caused multiple right-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. If Lidocaine patches (which contain 5%
lidocaine) are too expensive or not covered by your insurance,
you may try an over-the-counter alternative called Salonpas
patches (4% lidocaine).
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Regarding your kidney laceration:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
kidney injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Followup Instructions:
___
|
10713795-DS-10
| 10,713,795 | 22,479,802 |
DS
| 10 |
2128-07-06 00:00:00
|
2128-07-06 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided facial droop and Left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right handed man with a history of
recently diagnosed Afib (not on anticoagulation) as well as HTN
and DM2 who is brought in by ambulance after a fall at home and
concern for stroke.
The patient was in his USOH when he spoke to his son last night
around 8pm and then went to sleep. This morning he awoke at
10am, apparently was able to get dressed, but we cannot confirm
he was "normal" at this time. He did not talk to anyone via
phone etc. At approximately 11am, he fell to the ground. He was
able to call his son who called EMS. The patient is not aware
of all his
deficits, but knew that he fell to the ground.
In the ED, initial NIHSS 16. NCHCT showed dense R MCA sign with
early signs of ischemia. CTA head and neck showed right M1
clot, but with collaterals feeding the RMCA territory distally.
Decision was made not to give tpa as last
known well was at ___ the night prior.
Spoke with PCP on the phone who provided additional PMH/meds. At
their last regular scheduled follow-up visit yesterday, EKG
showed atrial fibrillation which was a new diagnosis. The
patient was asymptomatic and was rate controlled (already on
Atenolol). He was referred to Cardiology.
On neurologic review of systems, the patient endorses dull
headache and hearing loss. He denies other ROS, but ureliable
given neglect. [No difficulty comprehending speech. Denies loss
of vision, blurred vision, diplopia, vertigo, tinnitus or
dysphagia. Denies bowel or bladder incontinence or retention.
Denies fevers, rigors, night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough. Denies
nausea, vomiting, diarrhea, constipation, or abdominal pain. No
recent change in bowel or bladder habits. Denies dysuria or
hematuria. Denies myalgias, arthralgias, or rash.
Past Medical History:
- Afib - noted on PCP visit last week, on ASA 81
- HTN
- DM2 - diet controlled, dx ___, A1c 6.4-6.7
- CKD III - GFR ___ stable
- chronic hearing loss, wears left hearing aide
- depression, anxiety
- IBS
- elevated PSA
- vitamin B12 deficiency
- Tremor - seen by neurology outpatient in ___ - symptoms
thought to be related to medication induced Parkinsonism vs
essential tremor. No medication changes were made at that time
however.
- Right total knee replacement
- Squamous cell carcinoma
Social History:
___
Family History:
Father died at ___ of massive MI. Mother died in her ___ of
cancer. No family history of strokes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T 98.2 BP 159/72 HR 68 RR 20 POX 96% RA
General: appears stated age, looks to the right, NAD
HEENT: NCAT, wears glasses and left hearing aide, no
oropharyngeal lesions, neck supple
___: irregularly irregular, rate in the ___, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities/Skin: Scaling, hyperkeratotic lesions with
erythematous base, warm, no edema
Neurologic Examination: (exam difficult because he is hard of
hearing)
- Mental Status - Awake, alert, oriented x 3 (except said ___
instead of ___. Attention to examiner easily maintained, but he
requires repitition of most commands because of hearing loss).
Also difficult to understand entire history given his
dysarthria,
but he appears coherent. Able to recite months of year
backwards. Speech is dysarthric, yet fluent with full sentences,
intact repetition, and intact verbal comprehension. Naming
intact. No paraphasias. Normal prosody. Dense left hemibody
neglect. When reading, reads only right most words and describes
right most pictures. He identifies objects to the right of the
1
o'clock poisition. Somatoparaphrenia of left arm. Anosognosia
of deficits. Mild left and right confusion.
- Cranial Nerves - PERRL 3->2 sluggish. VF difficult to assess
given neglect, but there is a decreased blink rate to threat on
left compared to right. Right gaze preference, he does slightly
cross midline with strong stimulus, but does not look all the
way
left. Intact EOM w/ Dolls maneuver. Sensation intact on right
hemiface and neglected vs primary sensory loss on left. Left
lower facial droop at rest and with movement. Significantly
decreased hearing bilaterally, has hearing aide in left ear
only.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor - Normal bulk. Left arm hypotonic compared to right.
Tone in legs appears symmetric and normal. Left arm and leg hit
the bed when held outstretched. Right arm with coarse resting
tremor of low amplitude (chronic). Also with slight intention
tremor in that arm. No asterixis. Right hemibody is full
strength. Left hemibody is difficult to assess given neglect.
In the upper extremity there is some adduction and internal
rotation at the shoulder with strong stimulus (likely ___,
otherwise no clear antigravity movements seen in the left arm.
In the left leg there was some spontaneous hip flexion and
bending of the knee while in the scanner. To noxious stimuli,
there is some movement in plane of the bed.
- Sensory - Primary sensory loss vs neglect on left hemibody.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 2 1
R 2 2 2 0 1
Plantar response upgoing bilaterally, left is majestic, right is
more subtle.
- Coordination - Mild intention tremor with FNF on right. Not
dysmetric on right. Unable to assess left arm.
- Gait - deferred
===============================
DISCHARGE PHYSICAL EXAM
General: NAD
HEENT: NCAT, wears glasses and left hearing aide with recently
replaced battery, no oropharyngeal lesions, neck supple
CV: irregularly irregular, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities/Skin: Scaling, hyperkeratotic lesions with
erythematous base, warm, no lower extremity edema
Neurologic Examination: (exam difficult because he is hard of
hearing) Exam waxes and wanes over the course of the day. At
best he is awake, alert and oriented x3. He does require
repetition of most commands because of severe hearing loss.
- Mental Status - Speech is fluent. Follows commands
appendicular and in R extremity. Dense left hemibody neglect.
- Cranial Nerves - PERRL 3->2 sluggish. VF difficult to assess
given neglect. Right gaze preference, but will cross midline
with strong stimulus. Mild left lower facial droop at rest and
with movement.
- Motor - Normal bulk. Left hemiparesis. L arm flaccid, L leg
decreased tone. Right arm with coarse resting tremor of low
amplitude (chronic) with significant paratonia and cogwheeling.
Right hemibody is full strength. L arm is plegic, L leg with
triple flexion.
Pertinent Results:
___ 06:20AM BLOOD WBC-7.7 RBC-4.16* Hgb-12.6* Hct-36.4*
MCV-87 MCH-30.2 MCHC-34.6 RDW-13.5 Plt ___
___ 06:20AM BLOOD Neuts-72.7* Lymphs-17.7* Monos-9.1
Eos-0.2 Baso-0.3
___ 06:20AM BLOOD Plt ___
___ 11:15AM BLOOD ___ PTT-27.4 ___
___ 06:20AM BLOOD Glucose-133* UreaN-26* Creat-1.1 Na-146*
K-3.2* Cl-113* HCO3-20* AnGap-16
___ 06:20AM BLOOD ALT-39 AST-36 CK(CPK)-372* AlkPhos-66
___ 06:27AM BLOOD Lipase-21
___ 08:55PM BLOOD CK-MB-5 cTropnT-<0.01
___ 11:15AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.4
___ 12:02PM BLOOD %HbA1c-6.4* eAG-137*
___ 06:27AM BLOOD TSH-0.35
___ 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine Culture ___, on ceftriaxone): no growth
DISCHARGE LABS (___):
WBC-9.2 RBC-3.95* Hgb-12.2* Hct-35.6* MCV-90 MCH-31.0 MCHC-34.4
RDW-13.7 Plt ___
___
BLOOD Glucose-148* UreaN-36* Creat-1.3* Na-148* K-4.2 Cl-117*
HCO3-22 AnGap-13
CT/CTA:Right internal carotid bifurcation clot extending into
the proximal A1 with complete M1 occlusion. There is distal MCA
branch filling, likely from the posterior circulation
collaterals. The right lateral lenticulostriate are opacified by
contrast. No intracranial hemorrhage is seen. No aneurysms are
visualized on this examination.
MRI: Large acute infarction predominantly within the right MCA
territory with possible involvement of additional smaller right
anterior cerebral artery branches.
Repeat CT on ___ due to sleepiness: Evolving acute infarction,
predominantly in the right middle cerebral artery territory,
with mild mass effect. No acute hemorrhage.
CXR: No pneumonia. The lung volumes remain low. Moderate
cardiomegaly.
KUB: No dilated loops of bowel.
Echo: Symmetric LVH with normal global and regional
biventricular systolic function. Mild aortic stenosis. Mild
aortic regurgitation. Mild mitral regurgitation. Moderate
pulmonary hypertension.
Brief Hospital Course:
___ is a ___ year old right handed man with a history of
recently diagnosed Afib (not on anticoagulation) as well as HTN
and DM2 presenting with L facial droop and L sided weakness.
Initial NIHSS 16 and neurological exam notable for left neglect,
right gaze preference, dysarthria, left arm/face > hemiparesis
and upgoing toes. CT imaging shows dense R MCA sign and CTA
confirms clot in the M1 territory, but there is distal right MCA
perfusion from collaterals. Given LKW over 16 hours ago and his
age, he is not a candidate for IV or IA tPA. Etiology of stroke
likely cardioembolic given recent diagnosis of afib and not
anticoagulated.
# Neuro:
Mr. ___ presented with L sided weakness and L facial droop
found to have a Right Middle Cerebral Artery Ischemic Stroke.
His CT/CTA showed right internal carotid bifurcation clot
extending into the proximal A1 with complete M1 occlusion. There
is distal MCA branch filling, likely from the posterior
circulation collaterals. The right lateral lenticulostriate are
opacified by contrast. No intracranial hemorrhage is seen. No
aneurysms are visualized. On ___, Mr. ___ appeared
more sleepy and thus a repeat head CT was obtained. Repeat head
CT showed evolving acute infarction, predominantly in the right
middle cerebral artery territory, with mild mass effect. No
acute hemorrhage. MRI showed a large acute infarction
predominantly within the right MCA territory with possible
involvement of additional smaller right anterior cerebral artery
branches. Mr. ___ was already on aspirin 81mg prior to
admission. Thus, his aspirin was increased to 325mg qday. He
was already on Simvastatin 20mg prior to admission. His LDL was
73 and thus was continued on Simvastatin 20mg during
hospitalization. His HgA1c is 6.4. His TSH is 0.35. In the
setting of newly discovered atrial fibrillation and stroke,
anticoagulation was indicated. However, initiation was delayed
due to his hematuria. After this improved, he was started on
warfarin, with no worsening of his we decided to hold off on
anticoagulation at this time. After his hematuria resolves, we
recommend that anticoagulation is started.
# CV:
Mr. ___ has newly discovered atrial fibrillation and
hypertension. Intially his antihypertensives were held for his
blood pressure to autoregulate with goals of SBP <190. However,
after 24 hours, half of his antihypertensives were restarted.
The doses were increased to full on ___. His Echo showed
symmetric LVH with normal global and regional biventricular
systolic function. Mild aortic stenosis. Mild aortic
regurgitation. Mild mitral regurgitation. Moderate pulmonary
hypertension. His troponins were negative. His CK on admission
was 410 and peaked at 658 but now is downtrending to 372.
He continued in atrial fibrillation throughout his
hospitalization. On the day propr to discharge his rates were
consistently 110-120s. He remained asymptomatic. His atenolol
was changed to metoprolol in combination with hydration as
described below and his RVR improved.
# Urology:
Mr. ___ had a traumatic foley placement with persistent
hematuria. He was evaluated by urology and a new foley was
placed. During the hospitalization, his bladder was irrigated
multiple times and blood clots were seen. Flomax and
Finasteride was started. Per Urology recommendations, the Foley
is to remain in until Urology outpatient follow up on ___, in
which he will have a voiding trial. His hematuria has been
decreasing and has changed from frank blood to rusty-colored
clots. He still has occasional clots which clear with flushing
the Foley.
# ID/Tox/Metabolic:
Mr. ___ was febrile on ___ with a Tmax of 100.9. He had a
febrile work up which was negative except for a UA that is
difficult to interpret secondary to large blood. Thus, he was
started on Cipro 500mg BID x 7 days on ___. Cipro is to be
continued until ___. UA showed > 183 RBCs, 106 WBCS and no
nitrates. He has not had a leukocytosis.
# Nutrition:
Mr. ___ initially had a NG tube but on ___, passed speech
and swallow evaluation for nectar thick liquids and pureed and
meds crushed with pureed. He has had multiple swallow
assessments with no change in his diet. He initially had poor PO
intake, documented with a calorie count, but his intake
improved. He remains 1:1 for all meals.
He has had poor intake of fluids on the nectar thick diet with
evidence of dehydration on his chemistry panel as well as
tachycardia worsened with exertion. He received intermittent
boluses of NS with improvement in his vitals and was eventually
started on maintenance IVF with NS.
TRANSITION OF CARE ISSUES:
==========================
- FULL CODE
- Ceftriaxone 7 day course is complete on ___
- Foley decannulation trial on ___ at ___ clinic. Is still
requring intermittent flushing of foley for obstruction by clot.
- Continue to evaluate swallow, intake of liquids, and necessity
of IVF
- Continue to increase coumadin dose for therapeutic INR.
===============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL = )
- () No
5. Intensive statin therapy administered? () Yes - (X) No [if
LDL >= 100, reason not given: LDL is 73]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ] - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Venlafaxine 75 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. NIFEdipine CR 60 mg PO DAILY
8. Mirtazapine 15 mg PO QHS
9. Simvastatin 20 mg PO QPM
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Mirtazapine 15 mg PO QHS
4. Tamsulosin 0.4 mg PO QHS
5. Simvastatin 20 mg PO QPM
6. Lisinopril 20 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. NIFEdipine CR 60 mg PO DAILY
9. Venlafaxine 75 mg PO DAILY
10. Acetaminophen 650 mg PO Q4H:PRN pain
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
complete on ___. Heparin 5000 UNIT SC TID
Stop after therapeutic on coumadin.
13. Metoprolol Tartrate 25 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
1. Right Middle Cerebral Artery Ischemic Stroke
2. Atrial Fibrillation
3. Hypertension
4. Diabetes
5. Chronic Kidney Disease
6. Chronic Hearing Loss
7. Upper extremity tremor
8. Hematuria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided facial droop
and left sided weakness resulting from an ACUTE ISCHEMIC STROKE,
a condition in which a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: high blood pressure, diabetes
and atrial fibrillation
Please followup with Neurology and your primary care physician
as listed below.
While you were here you also developed bleeding in your urine.
This may have been some injury with the placement of your
urinary catheter, or a urinary tract infection. We are treating
you for a urinary tract infection and you have a catheter in
place. You will follow up with Urology after going to rehab.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10713795-DS-11
| 10,713,795 | 22,409,588 |
DS
| 11 |
2128-08-08 00:00:00
|
2128-08-09 09:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o afib (diagnosed on recent admission for R MCA stroke in
___, started on coumadin), HTN, DM, BPH and other issues
transferred from OSH after the patient was cardioverted for
unstable Afib.
He was admitted to the Neurology service ___ for R MCA
ischemic stroke (residual L sided weakness). His CT/CTA showed
right internal carotid bifurcation clot extending into the
proximal A1 with complete M1 occlusion. He was found to be in
Afib and anticoagulation was started though intitially delayed
due to his hematuria (which was felt to be related to a
traumatic foley, urology was involved and bladder was
irrigated). After hematuria improved coumadin was restarted and
he was rate controlled on
metoprolol.
He was discharged to rehab and at rehab he had hematuria again
and coumadin was held. The pt then developed a superficial LLE
saphenous vein thrombus so antocoagulation was restarted again
on ? ___ - per son's report.
Today his daughter was visiting pt and noted that he was not
responding to her. She called the nurse and blood pressure was
checked revealing hypotension (SBPs ___. The patient was
brought to an OSH and was found to have afib with RVR, requiring
cardioversion. The patient has a Trop leak of 0.06, + UA with
hematuria vs UTI, and INR of 5.9, hct of 22 (hct 35 in ___ at
OSH s/p 2 units of pRBCs. ___ showed laminar necrosis vs
possible small petechial hemorrhage within the area of prior
infarct. HD stable during this time at OSH (after
cardioversion). The patient was transferred to ___ for further
eval.
At ___, ED initial vitals were: 97.3 97 127/54 22 99% RA.
He recieved vitamin K in the ED (10mg IV) and 2u FFP -> INR now
1.6. The patient was noted to be anemic Ht 27 (down from 35) w/
repeat hct of 19 checked 12 hours later, no blood given in ED.
Pt did have a moderate volume melanotic stool in the ED. Started
on ppi gtt w/ bolus. GI aware, protecting aware and not yet
intubated. AAOx2 baseline. Receiving Ceftx for UTI. Confirmed
DNR/DNI with ED and son (HCP). VS on transfer: 97.8 113 114/45
18 98% RA.
- Labs were significant for UA>180 wbc, large blood and leuks
few bact, initial lactate 2.6-->1.5, trop .06 CK MB 13 (flat on
repeat), wbc 13 Ht 27 plat 308 cr 1.7 Na 146 HCO3 19 INR 5.9 ->
1.7. Cr 1.4 (baseline about ___, BUN 82. The sons were at
bedside and feel the patient looks back to his post-stroke
baseline.
- Neurology was consulted re the CT head images concerning for
petechial hemorrhages and they were wondering if the changes
were more consistant with laminar necrosis which is expected
after recent stroke and recommended anticoagulation be continued
(unless there is bleeding from another source) goal INR ___, q4H
neuro checks, repeat head CT in am. Goal SBP 100-160. Exam c/w
priors.
On arrival, pt denies CP, is drowsy. He does have L knee pain.
Past Medical History:
- Ischemic MCA stroke with left sided hemiparesis in ___
- Afib - diagnosed in ___ when he presented with stroke
- HTN
- DM2 - diet controlled, dx ___, A1c 6.4-6.7
- CKD III - GFR ___ stable
- chronic hearing loss, wears left hearing aide
- depression, anxiety
- IBS
- elevated PSA
- vitamin B12 deficiency
- Tremor - seen by neurology outpatient in ___ - symptoms
thought to be related to medication induced Parkinsonism vs
essential tremor. No medication changes were made at that time
however.
- Right total knee replacement
- Squamous cell carcinoma
Social History:
___
Family History:
Father died at ___ of massive MI. Mother died in her ___ of
cancer. No family history of strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.8, 110/70, 100, 20, 98% RA
GENERAL: NAD but drowsy, oriented to self but nothing else,
foley in place with yellow clear urine
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pale conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregular irregular, S1/S2, no obvious murmurs,
gallops, or rubs
LUNG: CTAB anteriorly, no wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing, edema barely appreciable
in legs, 1+ in L hand
PULSES: 2+ DP pulses bilaterally
NEURO: L facial droop, L arm plegic, L leg with triple flexion
at baseline per neuro note
SKIN: fragile elderly skin with multiple ecchymoses
DISCHARGE PHYSICAL EXAM:
VS - Tm 98.2, 151/76, 72, 18, 98% RA
GENERAL: Elderly male w/ severe hearing impairment in NAD.
A&Ox2.
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregular irregular, S1/S2, no obvious murmurs,
gallops, or rubs
LUNG: CTAB anteriorly
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
NEURO: L facial droop, left-sided hemiplegia, increased muscle
tone in R upper extremity
EXTREMITIES: Pitting edema in UEs and LEs, L > R (secondary to
positionining - patient slumped to left side due to loss of tone
on that side from prior stroke)
Pertinent Results:
ADMISSION:
==========
___ 09:20PM BLOOD ___ PTT-31.7 ___
___ 06:26AM BLOOD WBC-10.5 RBC-2.24*# Hgb-6.8*# Hct-19.9*#
MCV-89 MCH-30.3 MCHC-34.3 RDW-16.7* Plt ___
___ 09:20PM BLOOD Glucose-162* UreaN-74* Creat-1.7* Na-146*
K-4.4 Cl-112* HCO3-19* AnGap-19
___ 06:26AM BLOOD ALT-151* AST-103* LD(LDH)-267*
CK(CPK)-636* AlkPhos-95 TotBili-0.3
___ 09:38PM BLOOD Lactate-2.6*
PERTINENT:
=========
___ 09:20PM BLOOD CK-MB-13* MB Indx-2.3 cTropnT-0.06*
___ 06:26AM BLOOD cTropnT-0.06*
___ 01:23PM BLOOD Lactate-1.4
___ 01:20PM BLOOD WBC-9.2 RBC-2.73* Hgb-8.6*# Hct-24.1*
MCV-88 MCH-31.5 MCHC-35.7* RDW-16.1* Plt ___
___ 12:35AM BLOOD WBC-9.3 RBC-2.79* Hgb-8.7* Hct-25.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-16.7* Plt ___
___ 07:45AM BLOOD WBC-8.1 RBC-2.73* Hgb-8.4* Hct-25.1*
MCV-92 MCH-30.7 MCHC-33.4 RDW-18.1* Plt ___
___ 08:00AM BLOOD WBC-6.9 RBC-2.81* Hgb-8.4* Hct-26.1*
MCV-93 MCH-30.0 MCHC-32.3 RDW-18.5* Plt ___
DISCHARGE LABS:
==============
___ 07:45AM BLOOD WBC-6.0 RBC-2.96* Hgb-9.1* Hct-27.7*
MCV-94 MCH-30.6 MCHC-32.7 RDW-16.1* Plt ___
___ 07:45AM BLOOD Neuts-74.1* Lymphs-14.7* Monos-7.7
Eos-3.4 Baso-0.1
___ 07:45AM BLOOD ___ PTT-28.8 ___
___ 07:45AM BLOOD Glucose-102* UreaN-14 Creat-1.0 Na-143
K-4.0 Cl-110* HCO3-24 AnGap-13
___ 07:45AM BLOOD Phos-3.7 Mg-2.0
IMAGING:
========
BILATERAL LOWER EXTREMITY U/S (___):
IMPRESSION:
1. No evidence of deep venous thrombosis in the bilateral lower
extremity
veins.
2. Superficial venous thrombosis of the left lesser saphenous
vein with
subcutaneous edema in the left calf.
LEFT KNEE PLAIN FILMS (___):
No evidence of joint effusion. On this limited study, there is
minimal
tricompartmental hypertrophic spurring. There appears to be some
narrowing of the joint space medially, but this may not be a
true finding in the absence of an upright view.
CT HEAD WITHOUT CONTRAST (___):
1. Large right MCA distribution infarct with interval
development of cortical hyperdensity, which may represent
interval mineralization/ laminar necrosis although microvascular
bleed is not entirely excluded.
2. Right a region in the right matter focus of hyperdensity may
represent a focus of microhemorrhage.
CXR (___): Retrocardiac and left costophrenic angle opacity
potentially atelectasis, infection not excluded.
Brief Hospital Course:
___ year old male with history of AFib (diagnosed in ___ when
he presented w/ R MCA ischemic stroke, started on coumadin and
metoprolol), HTN, T2DM, and recent R MCA stroke (___) who
was transferred to ___ from an OSH for management of GI
bleeding.
ACTIVE ISSUES:
============
# GI Bleeding: Melenic stools in the ED. INR was 5.9 on arrival
to ___ secondary to outpatient coumadin use. Hgb 9.2 on arrival
but dropped to downtrended to 6.8 in approximately 10 hours.
Given a total of 4 units of blood over first 24 hours of
hospitalization. He also received 2 units of FFP and vitamin K
10mg, resulting in full reversal of INR to 1.2. Patient has not
had an EGD in the past. His risk factors for GI bleeding
included full dose daily ASA and supratherapeutic INR from
coumadin. In the ED and in the MICU, he was on a Protonix drip
for prevention of rebleeding. On ___, after his Hgb had
remained stable for 36 hours, he was transitioned to Protonix IV
BID and called out to the floor. The patient's son, ___ (HCP),
was clear that he wanted his father to receive supportive care
with blood transfusions if necessary, but that he did not want
any invasive procedures (including endoscopy). On ___, the
HCP additionally specified that escalation of care / ICU
transfer was NOT within the patient's goals of care. On
___ he was transitioned to oral Protonix. The patient's
Hgb remained stable for the duration of his hospital stay and
further bleeding did not recur, though he continued to have
small-volume melena, which was thought to represent GI transit
of old blood rather than a new bleed given his stability.
# AFib with RVR: Prior to admission the patient's AFib was
rate-controlled with metoprolol. He was also being
therapeutically anticoagulated with coumadin. Of note, he had a
right MCA ischemic stroke on ___. CHADS2 of 5. Stroke team
recommended resuming ASA if GI bleeding resolves, but felt
anticoagulation was of limited additional benefit. Apixaban
(lower bleeding risk) is a possibility if family/patient wishes
to purse anticoagulation. Coumadin and ASA were both held given
recent GI bleed as was metoprolol. On ___ metoprolol 25mg BID
was restarted. Overnight, Mr ___ experienced breakthrough
___ w RVR that was controlled with metoprolol 5mg IV x2. On
___ metoprolol was increased to 25mg QID and then further to
37.5 mg QID after two doses. On ___, his metoprolol was
converted to succinate 150mg qday.
# Cortical hyperdensity and possible microhemorrhage on head
CT:Had a right MCA stroke on ___. CT head on admission
revealed interval development of cortical hyperdensity as well
as a possible microhemorrhage. Neuro saw the pt in ED, neuro
exam at baseline compared to admission in ___. On ___, the
stroke team recommended no need to repeat CT to evaluate the
previously mentioned microhemorrhage unless the patient develops
new focal neurological deficits. Pt received Q4H neuro checks
until ___ and had no significant changes. His neurological
status remained unchanged for the remainder of his hospital
stay. OT and ___ evaluated patient and felt he had good rehab
potential
# Superficial LLE thrombus: Per report from ___, the
patient was diagnosed with a new LLE DVT on ___ and therefore
was restarted on warfarin. However, the report of this
ultrasound could not be obtained. LENIs performed on ___
that showed some superficial venous thrombosis of the left
lesser saphenous vein but no evidence of deep venous thrombosis
in the bilateral lower extremity veins. On ___ pneumatic
compression boots were started as prophylaxis against future
DVTs.
# Coagulopathy: Despite having his INR reversed with vitamin K
on admission, it slowly trended back up to 1.8 during this
admission - this was thought to be secondary to poor nutritional
status. He was given another 2 mg PO Vitamin K, and his INR
came back down to 1.1 on the day of discharge.
# BPH: Patient does not carry a formal diagnosis in his records
at ___, but the diagnosis is suggested by his medication list
including finasteride and tamsulosin. Finasteride was continued
during his hospital stay, but tamsulosin was held at discharge
because he failed his voiding trial and will be discharged with
a foley catheter in place. He has Urology follow up and should
undergo a voiding trial supervised by them in the future.
# Urinary retention and hematuria: The patient was discharged
from his prior admission in ___ with a foley due to
hematuria thought to be ___ traumatic insertion. During this
admission, voiding trial was attempted and failed. When foley
was replaced, sediment was evident in the foley bag with some
blood at the meatus. His urinary retention was thought to be
due to a combination of BPH and sediment in the bladder, with a
possible contribution of clot retention ___ hematuria. He was
continued on his home Finasteride, and discharged with an
indwelling foley. He has urology follow-up on ___ to
re-attempt voiding trial.
# L knee Pain: Affecting left knee, unremarkable findings on
plain film but effusion noted on exam without associated warmth
or erythema. Tylenol 1g TID was insufficient to control his
pain, so oxycodone 2.5 mg Q4H:PRN pain was added on ___ and
has been successful. Pt asks for ___ doses a day.
CHRONIC ISSUES:
==============
# HTN: Lisinopril 10mg was restarted at discharge given the
patient's SBPs in 130s-150s. It had been held during his stay
due to concern for recurrent GI bleeding. His home nifedipine
was also held during his hospitalization. This was not restarted
but his primary care physician may consider doing so if
necessary for control of his blood pressure in the future.
# Acute-on-chronic renal injury: Initial Cr of 1.7, thought to
represent pre-renal ___ vs ATN from hypotension at OSH. His Cr
downtrended to back to 1.0 on the day of discharge.
# DM2: Maintained on ISS during this hospital stay
# Depression / anxiety: the patient was continued on his home
venlafaxine and mirtazapine, and his armodafinil was replaced
with modafanil (formulary equivalent). Of note the patient was
on Aripiprazole prior to ___, but this was discontinued
during his previous hospitalization without clear documentation
as to why it was stopped. It was not restarted on this
admission. However, the patient was occasionally tearful and
anxious during this hospital stay - he would benefit from having
these issues addressed as an outpatient.
# Code: *** DNR/DNI *** (confirmed with son/HCP)
# Communication: Patient, HCP is ___ (son,
___
TRANSITIONAL ISSUES:
================
- Patient's warfarin was discontinued given GI bleed. In
consultation with neurology, he was discharged on Aspirin 81 mg
PO QD for stroke prevention.
- The patient DID NOT have a LLE DVT visualized on ultrasound
during this admission; he does not need anticoagulation for DVT
(he has a superficial LLE saphenous vein thrombosis).
- The patient's home Tizanidine was stopped given deliriogenic
potential
- Patient's metoprolol was uptitrated from tartarate 25 mg BID
to succinate 150 mg PO QD, and his home nifedipine was held at
discharge - if his BP tolerates, he may benefit from restarting
nifedipine for rate control in the future.
- patient's home tamsulosin was held at discharge, but he was
continued on finasteride. He will undergo another voiding trial
at the time of his urology follow-up on ___.
- Patient complained of L knee pain without clear etiology - a
small effusion was noted on exam, and his pain was
well-controlled with 2.5 mg oxycodone q6h PRN.
- Patient was previously on Aripiprazole,but it was discontinued
during his previous admission without clear documentation as to
why. He was occasionally tearful and anxious during this
hospital stay and would benefit from having his psychiatric
medications adjusted as an outpatient.
- Lisinopril was held at discharge given normotension - it may
be restarted as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Mirtazapine 15 mg PO QHS
4. Tamsulosin 0.4 mg PO QHS
5. Simvastatin 20 mg PO QPM
6. Lisinopril 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. NIFEdipine CR 60 mg PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Metoprolol Tartrate 25 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 17.2 mg PO QHS constipation
13. Warfarin 5 mg PO DAILY16
14. Bisacodyl ___AILY:PRN constipation
15. Docusate Sodium 100 mg PO BID
16. Nuvigil (armodafinil) 50 mg oral daily
17. Tizanidine 2 mg PO QHS
18. Tizanidine 4 mg PO BID
19. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 150 mg PO DAILY
2. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
3. Pantoprazole 40 mg PO Q12H GI rebleed prophylaxis
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Venlafaxine XR 75 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Bisacodyl ___AILY:PRN constipation
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Nuvigil (armodafinil) 50 mg oral daily
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 17.2 mg PO QHS:PRN constipation
15. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Gastrointestinal bleed, atrial fibrillation with rapid
ventricular response, superficial venous thrombosis of left
saphenous vein, urinary retention
Secondary: Ischemic stroke with hemorrhagic conversion,
hypertension, benign prostatic hyperplasia, acute kidney injury
Discharge Condition:
Mental Status: Confused - often.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital for
gastrointestinal bleeding and low blood pressure. This bleeding
was likely contributed to by the anticoagulation (warfarin) that
you were on to prevent future strokes from your atrial
fibrillation.
You were treated in the intensive care unit and given blood
transfusions until you stabilized. Together with your family,
you decided that you did not want to pursue aggressive or
invasive interventions for your bleeding such as endoscopy or
colonoscopy. The bleeding stopped on its own.
Our neurologists evaluated you and felt that because of your
gastrointestinal bleeding, you should not resume taking warfarin
despite having had a stroke from atrial fibrillation. Instead,
you will take a daily low-dose aspirin to help reduce your risk
of future strokes.
Also while you were here, we increased your metoprolol to better
control your heart rate. We repeated an ultrasound of your legs
to look for DVTs (blood clots) and did not find any; there was
only a superficial blood clot in the left leg, which is not
dangerous and does not need anticoagulation. We are discharging
you on an acid-suppressing medication to prevent more
gastrointestinal bleeding.
We attempted to remove the foley catheter that you were
discharged with on your last hospitalization, but you were
unable to urinate without it, so it had to be replaced. You
will see a urologist in clinic to have the foley removed.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10713800-DS-20
| 10,713,800 | 25,445,650 |
DS
| 20 |
2127-01-26 00:00:00
|
2127-01-27 20:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, chills and petechiae
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___, insertion of Central line
History of Present Illness:
Ms. ___ is a ___ yo woman with PMHx s/f pappillary thyroid
carcinoma s/p thyroidectomy and radioablation with residual
abnormal tissue who presents with 4 days of worsening
fevers/chills and rigors. She states that the symptoms initially
began on ___ and progressively worsened becoming associated
with peripheral petechiae, easy bruising, fatigue and
nausea/vomiting. Ms. ___ noted emesis with streaks of blood
yesterday. She also noted bruising of her knees and knuckles.
She noted no cough/shortness of breath or dysuria.
.
In ED initial vitals were 100.3 103 114/67 18 100% RA. In the
ED, pt was found to have thrombocytopenia to 11, anemia to hct
of 25. Tylenol x1 was given for fever. A BM biopsy was obtained,
cultures were obtained. UA demonstrated few bacteria.
.
.
Review of Systems:
(+) Per HPI
(-) Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC/MEDICAL HISTORY:
- Papillary thyroid cancer ___ stage I (T3N1bM0) s/p total
thyroidectomy (___) and 150mCi of ___. Currently has
stable enlarged lymph nodes. Local residual disease per last
endocrine note.
- Temporomandibular Joint dysfunction
Social History:
___
Family History:
Great uncle/aunt with cancer of unknown primary. Parents with
HTN and father with heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T: 102 BP: 103-110/64-70 HR: 103-110 RR: 20 02 sat:
94-95%
GENERAL: ill appearing woman, distress secondary to fevers
SKIN: warm and well perfused, diffusely distributed rare
petechiae, no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry MM, good dentition, nontender supple neck, no
LAD, no JVD, erythematous pharynx
CARDIAC: tachycardic , S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ diffusely
DISCHARGE PHYSICAL EXAM
Vitals - T: 97.7 BP: 94-124/48-84 HR: 84 RR: 20 02 sat: 99% RA
GENERAL: healthy appearing woman in NAD
SKIN: warm and well perfused, diffusely distributed rare
petechiae, no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry MM, good dentition, nontender supple neck, no
LAD, no JVD, erythematous pharynx. Erythematous gums on lower
jaw. Nontender.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, slightly TTP in lower abdomen, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
___ 12:23PM BLOOD WBC-2.1*# RBC-3.25* Hgb-10.1* Hct-27.9*
MCV-86 MCH-30.9 MCHC-36.0* RDW-13.0 Plt Ct-5*#
___ 12:23PM BLOOD Neuts-2* Bands-0 ___ Monos-0 Eos-0
Baso-0 Atyps-7* ___ Myelos-0 NRBC-6* Other-52*
___ 08:15AM BLOOD ___ PTT-29.8 ___
___ 08:15AM BLOOD ___ 08:47AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-136
K-4.3 Cl-97 HCO3-25 AnGap-18
___ 08:47AM BLOOD ALT-39 AST-32 LD(LDH)-287* AlkPhos-41
TotBili-0.5
___ 02:00PM BLOOD proBNP-___*
___ 08:47AM BLOOD TotProt-7.4 Albumin-4.5 Globuln-2.9
UricAcd-6.1*
___ 06:37AM BLOOD TSH-0.022*
.
URINE STUDIES
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:30PM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
.
DISCHARGE LABS
___ 12:00AM BLOOD WBC-1.8*# RBC-2.66* Hgb-8.0* Hct-22.8*
MCV-86 MCH-30.1 MCHC-35.3* RDW-14.7 Plt ___
___ 12:00AM BLOOD Neuts-47* Bands-0 ___ Monos-22*
Eos-0 Baso-0 ___ Myelos-0 Blasts-3*
___ 12:00AM BLOOD ___ PTT-34.0 ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-105* UreaN-12 Creat-0.5 Na-142
K-4.4 Cl-103 HCO3-32 AnGap-11
___ 12:00AM BLOOD ALT-30 AST-25 LD(LDH)-193 AlkPhos-75
TotBili-0.1
___ 12:00AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.6
___ 02:00PM BLOOD PML/RARA T(15:17), QUANTITATIVE
PCR-PML/RARA T(15,17), 1.389 H
.
IMAGING
___ ECHOCARDIOGRAPHY REPORT
Done ___ at 11:30:01 AM FINAL
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AS.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm).
Conclusions
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 aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. There is no aortic valve
stenosis. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Electronically signed by ___, MD,
Interpreting physician ___ ___ 12:02
.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 8:19
AM
FINDINGS:
Previously on ___ seen basilar (right greater than left)
opacities
remain and are essentially unchanged to ___.
The right subclavian line ends unchanged in the distal
SVC/cavoatrial
junction.
IMPRESSION: No change from yesterday.
.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 8:54 ___
Final Report
HISTORY: ___ female with APML on chemotherapy, now
presenting with
acutely worsening epigastric pain.
COMPARISON: PET-CT from ___ and chest radiograph
from ___.
TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to
the pubic
symphysis were displayed with 5-mm slice thickness. Oral and
intravenous
contrast was administered. Coronal and sagittal reformations
were prepared.
CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST: There are
bilateral simple pleural effusions at the lung bases, moderate
on the right and small on the left. Basilar heterogeneous
opacities in the lung bases appears similar to recent prior
radiographs and could reflect atelectasis, though the previously
suggested concern for transfusion related acute lung injury also
remains within the differential. Pneumonia or atelectasis should
also be considered in the appropriate circumstance. The imaged
cardiac apex is within normal limits.
The liver demonstrates homogeneous parenchymal enhancement
without suspicious focal lesion. Within segment ___, there
is an enhancing focus located peripherally measuring 1.3 x 1.5
cm (2E:45). The lesion appears to communicate with both a branch
of the left portal vein and middle hepatic veins, likely
reflecting an intrahepatic portosystemic venous shunt. The
clinical significance of this finding is uncertain. No prior
contrast-enhanced CT imaging is available for comparison to
determine the chronicity of the lesion, though it may very well
be congenital. However, there is mild diffuse periportal edema.
The hepatic veins and portal venous system are grossly patent.
No intra- or extra-hepatic biliary ductal dilation is evident.
The gallbladder is slightly contracted and elongated. The wall
is thin and demonstrates prominent wall enhancement, however
this may be attenuation difference as there is pericholecystic
fluid from the ascites. The spleen and pancreas are normal in
appearance. The adrenal glands are normal. The kidneys
demonstrate symmetric enhancement and excretion without
hydronephrosis. The bladder is unremarkable. The uterus and
adnexa appear within normal limits.
The stomach and small bowel loops are normal in caliber and
configuration
without evidence of obstruction or inflammation.The rectum and
colon are
normal in caliber and configuration without evidence of
obstruction or
inflammation. The appendix is well visualized and is normal in
appearance.
The abdominal aorta and its branch vessels are non-aneurysmal
and grossly
patent. There is no free air. There is a moderate amount of free
fluid within the abdomen and pelvis. The attenuation values of
the fluid range from ___ ___ units, which is
indeterminate, though not typical for hemorrhagic fluid.
OSSEOUS STRUCTURES: No aggressive osseous lesions. No fractures.
IMPRESSION:
1. Bilateral simple pleural effusions, moderate on the right and
small on the left.
2. Bibasilar consolidation, which may reflect atelectasis.
However, as
previously suggested transfusion related acute lung injury is
also within the differential as is aspiration or pneumonia in
the appropriate clinical circumstance.
3. Mild diffuse periportal edema and moderate ascites within the
abdomen and pelvis, including around the gallbladder. The
attenuation values range from ___ ___ units, which is
indeterminate.
4. 1.3 x 1.5 cm enhancing lesion in segment ___ of the liver,
likely an intrahepatic portosystemic shunt. Clinical
significance is uncertain, though this may represent a
congenital anomaly.
5. Normal appendix.
.
BONE MARROW STUDIES
SPECIMEN SUBMITTED: Immunophenotyping - PB
Procedure date Tissue received Report Date Diagnosed
by
___. ___. ___
Previous biopsies: ___ ___ #2 bx of right lower
parathyroid gland, #1 Lymph Node
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___,
Glycophorin A, Kappa, lambda, and CD antigens 2, 3, 4, 5, 7, 8,
10, 11c, 13, 14, 15, 19, 20, 33, 34, 41, 45, 56, 64, 71, 117,
Tdt.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield.
Cell marker analysis demonstrates that the majority of the cells
in the "Blast gate" (CD45 dim, moderate side scatter) isolated
from this peripheral bone marrow express immature antigens CD34,
___ (___), myeloid associated antigens CD13, CD33, CD117
(dim), CD64. They express lymphoid associated antigens CD2, CD4
(dim). They are CD10 (cALLa) negative, and are negative for CD8,
CD7, CD5, CD19, CD20, CD3, CD14, CD15, CD11C, CD41, CD56,
glycophorin A, TdT. Notably, CD34 and ___ ___
expression.
INTERPRETATION
Acute myeloid leukemia: There is bimodal expression of CD34 and
___. ___, t(15;17) was identified. Hence this leukemia
is best characterized as Acute promyelocytic leukemia.
Correlation with clinical findings and morphology (see
___ is recommended. Flow cytometry immunophenotyping
may not detect all abnormal populations due to topography,
sampling or artifacts of sample preparation.
.
SPECIMEN: BONE MARROW ASPIRATE ONLY:
DIAGNOSIS: Involvement by acute promyelocytic leukemia. See
note.
Note: The concurrent FISH reveals PML-RARa translocation,
supporting the above diagnosis.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
mildly hypochromic with anisopoikilocytosis including microcytes
and elliptocytes; immature forms with coarse basophilic
stippling are seen. The white blood cell count appears
decreased. Blasts are abnormal promyelocytes. They comprise the
majority of white blood cells; they are variably sized with dark
blue cytoplasm, enlarged, folded nuclei with prominent nucleoli
and purple cytoplasmic granules. Occasional forms with more
abundant light blue cytoplasm are seen. Rare Auer rods are
noted. Platelet count appears markedly decreased. Large and
giant forms are seen. Differential shows 4% neutrophils, 1%
bands, 1% monocytes, 21% of lymphocytes, 73% blasts. Nucleated
red blood cells are present.
Aspirate Smear:
The aspirate material is suboptimal for evaluation due to lack
of spicules and hemodilution. Erythroid precursors are
scarce.The vast majority of cells are myeloblasts (abnormal
promyelocytes) as morphologically described above. They are
gathered in abundance at the feathered edge of the aspirate
slides. Occasional lymphocytes and nucleated erythroids are
admixed. No megakaryocytes are seen.
.
KARYOTYPE: 46,XX,T(15;17)(Q24;Q21),DEL(16)(Q23)[20]
INTERPRETATION:
All 20 metaphases examined a translocation of chromosomes
15 and 17 and a deletion of the long arm of chromosome 16.
This translocation is associated with PML-RARA fusion and
is a characteristic finding in acute promyelocytic (M3)
leukemia. Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(PML,RARA)x3(PML con RARAx2)[97/100],
(ETO,AML1)x2,(CBFBx2)[100]
FISH evaluation for a PML-RARA rearrangement was performed
on nuclei with the Vysis LSI PML/RARA Dual Color, Dual
Fusion Translocation Probe for PML at 15q24 and RARA at
17q21.2 and is interpreted as ABNORMAL. Rearrangement was
observed in 97/100 nuclei, which exceeds the normal range
(up to 1% rearrangement) for this probe in our laboratory.
A PML-RARA rearrangement is found in most acute
promyelocytic leukemias (FAB M3).
FISH evaluation for an AML1-ETO rearrangement was
performed on nuclei with the Vysis LSI AML1/ETO Dual
Color, Dual Fusion Translocation Probe for ETO at 8q22 and
AML1 at 21q22 and is interpreted as NORMAL. No dual
rearrangement was observed in 100/100 nuclei, which is
within the normal range (up to 1% rearrangement) for this
probe in our laboratory. A normal finding can result from
absence of an AML1-ETO rearrangement, from a variant
AML1-ETO rearrangement, or from an insufficient number of
neoplastic cells in the specimen.
FISH evaluation for a CBFB rearrangement was performed on
nuclei with the LSI CBFB Dual Color, Break Apart Probe at
16q22 and is interpreted as NORMAL. No rearrangement was
observed in 100/100 nuclei, which is within the range of a
normal hybridization pattern (up to 1% rearrangement)
established for this probe in our laboratory. A normal
CBFB FISH finding can result from absence of a CBFB
rearrangement, from a variant CBFB rearrangement, or from
an insufficient number of neoplastic cells in the specimen.
This test was developed and its performance
determined by the ___ Cytogenetics Laboratory
as required by the ___ ___ regulations. It has not
been cleared or approved by the U.S. Food and Drug
Administration. This test is used for clinical
purposes.
PML
RARA
ETO
AML1
5'CBFB
3'CBFB
.
HEAD CT ___
INDICATION: ___ year old female with APML, now on chemotherapy,
with new
headache in setting of thrombocytopenia.
COMPARISON: No dedicated CT head available for comparison.
Partial
visualization of the head on PET-CT dated ___.
TECHINQUE: Axial CT images through the head were acquired
without intravenous contrast. Thin-slice bone reconstructed and
coronal and sagittal reformatted images were reviewed.
FINDINGS: There is no evidence for acute intracranial
hemorrhage, mass
effect, edema or hydrocephalus. There is preservation of
gray-white
differentiation without CT evidence for large territorial
infarct. Ventricles and sulci are slightly prominent for
patient's age. Visualized bones and soft tissues are within
normal limits. The visualized portions of the paranasal sinuses
and mastoid air cells are well aerated. Sphenoid sinus has
multiple septations, one of which inserts on the left carotid
groove.
IMPRESSION: No CT evidence for acute intracranial intracranial
hemorrhage or mass effect.
.
___ MR head
INDICATION: APML, severe headache; h/o CA Thyroid per Careweb
notes.
COMPARISON: CT head.
TECHNIQUE: MR venogram without contrast with MIP reformation;
limited axial
and coronal pre- and post-contrast images of the brain as per
the cavernous
sinus protocol.
FINDINGS: Pituitary appears prominent, measuring approximately
1.4 x 0.6 cm
in the transverse and Cc ___ with more focal rounded,
slightly
hypoenhancing focus on to the right side. This needs further
evaluation with dedicated imaging of the pituitary to assess for
focal lesions. However, the infundibulum appears to be displaced
towards the right side. The optic chiasm is grossly unremarkable
with mild indentation. The cavernous carotid flow voids are
noted, the right cavernous ICA is narrower than the left. The
enhancement in the cavernous sinuses is unremarkable. On the
axial FLAIR sequences, no obvious focal lesions are noted in the
brain parenchyma. There is mild mucosal thickening in the
ethmoid air cells.
MR VENOGRAM OF THE HEAD: The superior sagittal, transverse,
sigmoid and the
straight sinuses are patent. The inferior sagittal sinus is
faintly seen.
IMPRESSION:
1. Patent major venous sinuses except the inferior sagittal
sinus. However,
assessment is somewhat limited given the lack of T1 and GRE
sequences of the entire brain.
2. Prominent pituitary gland, with a more focal rounded
appearance on to the right side slightly hypointense on the
post-contrast images. This needs
further evaluation with dedicated MR of the pituitary without
and with IV
contrast at which time complete MR brain study can also be
considered in order to obtain the diffusion, the GRE and the
sagittal T1W sequences and
post-contrast sequences given the history of headached and
malignancies- CA
Thyroid and APML
.
RUQ Ultrasound ___
Final Report
INDICATION: History of APML on chemotherapy, now with right
upper quadrant
abdominal pain. Assess for gallbladder disease and check for
ascites.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS: As seen on CT from ___, there is a
1.2-cm vascular
anomaly in the left hepatic lobe, likely a portosystemic shunt.
No suspicious focal liver lesions are identified. There is no
intrahepatic biliary duct dilatation. The portal vein is patent
and shows normal hepatopetal flow. The gallbladder is somewhat
collapsed and otherwise normal in appearance. No gallstones are
seen. There is no pericholecystic fluid. The common bile duct
measures 1 mm. The spleen is normal in size, measuring 7.6 cm.
The visualized portion of the pancreas is unremarkable. There is
trace ascites tracking around both the liver and spleen. A right
pleural effusion is noted, as seen on recent CT.
IMPRESSION:
1. Normal-appearing gallbladder.
2. Trace ascites.
3. Right pleural effusion, as before.
4. Vascular malformation in the left hepatic lobe, as seen on
recent CT.
.
___ TECHNIQUE: MRI of the pituitary gland without and with
gad.
HISTORY: Incidental finding of pituitary enlargement on MRV.
COMPARISON: ___
FINDINGS: There is mild hypertrophy of the pituitary gland,
which may be
within physiologic limits in a patient in this demographic
group. No focal
lesion is seen within the gland. Minimal deviation of the
pituitary stalk is noted to the right.
No other abnormalities are seen.
IMPRESSION:
Probable physiologic hypertrophy of the pituitary gland with no
focal
abnormalities. Please correlate with hormonal levels.
.
___ CT ABDOMEN PELVIS
INDICATION: Acute APML. Diarrhea in the setting of neutropenia.
COMPARISONS: CT abdomen and pelvis, ___.
TECHNIQUE: 5-mm axial sections were taken through the abdomen
and pelvis
after the administration of IV contrast. Sagittal and coronal
reformats were obtained and reviewed. DLP: 383.13 mGy-cm.
FINDINGS:
CHEST: The base of the heart is unremarkable. There is no
pericardial
effusion. The bases of the lungs are clear without nodules or
consolidations.
The previously seen bilateral pleural effusions have resolved.
ABDOMEN: The liver is normal in shape and contour. There is a
stable 16 x 11 mm enhancing lesion in the periphery of the liver
(2A, 18). This likely
reflects a vascular shunt. There are no other hepatic lesions.
The portal
veins are patent. There is no intra- or extra-hepatic biliary
duct dilation. The gallbladder, spleen, pancreas, adrenal
glands, and kidneys are unremarkable. The kidneys enhance and
excrete contrast appropriately. The stomach and small bowel are
unremarkable. There is no dilation of the small bowel. The walls
appear normal and are not thickened. The small bowel is fluid
filled. There is no mesenteric or abdominal lymphadenopathy. The
vasculature is normal in course and caliber. There is no ascites
or free air.
PELVIS: The large bowel is fluid filled, consistent with the
patient's
history of diarrhea. There is no formed stool. The large bowel
itself is
unremarkable without wall thickening, masses, focal dilation or
focal
narrowing. The appendix is normal. The urinary bladder, uterus,
and adnexa
are unremarkable. There is no free fluid within the pelvis.
There is no
pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
bone lesions.
IMPRESSION:
1. Fluid-filled non-dilated large and small bowel with normal
appearing bowel walls.
2. Normal appendix.
3. Resolution of bilateral pleural effusions.
4. Stable enhancing hepatic lesion is likely a vascular shunt.
.
MICROBIOLOGY
Blood Cultures ___ x 2 ,___ x 2, ___ x 2, ___ x 2 - No
growth
.
Urine cultures
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___- No growth
.
C. Diff toxin ___ - negative
.
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
CMV Viral Load (Final ___:
CMV DNA not detected.
HBV Viral Load (Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test.
Linear range of quantification: 40 IU/mL - 110million
IU/mL.
Limit of detection: 10 IU/mL.
HCV VIRAL LOAD (Final ___:
HCV-RNA NOT DETECTED.
Brief Hospital Course:
Ms. ___ is a ___ yo with a PMHx of follicular thyroid carcinoma
who presented ___ with acute APML.
# AML: Patient initially presented with fevers/chills and
rigors. She was found to be anemic and thrombocytopenic causing
concern for acute leukemia. Bone marrow biopsy was performed and
showed AML. Cytogenetics were performed and demonstrated 15:17
translocation by FISH consistent with APL. Patient was also
found to be FLT-3 positive. Initial course was complicated by
DIC (see DIC below). On day two of admission, Idarubicin and
ATRA initiated. Allopurinol was started prophylactically to
prevent tumor lysis syndrome and creatinine remained stable.
Allopurinol was discontinued when uric acid trended downward.
Course was complicated by abdominal pain, headaches and ATRA
syndrome as below. She was continued on idarubicin through day 8
of therapy. ATRA was continued until the patient white blood
cell count recovered. Counts trended downward nadired on day
___ and subsequently trended upward and showed appropriate
differentiation. She was discharged on day ___ and will
follow up with ___ hematology for further therapy.
# Hypoxemia: Patient experienced shortness of breath with
associated hypoxemia to 88% on RA on ___. CXR c/w fluid
overload vs. TRALI vs. ATRA syndrome. SOB improved s/p lasix
10mg IV x 2. Periodic lasix improved hypoxemia. Symptoms
resolved and did not recur.
# Epigastric Pain: Ms. ___ began to experience abdominal pain on
___ which was located primarily in the epigastrium. Initial
differential diagnosis included serositis secondary to ATRA
syndrome vs. pancreatitis vs. gastric ulcers. Negative
amylase/lipase ___ pancreatitis unlikely. CT abdomen with
contrast demonstrated mild diffuse periportal edema and moderate
ascites with ___ Hounsfield units which was intermediate
between blood and transudative ascites and concerning for
serositis. She was started on dexamethasone with improvement in
symptoms. Pain continued for approximately 1 week. RUQ
ultrasound was performed on ___ and demonstrated improvement
in ascities but no other acute processes. Steriods were tapered
off without recurrence of symptoms.
# DIC: Patient was in ___ on presentation. ___ labs including
fibrinogen, platelets and INR were monitored closely. She was
maintained with periodic transfusions of FFP, cryoprecipitate
and PRBCS. In total she was transfused 8 units of platelets, 13
units of PRBCs, 5 units of FFP, and 10 units of cryoprecipitate.
At the time of discharge labs were stable.
# Febrile Neutropenia: On admission patient was febrile she
subsequently developed oropharyngeal mucositis. She was
therefore started on Vanc, Cefepime and fluconazole. CXR w/o
evidence of pneumonia. Blood and urine cultures were negative.
Fevers resolved and vancomycin was discontinued. Acyclovir was
also started as prophylaxis during the neutropenic period.
Cefepime and fluconazole were continued until white blood cell
improved.
# Headaches- Patient with complaint of headache ___. Head CT
negative for acute process. MRV was negative for thrombosis,
but did show prominence of pituitary. There was concern that
headaches may be related to the high dose of zofran she received
with chemotherapy. Her dose of zofran was decreased and headache
improved. Headaches recurred ___ but were much less severe
and felt to be due to ATRA. She was headache-free at the time of
discharge.
#Diarrhea - Patient developed diarrhea beginning on ___. She
was noted to have up to ___ L of stool per day x 3 days which
was guaiac positive. CT of the abdomen and pelvis was
unremarkable. C. diff toxin was negative. GI was consulted and
recommended infectious work-up. Stool studies including O+P,
microsporidia, vibrio, yersinia, cyclospora, camplybacter, E.
coli 0157:H7 were negative. GI recommended empiric therapy for
C. diff with PO vancomycin which was continued until WBC
improved. Diarrhea resolved after a few days and did not recur.
# Chest pressure- Patient complained of chest pressure from
___. EKG was normal. No pulsus on exam. Chest xray was
negative. Pain was noted to improve with simethicone. She
again noted squeezing pain on ___ x ___ minutes. EKG and chest
xray were again normal. Pain resolved on its own and did not
recur.
# Pituitary enlargement- Patient was noted to have an enlarged
pituitary on MRV performed due to headaches. A MRI of the
pituitary was subsequently performed which showed physiologic
enlargement of the pituitary with no focal abnormalities. She
should follow-up with her endocrinologist.
# Prior papillary carcioma of the thyroid with residual disease.
Seen by Endocrine in house who recommended continuation of
levothyroxine at current levels and outpatient follow up.
Transitional Issues:
- will need follow up with endocrine regarding residual
papillary thyroid carcinoma as well as pituitary enlargement.
- Patient will need to follow up with hematology oncology
regarding further therapy
Medications on Admission:
Levothyroxine 125mcg daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Patient was written for prescription for ATRA that went through
prior authorization so patient can take 30mg twice daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Acute promyelocytic leukemia
Secondary Diagnosis
Follicular thyroid carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted because of fevers/chills,
nausea/vomiting, and easy bruising. A bone marrow biopsy was
performed, which showed acute promyelocytic leukemia. You were
treated for this with ATRA (all-trans retinoic acid) and
idarubacin.
You were given enough medication to take 3 pills tomorrow
morning and 3 pills tomorrow evening of the ATRA. If we cannot
get you the prescription before ___, an appointment will
be made for you on ___ in the hematology/oncology
outpatient clinic at ___ so that we can provide you the
pills (we will contact you with the time of the appointment). An
appointment will also be made for you to see Dr. ___
will be your primary hematologist, this week. You will be
notified once these appointments are made.
Please make the following changes to your medications.
Please START taking:
1. Tretinoin (ATRA-All Transretinoic Acid) - take 3 tablets of
10mg pills in the morning and 3 tablets of 10mg in the evening
(total of 30mg twice daily)
Otherwise, please continue taking your home medications as
prescribed in your discharge paperwork.
Followup Instructions:
___
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|
2127-02-01 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMHx of thyroid cancer s/p thryoidectomy and RAI,
recently diagnosed with acute prolmyelocytic leukemia after
presenting with petechiae, bruising and fevers. She was
recently discharged 3 days ago and presents today with fever to
101.8 in the ED. The fever started today and she did not feel
warm or sick but had measuring her temperature. After this, her
only other complaint is diarrhea, which she has had 2 episodes
of overnight. She describes large volume diarrhea, non bloddy,
non-mucosy, not associated to abdominal pain, nausea or
vomiting. She also denies any urinary ferquency, dysuria,
hematuria, cough, SOB, sputum production, nasal congestion,
rash, skin breaks.
She also denies changes in weight, bleeding, bruising,
headaches, problems with her medications. Full 10 point ROS is
otherwise negative.
Past Medical History:
PAST ONCOLOGIC/MEDICAL HISTORY:
-APML diagnosed ___ s/p Idarubicin and ATRA, currently on
ATRA
- Papillary thyroid cancer ___ stage I (T3N1bM0) s/p total
thyroidectomy (___) and 150mCi of ___. Currently has
stable enlarged lymph nodes. Local residual disease per last
endocrine note.
- Temporomandibular Joint dysfunction
Social History:
___
Family History:
Great uncle/aunt with cancer of unknown primary. Parents with
HTN and father with heart disease.
Physical Exam:
VS T current 99.2 BP 122/80 HR 104 RR 18
O2sat99%RA
Gen: In NAD.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation. midline thyroidectomy
scar
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, grossly intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Discharge FEX not significantly changed, although afebrile.
Pertinent Results:
ADMISSION LABS:
___ 12:45PM WBC-7.9# RBC-3.58*# HGB-10.4*# HCT-31.1*#
MCV-87 MCH-29.1 MCHC-33.5 RDW-16.0*
___ 12:45PM NEUTS-83.8* LYMPHS-7.8* MONOS-8.1 EOS-0.1
BASOS-0.2
___ 12:45PM PLT COUNT-762*
___ 12:45PM UREA N-14 CREAT-0.4 SODIUM-142 POTASSIUM-5.1
CHLORIDE-100 TOTAL CO2-34* ANION GAP-13
___ 12:45PM ALT(SGPT)-41* AST(SGOT)-35 LD(LDH)-233 ALK
PHOS-93 TOT BILI-0.2
___ 12:22AM LACTATE-2.0
___ 12:15AM GLUCOSE-124* UREA N-14 CREAT-0.5 SODIUM-137
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-30 ANION GAP-14
___ 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
MICROBIOLOGY, Negative unless otherwise noted.
___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
___ STOOL FECAL CULTURE-PENDING; CAMPYLOBACTER
CULTURE-PENDING; OVA + PARASITES-PENDING; FECAL CULTURE - R/O
E.COLI 0157:H7-PENDING; VIRAL CULTURE-PENDING
___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-PENDING; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
STUDIES
CXR ___
No acute intrathoracic process.
Urine
___ 01:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 01:30AM URINE Color-Straw Appear-Clear Sp ___
Discharge Labs
___ 07:30AM BLOOD WBC-2.9* RBC-3.37* Hgb-9.9* Hct-29.3*
MCV-87 MCH-29.3 MCHC-33.7 RDW-16.2* Plt ___
___ 07:07AM BLOOD Neuts-76.0* Lymphs-10.4* Monos-13.2*
Eos-0.2 Baso-0.2
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-35.1 ___
___ 07:30AM BLOOD ___ ___
___ 07:30AM BLOOD Glucose-82 UreaN-7 Creat-0.4 Na-140 K-4.3
Cl-105 HCO3-28 AnGap-11
___ 07:30AM BLOOD ALT-28 AST-29 LD(LDH)-199 AlkPhos-66
TotBili-0.1
___ 07:30AM BLOOD Calcium-9.2 Phos-4.8* Mg-1.8
___ 07:07AM BLOOD TSH-<0.02*
___ 07:07AM BLOOD T4-5.7 T___
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ y/o F with recent diagnosis of APML s/p induction with
Idarubicin and ATRA (currently on ATRA), who is admitted 3 days
after discharge with fever and diarrhea.
#Fever: Pt was not neutropenic. Source of fever suspected to be
due to diarrheal symptoms with abdominal cramping pain. CDiff
toxing was negativex2, UA bland and urine cx grew <10,000 CFU.
CXR unremarkable. Blood cultures from admission remain with no
growth to date. Stool cutlures have also been negative to date.
Received cefepime and empiric po vanco on admission but was
switched to cipro/flagyl. She defevervesced and diarrhea and
abdominal pain improved. She was discharged to
.
#Diarrhea: Suspect due to infectious colitis as above. Last CMV
VL on ___ was negative. Improved with empiric antiobiotics.
Did note some streaks of blood in stool, so could consider IBD
if diarrheal symptoms persist.
.
#APML: Continued ATRA. Patient remained non-neutropenic and
hematocrit was stable. Did note decrease in WBC to 2.9 on day of
discharge. Discharged patient on prophylactic acyclovir and
Bactrim.
#Thyroid cancer: Patient is status post thyroidectomy and RAI
in ___ with
residual disease (Tg 4 and LN in R thyroid bed). Continued
levothyroxine 125mcg daily. THS was noted to be <0.02, although
T3 and T4 were normal. No adjustment to levothyroxine dose was
made. Patient should follow up with endocrinology.
TRANSITIONAL ISSUES
- Monitor of resolution of diarrhea. If bloody diarrhea becomes
chronic, would consider GI evaluation
- Continued monitoring of cell counts, especially considering
decrease in WBC on day of discharge.
- ___ final reports of blood and stool cultures.
Medications on Admission:
1. Tretinoin (ATRA-All Transretinoic Acid) - take 3 tablets of
10mg pills in the morning and 3 tablets of 10mg in the evening
(total of 30mg twice daily)
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. tretinoin (chemotherapy) 10 mg Capsule Sig: Three (3) Capsule
PO BID (2 times a day).
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
6. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Fever, diarrhea
Secondary: Acute promyelocytic leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
were having fevers and diarrhea soon after receiving
chemotherapy for leukemia. We think your symptoms were caused by
a infectious agent, although the cultures we sent have not been
positive. We started you on antibiotics and gave you IV fluids,
and you began feeling better. Please note the following changes
to your medications:
START Ciprofloxacin 500mg tablet by mouth twice daily through
___
START Flagyl 500mg tablet by mouth twice daily through ___
START Acyclovir 400 mg three times per day to prevent virus
reactivation on chemotherapy
START Bactrim SS daily to prevent PCP pneumonia on chemotherapy
No other changes were made to your medications, please keep
taking them as prescribed. You should also follow up with the
appointments below, that have already been scheduled. It has
been a pleasure taking care of you.
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with APML diagnosed ___, who achieved
remission after induction with idarubicin and ATRA and is now
undergoing consolidation chemotherapy cycle 2, presenting with
febrile neutropenia. She reports a fever to 100.4 at home at
approximately 12am. She reports that she had a progressively
developing fever over the day, finally peaking at 100.4. She
reports that she is otherwise asymptomatic, with no localizing
symptoms. She denies shortness of breath, rhinorrhea, cough,
sore throat, abdominal pain, diarrhea/constipation, dysuria,
urgency/frequency of urination.
.
In the BID ED initial VS were T99.1 118 116/74 16 100% RA. She
received NS, blood cultures were sent and she was started
empirically on vancomycin and cefepime. A CXR showed no acute
intrathoracic process. VS prior to transfer to the floor were T
98.7 hr 96 bp 110/70 rr 16 sa 02
.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies visual changes, headache, dizziness, sinus tenderness,
neck stiffness, rhinorrhea, congestion, sore throat or
dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea
on exertion. Denies shortness of breath, cough or wheezes.
Denies nausea, vomiting, heartburn, diarrhea, constipation,
BRBPR, melena, or abdominal pain. No dysuria, urinary frequency.
Denies arthralgias or myalgias. Denies rashes. No increasing
lower extremity swelling. No numbness/tingling or muscle
weakness in extremities. No feelings of depression or anxiety.
All other review of systems negative.
Past Medical History:
- APML (FLT3+/NPM-)
- diagnosed ___ BMbx; FISH t(___), cytogenetics with
16q(-)
- s/p Idarubicin and ATRA, achieved remission
- completed cycle 1 of consolidation with idarubicin
- Papillary thyroid cancer ___ stage I (T3N1bM0) s/p total
thyroidectomy (___) and 150mCi of ___. Currently has
stable enlarged lymph nodes. Local residual disease per last
endocrine note.
- Temporomandibular joint dysfunction
Social History:
___
Family History:
Great uncle/aunt with cancer of unknown primary. Parents with
HTN and father with heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 99.1 BP 112/63 HR 106 RR 16 O2 100% RA
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: no lesions appreciated
DISCHARGE PHYSICAL EXAM:
VS- Tm 98.6 BP 116/68 P 75 RR 18 O2 100%RA
Gen- Well nourished female in NAD
HEENT- PERRL, sclera anicteric, no conjunctival pallor,
oropharynx clear without erythema, exudate or lesions
CV- regular rate and rhythm, no murmurs/gallops/rubs
Pulm- CTA bilaterally, no wheezes, ronchi or rales
Abd- +BS, soft, non-tender, non-distended; no rebound or
guarding
Ext- warm and well perfused, no cyanosis or edema, 2+ ___
pulses
Skin - no rash
Neuro - Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
Access- L PICC clean, dry and intact, without erythema or
exudate
Pertinent Results:
Admission labs:
WBC 0.4 Hgb 8.6 Hct 23.3 Plts29 ___
N:5.3 Band:0 L:91.9 M:1.3 E:0.3 Bas:1.1
.
___: 11.8 PTT: 32.4 INR: 1.1
.
138 100 10
--------------< 120
3.9 25 0.5
.
Lactate 1.3
.
Discharge labs (___):
WBC-2.4* RBC-2.87* Hgb-9.2* Hct-26.2* MCV-92 MCH-32.1*
MCHC-35.1* RDW-16.0* Plt ___
Neuts-53 Bands-0 ___ Monos-22* Eos-0 Baso-0 Atyps-3*
___ Myelos-0
ANC - ___
--------------< 106
4.1 29 0.6
.
Microbiology:
Blood culture ___- no growth x 2
Urine culture ___- no growth
C. difficle Toxin A&B ___ - negative
.
Imaging:
CXR ___- no acute intrathoracic process
Brief Hospital Course:
___ year old woman with APML undergoing C2 consolidation with
mitoxantrone and ATRA, admitted with febrile neutropenia.
.
# Febrile neutropenia- Patient presented with fever to 100.4.
Urine and CXR both negative and blood cultures without growth.
Patient had no diarrhea. She was placed on vancomycin and
cefepime. Patient developed perirectal pain without tenderness,
fluctuance or erythema in outer perirectal region. Given
concern for potential perirectal abscess, Flagyl was added.
Patient became severely nauseated on Flagyl, so regimen was
changed to vancomycin and piperacillin-tazobactam. Fevers and
perirectal pain resolved. Once ANC was >500, the patient was
transitioned to oral ciprofloxacin and flagyl (following 15 days
of IV antibiotics). She did not tolerate PO antibiotics due to
nausea. She was discharged to home off of antibiotics when ___
reached 1000.
.
# APML- Achieved remission with idarubicin/ATRA induction in
___. Completed cycle 2 of consolidation with mitoxantrone
10mg/m2/day and ATRA 30mg po BID during admission. She was
followed in the hospital until ___ returned to > 1000. She was
continued on prophylaxis with acyclovir. Bactrim prophylaxis
was discontinued to avoid further myelosuppression as patient
was neutropenic for a prolonged period of time. She should
discuss resuming Bactrim with her outpatient oncologist on
followup.
.
# Nausea/Diarrhea - With transition from IV antibiotics to PO
ciprofloxacin and Flagyl, the patient experienced chest
discomfort with swallowing, associated with nausea and diarrhea.
C. Difficile ___ for toxin A&B returned negative. The
patient was started on omeprazole for heartburn. Her oral
antibiotics were discontinued, as she had been on a prolonged
course of IV antibiotics without recent fever and with returning
cell counts. Her symptoms resolved.
.
# Transitional issues-
Patient should discuss reinitiation of Bactrim with her primary
oncologist.
Medications on Admission:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tretinoin (chemotherapy) 10 mg Capsule Sig: Three (3) Capsule
PO BID (2 times a day) for 10 days: ending ___.
5. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for nausea.
6. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for anxiety, nausea, insomnia.
4. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for nausea.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
# Febrile neutropenia (fever with low blood counts)
# Acute promyelocytic leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___!
.
You were admitted for fever while your blood counts were low.
You completed your chemotherapy, and were started on IV
antibiotics until your counts improved. There was no infection
identified.
.
During your admission, you experienced nausea, likely caused by
antibiotics. Your nausea resolved once antibiotics were
stopped.
.
Please make the following changes to your medication regimen:
- STOP ATRA
- STOP bactrim. Discuss restarting this with your oncologist
during your visit on ___.
Followup Instructions:
___
|
10713934-DS-21
| 10,713,934 | 21,348,234 |
DS
| 21 |
2161-08-22 00:00:00
|
2161-08-22 17:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle pain
Major Surgical or Invasive Procedure:
L ankle ORIF on ___ (Dr. ___
History of Present Illness:
___ brought in by EMS for left ankle pain. Just PTA she slipped
on black ice and twisted her left ankle. She does not know how
exactly she landed on the ankle because it happened so fast. She
had immediate sharp, nonradiating pain in the ankle and noticed
a deformity. She was not able to get up. Someone saw her and
called EMS. She was given fentanyl PTA with improvement. No
weakness, numbness. No prior injury.
Past Medical History:
GERD
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
Breathing comfortably
LLE
Splint in place. Fires ___ SITLT
s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
___ 10:40AM GLUCOSE-117* UREA N-9 CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-27 ANION GAP-10
___ 10:40AM estGFR-Using this
___ 10:40AM WBC-10.5 RBC-4.31 HGB-11.7* HCT-36.1 MCV-84
MCH-27.0 MCHC-32.3 RDW-13.2
___ 10:40AM NEUTS-72.4* ___ MONOS-5.1 EOS-0.7
BASOS-0.4
___ 10:15AM URINE HOURS-RANDOM
___ 10:15AM URINE HOURS-RANDOM
___ 10:15AM URINE GR HOLD-HOLD
___ 10:15AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
___ 10:15AM URINE HYALINE-5*
___ 10:15AM URINE MUCOUS-MANY
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bimal equivalent ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for L ankle ORIF which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with 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
TDWB LLE, and will be discharged on lovenox x 2 weeks for DVT
prophylaxis. The patient will follow up in two weeks 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:
ZyrTEC, cholecalciferol
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Cetirizine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC Q24H blood clot prevention
Duration: 14 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Wean yourself off to just tylenol asap
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H as needed Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L bimal-equivalent ankle fracture-dislocation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox injections daily for 2 weeks to help
prevent the formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: Touch down weight
bearing in the left lower extremity. Please wear your splint at
all times until follow up. Please cover it with water tight bag
while bathing - it cannot get wet.
Physical Therapy:
TDWB LLE in splint at all times. Otherwise, ROMAT.
Treatments Frequency:
splint and sutures will remain in until follow up appointment in
2 weeks.
Followup Instructions:
___
|
10714214-DS-5
| 10,714,214 | 26,034,370 |
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| 5 |
2153-06-09 00:00:00
|
2153-06-09 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ICD malfunction
Major Surgical or Invasive Procedure:
ICD lead extraction and device replacement (___)
History of Present Illness:
Mr. ___ is a ___ w/ a PMHx of wide-complex SVT (diagnosed
in ___ after presyncope, s/p ICD placement in ___, who
presented to ED for evaluation by cardiology for ICD lead
failure.
Pt noticed the ICD beeping a few days ago. He had no new
symptoms, including shortness of breath, chest pain, n/v,
changes in vision, diaphoresis, dizziness and lightheadedness.
He contacted his Cardiologist, who recommended he come to the ED
to be evaluated.
In the ED, initial vitals were T 98.0 P 55 BP 129/80 R 16 O2 Sat
97% on RA. Labs were unremarkable. Pt was evaluated by EP and
was found to have lead malfunction. He was taken to the OR where
the lead was extracted. He was given vancomycin and 1L of NS in
the OR. He was given percocet 2 tabs for pain. His L shoulder
and chest were placed in sling. He was also noted to have an
atraumatic foley placement with bloody urine. He was then
transfer to the floor and the vitals at that time were: 98.1
137/66 HR:58 RR:17 O2 sat of 99 and in sinus rhythm.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) HLD, (+) HTN
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ ___
___, by report, normal coronary arteries and a preserved
ejection fraction.
- PACING/ICD: ICD placement ___ ___, EnTrust
___)
- Supraventricular tachycardia (non-sustained, previously
thought to be catecholamine-induced polymorphic, diagnosed in
___ after presyncope, s/p ICD placement in ___ sp 1 shock per
pt)
3. OTHER PAST MEDICAL HISTORY:
- Tonsillectomy
- Adenoidectomy
- Anemia
- Colon cancer s/p surgical resection and chemotherapy in ___
Social History:
___
Family History:
- Mother - PPM at age ___
- Sister - PPM at age ___
- Father with hx of MI (unknown age), died at ___ of emphysema
Physical Exam:
ADMISSION EXAM:
VS: 97.8, 138/78, 58, 16, 97%onRA
General: Obese, pleasant, NAD
HEENT: PERRL, EOMI, NCAT, MMM, no OP lesions
Neck: Supple, unable to assess JVP
CV: RRR, no MGR; Dressing on L chest wall c/d/i
Lungs: LCTA-bl at sides, no w/r/r
Abdomen: Oese, NTND, +NABS, no HSM
Ext: FROM, no c/e/e
Neuro: CNII-XII grossly intact; moving all extremities
spontaneoulsy
PULSES: 2+ radial and DP pulses
DISCHARGE EXAM:
VS: 97.5, 128/88, 54, 18, 97%RA
General: Obese, pleasant, NAD
HEENT: PERRL, EOMI, NCAT, MMM, no OP lesions
Neck: Supple, unable to assess JVP
CV: RRR, no MGR; Dressing on L chest wall c/d/i
Lungs: LCTA-bl at sides, no w/r/r
Abdomen: Oese, NTND, +NABS, no HSM
Ext: FROM, no c/e/e
Neuro: CNII-XII grossly intact; moving all extremities
spontaneoulsy
PULSES: 2+ radial and DP pulses
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-9.1 RBC-5.04 Hgb-14.9 Hct-43.4 MCV-86
MCH-29.5 MCHC-34.3 RDW-13.6 Plt ___
___ 12:45PM BLOOD ___ PTT-31.4 ___
___ 12:45PM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-143
K-4.2 Cl-107 HCO3-25 AnGap-15
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-11.6* RBC-4.61 Hgb-14.0 Hct-40.1
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.4 Plt ___
___ 06:10AM BLOOD ___ PTT-29.1 ___
___ 06:10AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
___ 06:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
IMAGING:
CXR ___:
FINDINGS: Left chest wall ICD is present with a single lead in
the right
ventricle. Lung volumes are slightly low, but there is no focal
consolidation, pleural effusion, or pneumothorax.
Cardiomediastinal
silhouette is within normal limits. The bones are intact.
IMPRESSION: Single chamber ICD with lead in the right
ventricle.
Brief Hospital Course:
Mr. ___ is a ___ w/ a PMHx of wide-complex SVT (diagnosed
in ___ after presyncope, s/p ICD placement in ___, who
presented to ED for evaluation by Cardiology for ICD lead
failure (his device box was "beeping").
# SVT/ICD Lead Malfunction
Pt had malfunction of ICD lead. Pt had no symptoms. He underwent
lead extraction and device replacement on ___. He receive
Vancomycin in OR and was started on cephalexin for ppx. Per EP,
ICD was functioning properly on interogation in AM. Metoprolol
was fractionated to tartrate during his brief admission. He was
discharged with analgesics and cephalexin for infection
prophylaxis.
# HLD: Continued home Atorvastatin 80mg po
TRANSITIONAL ISSUES:
# CODE: Full Code
# CONTACT: Patient, Wife ___ ___ ___.9132)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Metoprolol Succinate XL 150 mg PO BID
3. Vitamin D 4000 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*40 Tablet Refills:*0
3. Metoprolol Succinate XL 150 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 4000 UNIT PO DAILY
6. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Capsule Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ICD lead failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a malfunctioning ICD. You underwent ICD
replacement. You are being discharged with instructions for
follow-up.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10714315-DS-18
| 10,714,315 | 29,401,798 |
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| 18 |
2119-11-15 00:00:00
|
2119-11-17 07:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Throat pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of emergency repair acute Type A dissection
___ at ___ (30mm Gelveave graft from STJ -
innominate artery) who presents with chest pain and concern for
new dissection or aortic clot on CT scan.
Patient was in his USOH until ___ when he developed a
senstation that his throat was 'bruised' during inspiration. He
then developed intermittent left sided chest, axilla, and back
pain on ___ at rest. The pain would come and go, and could
get up to ___. He notes the chest pain more when laying on his
right side and the throat sensation more when he is lying on his
back. Due to his symptoms, his PCP told him to proceed to ___,
and he went to ___ on ___. There, a CTA showed concern
for a Type A aortic dissection of indeterminate age, but no
active extravasation. There was also some concern for an aortic
clot at some point, although not mentioned in the read. He was
then transferred to ___ for further evaluation.
In the ___ intial vitals were pain 4, T 98.5, HR 106, BP 123/84,
RR 18, O2 92% RA. Initial labs were notabele for WBC 11.1, INR
1.2, and trops negative x1. Remainder of CBC and chem10 were
wnl. Cardiac surgery was consulted who felt that this was not an
acute issue, but recommended repeat imaging in 48-72 hours. They
also recommended against any anticoagulation. Patient was then
transferred to cardiology for further management. Vitals on
transfer were pain 0, T 97.7, HR 98, BP 130/77, RR 15, O2 94%RA.
On the floor patient notes only mild throat discomfort, and
denies dysphagia or difficulty breathing. He also notes he will
have some chest pain as above when he rolls on his left side.
Both of these are significantly improved from earlier in the
week. He denies recent fevers or chills. No SOB or cough. No
palpitations. No nausea, vomiting or diarrhea. No recent travel
and no pain or swelling in his legs. He does note he started
taking tiotropium inhaler and atorvastatin on ___ preceeding
these symptoms. ROS is otherwise unremarkable.
Past Medical History:
1. Type A aortic dissection status post emergent repair at ___
___ in ___ with a 30 mm Gelweave graft from
the sinotubular junction to takeoff of the innominate artery.
2. Dyslipidemia.
3. Hypertension.
4. PFO and atrial septal aneurysm with apparent small stroke by
brain MRI.
5. Reported history of cluster headaches, also with complaint of
visual auras in the absence of headache.
6. Tobacco use.
7. ?CODP
Social History:
___
Family History:
-Maternal aunt, ___ who has an ascending aortic aneurysm and
is being evaluated at ___ without as
yet a clear genetic diagnosis.
-Cousin, (son of ___ also had an ascending aortic aneurysm
and has been seen at ___.
-Father with PE at ___
Physical Exam:
ON ADMISSION
VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA
General: Well appearing pleasant man in NAD
HEENT: Anicteric sclerae, PERLL, OP clear
Neck: No LAD, JVD not elevated
CV: RRR, no MRG
Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL
Abdomen: Soft, NT, nondistended. No HSM
Ext: No unilateral swelling or erythema. No edema
Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all
extremities equally.
ON DISCHARGE
VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA
General: Well appearing pleasant man in NAD
HEENT: Anicteric sclerae, PERLL, OP clear
Neck: No LAD, JVD not elevated
CV: RRR, no MRG
Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL
Abdomen: Soft, NT, nondistended. No HSM
Ext: No unilateral swelling or erythema. No edema
Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all
extremities equally.
Pertinent Results:
ON ADMISSION
___ 06:30PM BLOOD WBC-11.1* RBC-5.27 Hgb-14.1 Hct-42.7
MCV-81* MCH-26.7* MCHC-33.0 RDW-13.1 Plt ___
___ 06:30PM BLOOD Neuts-62.6 ___ Monos-8.5 Eos-1.5
Baso-0.8
___ 06:30PM BLOOD ___ PTT-28.9 ___
___ 06:30PM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-133 K-3.5
Cl-101 HCO3-23 AnGap-13
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
ON DISCHARGE
___ 07:05AM BLOOD WBC-10.4 RBC-4.84 Hgb-13.3* Hct-39.9*
MCV-83 MCH-27.5 MCHC-33.3 RDW-12.9 Plt ___
___ 07:05AM BLOOD Neuts-54.5 ___ Monos-5.6 Eos-3.0
Baso-0.5
___ 07:05AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-138
K-4.4 Cl-104 HCO3-26 AnGap-12
___ 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
___ 07:10AM BLOOD TSH-3.0
___ 07:10AM BLOOD T4-8.3
STUDIES:
CTA TORSO (___)
1. Apparent discontinuity of the ascending aorta with
communication to an
adjacent hematoma/fluid collection. Hyperdense areas adjacent
to this site
raise concern for extravasation of contrast into a contained
rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA
to assess for
active extravasation of contrast into the adjacent mediastinal
collections.
Comparison with any prior post-operative chest CTs would also be
helpful to
determine chronicity of findings.
2. 2-cm partially thrombosed aneurysm of the left gastric
artery
3. Nonspecific mediastinal and hilar adenopathy which is stable
since ___
suggesting a benign etiology.
4. Borderline pelvic lymph nodes of uncertain etiology and
chronicity.
5. Stable 3-cm left adrenal adenoma.
6. Ectasia of the right common iliac artery measuring 1.7 cm.
7. Diverticulosis
CT NECK (___)
1. No abnormal fluid collection or lymphadenopathy in the neck.
2. Mediastinal fluid collection and aortic dissection remain
unchanged since
prior study on ___.
CTA CHEST (___)
Probable thrombosed traumatic pseudoaneurysm medial to the
ascending aortic graft. The chronicity of these findings is
uncertain, though given probable surrounding granulation tissue,
findings are at least subacute or chronic. No acute active
extravasation is identified. Comparison with prior
post-operative CT examinations would be helpful. Recommend
short interval followup CT (~3 months) to assess for stability
and to guide any potential further interventional management.
Brief Hospital Course:
___ with history of emergency repair acute Type A dissection
___ at ___ (30mm Gelveave graft from STJ -
innominate artery) who presents with throat pain.
# Throat pain:
Due to the patient's history of type A dissection, there was
concern for aortic dissection. CTA from the outside hospital
showed evidence of dissection, but this was thought to represent
a chronic flap from his previous dissection. Cardiac surgery was
consulted, who recommended repeat CTA in 48 hours to evaluate
for progression. Repeat CTA on ___ showed extravasation of
contrast into a contained rupture/pseudoaneurysm. Radiology
recommended repeat multiphase CTA to assess for active
extravasation. Repeat CTA on ___ was negative for acute/active
extravasation, however the patient likely had a leak in the
past, given the presence of granulation tissue. Radiology
recommended repeat CTA in 3 months to evaluate for progression.
We were unable to obtain films from ___, where
the patient was diagnosed with his dissection. However a
post-operative CTA report did not note any leak. The patient
remained hemodynamically stable. Blood pressure and pulses were
equal in both arms. His losartan dose was increased to 50mg. The
patient's throat pain resolved during hospitalization, and the
etiology was thought to be due to a viral infection.
# COPD:
The patient denied any shortness of breath. CT chest with
extensive centrilobular and paraseptal emphysema. He was also
found to be slightly hypoxic (SpO2 89-91% with ambulation). The
patient was continued on spiriva. Smoking cessation was
encouraged.
# HTN: Currently normotensive. His dose of losartan was
increased to 50mg daily as losartan as it has been shown to be
beneficial in patients with cystic medial necrosis.
# Leukocytosis:
Noted on admission labs. Differential was within normal limits.
Baseline unknown. The patient was afebrile and without
infectious symptoms besides throat pain. WBC trended down during
hospitalization.
# HLD: Continued atorvastatin.
TRANSITIONAL ISSUES:
* Repeat CTA in 3 months to evaluate for progression of subacute
extravasation.
* Consider referral to cardiothoracic surgeon as an outpatient.
* Patient's SpO2 decreased to 89-91% on room air with
ambulation. Likely secondary to COPD.
* CTA notable for multiple mediastinal lymph nodes, which are
present on ___ CT chest.
* Losartan increased to 50mg daily.
* Encourage smoking cessation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Throat pain
Hypoxia
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
COPD
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 ___
___. As you recall, you were admitted for throat
pain. Imaging did not show progression of your previous known
dissection. Imaging of your neck did not show anything that may
cause throat pain.
Please see below for follow up appointments.
Followup Instructions:
___
|
10714465-DS-2
| 10,714,465 | 23,212,011 |
DS
| 2 |
2140-01-08 00:00:00
|
2140-01-08 15:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Zofran / acetaminophen / acetaminophen / Iodinated
Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Back pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with chronic back pain, IV heroin abuse c/b
epidural abscess ___ years ago and skin abscess 4 months ago, mood
disorder, anxiety who presented with fever and worsening back
pain.
She moved to ___ temporarily to stay with her grandmother in
an attempt to get away from her social situation in ___. By
her report, she had been clean for 2 months, taking prescription
narcotics, but with this move from ___ she started to run low
on her pain medication, requiring that she space it out more and
more, and her back pain started to worsen. In this context, 6
days ago she used IV heroin x1. She took several stabs in a few
different sites in order to access a vein. A few days later, she
started to feel sweaty, more anxious, and possibly febrile. Her
back pain continued to worsen. She felt progressively worse, and
her grandmother decided to take her to the hospital.
She presented to ___, reportedly had a documented fever to 102
there, and they transferred her to ___ for further eval given
need for MRI. In the ___, she was afebrile with stable vital
signs. She had an MRI of her C, T, and L spine which showed no
signs of epidural abscess or osteomyelitis. She received 1mg IV
dilaudid with substantial relief. She was admitted to the
medicine service.
Today, she endorses slightly improved pain but worsening
anxiety. She gets flashbacks of her children and a recent rape
or near-rape situation, which is apparently why she decided to
come down to ___ to stay with her grandmother.
She tells me she plans to leave, no matter what I plan to do
here. She requests medications on discharge but would be OK with
leaving without medications. She says she will leave AMA if I
don't discharge her.
ROS: Per HPI, otherwise 13 points ROS notable for:
+ for some sore throat, some very mild chest pain which she
attributes to anxiety
- for HA, dizziness, blurry vision, ringing in her ears,
difficulty swallowing, shortness of breath, palpitations,
syncope, cough, nausea/vomiting, diarrhea, bloody stools,
dysuria, dark urine, difficulty voiding, heat/cold intolerance,
skin changes, numbness/tingling anywhere, arthritis, weakness.
Past Medical History:
Chronic back pain since car accident at age ___
Epidural abscess, treated with I&D and 1 month of antibiotics, ___
years ago
Skin abscess a couple of months
Iatrogenic dilaudid overdose at ___ a couple of months
ago, caused a respiratory arrest
HCV infection
Mood disorder
Anxiety
Possible ADHD, intolerant of stimulants (psychosis)
Eating disorder NOS, big weight swings
Anemia
Gestational diabetes
Early cervical cancer s/p cone resection
Allergies: Demerol (hives), Zofran (hives), Iodinated contrast
(hives), Shellfish (hives)
Social History:
___
Family History:
Cancer runs in the family
Mother died of renal cell carcinoma
Father has CAD and DM
Physical Exam:
Admit and discharge exam:
Vitals: 98.1, 100/69, 59, 18, 98 on RA
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: heart was entirely regular without any murmurs,
rubs, or ___. She had full pulses. She had no edema.
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, ND, BS+, some suprapubic tenderness. No CVAT.
MSK: No significant kyphosis. Mild tenderness over the central
bony spine from about T8 to L5/S1. No paraspinal muscle
tenderness.. No palpable synovitis in any joints. Full ROM at
the thumb and forefinger on the right, which is near where she
injected 6 days ago.
Skin: No visible rashes. No ___ nodes ___ lesions. She
does have mild erythema, warmth, and tenderness at the site of
her injection 6 days ago. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Somewhat anxious and sad appearing.
GU: No foley.
Pertinent Results:
___ 03:25AM GLUCOSE-102* UREA N-11 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 03:25AM WBC-4.6 RBC-3.90* HGB-10.6* HCT-31.4* MCV-81*
MCH-27.2 MCHC-33.8 RDW-12.9
___ 03:25AM PLT COUNT-176
MRI of the C, T, and L spine with and without contrast ___:
Wet Read: ___ ___ 7:55 AM
No acute abnormality in the cervical, thoracic, or lumbar spine.
No epidural fluid collection, no evidence of diskitis,
osteomyelitis, or prevertebral inflammation. No focal severe
degenerative change. No abnormal contrast enhancement and no
cord edema.
CXR ___ - Some radio-opaque material likely subQ or extrinsic
to patient, but otherwise normal chest.
Brief Hospital Course:
Assessment & Plan:
# Acute on chronic back pain, stable to improved with narcotic
pain medication
# Fever, resolved without intervention, unclear cause
# Soft tissue infection vs thrombophlebitis in right hand, very
mild
# IV drug abuse, active with very recent relapse
# Mood disorder NOS, anxiety disorder NOS, on Klonopin and SSRI
# Difficult social situation, doesn't want to wait to see social
work, currently safe at home
This is a ___ with prior epidural abscess, active IVDU,
mood/anxiety disorder, and chronic back pain who presented with
fever and back pain. Her fever resolved on its own, her back
pain is improved with her home pain medication, and she wants to
go home today and is willing to leave AMA.
I think she is safe for discharge at this time: She appears
well, and her only localizing sign is suprapubic tenderness. She
has had a negative contrast-enhanced MRI. Blood cultures are
NGTD. It is possible that her fever was related to drug
withdrawal, possible UTI, and possibly a mild soft tissue
infection in her hand. The history she gives me is that her back
pain was worsening prior to any fever or IVDU in the setting of
spacing out her dilaudid.
For her back pain, I will continue her home medication regimen
and will plan to discharge her with a limited supply of pain
medication.
For her fever, will obtain a UA and urine culture prior to
discharge. I will prescribe her bactrim and keflex at discharge
to treat a possible soft tissue infection at the injection site.
For her mood disorder, will continue her Zoloft.
For her active IVDU and difficult social situation, I ordered a
social work consult. She tells me she plans to quit IVDU
entirely, and is quite remorseful about her recent relapse. She
plans to leave when her father arrives, regardless of whether
social work has seen her. I will try to get her set up with a
local PCP prior to discharge, though it may not be possible
given her wishes.
TRANSITIONAL/UPDATE:
# Blood cultures will need to be followed up.
# Consider early re-imaging of spine if symptoms persist,
especially if fevers persist.
# Hand thrombophlebitis vs early injection site infection will
need to be followed closely to ensure no abscess or progression
to joint involvement. ___ need imaging if fails to improve.
# She left prior to submitting a urinalysis. I discharged her
with Bactrim and Keflex, so this should cover most uropathogens.
Consider UA/UCx at followup appointment, especially if SP
tenderness continues.
# She was seen by social work prior to discharge and was given
information on drug abuse and domestic abuse.
# She was given followup appointment as noted below.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
Confirmed with the office of Dr ___ in ___ that she was
discharged ___ on the following medications:
1. Zolpidem Tartrate 10 mg PO HS
2. ClonazePAM 1 mg PO TID
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN back pain
4. Promethazine 25 mg PO Q8H:PRN nausea
5. CloniDINE 0.1 mg PO PRN hypertension
6. Ibuprofen 800 mg PO Q8H:PRN back pain
7. Sertraline 100 mg PO DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO TID
RX *clonazepam 1 mg 1 tablet(s) by mouth three times daily Disp
#*21 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN back pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4
hours Disp #*28 Tablet Refills:*0
3. Ibuprofen 800 mg PO Q8H:PRN back pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
4. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
5. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*10 Tablet Refills:*0
7. CloniDINE 0.1 mg PO PRN hypertension
8. Promethazine 25 mg PO Q8H:PRN nausea
9. Zolpidem Tartrate 10 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic back pain
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with worsening back pain and a
fever in the context of having spaced out your pain medication
to make it last longer and having used IV drugs. You had imaging
of your spine which did not show any infection. You had blood
cultures which are still pending. You were treated with pain
medication and improved. You requested to be discharged from the
hospital, and we are doing so, but you may have a serious
condition that could make you very sick. It will be important
that you follow up with Dr ___ can make sure you are
doing OK and then help you with your other medical problems.
Followup Instructions:
___
|
10714577-DS-12
| 10,714,577 | 21,784,379 |
DS
| 12 |
2173-12-04 00:00:00
|
2173-12-09 15:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
elevated LFTS
Major Surgical or Invasive Procedure:
ERCP ___
Port ___
History of Present Illness:
Mr. ___ is a ___ male with recent
diagnosis of metastatic colon cancer who presents for elevated
LFTs.
Patient established care with Oncologist Dr. ___ at ___ on
___. Labs were notable for ALT 235, AST 190, ALP 1304, Tbili
14.6 (Dbili 8.8) as well as Na 130, WBC 9.5, H/H 12.8/37.5, and
Plt 426. He was called by his Oncologist due to concern for
biliary obstruction and instructed to present to the ___ ED.
He reports increasing pruritus and worsening rectal pain over
the
last 2 weeks. He also notes left testicular pain. He notes
worsening yellowing of the skin over past several days. He has
been taking oxycodone for the pain which has helped some. He
denies any fever, abdominal pain, and nausea/vomiting.
On arrival to the ED, initial vitals were 97.8 ___ 16
100% RA. Labs were notable for WBC 10.9, H/H 12.5/35.6, Plt 419,
Na 129, K 3.4, BUN/CR ___, INR 1.2, ALT 261, AST 252, ALP
1687,
Tbili 15.8, lipase 11, lactate 1.4, and UA negative. Patient had
RUQ US which showed scattered mild intrahepatic biliary
dilatation likely due to malignant obstruction secondary to
hepatic metastatic masses. ERCP was consulted and recommended
obtaining MRCP. Patient was given dilaudid 1mg IV x 3 and 1L NS.
Prior to transfer vitals were 98.8 102 163/90 18 97% RA.
On arrival to the floor, patient reports ___ rectal and left
testicular pain. He notes occasional shortness of breath. He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, cough, hemoptysis,
chest pain, palpitations, nausea/vomiting, diarrhea,
hematemesis,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
Patient evaluated by PCP ___ ___ for symptoms including months
of passing mucousy stools streaked with blood. Also 6 months of
constipation for which he took laxatives with improvement. He
changed his diet and began to eat more fruits and vegetables and
then he began to move his bowels more easily. He developed
rectal
pain and was seen by an MD in ___ who sent him to a
colorectal surgeon at ___ who did a banding procedure about 1
month ago. He has lost 40 lbs in 6 months. He underwent CT torso
which showed innumerable pulmonary and hepatic nodules and
masses, worrisome for metastases, abdominal and pelvic
lymphadenopathy and probable left sacral metastases, and long
segment of thickened sigmoid with luminal narrowing, correlate
with colonoscopy. He underwent FNA of the supraclavicular node
which showed metastatic colorectal adenocarcinoma. On ___,
PET CT scan at ___ confirmed extensive metastatic cancer:
Colon
cancer with multiple sites of metabolically active metastatic
disease as described above involving pulmonary nodules, liver
lesions, left adrenal gland lesion, osseous lesions,
retroperitoneal lymph nodes, inguinal lymph nodes, bilateral
hilar lymph nodes, a left paratracheal lymph node, and a left
supraclavicular lymph node
Past Medical History:
- Asthma
- Hemorrhoids s/p homorrhoidectomy
- s/p right ankle surgery
Social History:
___
Family History:
Father with CAD/PVD in his father and cancer.
Physical Exam:
===ADMISSION PHYSICAL EXAM===
VS: Temp 99.3, BP 194/121, HR 102, RR 18, O2 sat 96% RA.
GENERAL: Pleasant man, appears in pain.
HEENT: Icteric scerae, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
===DISCHARGE PHYSICAL EXAM===
VS: 98.8 157/100 98 18 96 RA
GENERAL: Pleasant man, appears in pain.
HEENT: Icteric scerae, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: CTAB
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, no focal deficits
Pertinent Results:
===ADMISSION LABS===
___ 04:40PM BLOOD WBC-10.9* RBC-4.42* Hgb-12.5* Hct-35.6*
MCV-81* MCH-28.3 MCHC-35.1 RDW-16.4* RDWSD-47.0* Plt ___
___ 05:07PM BLOOD ___ PTT-33.7 ___
___ 04:40PM BLOOD Plt ___
___ 04:40PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-129*
K-3.4 Cl-88* HCO3-26 AnGap-18
___ 04:40PM BLOOD ALT-261* AST-252* AlkPhos-1687*
TotBili-15.8* DirBili-12.4* IndBili-3.4
___ 04:40PM BLOOD Albumin-3.4* Calcium-10.4* Phos-3.8
Mg-2.0
===DISCHARGE LABS===
___ 07:10AM BLOOD WBC-13.0* RBC-4.21* Hgb-11.5* Hct-33.1*
MCV-79* MCH-27.3 MCHC-34.7 RDW-17.9* RDWSD-50.3* Plt ___
___ 07:10AM BLOOD Glucose-104* UreaN-7 Creat-0.7 Na-131*
K-3.5 Cl-92* HCO3-26 AnGap-17
___ 07:10AM BLOOD ALT-223* AST-212* LD(LDH)-1242*
AlkPhos-1537* TotBili-11.6*
___ 07:10AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.1
===MICRO===
___ URINE URINE CULTURE-FINAL
===RADIOLOGY===
___ MRCP
1. Re-demonstration of metastatic disease involving the lungs
and liver, with retroperitoneal lymphadenopathy.
2. Extensive hepatic metastases with almost complete replacement
of the left hepatic lobe. There is severe attenuation of the
left hepatic vein and the left portal vein is not visualized.
3. The right anterior and right posterior branches of the right
hepatic duct are each obstructed by the metastatic disease at
the hilum. Additionally, extensive metastases in the left
hepatic lobe causes multiple regions of peripheral segmental
bile duct dilatation.
___ ruq us
1. Segmental intrahepatic biliary ductal dilation due to
malignant
obstruction.
2. Scattered masses are once again seen throughout the hepatic
parenchyma
consistent with known metastasis
3. Gallbladder wall is thickened and edematous which is likely
secondary to
liver disease. There is no evidence of acute cholecystitis. CBD
is within
normal limits.
___ ERCP
Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film was normal.
The major papilla appeared normal.
The CBD was successfully cannulated with the Hydratome
sphincterotome preloaded with a 0.035in guidewire.
The guidewire was advanced into the right IHD.
Contrast injection revealed a CBD of approximately 6mm in
diameter and a tight malignant appearing 1 cm stricture at the
level of the bifurcation involving the proximal right IHD.
The left IHD system was not opacified.
A sphincterotomy was successfully performed at the 12 o'clock
position.
No post sphincterotomy bleeding was noted.
A 8mm X 80mm uncovered WallFlex metal stent (REF ___
___ was successfully placed across the stricture.
There was excellent drainage of bile and contrast at the end of
the procedure.
The PD was cannulated but not injected.
Otherwise normal ercp to third part of the duodenum.
Brief Hospital Course:
Mr. ___ is a ___ male with recent
diagnosis of metastatic colon cancer who presents for elevated
LFTs.
# Malignant Biliary Obstruction: Significantly elevated ALP and
bilirubin consistent with obstructive pattern. Also likely
component of extensive replacement of liver parenchyma by
metastatic disease. RUQ US showed scattered mild intrahepatic
biliary dilatation. MRCP with malignant obstruction, ERCP ___
with sphinterotomy and metal stent placed across a tight
malignant appearing 1 cm stricture at the level of the
bifurcation involving the proximal right IHD, with excellent
drainage of bile and contrast at the end of the procedure.
Patient received adequate post-ERCP hydration, and diet was
advanced as tolerated. Patient was started on ciprofloxacin
500mg BID x 5 days (___)
# Rectal Pain:
# Cancer-Related Pain: Rectal pain secondary to localized
disease. Continued oxycodone as well as IV dilaudid PRN. Patient
was started on a fentanyl patch, as patient was reluctant to
uptitrate PO medications, and pain was poorly controlled. Pain
was better controlled with this new regimen, and he was
discharged with rx for fentanyl patch as well as bowel meds prn.
# Metastatic Colon Cancer: Metastatic to liver, lung, left
adrenal gland, bone, and lymph nodes. Plan to start FOLFIRI.
Port placement ___.
# Hyponatremia: Likely hypovolemic, improved with IVF.
# Anemia: Likely secondary to colon cancer. Remained stable
during admission.
TRANSITIONAL ISSUES:
=====================
- ciprofloxacin 500mg BID x 5 days (___)
- ___ 10:45 AM ___, MD ___
- monitor LFTs closely
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (girlfriend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Fentanyl Patch 37 mcg/h TD Q72H
RX *fentanyl 37.5 mcg/hour apply 1 patch to skin every 72 hours
Disp #*5 Patch Refills:*0
5. Lactulose 15 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth daily prn:
constipation Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constpation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*28 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
malignant biliary obstruction
Secondary Diagnoses:
cancer-related pain
metastatic colon cancer
hyponatremia
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you were found to have abnormal labs in clinic. We were
concerned that your liver may not have been draining well. While
you were here, we found that the cancer cells in your liver were
compressing the drainage system of your liver. We put a stent in
your liver, which acts like a scaffold to keep everything
draining well. The procedure went very well.
While you were here, we also made adjustments to your pain
medications, and your pain was much better controlled. We also
helped you get your port for chemotherapy.
Please continue taking your antibiotic (ciprofloxacin) twice
daily until the last day on ___. You can take Colace and
senna twice daily every day to prevent constipation and then
take miralax (poly ethylene glycol) daily and lactulose daily if
you have not had a bowel movement that day. If you are still
constipated for two days despite taking Colace, senna, miralax,
and lactulose then take bisacodyl at night to help with
constipation.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10714577-DS-13
| 10,714,577 | 24,084,445 |
DS
| 13 |
2173-12-28 00:00:00
|
2173-12-28 23:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ Endoscopic Retrograde Pancreato-Cholangiography with
debris removal from common bile duct stent
History of Present Illness:
Mr. ___ is a ___ male with recent
diagnosis of metastatic colon cancer, recent admit for high
T.Bili s/p biliary sphincterotomy on ___ and metal stent
insertion who presents for fevers.just finished first round of
oral chemo. reports he was in his usual state of health until
today
VS in ER 100.8 115 158/83 18 99% RA. ERCP was consulted in
ER.
He received Vancomycin and Cefepime in the ER.
On floor, he is seen shivering with fever. He does not have any
other sx apart from fever. No mouth pain. No CP or SOB. No cough
or cold sx. No sick contacts.
His abdominal pain is at baseline. No worsening. Normal
urination
. Endorses some diarrhea. This is after he had constiopation
requiring fleets enema a few days ago sa outpatient. No blood
noted in BM. No Nausea or Vomiting.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Patient evaluated by PCP ___ ___ for symptoms including months
of passing mucousy stools streaked with blood. Also 6 months of
constipation for which he took laxatives with improvement. He
changed his diet and began to eat more fruits and vegetables and
then he began to move his bowels more easily. He developed
rectal
pain and was seen by an MD in ___ who sent him to a
colorectal surgeon at ___ who did a banding procedure about 1
month ago. He has lost 40 lbs in 6 months. He underwent CT torso
which showed innumerable pulmonary and hepatic nodules and
masses, worrisome for metastases, abdominal and pelvic
lymphadenopathy and probable left sacral metastases, and long
segment of thickened sigmoid with luminal narrowing, correlate
with colonoscopy. He underwent FNA of the supraclavicular node
which showed metastatic colorectal adenocarcinoma. On ___,
PET CT scan at ___ confirmed extensive metastatic cancer:
Colon
cancer with multiple sites of metabolically active metastatic
disease as described above involving pulmonary nodules, liver
lesions, left adrenal gland lesion, osseous lesions,
retroperitoneal lymph nodes, inguinal lymph nodes, bilateral
hilar lymph nodes, a left paratracheal lymph node, and a left
supraclavicular lymph node.
___- Irinotecan 125 mg/m2
___ (XELODA) 500 mgTake 4 tablets by mouth
twice daily for 14 days Two weeks on one week off.
PAST MEDICAL HISTORY:
- Asthma
- Hemorrhoids s/p homorrhoidectomy
- s/p right ankle surgery
Social History:
___
Family History:
Father with CAD/PVD in his father and cancer.
Physical Exam:
ON ADMISSION
=============
PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 102.1 Axillary 145 / 81 L Lying ___ RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB No crackles or wheezes,
ABD: BS+, soft, NTND, No RUQ tenderness. Normal BS.
LIMBS: No edema, clubbing, tremors, or asterixis;
SKIN: No rashes or skin breakdown
Neuro- No focal neurologic deficits.
ON DISCHARGE
============
98.2 PO 144 / 88 L Lying 92 18 99 RA
GENERAL: Well-appearing young man, lying in bed comfortably.
HEENT: Mildly icteric sclerae, PERLL, Mucous membranes dry, OP
clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes
Pertinent Results:
ON ADMISSION
=============
___ 01:12AM BLOOD WBC-7.8 RBC-3.11*# Hgb-9.2* Hct-27.2*
MCV-88# MCH-29.6 MCHC-33.8 RDW-18.9* RDWSD-58.2* Plt ___
___ 01:12AM BLOOD Neuts-73.4* Lymphs-9.2* Monos-15.5*
Eos-0.4* Baso-0.6 Im ___ AbsNeut-5.75 AbsLymp-0.72*
AbsMono-1.21* AbsEos-0.03* AbsBaso-0.05
___ 01:43AM BLOOD ___ PTT-31.5 ___
___ 01:12AM BLOOD ALT-104* AST-116* AlkPhos-917*
TotBili-3.3*
___ 09:20AM BLOOD hsCRP-56.2
___ 01:12AM BLOOD Albumin-2.9* Phos-3.5 Mg-1.8
ON DISCHARGE
============
___ 07:50AM BLOOD ALT-76* AST-77* LD(LDH)-557* AlkPhos-766*
TotBili-3.1*
MICRO
=====
___ 1:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___
315PM.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with metastatic CRC on
C1 Cap-Iri complicated by R liver lobe metastatic disease now
s/p stent/sphincterotomy who presents with new fever. Found to
have E.cloacae bloodstream infection, likely source is
cholangitis now s/p ERCP with CBD stent debris removal.
#Enterobacter cloacae Bloodstream infection
#Presumed cholangitis
Most likely source is intra-abdominal given sterile urine and
GNR BSI. Among intra-abdominal sources the likeliest is
cholangitis in setting of debris in CBD metal stent now swept.
Alternative source is likely to be primary recto-sigmoid mass
with bacterial translocation. Received 3 day of
cefepime/metronidazole and was then switched to po ciprofloxacin
to complete a 14-day course.
#Cancer-related pain: Mostly localized to anorectal region.
Exacerbated in setting of alternating constipation and diarrhea.
Was continued on home oxycodone 10mg q4h prn and receive
hydromorphone 0.5-1mg q3h prn breakthrough.
#Constipation: Secondary to partially obstructing mass. Was
continued on PEG 17g daily and bisacodyl 10mg qod. Started on
Psyllium wafers bid to good effect.
# Metastatic Colon Cancer: Metastatic to liver, lung, left
adrenal gland, bone, and lymph nodes. Plan to start FOLFIRI and
port placement per outpatient note. To follow-up with primary
oncologist as an outpatient.
# Anemia: Secondary to GI losses and chronic inflammation.
Monitored. Did not require transfusion.
TRANSITIONAL ISSUES:
====================
#Antibiotic course: Plan to complete a 14-day course of oral
ciprofloxacin for bloodstream infection through ___.
#Surveillance blood cultures: From ___ and ___ without any
growth to date but pending upon discharge. Please follow-up. If
positive and remains afebrile and asymptomatic can obtain
additional surveillance culture.
#If repeat cholangitis may consider suppressive rifaximin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Fentanyl Patch 37 mcg/h TD Q72H
4. Lactulose 15 mL PO DAILY:PRN constipation
5. Polyethylene Glycol 17 g PO DAILY:PRN constpation
6. Senna 8.6 mg PO BID:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*24 Tablet Refills:*0
2. Psyllium Wafer 1 WAF PO BID
RX *psyllium [Metamucil (sugar)] 1.7 g 1 wafer(s) by mouth twice
to three times a day Disp #*90 Wafer Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fentanyl Patch 37 mcg/h TD Q72H
6. Lactulose 15 mL PO DAILY:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN constpation
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Enterobacter Blood Stream Infection
Presumed Cholangitis
Metastatic Colorectal Cancer
Cancer related-pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for an infectious to your bloodstream, likely
coming from your bile tree. You were treated with antibiotics,
received an ERCP and improved significantly.
It is EXTREMELY IMPORTANT that you complete 2 FULL WEEKS of
treatment with the antibiotic ciprofloxacin. Please do not miss
even one dose. If you have any fever, you need to call your
oncologist IMMEDIATELY.
It was a pleasure to take care of you.
Your ___ Team
Followup Instructions:
___
|
10714577-DS-14
| 10,714,577 | 26,734,367 |
DS
| 14 |
2174-01-31 00:00:00
|
2174-01-31 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old M with metastatic rectal cancer who is admitted with
fevers. Pt diagnosed in ___ w/ colorectal cancer with extensive
mets to liver, sacrum, and lungs. Pt's disease was complicated
by
obstructive jaundice for which he had ERCP with stenting. He was
subsequently hospitalized in ___ with fevers and chills with
enterobacter bacteremia presumably from biliary source for which
he underwent repeat ERCP with cleanout of stent. Pt was
initially
treated with irinotecan/capecitabine and subsequently started
FOLFIRI on ___ with improvement in his hyperbilirubinemia. He
is
now s/p cycle 2 on ___.
Pt presented to the ED today due to fever. Pt's girlfriend noted
that he felt warm and checked temperature which was around 101.
Temperature was elevated to 101 when he presented to the ED
without any other vital signs abnormalities aside from moderate
hypertension. He was started on Vanc/Zosyn after cultures were
obtained from blood and urine. Abdominal ultrasound was
unremarkable and did not show any liver abscess or biliary
abnormality with patent stent. He was admitted for further care.
He denies chills or other changes in symptoms. He does have
rectal pain related to his tumor. He also has intermittent
diarrhea for which he takes Imodium. Pt did not have diarrhea
earlier today, but on arrival to floor, he was making frequent
trips to the bathroom. He denies hematochezia.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: presented with increasing rectal pain over six months
with progressive weight loss and was diagnosed extensive
metastatic colon rectal cancer. The primary tumor was in the
rectosigmoid with partial bowel obstruction. Metastases include
extensive liver involvement and nodal involvement with
obstructive jaundice; pulmonary nodules and bony involvement of
the left S5 sacral ala extending into the neural foraminal. The
tumor cells retain expression of the mismatch repair proteins,
MLH1, PMS2, MSH2, and MSH6, i.e., no evidence of microsatellite
instability. The tumor is positive for K-ras mutation (Codon 12
GGT>GTT).
___: underwent sphincterotomy and biliary stenting for
severe obstructive jaundice due to the extensive liver
metastases.
___: cycle 1 irinotecan/capecitabine ___ cannot be
used due to hyperbilirubinemia)
___: admitted to ___ for fever, blood cultures were
positive for a pan-sensitive Enterobacter cloacae and after two
days of cefepime and metronidazole, he was prescribed oral cipro
for two weeks.
___: cycle ___ F___
___: cycle ___ FOLFIRI
PAST MEDICAL HISTORY:
- Asthma
- Hemorrhoids s/p homorrhoidectomy
- s/p right ankle surgery
Social History:
___
Family History:
Father with CAD/PVD in his father and cancer.
Physical Exam:
ON ADMISSION
============
Vitals: 98.8 160/90 82 18 100 RA
GENERAL: NAD
HEENT: no scleral icterus
NECK: supple
LUNGS: clear bl
CV: rrr, no r/m/g
ABD: soft, nt/nd
EXT: trace edema b/l
SKIN: no jaundice, no rashes
NEURO: alert and oriented x 3
ACCESS: R sided port
ON DISCHARGE:
==============
98.7 PO 135 / 87 96 18 96 RA
Vitals: 98.3 145/93 77 18 99 RA
GENERAL: Well-appearing young man, thin sitting in bed
HEENT: no scleral icterus, MMM
NECK: supple
LUNGS: CTAB
CV: RRR, no m/r/g
ABD: Non-distended, normal bowel sounds, soft and non-tender. No
organomegaly.
EXT: No edema.
SKIN: no jaundice, no rashes
NEURO: alert and oriented x 3, no focal deficits.
ACCESS: R sided port
Pertinent Results:
ON ADMISSION
=============
___ 07:45PM BLOOD WBC-8.8 RBC-3.37* Hgb-9.8* Hct-29.4*
MCV-87 MCH-29.1 MCHC-33.3 RDW-16.3* RDWSD-52.0* Plt ___
___ 07:45PM BLOOD Plt ___
___ 07:45PM BLOOD Glucose-87 UreaN-7 Creat-0.8 Na-136 K-3.6
Cl-96 HCO3-26 AnGap-14
___ 07:45PM BLOOD ALT-69* AST-68* AlkPhos-1059* TotBili-1.5
ON DISCHARGE
==============
___ 06:15AM BLOOD WBC-5.9 RBC-3.56* Hgb-10.4* Hct-30.9*
MCV-87 MCH-29.2 MCHC-33.7 RDW-15.9* RDWSD-50.5* Plt ___
___ 06:15AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-136 K-3.9
Cl-96 HCO3-24 AnGap-16
___ 06:15AM BLOOD ALT-63* AST-77* AlkPhos-1022*
TotBili-1.7*
MICROBIOLOGY:
==============
___ STOOL FECAL CULTURE; CAMPYLOBACTER CULTURE; FECAL
CULTURE - R/O E.COLI 0157:H7: Negative
___ STOOL C. difficile DNA amplification assay-Negative
___ Blood Culture- NGTD
___ URINE CULTURE-Negative
___ Blood Culture-NGTD
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with metastatic rectal
cancer on FOLFIRI with substantial liver involvement who had a
recent episode of GNR BSI from cholangitis and presented with a
new episode of fever and relative cholestasis.
#Fever
#Presumed cholangitis
Patient had one episode of fever that did not repeat. His
transaminases and baseline bilirubin are vastly improved over
the long term but remain abnormal. Nonetheless, he has had a
recent episode of cholangitis and he is at high risk for having
cholangitis. Alternatively his fever could be due to his tumor
but it was decided to treat for presumed cholangitis given high
risk and plan for next cycle of chemotherapy approaching.
Received broad spectrum antibiotics initially then narrowed to
PO ciprofloxacin. Stool, urine and blood cultures did not grow
organisms on discharge. To complete 7-day course of
ciprofloxacin (d1 ___.
#Metastatic CRC: With large burden of metastatic disease to the
liver. Has had improvement of bilirubin with 2 cycles of
FOLFIRI. Was due for second cycle ___.
To reschedule next cycle with Dr. ___ on ___.
#Cancer-related pain:
#Constipation / diarrhea
#Partial rectal obstruction
Patient has chronic ano-rectal pain from large partially
obstructing recto-sigmoid mass. Has constipation alternating
with diarrhea after receiving irinotecan. Management of his pain
is complex and has so far been frustrating in spite of multiple
attempts. Continued fentanyl 37mcg/h q72h and oxycodone 10mg
q4h prn. Discharged on prn loperamide and diphenoxylate-atropine
prn.
#Anemia: Likely secondary to chronic blood loss as well as
inflammation. Did not require transfusions during this
admission.
TRANSITIONAL ISSUES
===================
#ANTIBIOTIC COURSE: To complete 7-day course of ciprofloxacin up
to and including ___.
#RECURRENT CHOLANGITIS: Second bout of cholangitis in spite of
improving cholestasis. If recurs would consider prophylaxis with
rifaximin.
45 minutes were spent formulating and coordinating this
patient's discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Fentanyl Patch 37 mcg/h TD Q72H
3. Multivitamins 1 TAB PO DAILY
4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
2. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea not
responding to loperamide
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
3. Labetalol 100 mg PO TID
RX *labetalol 100 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. LOPERamide 2 mg PO TID:PRN diarrhea
RX *loperamide 2 mg 1 tablet by mouth three times a day Disp
#*30 Capsule Refills:*0
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fentanyl Patch 37 mcg/h TD Q72H
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
-Presumed acute infectious cholangitis
SECONDARY
-Metastatic Rectal Cancer
-Liver metastatases with cholestasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a single episode of fever. Given the
amount of cancer you have in your liver we are assuming that you
had a new bile duct infection and are sending you out to
complete a 7-day course of antibiotics.
It was a pleasure to take care of you.
Your ___ Team
Followup Instructions:
___
|
10714577-DS-15
| 10,714,577 | 28,945,938 |
DS
| 15 |
2174-04-25 00:00:00
|
2174-04-25 21:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
fever
Major Surgical or Invasive Procedure:
ERCP (___)
History of Present Illness:
___ PMH of Metastatic Colon Cancer (to liver and lung, on
FOLFIRI), Malignant CBD stricture (s/p metal stent last
instrumented ___ obstruction causing GNR bacteremia),
HTN,
who presented to ED with fever found to have elevated LFTs, c/f
possible recurrent CBD stent blockage
Pt reports he had fever and malaise at home. He noted that he
had a single episode of cough with productive sputum but then
self resolved and never recurred and is currently without cough
or shortness of breath. He noted that respiration is currently
at baseline. He denied any headache, sore throat,
nausea/vomiting/abdominal pain, dysuria, rash. He noted that he
is tolerating a normal diet and is voiding/stooling without any
difficulty. He noted that he was unsure as to what was causing
his fever
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last onc clinc note:
___: presented with increasing rectal pain over six months
with progressive weight loss and was diagnosed extensive
metastatic colon rectal cancer. The primary tumor was in the
rectosigmoid with partial bowel obstruction. Metastases include
extensive liver involvement and nodal involvement with
obstructive jaundice; pulmonary nodules and bony involvement of
the left S5 sacral ala extending into the neural foraminal. The
tumor cells retain expression of the mismatch repair proteins,
MLH1, PMS2, MSH2, and MSH6, i.e., no evidence of microsatellite
instability. The tumor is positive for K-ras mutation (Codon 12
GGT>GTT).
___: underwent sphincterotomy and biliary stenting for
severe obstructive jaundice due to the extensive liver
metastases.
___: cycle 1 irinotecan/capecitabine ___ cannot be
used due to hyperbilirubinemia)
___: admitted to ___ for fever, blood cultures were
positive for a pan-sensitive Enterobacter cloacae and after two
days of cefepime and metronidazole, he was prescribed oral cipro
for two weeks.
___: cycle ___ FOLFIRI
___: cycle ___ FOLFIRI
___: Admitted to ___ for fever, cultures negative but
was prescribed empirical antibiotics.
___: cycle ___ FOLFIRI
___: cycle ___ FOLFIRI
___: cycle ___ FOLFIRI
___: cycle ___ FOLFIRI
___: cycle ___ FOLFIRI
PAST MEDICAL HISTORY:
Pulmonary nodule
Malignant neoplasm metastatic to lung
Bone metastases
Metastatic colon cancer to liver
HTN
Malignant CBD stricture s/p metal stent last instrumented ___ obstruction causing GNR bacteremia
Social History:
___
Family History:
CAD/PVD in his father
Cancer in his father
Physical ___:
ADMISSION EXAM
===============================
Vitals: 98.7
PO 138 / 73 82 18 99 RA
GENERAL: Sitting upright in bed, in no acute distress, appears
comfortable
EYES: Pupils equally round and reactive to light
HEENT: Oropharynx clear, moist mucous membranes
NECK: Supple
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi, normal respiratory rate
CV: Regular rate and rhythm, no murmurs rubs or gallops, distal
perfusion intact
ABD: Soft, nontender, not distended, normoactive bowel sounds,
no
rebound or guarding
GENITOURINARY: No Foley
EXT: Normal muscle bulk, no deformity
SKIN: Warm dry, no rash
NEURO: Alert and oriented ×3, fluent speech
DISCHARGE EXAM
===============================
Vital signs stable
GEN: NAD
HEENT: MMM.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding.
Extremities: WWP, no edema.
Skin: no rashes.
Neuro: AOx3, moves all extremities with purpose
Pertinent Results:
ADMISSION LABS
========================
___ 08:59AM BLOOD WBC-3.3* RBC-3.08* Hgb-8.3* Hct-25.5*
MCV-83 MCH-26.9 MCHC-32.5 RDW-15.0 RDWSD-45.1 Plt ___
___ 08:59AM BLOOD Plt ___
___ 08:59AM BLOOD Glucose-77 UreaN-9 Creat-0.5 Na-135 K-3.8
Cl-95* HCO3-24 AnGap-16
___ 08:59AM BLOOD ALT-64* AST-77* AlkPhos-874* TotBili-4.7*
___ 08:59AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.8
PERTINENT LABS
========================
___ 05:37AM BLOOD ALT-45* AST-57* AlkPhos-703* TotBili-1.7*
___ 05:37AM BLOOD WBC-5.2 RBC-2.95* Hgb-7.9* Hct-24.1*
MCV-82 MCH-26.8 MCHC-32.8 RDW-15.5 RDWSD-45.6 Plt ___
___ 05:37AM BLOOD ___ PTT-29.7 ___
DISCHARGE LABS
========================
___ 05:37AM BLOOD WBC-5.2 RBC-2.95* Hgb-7.9* Hct-24.1*
MCV-82 MCH-26.8 MCHC-32.8 RDW-15.5 RDWSD-45.6 Plt ___
___ 05:37AM BLOOD Plt ___
___ 05:37AM BLOOD ___ PTT-29.7 ___
___ 05:37AM BLOOD Glucose-80 UreaN-7 Creat-0.5 Na-138 K-3.4
Cl-99 HCO3-27 AnGap-12
___ 05:37AM BLOOD ALT-45* AST-57* AlkPhos-703* TotBili-1.7*
___ 05:37AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2
PERTINENT STUDIES
========================
CXR (___)
Increase innumerable nodular opacities throughout the lungs,
concerning for
worsening metastatic disease. However, underlying infectious
etiology cannot
be excluded.
RUQUS (___)
1. Grossly stable innumerable echogenic lesions throughout the
liver. The
extent of the hepatic masses is better evaluated on prior CT.
Trace
perihepatic ascites.
2. Chronic gallbladder wall thickening and pericholecystic
fluid, likely due
to chronic liver disease. No evidence of cholecystitis.
3. Satisfactorily positioned CBD stent.
CT ABD/PELVIS (___)
1. Interval progression of osseous metastatic disease, with
significant
increase in size of bilateral sacral metastases which have
coalesced to form a
large 12 cm sacral mass, significant increase in size of a 6.0
cm exophytic
left inferior pubic ramus mass, and new left iliac bone lesion.
Correlate
with physical exam for signs of sacral nerve root compression.
2. Interval increase in size and number of innumerable pulmonary
metastases at
the lung bases.
3. No significant change in extent of hepatic metastatic
disease.
4. No evidence of biliary obstruction.
5. Lymphadenopathy is stable to slightly decreased from prior.
6. Severe distention of the bladder.
PERTINENT MICRO
========================
BCx / UCx all negative to date
Brief Hospital Course:
___ man with PMHx notable for metastatic colon cancer
(on FOLFIRI) complicated by malignant common bile duct stricture
stricture s/p metal stent and hypertension who was admitted for
CBD stent blockage. Underwent ERCP ___ with removal of stent
debris without complication. Course notable for persistent
rectal pain with bowel movements due to significant disease
burden in ___ area, however patient would prefer to
avoid stool softeners given history of fecal incontinence.
Otherwise improved with plan to complete course of ciprofloxacin
at home.
# TRANSAMINITIS/CHOLESTASIS
# FEVERS, LIKELY CHOLANGITIS
# H/O MALIGNANT CBD STRICTURE S/P METAL STENT
Initially presented with fever and malaise. Initial workup
notable for rising LFTs (particularly Alk Phos and T-bili)
suggestive of cholestasis. Started on Zosyn. RUQUS was obtained
without evidence of biliary ductal dilatation, however overall
clinical picture was consistent with likely cholangitis. Further
obtained CT abdomen/pelvis which did not show acute biliary
obstruction. Infectious workup otherwise reassuring including
negative. Underwent ERCP on ___ which did show debris in
the CBD metal stent which was cleared without complication.
Antibiotic coverage narrowed to ciprofloxacin to complete 7-day
course at home. At time of discharge, was pain-free in abdomen
without symptoms nausea, vomiting, or other GI symptoms (with
exception of constipation, discussed below). ___ home
with plan for oncology follow up.
# METASTATIC COLON CANCER
# RECTAL PAIN
Oncologic history notable for metastases to liver and lung, on
FOLFIRI. CXR on admission
concerning for possible disease progression, further
characterized on CT abdomen/pelvis. Hospital course notable for
significant amount of pain with bowel movements, most likely due
to significant disease burden in ___ area. Recommended
stool softener to reduce pain however patient would like to
defer at this time due to history of fecal incontinence. Held
home loperamide.
# ANEMIA
Hgb 9 at baseline. Likely related to underlying malignancy and
concurrent chemotherapy. Hgb at discharge 7.9. Recommend
outpatient re-check to ensure stability.
# COAGULOPATHY:
Most likely liver synthetic dysfunction in the setting of liver
metastasis vs. nutritional deficiency. INR at discharge was 1.3.
# HYPERTENSION
- continued labetalol
TRANSITIONAL ISSUES
================================
[ ] Plan to complete 7-day ciprofloxacin course (last day ___
for biliary infection.
[ ] Obtained CT abdomen/pelvis while inpatient to assess biliary
infection. Recommend further discussion with patient regarding
overall amount of disease burden. Full CT read available in OMR.
[ ] Hospital stay notable for significant constipation with
significant pain with bowel movements, most likely due to extent
of ___ disease burden. Offered stool softeners however
patient declined given history of fecal incontinence. Would
pursue this possibility if continues to have constipation.
[ ] Ongoing anemia in setting malignancy. Discharge Hgb 7.9.
Recommend re-check as outpatient to ensure stability.
#CODE: full (confirmed)
#CONTACT: ___ (fiancé: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Labetalol 100 mg PO TID
3. LOPERamide 2 mg PO TID:PRN diarrhea
4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
5. Morphine SR (MS ___ 60 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*11 Tablet Refills:*0
2. Labetalol 100 mg PO TID
3. Morphine SR (MS ___ 60 mg PO Q12H
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
6. HELD- LOPERamide 2 mg PO TID:PRN diarrhea This medication
was held. Do not restart LOPERamide until you discuss with your
oncologist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
cholangitis
SECONDARY DIAGNOSES
biliary stent obstruction
metastatic rectal cancer
constipation
anemia
coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- you were having worsening fever
What was done for you in the hospital:
- we obtained an ultrasound and CT scan of your abdomen
- we performed a procedure called ERCP to clear a blockage in
your bile duct stent
- we gave you antibiotics to treat any infection in your
abdomen
What you should do when you get home:
- continue to take your medications as prescribed in the
discharge papers
- attend your follow up appointments as scheduled in the
discharge papers
- contact your doctor or return to the hospital if you have any
worsening fever or symptoms
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10714590-DS-23
| 10,714,590 | 26,482,308 |
DS
| 23 |
2189-01-16 00:00:00
|
2189-01-16 23:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Levaquin / Macrodantin /
Cephalosporins / Lisinopril
Attending: ___.
Chief Complaint:
S/p fall, syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o baradycardia s/p pacer placement for bradycardia
who was walking back from bathroom at 730 am when her vision
went black and the next thing she remembers is waking up on the
floor. Associated with this was dizziness upon standing,
flushed feeling and resolution of sypmtoms immediately upon
hitting the floor. She denies any loss of consciouenss.
Patient was unable to right her self after the fall and called
her son who called EMS. She also reports another event similar
to this a week prior, that she did not present to the hospital
for. After the fall she reported some pain in her left
shoulder/elbow as well as hip.
.
In the ED, initial vitals: 98.2 72 165/61 16 100% 4L. She
c/o left head pain, and left shoulder/elbow pain, and has L eye
abrasion, but no lightheadedness, dizziness, diaphoresis, CP,
SOB before syncopal event. Left shoulder and elbow plain films
were negative for fracture. CT head and C-spine without
worrisome process. Pt was given 1g Tylenol.
.
On the floor, patient's vital signs were 96, 134/40, 60, 16,
100. Patient denied any significant pain.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Hypertension
2. Left ventricular hypertrophy
3. Hx of bradycardia s/p pacemaker placement
4. Hx of herpes zoster c/b postherpetic neuralgia of RUE,
followed in the Pain Clinic.
5. Osteoarthritis, especially of the knees.
6. Vitamin B12 deficiency.
7. Hx of Glaucoma s/p bilateral surgeries
8. H/o frequent UTIs
9. H/o frequent falls
10. Partial hysterectomy for menorrhagia
11. SP appendectomy
12. Hx of intertigo - ___ by derm, under breasts, in abdominal
folds and in groin since ___, last seen by ___ ___. Bilateral peripheral arterial disease: recent angiogram that
showed "high-grade SFA stenosis and occlusion at the knee with
reconstitution, very limited runoff distally". No intervention.
14. seborrheic dermatitis
15. gastric adenocarcinoma
Social History:
___
Family History:
Son: ___
Brother: HOCM
Sister: colon cancer
Both parents: stroke
Physical Exam:
ADMISSION EXAM:
Vitals: T: 96 BP: 134/40 P: 60 R: 16 O2: 100
General: Alert, oriented, no acute distress, spunky elderly
patient
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, ___ systolic murmur
of MR
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 limitation or pain with movement of RU and ___
extremity. no hip pain or restriction, right knee is painful
nad has limited mobility compared to elft.
Neuro: CNs2-12 intact, motor function grossly normal
.
DISCHARGE EXAM:
Vitals: 97.0, 98.2, 153/63, 72, 18, 100RA
Orthostatics:
Laying: 160/68, 82
Sitting: 125/57, 87
Standing: 136/57, 91
General: AOx3 very sharp, NAD
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, ___ SEM at Right
base with radiation into clavicle
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
RECTAL: Heme occult negative stool, no masses
Pertinent Results:
ADMISSION LABS:
___ 10:16AM BLOOD WBC-4.2 RBC-3.97* Hgb-10.6* Hct-33.3*
MCV-84 MCH-26.7* MCHC-31.8 RDW-14.9 Plt ___
___ 10:16AM BLOOD Glucose-90 UreaN-25* Creat-1.0 Na-140
K-4.3 Cl-102 HCO3-31 AnGap-11
___ 10:16AM BLOOD cTropnT-0.03*
___ 05:20PM BLOOD CK-MB-4 cTropnT-0.01
___ 10:16AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.2
___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-5.0 RBC-4.16* Hgb-11.2* Hct-35.0*
MCV-84 MCH-26.9* MCHC-32.0 RDW-14.8 Plt ___
___ 06:50AM BLOOD Glucose-82 UreaN-22* Creat-0.8 Na-144
K-4.1 Cl-103 HCO3-35* AnGap-10
___ 06:50AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
EKG:
Sinus rhythm. Likely left anterior fascicular block. Left
ventricular
hypertrophy with secondary repolarization changes. Compared to
the previous tracing of ___ no diagnostic interim change.
CT C-SPINE:
IMPRESSION:
1. No fracture or traumatic malalignment in the cervical spine.
2. Extensive degenerative change, with osteophytes and
calcification of the anterior longitudinal ligament resulting in
moderate to severe central canal stenosis.
NON-CONTRAST HEAD CT:
IMPRESSION: No intracranial hemorrhage or other traumatic
sequelae.
Unchanged appearance compared to prior study, ___.
CXR: No focal opacity to suggest pneumonia is seen. No pleural
effusion, pulmonary edema, or pneumothorax is present. Linear
opacity at the left base is consistent with
atelectasis/scarring, similar to the prior examination. A
dual-lead left-sided pacemaker is in standard position. There is
mild cardiomegaly, unchanged.
PELVIS: No acute fracture or dislocation is seen. There are
degenerative
changes of the hips, lower lumbar spine, and sacroiliac joints
including
osteophyte formation and some sclerosis of the sacroiliac
joints. The bones are diffusely demineralized.
LEFT SHOULDER: Evaluation on the axillary view is somewhat
limited due to
patient positioning. A slight irregularity at the medial aspect
of the
humeral head seen only one frontal view may be positioning,
though a
non-displaced fracture is not entirely excluded. No dislocation
is
identified. There are mild degenerative changes at the
acromioclavicular
joint. No radiopaque foreign body is seen within the shoulder. A
left-sided pacemaker is partially imaged.
LEFT ELBOW: No acute fracture or dislocation is seen. No
radiopaque foreign body is detected. No joint effusion is seen.
TTE: LVEF 70%
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
diastolic LV dysfunction. Aortic valve sclerosis without
stenosis. Mild pulmonary hypertension.
Brief Hospital Course:
___ with hx of symptomatic bradycardia s/p pacer placement
(DDD), HTN, HL and PVD who presents from home after a syncopal
event resulting in fall and head strike complaining of left arm
and hip pain.
.
ACTIVE DIAGNOSES:
.
# SYNCOPE: She was admitted for workup of what seemed to be
orthostatic, medication-related, or vasovagal syncope. Given her
concerning history of symptomatic bradycardia requiring PPM,
cardiogenic syncope was also considered carefully. Her CT head
was negative for bleed or acute stroke. She ruled out for MI
with enzymes and negative EKG. EP interrogated her pacemaker and
found it to be functioning normally without any recorded events.
Given a loud SEM radiating to the clavicles she underwent TTE
which did not demonstrate frank AS or a stuctural/valvular cause
of syncope. She also had no concerning events on tele. Her
orthostatics were positive for drop in SBP but not rise in HR or
symptoms. She was given fluids, and some of her medications were
discontinued including risperidone which made her dizzy
(delusions of parasitosis and picking behavior). She was
evaluated by ___ and performed well enough not to require home
___. She was set up with geriatrics follow-up and encouraged to
take in fluids generously.
.
# TRAUMA/ARM/HIP PAIN: She presented with pains in various parts
of her body related to her fall but most notably her hips. She
had CT head, CT Cspine, XR or her left shoulder and elbow, as
well as pelvis which were all negative for fractures or acute
derangements. She was treated with PRN tylenol and low-dose
oxycodone PRN for breakthrough and her pain had nearly
completely resolved at the time of discharge.
.
CHRONIC DIAGNOSES:
.
# HTN: Stable if not slightly hypertensive while in-house. Her
medications were not changed given her age and somewhat
orthostatic physiology and she was continued on amlodipine 5mg
daily.
.
# RECURRENT UTIs: no evidence of UTI on UA, will continue
vaginal estrogens while inpatient.
.
# DERMATITIS: Stable, continued home creams.
.
# HLD: Given her age and complaints of taking too many pills her
home simvastatin was discontinued.
.
# GERD: Continued her omeprazole.
.
# POST-HERPATIC NEURALGIA: Stable and without symptoms. Per her
request we discontinued her home lyrica.
.
# PVD: Pulses on exam were strong and there was felt to be no
need to involve vascular. She was continued on her aspiring and
cilastazol.
.
# DEPRESSION: Stable, continued on her home cymbalta.
.
TRANSITIONAL ISSUES:
-Her risperidone, lyrica, and simvastatin were all discontinued.
-She had positive orthostatics by SBP but not by pulse or
symptoms. She was given fluids and encouraged to take in PO
generously. Despite her hypertension she may benefit from
midodrine or other agents that may increase her orthostatic
reflex if she continues to be orthostatic.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
BRIMONIDINE [ALPHAGAN P] - 0.15 % Drops - 1 gtt twice a day
CILOSTAZOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
CONJUGATED ESTROGENS [PREMARIN] - 0.625 mg/gram Cream - apply as
directed twice weekly for one month then weekly
DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
FLUOCINOLONE - 0.01 % Solution - at bedtime as needed for scalp
itch to scalp
KETOCONAZOLE - 2 % Shampoo - apply to scalp, ears in shower Qday
in shower
LATANOPROST [XALATAN] - 0.005 % Drops - 1 drop(s) in both eyes
at
bedtime
MUPIROCIN - 2 % Ointment - twice a day to open areas of skin
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every ___ minutes x 3 as needed for chest pain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day Take 30 minutes before breakfast.
PREGABALIN [LYRICA] - 150 mg Capsule - 1 Capsule(s) by mouth
once
a day
RISPERIDONE - (Not Taking as Prescribed: Taking ___ dose. Feels
full dose is too sedating) - 0.5 mg Tablet - 1 (One) Tablet(s)
by
mouth at bedtime
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply to itchy areas
once daily for 2 weeks, avoid face/folds/groin
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: MAX OF 3 GRAMS DAILY.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
5. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical twice a day as needed for itching: Please apply to
affected areas twice daily for 2 weeks, avoid face and groin.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. mupirocin 2 % Ointment Sig: One (1) Topical twice a day:
Apply to affected areas (open skin and scratches) twice daily.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablets
Sublingual every ___ minutes x 3 as needed for chest pain as
needed for chest pain: Please call your doctor if you take this
medication.
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Apply to both eyes.
12. ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS
DIRECTED): Apply to affected areas including scalp and ears in
the shower every day.
13. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
16. Premarin 0.625 mg/gram Cream Sig: One (1) application
Vaginal once a week.
17. fluocinolone 0.01 % Solution Sig: One (1) Topical at
bedtime as needed for itching: Apply to scalp for itching as
needed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Syncope (likely orthostatic or medication-related)
SECONDARY:
- Gastric adenocarcinoma, locally aggressive
- Cutaneous T-cell lymphoma
- Bilateral peripheral arterial disease: recent angiogram that
showed "high-grade SFA stenosis and occlusion at the knee with
reconstitution, very limited runoff distally". No intervention.
- Hypertension
- Left ventricular hypertrophy
- Hx of bradycardia s/p pacemaker placement
- Delusions of parasitosis
- Hx of herpes zoster c/b postherpetic neuralgia of RUE,
followed in the Pain Clinic.
- Osteoarthritis, especially of the knees.
- Vitamin B12 deficiency.
- Hx of Glaucoma s/p bilateral surgeries
- H/o frequent UTIs
- H/o frequent falls
- Partial hysterectomy for menorrhagia
- S/P appendectomy
- Hx of intertigo
- Seborrheic dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital! You were admitted for evaluation after falling at
home. This was felt to be caused by a syncopal episode. Our
cardiologists interrogated your pace maker and found it to be
functioning normally. You had x-rays of your shoulder and hips
and did not find any evidence of fracture. You also had CT scans
of your head and neck which did not show any serious injuries.
You were found to be mildly dehydrated and to be on medications
that make you dizzy. You were treated with IV fluids and some of
your medicaitons were discontinued. You had and echocardiogram
which showed no significant valvular or structural problem to
explain your falls. You were evaluated by physical therapy who
felt you are doing well and are discharged to your home.
The following changes were made to your medications:
-STOP Simvastatin
-STOP Risperidone
-STOP Pregabalin (lyrica)
Continue taking your other home medications as directed and be
sure to take in plenty of fluids by mouth
Please follow-up with your appointments below.
Followup Instructions:
___
|
10714633-DS-3
| 10,714,633 | 23,612,311 |
DS
| 3 |
2138-02-07 00:00:00
|
2138-02-08 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / Bupropion
Attending: ___.
Chief Complaint:
cough, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old F with h/o CAD s/p stent placement, HTN, significant
smoking history presents with 12 days of cough, sob, and
'laryngitis.' Reports sudden onset of non-productive cough
starting ___ and fevers up to 101. Fevers resolved after two
days, but cough persisted. During the last five days, she has
also experienced sob on exertion and loss of her voice which she
attributes to laryngitis. +chest congestion that is worst at
night, but unable to cough up any sputum. She currently smokes
about ___ ppd and has been smoking for ___ years. Her last
cigarette was five days ago. She has never been diagnosed with a
reactive airway disease or ILD. Patient also never experienced
cough of this severity and that lasted for this long. No
occupational exposures. Denies recent travel, sick contacts,
immobilization, h/o DVT, nasal congestion, sore throat, n/v/d,
cp, abdominal pain, swelling, orthopnea.
In ED, she is afebrile with stable VS, ambulatory pulse oximetry
was 88% RA, troponins <0.01, CXR showed diffuse interstitial
markings. Given albuterol and ipratropium nebs x 3, 500mg PO
azithromycin and 125mg IV methylprednisolone, and 30mL ketorolac
for pain.
On admission to the floor, patient continued to complain of
cough that persisted throughout the night and prevented her from
sleep. She continues to have hoarseness. No improvement with
nebs. Reports no SOB while lying in bed. Denies feves/chills,
cp, sore throat, hemoptysis, rhinorrhea, headache, difficulty
swallowing.
ROS: no vision changes, n/v/d, abdominal pain, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria, swollen nodes,
hot/cold intolerance
Past Medical History:
CAD s/p stent placement
HTN
CVA: lacunar stroke, residual R hand and arm numbness
proteinuria
back pain
tobacco abuse
thrombocytosis
s/p partial hysterectomy - retained ovaries
Social History:
___
Family History:
FH:
Mother: hypothyroidism
Daughter: SLE
No history of pulmonary disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: T 97.9 BP 126/86 P 83 R 20, 93% on 2L
GENERAL: alert and oriented x3, laying in bed, appears
uncomfortable but in NAD
HEENT: PERRLA, MMM with no lesions noted
NECK: JVP not elevated, no cervical LAD
LUNGS: crackles scattered throughout lung fields L>R. No
wheezing, rhonchi. No dullness to percussion
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NTND, NABS
EXTREMITIES: No c/c/e, WWP, no clubbing of fingers
NEUROLOGIC: moving all extremities
DISCHARGE PHYSICAL EXAM
VS: T: 98.1 BP: 135-144/80-85 HR:67-70, RR:18, sat: 94% on RA,
on ambulation 92% RA
GENERAL: sleeping, comfortable, but in NAD
LUNGS: very faint crackles at left base, much improved from
yesterday. clear on right side. No wheezing, rhonchi. No upper
respiratory secretions.
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NTND, NABS
EXTREMITIES: No c/c/e, WWP, no clubbing of fingers
NEUROLOGIC: A&Ox3, moving all extremeties
Pertinent Results:
ADMISSION LABS:
___ 06:40PM BLOOD WBC-8.9 RBC-4.30 Hgb-12.3 Hct-37.8 MCV-88
MCH-28.6 MCHC-32.5 RDW-13.3 Plt ___
___ 06:40PM BLOOD Neuts-67.3 ___ Monos-4.3 Eos-2.7
Baso-0.6
___ 06:40PM BLOOD Glucose-97 UreaN-9 Creat-0.6 Na-141 K-4.2
Cl-101 HCO3-29 AnGap-15
___ 06:40PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.1
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-8.0 RBC-4.43 Hgb-12.6 Hct-39.0 MCV-88
MCH-28.5 MCHC-32.4 RDW-13.2 Plt ___
___ 05:55AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-139
K-4.6 Cl-102 HCO3-27 AnGap-15
Legionella urine antigen: negative
Sputum cx: contamination
___ EKG: 87bpm, Sinus rhythm. Left ventricular hypertrophy.
Compared to the previous tracing the findings are similar.
IMAGING:
___ CXR: PA and lateral views of the chest. No prior.
There are diffusely increased interstitial markings throughout
the lungs, slightly more prominent at the left upper lung
laterally. There is no large confluent consolidation nor
effusion. Cardiomediastinal silhouette is within normal limits.
Coronary artery stents are noted. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: Diffusely increased interstitial markings
throughout the lungs. This could represent atypical infection,
although chronic underlying lung disease is also possible.
Please correlate with patient's history and onset of symptoms.
CT scan may offer additional detail.
___ CT chest:
1. Multifocal consolidation, peribronchiolar nodules and
diffuse bronchial
wall thickening. These findings may be due to multifocal
bacterial
bronchopneumonia but similar findings can also be seen in viral
infections.
Recommend follow up with CT in eight weeks to document
resolution given
presence of emhysema and the rounded/nodular apperance of the
left upper lobe and right lower lobe opacities.
2. Enlarged lymph node in the AP window, which is most likely
reactive. This finding can also be reassessed at the time of
follow up CT.
3. Small hiatal hernia.
___ CXR: In comparison with the study of ___, there again is
prominence of interstitial markings throughout the lungs in a
patient with cardiac
silhouette at the upper limits of normal in size. This could
well represent pulmonary vascular congestion or diffuse
interstitial infiltrate such as a viral pneumonia. As on the
recent CT scan, there is some fullness in the region of the AP
window consistent with reactive enlarged lymph node. An area of
increased opacification is again seen in the upper left lung
laterally,which could be a focus of consolidation.
Brief Hospital Course:
Ms. ___ is a ___ year old female with h/o CAD s/p stent
placement, HTN, CVA, tobacco abuse admitted for non-productive
cough, loss of voice, and shortness of breath suspicious for
community acquired pneumonia. No risk factors for PE.
#COMMUNITY ACQUIRED PNEUMONIA: Initial CXR and CT showed diffuse
interstitial markings and multifocal consolidation that was
suspicious for bacterial bronchopneumonia or viral infection.
Given subacute time course, non-productive cough, and diffuse
interstitial markings, an atypical pneumonia was suspected.
Patient was first treated with azithromycin and then
transitioned to levofloxacin for coverage of atypical organisms.
She completed a five day course of antibiotics.
Ms. ___ most likely has a superimposed reactive airway
disease that probably did not manifest until now (during an
infection). She has a significant smoking history and imaging
showed an enlarged lymph node with signs of emphysema. She was
given albuterol and ipratropium inhalers. Since patient showed a
slow improvement of her symptoms and continued to desat to the
___ during ambulation, she was given a ten day course of
prednisone (starting with 60mg while at the hospital and
tapering off after discharge). A follow up xray showed a cardiac
silhoutte at upper limits of normal in size and possible
vascular congestion. She was thus given one dose of 20mg lasix
po. No HIV risk factors to suspect PCP and patient reports a
negative HIV test ___ years ago.
At time of discharge, Ms. ___ reports improvement, with no
desaturation during ambulation. She had also been off O2 for >24
hours and satting >90% on room air. Her lung exam also showed
significant improvement, with only faint crackles at the left
base.
# LARYNGITIS: patient's hoarseness persisted throughout
hospitalization. Most likely viral infection and worsened by
smoking. Will likely improve with smoking cessation. Patient
advised to see PCP if symptoms do not improve.
# TOBACCO ABUSE: advised about the risk of lung infection and
cancer while smoking. Her last cigarette was ___. Patient
states that she has had multiple conversations with her PCP
about quitting. During her hospitalization she was kept on
nicotine patch and she was given a prescription at discharge.
# YEAST INFECTION: On day of discharge, patient reported vaginal
pruritus with cottage cheese like discharge similar to her
previous yeast infections. She was given one dose of fluconazole
150mg po.
# CHRONIC ISSUES:
-HTN: continued on home lisinopril, metoprolol, nifedipine, and
spironolactone
-CAD: continued on home aspirin, clopidogrel, atorvastatin
-thrombocytosis: platelet counts in the 690s with probably some
contribution from acute infection process. Baseline: 560s-650s
per records.
# TRANSITIONAL ISSUES
-please obtain a follow up chest CT in 8 weeks per radiology
recommendations
-please ensure patient has set up an appointment with a
pulmonologist for PFTs
-please follow up with patient's hoarseness/laryngitis. If
symptoms do not improve, consider ENT evaluation and possible
acid reflux given small hiatal hernia seen on CT scan
-please continue to discuss smoking cessation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheezing
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
hold for sbp<100
5. Metoprolol Succinate XL 300 mg PO DAILY
hold for sbp<100, hr<60
6. NIFEdipine CR 90 mg PO DAILY
hold for sbp<100
7. Nitroglycerin SL 0.6 mg SL PRN chest pain
8. Spironolactone 50 mg PO DAILY
hold for sbp<100, k>5
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheezing
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
hold for sbp<100
6. Metoprolol Succinate XL 300 mg PO DAILY
hold for sbp<100, hr<60
7. NIFEdipine CR 90 mg PO DAILY
hold for sbp<100
8. Spironolactone 50 mg PO DAILY
hold for sbp<100, k>5
9. Nicotine Patch 14 mg TD DAILY
RX *Nicoderm CQ 14 mg/24 hour three times a day Disp #*30
Tablet Refills:*0
10. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN Disp #*30
Tablet Refills:*0
11. Nitroglycerin SL 0.6 mg SL PRN chest pain
12. PredniSONE 10 mg PO DAILY
1) Take four pills daily for three days (___)
2) Take two pills daily for two days (___)
3) Take one pill daily for two days (___)
RX *prednisone 10 mg see instructions tablet(s) by mouth daily
Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: community acquired pneumonia, possible reactive airway
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted to the hospital because you had an infection in your
lungs. We treated you with antibiotics for five days. We also
started you on a steroid to help treat for a possible
inflammation in your lungs. You may have some underlying lung
disease and you should make sure to make an appointment with a
pulmonologist for additional testing.
Please continue to take the prednisone in the following manner:
1) Take prednisone 40mg for three days ___ to ___
2) Take prednisone 20mg for two days ___ to ___
3) Take prednisone 10mg for two days ___ to ___
4) Stop taking prednisone starting ___
While you were here, you had a CT scan of your chest that showed
a pneumonia. You should have a follow-up CT scan in 8 weeks to
be sure the infection has resolved. Please discuss this with
your primary care doctor.
We strongly encourage you to quit smoking as this can predispose
you to infections and lung cancer.
Followup Instructions:
___
|
10714633-DS-4
| 10,714,633 | 23,334,003 |
DS
| 4 |
2142-05-28 00:00:00
|
2142-05-29 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Darvon / Bupropion
Attending: ___.
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Ms. ___ is a ___ yo female with a
PMH of CAD (DES to LAD and D1 ___ c/b by in-stent thrombosis 3
days after discharge), left thalamic stroke in ___, HTN, and
HLD, who presents with chest pressure and cough for three day.
Patient states that she's had two days of "heart burn" relieved
with nitroglycerin. Patient also with dyspnea for one day.
Describes chest pressure since this morning; also c/o
light-headedness for one day. Minimal orthopnea, minimal doe,
cough for 3 days.
Notably, patient with no hemoptysis, no hx of pe or dvt, no ___
swelling or pain.
In the ED, initial vital signs were: 98.6 90 ___ 96% RA
- Exam notable for: bibasilar crackles
- Labs were notable for: WBC 12.1, proBNP 208, Trop-T<0.01 x2
- Studies performed include:
-- CXR (___): No acute intrathoracic process.
-- ECG (___): Sinus rhythm at 76 bpm, normal axis, normal
intervals, no ischemic changes
- Patient was given:
___ 10:45 SL Nitroglycerin SL .4 mg
___ 10:45 PO Aspirin 243 mg
___ 10:45 PO Benzonatate 100 mg
___ 10:53 IH Albuterol 0.083% Neb Soln 1 NEB
___ 10:53 IH Ipratropium Bromide Neb 1 NEB
___ 12:33 IV Azithromycin
___ 12:33 IH Albuterol 0.083% Neb Soln 1 NEB
___ 12:33 IH Ipratropium Bromide Neb 1 NEB
___ 12:33 IV MethylPREDNISolone Sodium Succ 125 mg
___ 12:40 IV Morphine Sulfate 2 mg
___ 14:06 IV Azithromycin 500 mg
- Vitals on transfer: 80 133/69 20 98% Nasal Cannula
Upon arrival to the floor, the patient reports the story as
above. The patient describes cough and "chest heaviness" since
___ (3 days prior to admission). The tightness/fullness is
not affected by position or exertion. No radiation. Some
associated dyspnea and post-tussive emesis with coughing. Not
relieved by Tums, but helped by nitroglycerin.
Her cough is the most bothersome symptom, keeping her up for the
past three nights. She's had bot post-tussive vomiting and
post-tussive fecal incontinence.
Patient denies any preceding URI symptoms or sick contacts. She
received a flu shot this year. Patient states that this
heaviness feels different than her prior MI but similar to prior
pneumonia in ___. Patient denies orthopnea but does state she
gets a cough when lying flat.
Patient denies fever, chills, constipation, diarrhea, abdominal
pain.
Past Medical History:
CAD s/p stent placement
HTN
CVA: lacunar stroke, residual R hand and arm numbness
proteinuria
back pain
tobacco abuse
thrombocytosis
s/p partial hysterectomy - retained ovaries
Social History:
___
Family History:
Mother: hypothyroidism
Daughter: SLE
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 97.3 PO 111/66 85 18 93RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. Slight tales in bases
bilaterally
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis; very trace edema in ankles
bilaterally
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
Normal sensation.
DISCHARGE PHYSICALE EXAM
========================
Vitals- Tmax 98.0 BP 100-110/60s HR 70-80s RR 18 ___ on RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. Slight tales in bases
bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
Normal sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 10:25AM BLOOD WBC-12.1* RBC-4.31 Hgb-11.7 Hct-37.3
MCV-87# MCH-27.1 MCHC-31.4* RDW-14.6 RDWSD-46.7* Plt ___
___ 10:25AM BLOOD Neuts-74.4* Lymphs-17.8* Monos-7.0
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.99* AbsLymp-2.16
AbsMono-0.85* AbsEos-0.04 AbsBaso-0.03
___ 10:25AM BLOOD ___ PTT-31.0 ___
___ 10:25AM BLOOD Plt ___
___ 10:25AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-138
K-3.6 Cl-98 HCO3-25 AnGap-19
___ 10:25AM BLOOD proBNP-208
___ 10:25AM BLOOD cTropnT-<0.01
___ 03:20PM BLOOD cTropnT-<0.01
MIRCOBIOLOGY
============
NONE
IMAGING
=======
___ CXR
IMPRESSION:
Comparison to ___. No relevant change is seen. No
pneumonia, no
pulmonary edema, no pleural effusions. The lateral radiograph
is also
unremarkable.
DISCHARGE LABS
==============
___ 08:00AM BLOOD WBC-12.7* RBC-4.16 Hgb-12.0 Hct-36.2
MCV-87 MCH-28.8 MCHC-33.1 RDW-14.6 RDWSD-46.4* Plt ___
___ 08:00AM BLOOD Plt ___
Brief Hospital Course:
HOSPITAL COURSE
===============
Ms. ___ is a ___ y/o woman with a PMH of CAD (DES to LAD and
D1 ___ c/b by in-stent thrombosis 3 days after discharge), left
thalamic stroke in ___, HTN, and HLD, who presented with chest
pressure and cough for three day consistent with viral
bronchitis. Chest radiograph was negative for pneumonia. ECG was
without evidence of ischemia and cardiac biomarkers were
negative. The patient remained hemodynamically stable and
saturating well on room air throughout her admission. She was
given cough suppressants. She was also started on ranitidine due
to complaint of heartburn related to her cough.
ACTIVE ISSUES
=============
# Acute viral bronchitis: Patient presents with three days of
cough, chest tightness, post-tussive vomiting concerning for
acute viral bronchitis. No CXR findings, fever, or physical exam
findings concerning for pneumonia. Patient with negative trops x
2, no EKG changes, atypical chest pain, low concern for ACS. PE
unlikely with Well's 0. Cough suppression with
Guaifenesin-CODEINE Phosphate ___ mL PO/NG Q4H:PRN, will follow
up with PCP to ensure that symptoms have improved or resolved.
CHRONIC ISSUES
==============
# CAD: Continued aspirin, statin, metoprolol, Plavix.
# CVA: Continued aspirin, statin, metoprolol.
# Hypertension: Continue metoprolol, lisinopril, nifedipine.
# Housing instability: Patient living with daughter, was
previously ___. She has plans to move into an apartment
on her own this ___.
TRANSITIONAL ISSUES
===================
- NEW MEDICATIONS:
-- Ranitidine 150 mg BID; please re-assess continued need for
this medication and discontinue as appropriate
-- Guaifenesin-CODEINE Phosphate ___ mL PO/NG Q4H:PRN cough
- Please encourage patient's continued efforts at smoking
cessation. Patient reports that she plans to quit smoking on
___.
- Patient reports that she takes her aspirin 81 mg
inconsistently. Please encourage adherence with this medication.
- Code: Full
- Communication: ___, ___, ___ ___,
friend, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Aspirin 81 mg PO DAILY
9. Nicotine Patch Dose is Unknown TD DAILY
Discharge Medications:
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth Every
four hours as needed Refills:*0
2. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth Twice a day Disp
#*60 Capsule Refills:*0
3. Nicotine Patch 14 mg TD DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. NIFEdipine CR 90 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Acute viral bronchitis
SECONDARY:
- Coronary artery disease
- Cerebrovascular accident
- Hypertension
- Hyperlipidemia
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 having severe
cough and chest discomfort for three days. We think that this is
caused by a virus irritating the airways of your lungs. We gave
you medications to help with your cough. We expect that your
cough will get better over time.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10714685-DS-20
| 10,714,685 | 29,225,643 |
DS
| 20 |
2146-05-14 00:00:00
|
2146-05-14 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ y/o man w/ Vascular Dementia, Afib on
Coumadin, Stage 3a CKD (Baseline Cr 1.4-1.6), and HTN,
presenting from nursing facility with fever and productive cough
Per documented history, patient lives in extended care facility,
where there has been a respiratory illness passing through the
residents. For the past 2 days, patient's caretaker has noticed
increasing cough, productive of dark, red sputum as well as
fever of ___ on day of presentation to ___. He has also
vomited a few times ?in the setting of coughing.
-He was brought to the ___ ED via ambulance, where his initial
vitals were:
99.8 96 113/96 22 and O2 saturations initially in the 80's on
NC, up to 95-100% on non-rebreather. Patient was notably febrile
x 2 (101.1 and 102.6).
-Exam notable for patient being alert, confused, with rhoncorous
breath sounds and increased work of breathing.
- Labs were notable for:
-----WBC 17.5 (77.2% NE)
-----Cr 1.6 (near baseline of 1.4-1.6), Mg 1.5, Ph 1.7
-----lactate 2.4, VBG showing 7.37/___
-----Infectious work-up was sent with Bcx x2, U/A showing no ___,
blood, and protein c/w CKD, sputum Cx, and FluA/B PCR
- Imaging:
-----CXR showing possible RLL pneumonia
-----EKG showing afib with ventricular rate of 96, normal axis,
normal intervals, QTc 440, normal RWP, non-specific TW
flattening in inferior leads, voltage criteria for LVH, similar
overall compared to last EKG from ___
- Patient was given Vancomycin 1g x1, Cefepime 2g x1, levoflox
750mg IV x1, ipratropium neb x1, NS x1L
- Patient was admitted to MICU for further management.
On arrival to the MICU, patient was on 50% ventimask and
children state that patient looks much better. He has no
complaints.
Of note, per discussion with patient's daughter and HCP, both in
the ED and on the floor, patient is DNR without clear status
regarding intubation. Per daughter, overall goal of patient
would be in line with intubation for short term in setting of
acute illness. No known history of asthma, smoking, or
heart/lung disease.
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
ADMISSION EXAM:
Vitals: 98.8 HR 89-116 BP 97/66 RR 26 99% on 50%
GEN: Alert, AOx3, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNG: Difficult to appreciate.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE EXAM:
Vitals: 98 145/88 83 20 97% RA
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva
NECK: supple neck, no LAD
CARDIAC: Irregularly irregular, S1/S2, II/VI systolic murmur
heard throughout precordium
LUNG: rhonochi bilaterally, improved after coughing, very faint
crackles RLL
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: oriented only to self, not to place (in bed) or time
(does
not know year)
Pertinent Results:
==============
ADMISSION LABS
==============
___ 09:20PM BLOOD WBC-17.5* RBC-4.74 Hgb-13.9 Hct-43.5
MCV-92 MCH-29.3 MCHC-32.0 RDW-14.1 RDWSD-47.8* Plt ___
___ 09:20PM BLOOD Neuts-77.2* Lymphs-10.8* Monos-11.2
Eos-0.0* Baso-0.4 Im ___ AbsNeut-13.48*# AbsLymp-1.89
AbsMono-1.96* AbsEos-0.00* AbsBaso-0.07
___ 09:20PM BLOOD ___ PTT-34.4 ___
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-103* UreaN-28* Creat-1.6* Na-142
K-3.8 Cl-104 HCO3-27 AnGap-15
___ 09:20PM BLOOD ALT-10 AST-16 AlkPhos-72 TotBili-0.6
___ 09:20PM BLOOD Albumin-4.2 Calcium-9.2 Phos-1.7* Mg-1.5*
___ 10:00PM BLOOD ___ pO2-46* pCO2-48* pH-7.37
calTCO2-29 Base XS-1
___ 09:34PM BLOOD Lactate-2.4*
___ 03:47AM BLOOD Lactate-4.2*
___ 10:00PM URINE Color-Straw Appear-Clear Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:00PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 10:00PM URINE CastHy-1*
==============
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-9.9 RBC-4.10* Hgb-11.9* Hct-37.4*
MCV-91 MCH-29.0 MCHC-31.8* RDW-13.6 RDWSD-46.0 Plt ___
___ 05:50AM BLOOD ___ PTT-33.0 ___
___ 05:50AM BLOOD Glucose-94 UreaN-29* Creat-1.3* Na-139
K-4.2 Cl-102 HCO3-25 AnGap-16
___ 05:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
=============
MICROBIOLOGY
=============
Blood culture ___ x2: No growth to date
Sputum culture ___:
GRAM STAIN (Final ___:
>25 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.
Urine culture ___: No growth
Urine culture ___: No growth
Sputum culture ___: Pending, no growth
============
IMAGING
============
CXR ___:
Bibasilar airspace opacities, more pronounced on the right,
concerning for
pneumonia or aspiration.
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman with PMH of a. fib on
warfarin and vascular dementia who presented with respiratory
distress, increased secretions, nausea, vomiting, found to have
pneumonia.
ACTIVE PROBLEMS
===============
#Pneumonia: Patient presented with leukocytosis, fevers,
tachypnea, and rising lactate to 4.2 concerning for severe
sepsis. He was initially admitted to the MICU for advanced
airway support (did not require intubation). CXR showed a RLL
consolidation concerning for pneumonia vs aspiration. Urinary
legionella was sent given GI symptoms, and it was negative. He
was initially treated with vancomycin and cefepime. MRSA swab
was negative and thus, vancomycin was discontinued. He was also
covered with azithromycin and completed a 5-day course. He was
transitioned to ceftriaxone and then cefpodoxime to complete a 7
day course. Lactate initially continued to uptrend, but on
re-check after fluid administration, it trended down. Sputum,
blood, and urine cultures showed no growth.
#Acute Encephalopathy: Likely ___ to pneumonia as described
above. Other sources of infection were ruled out (urine and
blood cultures were negative) and electrolytes were wnl. Patient
significantly improved when he was started on antibiotics and by
the time he left the ICU he was at baseline per family.
#Urinary Retention: Patient in the setting of foley placement
for UOP monitoring and administration of seroquel for delirium
developed urinary retention with multiple episode of post-void
residuals >600cc. Patient had foley placed. Voiding trial in the
hospital was not successful, thus ___ was replaced. Patient
should have f/u with Dr. ___ on ___ for ToV.
#Supratherapeutic INR: Patient's INR was elevated this admission
to 3.5, likely in context of poor PO intake and ongoing warfarin
administration. Coumadin was held initially on admission and
restarted at time of discharge with discharge INR of 2.0. Next
INR should be checked on ___.
CHRONIC ISSUES:
# Chronic Kidney Disease: Cr at baseline (1.6)
# Atrial Fibrillation: Presented with INR 3.0. Continued
metoprolol, warfarin.
# Peripheral neuropathy: Patient continued on gabapentin.
# BPH: Continued on tamsulosin.
# HLD: Continued on simvastatin.
# Depression: Continued on sertraline.
TRANSITIONAL ISSUES:
- Patient will need to schedule TOV with Dr. ___ by calling
___ for an appointment ___.
- INR 2.0 at discharge, please draw next INR on ___
and adjust Coumadin level as needed
- Patient to complete 7 day course of cefpodoxime (day 7: ___
for PNA, he completed 5 day course of azithromycin in house
# Communication: ___ (HCP/Daughter -
___ and ___
# Code: DNR/OK to intubate only briefly
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Pantoprazole 40 mg PO Q24H
4. Sertraline 50 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Tamsulosin 0.4 mg PO QHS
7. Warfarin 3.5 mg PO ONCE
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*5 Tablet Refills:*0
2. Warfarin 2 mg PO DAILY16
3. Gabapentin 100 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Sertraline 50 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Healthcare associated pneumonia
Atrial fibrillation
Vascular dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had fever and
cough. You were found to have a pneumonia. You were treated with
antibiotics and oxygen. You rapidly improved and were able to
come off oxygen completely. You are being discharged home to
continue your antibiotics for 2 additional days. You will follow
up with the doctors at your facility.
You were also found to have difficulty with urination and thus,
a foley catheter was placed. You should see Dr. ___ on
___ (please call ___ to make an appointment.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
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DS
| 21 |
2146-07-07 00:00:00
|
2146-07-07 19:36:00
|
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, pneumonia/aspiration
Major Surgical or Invasive Procedure:
Intubation for airway protection
History of Present Illness:
History/ROS is very limited in light of patient's dementia and
superimposed toxic encephalopathy.
Mr ___ is an ___ with Vascular Dementia, AF on Coumadin, CKD,
and HTN who presented from ___ with dyspnea.
He was noted to be coughing, and then febrile and tachypneic so
EMS was called. On arrival to the ED, he was in severe
respiratory distress and he began actively vomiting so he was
emergently intubated for airway protection. (Of note, he is DNR
but after brief discussion HCP agreed to intubation). He was
given antibiotics and then transferred to the FICU.
In the FICU, antibiotics were continued. He quickly weaned from
the ventilator. Other home medications were resumed. He worked
with SLP shortly after extubation and failed, recommended for
NPO with plans for re-evaluation. He had some urinary retention
after foley placement necessitating intermittent straight
catheterization, which he tolerated well. He remained otherwise
very stable and was therefore called out to the general medical
ward this evening.
ROS unobtainable due to mental status.
Of note, Mr. ___ was hospitalized ___ for a RLL pneumonia.
Was initially on vancomycin and cefepime. MRSA swab negative.
D/C'ed vancomycin and cefepime and began ceftriaxone and
azithromycin. Went home on cefpodoxime to finish 7 day
antibiotic course.
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
ADMISSION EXAM:
===============
VITALS: T101.2F BP 73/48 P81 CMV, f 20, Vt 450, PEEP 10, FiO2
0.5
GENERAL: sedated
HEENT: PERRL though sluggish, no facial droop
CARDIAC: not tachycardic, normal S1 or S2, no murmurs
LUNG: CTA bilaterally on posterior auscultation aside from
bibasilar crackles. No wheezes
ABDOMEN: soft, normal bowel sounds, non-distended
EXTREMITIES: warm, no edema
PULSES: 2+ radial and DP pulses bilaterally
NEURO: intubated, does withdraw from painful stimuli but not to
voice
TRANSFER EXAM:
===============
Vitals AVSS
Gen NAD, sleepy but easily arousable, not answering questions
Abd soft, NT, ND, bs+
CV irreg, systolic murmur
Lungs CTA right crackles left
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro will not cooperate with exam
Psych cannot ascertain
DISCHARGE EXAM:
===============
VS: 98.2 163/88 76 18 95% RA
General: Chronically ill appearing gentleman, sitting up in a
chair, comfortable
Eyes: PERLL, EOMI, sclera anicteric, missing front tooth
ENT: Oropharynx clear
Respiratory: Faint bibasilar crackles
Cardiovascular: RRR, normal S1 and S2, III/VI holosystolic
murmur
heard loudest at apex
Gastrointestinal: Soft, nontender, nondistended, +BS, no masses
or HSM
Extremities: Warm and well perfused, no peripheral edema, gauze
dressings in place bilaterally
Neurological: Alert, oriented x1 (self only), motor and sensory
exam grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 11:35PM BLOOD WBC-12.5* RBC-5.13# Hgb-14.8 Hct-48.2#
MCV-94 MCH-28.8 MCHC-30.7* RDW-14.2 RDWSD-49.1* Plt ___
___ 11:35PM BLOOD Neuts-73.4* ___ Monos-4.0*
Eos-0.7* Baso-0.6 Im ___ AbsNeut-9.19* AbsLymp-2.61
AbsMono-0.50 AbsEos-0.09 AbsBaso-0.07
___ 02:09AM BLOOD ___ PTT-33.0 ___
___ 11:35PM BLOOD Glucose-135* UreaN-26* Creat-1.6* Na-142
K-5.2* Cl-102 HCO3-24 AnGap-21*
___ 12:48AM BLOOD Type-ART Rates-20/ Tidal V-450 PEEP-10
FiO2-100 pO2-310* pCO2-43 pH-7.34* calTCO2-24 Base XS--2
AADO2-367 REQ O2-65 As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 02:19AM BLOOD Type-ART Temp-38.4 pO2-129* pCO2-36
pH-7.40 calTCO2-23 Base XS--1 Intubat-INTUBATED
___ 11:45PM BLOOD Lactate-3.5*
___ 02:19AM BLOOD Lactate-2.7*
INTERIM LABS:
=============
___ 05:16AM BLOOD WBC-9.2 RBC-3.66* Hgb-10.5* Hct-33.4*
MCV-91 MCH-28.7 MCHC-31.4* RDW-14.3 RDWSD-48.0* Plt ___
___ 05:16AM BLOOD ___ PTT-35.5 ___
___ 05:16AM BLOOD Glucose-102* UreaN-19 Creat-1.2 Na-140
K-3.3 Cl-106 HCO3-22 AnGap-15
___ 02:09AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:10AM BLOOD ALT-6 AST-16 CK(CPK)-89 AlkPhos-48
TotBili-1.0
___ 05:16AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9
___ 05:41AM BLOOD Vanco-9.1*
___ 06:13AM BLOOD Lactate-1.5
INR TREND:
___ 02:09AM BLOOD ___ PTT-33.0 ___
___ 12:52AM BLOOD ___ PTT-44.2* ___
___ 05:30PM BLOOD ___ PTT-39.5* ___
___ 05:41AM BLOOD ___ PTT-37.7* ___
___ 05:16AM BLOOD ___ PTT-35.5 ___
___ 05:51AM BLOOD ___
___ 06:59AM BLOOD ___ PTT-41.0* ___
___ 06:15AM BLOOD ___
___ 06:28AM BLOOD ___
___ 06:05AM BLOOD ___
___ 06:50AM BLOOD ___
___ 07:05AM BLOOD ___
___ 06:45AM BLOOD ___
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-9.6 RBC-3.83* Hgb-11.2* Hct-35.4*
MCV-92 MCH-29.2 MCHC-31.6* RDW-14.1 RDWSD-47.8* Plt ___
___ 06:50AM BLOOD Glucose-107* UreaN-14 Creat-1.1 Na-144
K-3.9 Cl-105 HCO3-30 AnGap-13
___ 06:50AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
STUDIES:
========
___ CXR AP IMPRESSION: In comparison with the study of
___, the tip of the endotracheal tube now measures
approximately 3.6 cm above the carina. The side-port of the
nasogastric tube again is at or above the esophagogastric
junction and the tube should be pushed forward a about 10 cm for
more optimal positioning. The opacification at the right base
may be slightly less prominent. Retrocardiac opacification again
could represent substantial volume loss in the left lower lobe,
though the possibility of a consolidation on this side as well
would have to be considered.
___ Video swallow:
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is penetration of thin
liquids. No aspiration. There is moderate pharyngeal residue,
valleculae greater than piriform sinuses, with attempted
swallowing of solids.
IMPRESSION:
1. Penetration of thin liquids without aspiration.
2. Moderate pharyngeal residue with solids.
MICROBIOLOGY:
=============
___ SPUTUM Gram Stain negative but large PMNs
___ SPUTUM Respiratory culture NGTD
___ BAL NGTD
___ RAPID RESP VIRAL SCREEN & CX Negative
Brief Hospital Course:
Mr. ___ is a ___ with Vascular Dementia, AF on Coumadin, CKD,
and HTN who presented from ___ with dyspnea, required intubation
in the ED for airway protection, and was found to have a RLL
consolidation on CXR. He was treated with broad spectrum
antibiotics in the ICU, improved, tolerated extubation, and
remained stable so transferred to floor.
# Sepsis/Acute hypoxic resp failure/Pneumonia: History
suggestive of primary pneumonia vs aspiration event. Given
recent PNA tx in ___ and failed management of
secretions/swallowing per SLP, recurrent aspiration is likely.
High quality micro data all with no growth, so abx de-escalated
from zosyn->ceftazidime and vanc
with azithro to CTX/azithro. VSS, on room air. Lung exam and CXR
with persistent consolidations, though producing good sputum
after chest ___. He was seen by speech and swallow who advised
pureed diet/thin liquids, which he is discharged on. He has
completed an 8 day course of antibiotics. He will require speech
and swallow follow up at his nursing facility prior to advancing
his diet. He should continue to receive chest ___ daily. Strict
aspiration precautions at all times with 1:1 supervision with
all meals. HOB elevated at all times to 30 degrees. Diet on
discharge as listed.
# Dementia/Toxic-metabolic encephalopathy: Vascular dementia,
with baseline mental status reportedly alert and oriented to
self only, often speaking in non-sequiturs. Mental status waxed
and waned in house but improved in ICU with low-dose
quetiapine BID for agitation and delirium precautions. After
call-out from the ICU and several days of treatment with
antibiotics his mental status returned to baseline. He is
discharged with seroquel to be given on an as needed basis for
agitation.
# New ST depressions: >1mm in V4-V6, <1mm in II, III, aVF. New
change in comparison to ___ baseline on admission. Repeat
EKG revealed resolution of ST depressions in all aforementioned
leads. Troponins and CKMB were negative. No active concern for
ischemia during his hospitalization.
# Supratherapeutic INR/Atrial Fibrillation: INR 3.1 upon arrival
to ED. Continued home regimen of metoprolol but initially held
warfarin given supratherapeutic INR (to a peak of 3.8).
Continued on slightly lower-than-home dose of warfarin (3mg
daily) but INR subsequently supratherapeutic again at 4.2 likely
in the setting of antibiotics/reduced nutrition. Warfarin was
held until INR began to downtrend. It was restarted on ___
when INR downtrending to 3.2, though on the following day rose
again to 3.6 and warfarin was held. Warfarin was restarted on
___ when INR was 2.4. Dose was increased on ___ to 5 mg when
INR 1.6 (likely in the setting of improved nutrition and
discontinuation of antibiotics). On the day of discharge INR
1.6. He is continued on warfarin 5 mg daily. He should have INR
checked on ___ and adjusted as necessary. If supratherapeutic
he may need decrease in dose to 3.5 mg daily.
# Acute on chronic urinary retention: Patient failed voiding
trial during ___ admission and went home with a Foley. Foley
initially placed on admission to ICU to protect skin integrity,
but was d/c'd in FICU so as to improve delirium. He was
urinating spontaneously but occasionally requiring straight
catheterizations on transfer out of FICU. He continued to
require intermittent straight catheterization while on the
medicine floor. In speaking with his SNF, routine bladder scans
would not be performed and he also could not be discharged with
a foley. He remained in-house for monitoring of urinary
retention. He was able to void spontaneously and post-void
residuals were routinely <400 and most often 100-200. He did not
require straight catheterization for >36 hours prior to
discharge. He will be seen by ___ services on a daily basis for
1 week after discharge for bladder scans and to ensure he is not
retaining.
# Anemia/thrombocytopenia: Nadir of hgb 9.9 and plt 115, likely
in the setting of brisk fluid resuscitation and infection. Had
improved to baseline (10.5/143) by time of transfer out of FICU.
Subsequently resolved to basline.
# CKD: Cr on admission 1.6 with apparent baseline of 1.6.
Improved to 1.2 by transfer out of ICU. Resolved to 1.1.
# Peripheral neuropathy: Continued home regimen of gabapentin
# BPH: Continued home regimen of tamsulosin
# HLD: Switched simvastatin to atorvastatin when amlodipine
added for blood pressure control
# Hypertension: BPs in-house ranged in the 150-170s. Started on
amlodipine.
# Depression: Continued home regimen of sertraline
Transitional:
# Communication: ___ (HCP/Daughter -
___ and ___
# Code: ___/OK to intubate
DIET:
1. PO diet: Thin liquids, pureed solids
2. Pills crushed in applesauce
3. 1:1 supervision
4. Aspiration precautions:
- SMALL bites and sips
- Take a sip of liquid after every ___ bites
5. SLP f/u at rehab for dx/tx for diet advancement and
oropharyngeal strengthening exercises
- Patient was having intermittent diarrhea while on antibiotics.
C.diff negative. He was prescribed loperamide and Metamucil.
Diarrhea subsided once antibiotics discontinued.
- Patient awaiting his appointment with outpatient urology
- Please check INR on ___ and adjust warfarin dose as
necessary
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Sertraline 50 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Vitamin D ___ UNIT PO 1X/WEEK (FR)
5. Gabapentin 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
7. Simvastatin 40 mg PO QPM
8. Warfarin 3.5 mg PO DAILY16
9. Ondansetron 4 mg PO Q8H:PRN NAUSEA
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. GuaiFENesin ___ mL PO Q6H:PRN productive cough
4. LOPERamide 2 mg PO QID:PRN Diarrhea
5. Mupirocin Ointment 2% 1 Appl TP BID
6. Psyllium Powder 1 PKT PO TID:PRN loose stools
7. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
8. Gabapentin 100 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Pantoprazole 40 mg PO Q24H
11. Sertraline 50 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D ___ UNIT PO 1X/WEEK (FR)
14. Warfarin 3.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Pneumonia, acute hypoxic respiratory failure
Secondary: Aspiration, urinary retention, anemia,
thrombocytopenia, chronic kidney disease, dementia, acute
toxic-metabolic encephalopathy, sepsis
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 Mr. ___,
You were admitted to ___ with severe pneumonia which required
you to have a tube placed in your lungs with a machine to breath
for you. This was likely due to inhaling food and saliva. You
improved in the ICU with antibiotics so the breathing tube was
removed and you were transferred to the medical floor. You were
evaluated by the swallow specialists who recommended a modified
(pureed) diet. You have completed a course of antibiotics.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
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| 22 |
2147-07-20 00:00:00
|
2147-07-24 05:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
aspiration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with vascular dementia, afib on
Coumadin, CKD and HTN who presented to ED from ___ after
presumed aspiration event.
According to EMS/ED records patient was observed to have
aspirated during breakfast at ___ where he resides. Patient
subsequently became hypoxemic w/new O2 requirement, with
rhoncherous lung sounds so EMS was called. Of note, patient had
admission approximately one year ago after similar event,
requiring ICU admission and intubation.
___ ED initial VS: T 98.4, BP 90/50, P 60, RR 20, O2 96% 4L NC
Exam: oriented only to self, copious oral secretions, diffuse
crackles.
Labs significant for: WBC 19.2, 3% bands, Hb 13.1, Plt 142, K
6.1 (hemolysed), BUN/Cr ___, INR 2.3, lactate 2.3. EKG rate
65, QTc 515, no ST changes.
Patient was given: 2L IVF, Vancomycin, Zosyn.
Imaging notable for: CXR w/no obvious focal consolidation.
VS prior to transfer: BP 115/50, P 60, RR 20, O2 100% 2L NC
On admission to MICU patient denies pain or SOB, but unable to
provide meaningful history or ROS.
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
Admission Exam
===============
VITALS: Reviewed ___ Metavision
GENERAL: Alert, oriented to self, no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear anteriorly
CV: Irregular rhythm, normal rate, systolic murmur
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: Non focal
Discharge Exam
================
VS: T 97.7 BP 155/89 HR 83 RR 17 97% ra
GENERAL: NAD, A+Ox1
HEENT: AT/NC, EOMI, PERRL, poor dentition.
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, ___ holosystolic murmur heard best at the
apex, gallops, or rubs
LUNGS: Rhonchorus at the bases improving, breathing comfortably
on room air
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
===============
___ 12:17AM BLOOD WBC-19.2*# RBC-4.46* Hgb-13.1* Hct-40.5
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.0 RDWSD-46.8* Plt ___
___ 12:17AM BLOOD Neuts-68 Bands-3 ___ Monos-10 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-13.63* AbsLymp-3.65
AbsMono-1.92* AbsEos-0.00* AbsBaso-0.00*
___ 12:17AM BLOOD ___ PTT-34.1 ___
___ 01:34AM BLOOD Glucose-373* UreaN-19 Creat-1.3* Na-138
K-3.2* Cl-85* HCO3-19* AnGap-34*
___ 12:26AM BLOOD Lactate-2.3*
Imaging
========
___ CXR
IMPRESSION:
Lungs are low volume with bibasilar atelectasis.
Cardiomediastinal silhouette is stable. There is wall
calcification involving the aorta. There is no pleural
effusion. No pneumothorax is seen. There is no evidence of
pulmonary edema or pneumonia
___ CXR
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Mild cardiomegaly has improved and pulmonary vascular
engorgement has
resolved. Tiny right pleural effusion is residual. Lungs are
clear. No
pneumothorax.
Micro
========
___ Blood culture x2: pending
___ 3:43 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:27 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Preliminary):
___ 6:20 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).
Discharge Labs
==============
___ 09:00AM BLOOD WBC-9.4 RBC-4.17* Hgb-12.4* Hct-38.0*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.0 RDWSD-47.3* Plt ___
___ 09:00AM BLOOD ___ PTT-37.0* ___
Brief Hospital Course:
Mr. ___ is an ___ year old man with vascular dementia, afib on
Coumadin, CKD and HTN who presented to ED from SNF after
presumed aspiration event with hypotension, hypoxemia concerning
for evolving aspiration pneumonia.
#Aspiration pneumonitis:
#Acute hypoxemic respiratory failure:
patient presented after observed aspiration event w/hypotension,
leukocytosis w/3% bands, concerning for evolving pneumonia,
although CXR without focal consolidation. Blood pressure
improved s/p IVF. Given Vanc/Zosyn ___ ED which were continued ___
the ICU. He was maintained on nasal cannula which was slowly
weaned. Speech and swallow were consulted. Palliative care was
also consulted ___ setting of recurrent aspiration requiring
ICU-level care, but did not need to follow him upon discharge.
Sputum cultures c/w aspiration, but no clear pneumonia so
antibiotics were discontinued with continued improvement.
#Hypotension:
possibly ___ setting of sepsis, but could also be ___ setting of
volume depletion ___ poor PO intake. Resolved s/p IVF. He was
able to take PO prior to discharge.
#Acute on chronic:
Cr on admission 1.9 with apparent baseline 1.1-1.2. Likely
pre-renal, although patient does have history of BPH so
obstruction a possibility. Improved w/ IVF.
#Afib on Coumadin:
INR therapeutic on admission, then supratherapeutic after
antibiotics. Held warfarin for 3 days and recommend restarting
at 2 mg upon discharge with frequent INR checks.
#GOC discussion:
patient's daughter re-iterated DNR/DNI but would still want less
invasive measures such as CVL, a line, pressors if needed. She
requests palliative care consult to help with these decisions.
#Dementia:
mental status at baseline per daughter. Will try to minimize
tethers, frequently re-orient, avoid deliriogenic medications ___
attempt to prevent delirium.
Chronic Issues:
# Gastroesophageal reflux disease: continue pantoprazole
# Peripheral neuropathy: Continue home gabapentin
# Benign prostatic hypertrophy: holding tamsulosin for now
# Hyperlipidemia: continue statin
# Depression: Continue home regimen of sertraline
Transitional Issues:
====================
-Follow-up: Will follow-up with PCP at his facility
-New medications: Metoprolol XL 50 mg qd
-Held medications: Metoprolol tartrate
-Changed medications: Changed warfarin to 2 mg qd
-Labs: Hgb 12.2, INR 3.1 (downtrending), and Cr 1.1 upon
discharge.
-Atrial fibrillation: He was restarted on warfarin upon
discharge at half his dose (2 mg instead of 4 mg). Please
recheck an INR within 2 days and redose as needed.
#Communication: HCP: Daughter, ___ ___
#Code: DNR/DNI confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ODT 4 mg SL Q8H:PRN nausea
2. Gabapentin 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Sertraline 50 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. amLODIPine 2.5 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Pantoprazole 40 mg PO Q24H
9. Vitamin D ___ UNIT PO 1X/WEEK (FR)
10. Warfarin 4 mg PO 6X/WEEK (___)
11. Warfarin 3 mg PO 1X/WEEK (___)
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. amLODIPine 2.5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Gabapentin 100 mg PO BID
6. Ondansetron ODT 4 mg SL Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Sertraline 50 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Aspiration pneumonitis
Acute hypoxemic respiratory failure
Acute kidney disease
Secondary diagnosis:
====================
Gastroesophageal reflux disease
Hyperlipidemia
Atrial fibrillation
Hypertension
Benign prostatic hypertrophy
Chronic kidney disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted for aspiration. You were monitored ___ the ICU
and you got better. One of your medications was changed (see
below) and your warfarin was decreased upon discharge. Please
follow-up with your outpatient appointments and see your primary
care physician at your facility.
It was a pleasure caring for you,
-___ medical care team
Followup Instructions:
___
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2148-03-10 13:40:00
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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:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI in H&P by Dr. ___ ___:
___ year old man with history of vascular dementia, AFib on
Coumadin, CKD and HTN, who was referred to the ED from ___ for a
cough. Of note, he has a history of aspiration pneumonia
requiring intubation and ICU admission in ___.
Patient is unable to provide history due to dementia. Based on
documentation from ED and nursing facility, it appears the
patient may have aspirated yesterday, and since then he has had
a
productive cough of tan colored sputum. Day of admission he was
noted to be pale today and hypotensive, referred to the ED for
evaluation.
In the ED, initial vitals were: HR 80 BP 156/80 RR 16 96% RA.
Exam notable for significant audible upper airway noise. Rhonchi
especially in the right lower lobe. CXR showing RLL pneumonia.
He
was treated with IVFs and IV Pi-Tazo and admitted to medicine.
O2 sats on transfer - 98% 2L NC
On the floor, he is unable to answer questions meaningfully
though he makes eye contacts and answers questions, just
inappropriately. "Do you know where you are?" -> "I better" ->
"where are you?"-> "It's pretty quiet around here." HE is
actively coughing during exam and producing thick tan-green
sputum, without hemoptysis.
Review of systems: Unable due to mental status"
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
ADMISSION EXAM:
Vitals: 82 145/80 12 98% RA
Pain Scale: ___
General: Patient appears chronically ill, but not acutely
decompensating. He is alert, makes eye contact, responds to
questions but not appropriately. He is not oriented. Actively
coughing throughout encounter, thick tan-green sputum without
blood.
HEENT: Poor dentition, halitosis, sputum as described above,
sclera anicteric
Neck: supple, JVP low, no LAD appreciated
Lungs: Rales at right base, but otherwise clear to auscultation
bilaterally, moving air well and symmetrically, no accessory
muscle use or retractions.
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality,
no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: Cannot participate in neuro exam, oriented to self only
DISCHARGE EXAM:
T 98.4, HR 77, BP 143/79, RR 18, SpO2 93% on RA
GENERAL: Alert, NAD, breathing comfortably
EYES: Anicteric, PERRL
ENT: OP clear, poor dentition, MMM
CV: normal rate, irregularly irregular, no m/r/g
RESP: Bilateral coarse rhonchi R>L, no wheezes or crackles
GI: Soft, ND, NTTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
VASC: no ___ edema, 2+ DP pulses
NEURO: Alert, only oriented to self, face symmetric, gaze
conjugate with EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 05:04PM BLOOD WBC-15.0* RBC-4.18* Hgb-12.1* Hct-37.7*
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.3 RDWSD-47.0* Plt ___
___ 05:04PM BLOOD Neuts-76.0* Lymphs-12.8* Monos-10.0
Eos-0.2* Baso-0.5 Im ___ AbsNeut-11.38* AbsLymp-1.91
AbsMono-1.49* AbsEos-0.03* AbsBaso-0.07
___ 05:04PM BLOOD ___ PTT-35.4 ___
___ 05:04PM BLOOD Glucose-99 UreaN-16 Creat-1.2 Na-137
K-4.3 Cl-96 HCO3-25 AnGap-16
___ 06:20AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5*
___ 05:04PM BLOOD cTropnT-<0.01
___ 05:25PM BLOOD Lactate-2.0
MICRO:
Blood cultures (___): pending x2
IMAGING:
CXR PA/Lat (___):
IMPRESSION:
Right lower lobe consolidation compatible with pneumonia in the
proper clinical setting. Recommend follow-up after treatment to
document resolution.
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-10.7* RBC-3.40* Hgb-9.8* Hct-31.0*
MCV-91 MCH-28.8 MCHC-31.6* RDW-14.2 RDWSD-47.3* Plt ___
___ 05:45AM BLOOD ___
___ 05:45AM BLOOD Glucose-105* UreaN-22* Creat-1.1 Na-139
K-4.8 Cl-99 HCO3-30 AnGap-10
___ 05:45AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.8
Brief Hospital Course:
SUMMARY/ASSESSMENT:
Mr. ___ is a ___ year old man with history of vascular
dementia, AFib on Coumadin, CKD and HTN, and prior aspiration
pneumonias requiring ICU admission ___ referred to the ED
from ___ for a cough found to have likely aspiration pneumonia.
# Aspiration pneumonitis
# Pneumonia, aspiration
Patient presented after observed aspiration event w/ hypotension
at facility, leukocytosis, and CXR showing RLL consolidation,
but without significant hypoxemia. He has not been hypotensive
since arrival to the ED. He received a dose of IV Zosyn in ED.
This was changed to ceftriaxone and azithromycin on admission.
The following day, ceftriaxone was changed to Augmentin for
aspiration pneumonia (7 day course total, end date = ___ and
azithromycin was continued for atypical coverage (end ate
___. Speech language pathology was consulted. They did not
see any overt evidence of aspiration and recommended continuing
the same pureed solid and thin liquid diet. They did recommend
continued outpatient SLP follow up and video swallow study as an
outpatient.
# Atrial fibrillation
# Supratherapeutic INR
Rate-controlled and anticoagulated with warfarin. His INR was
supratherapeutic in the setting of antibiotic use so his
warfarin dose was reduced from his home dose of 2 mg daily to
1.5 mg daily while he is on antibiotics. This should be watched
closely, and likely increased back to his home dose once he is
off antibiotics.
# Chronic kidney disease, stage 3:
Baseline Creatinine is 1.1 and his Cr since admission has been
1.2-1.3.
# HTN
Home amlodipine 2.5 mg increased to 5 mg daily due to
hypertension (SBPs as high as 180).
# GOC:
Per discharge summary from last admission "patient's daughter
re-iterated DNR/DNI but would still want less invasive measures
such as CVL, a line, pressors if needed. She requests palliative
care consult to help with these decisions." Discussed with his
daughter at the bedside and she reaffirmed these wishes.
# Vascular dementia:
Chronic, stable at baseline mental status.
Chronic Issues:
# Gastroesophageal reflux disease - continued pantoprazole
# Peripheral neuropathy - Continued gabapentin
# Benign prostatic hypertrophy - initially held tamsulosin in
setting of pneumonia; resumed prior to discharge
# Hyperlipidemia:
- Discontinue statin, given age and dementia, he is not likely
to
have long term benefit from a statin, and will attempt to limit
polypharmacy as much as possible, can discuss with family prior
to discharge
# Depression - Continued home sertraline
TRANSITIONAL ISSUES:
[ ] Repeat CXR to ensure RML opacity has resolved
[ ] Adjust warfarin by INR as needed on antibiotics (warfarin
dose reduced)
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 2.5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Gabapentin 100 mg PO BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Sertraline 50 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Vitamin D ___ UNIT PO 1X/WEEK (FR)
9. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*7 Tablet Refills:*0
2. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Warfarin 1.5 mg PO DAILY16
5. Atorvastatin 20 mg PO QPM
6. Gabapentin 100 mg PO BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sertraline 50 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Aspiration pneumonia
# Hypertension
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 Mr. ___,
You were admitted to the hospital for aspiration pneumonia. You
were treated with IV antibiotics initially, which were narrowed
to oral antibiotics. You should continue to take the antibiotics
as an outpatient to complete the course as directed. You were
evaluated by the Speech Language Pathology team who recommended
a pureed solid diet and thin liquids. They recommended you
follow up with speech language pathology as an outpatient as
well.
Your blood pressure was also high so your amlodipine was
increased from 2.5 mg to 5 mg daily.
Best of luck with your continued healing.
Take care,
Your ___ Care Team
Followup Instructions:
___
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2148-05-28 09:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough x3d
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with vascular dementia,
AFib on Coumadin, CKD and HTN, and prior aspiration pneumonias
(most recently ___, once requiring ICU admission ___
presenting with cough and sputum production from SNF. History is
limited by patient's baseline dementia. Discussed with patient's
aide at bedside, who provides additional history.
Aide states pt had increased sputum, cough starting ___,
consistent since then, duration until now. No fever associated,
nor dyspnea. No c/o chest pain. Pt's dementia is baseline. No
witnessed aspiration events. He continues to amublate with
walker
and tolerate diet. Sent in from ___
In ED
VS stable, BP 112/80, on RA
Labs: wbc 15, hb 12, Cr 1.5; INR 2.3 (on ___ lact 1.3
CXR read of subtle RLL opacities, unclear new vs resolving PNA
blood culture drawn
given zosyn x1
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
VITALS: 97.3, 108/67, 82, 16, 96% RA
GENERAL: Alert and in no apparent distress; alert but oriented
only to self and daughter(baseline per daughter)
EYES: ___, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart irregular, no murmur, no S3, no S4. No JVD.
RESP: Poor inspiratory effort. Some faint right sided rhonchi
and somewhat decreased BS RLL;
not following directions well to participate in exam
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes; site of recent excision on left shin - clean
base, no drainage, erythema, tenderness
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:55AM BLOOD WBC-11.7* RBC-3.99* Hgb-11.4* Hct-35.9*
MCV-90 MCH-28.6 MCHC-31.8* RDW-13.7 RDWSD-45.3 Plt ___
___ 05:55AM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-140
K-4.5 Cl-100 HCO3-28 AnGap-12
CXR ___
IMPRESSION:
Subtle opacities at the right lung base could reflect residua of
recent right
lower lobe pneumonia, though difficult to exclude an ongoing
infectious or
inflammatory process.
Brief Hospital Course:
Patient admitted for PNA, likely with aspiration component given
history of it in the past and family reports that the patient's
general decline is more in swallowing function. He was started
on ceftriaxone azithromycin, with near-resolution of
leukocytosis. We will continue 3 more days with augmentin to
cover anaerobes. He is stable for discharge with PCP follow up.
___ recommend that you get an outpatient video swallow eval
according to our speech therapy recommendations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q6H unknown
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID rash
3. fluorouracil 5 % topical 2X/WEEK
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Gabapentin 100 mg PO BID
9. Warfarin 1 mg PO DAILY16 afib
10. Tamsulosin 0.4 mg PO QHS
11. Preparation H Maximum Strength
(phenyleph-pramoxin-glycr-w.pet) ___ % rectal BID:PRN
12. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
2. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough
3. Gabapentin 100 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Preparation H Maximum Strength
(phenyleph-pramoxin-glycr-w.pet) ___ % rectal BID:PRN
7. Tamsulosin 0.4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 1 mg PO DAILY16 afib
10. HELD- Cephalexin 500 mg PO Q6H unknown This medication was
held. Do not restart Cephalexin until instructed by dermatology
11. HELD- Clobetasol Propionate 0.05% Cream 1 Appl TP BID rash
This medication was held. Do not restart Clobetasol Propionate
0.05% Cream until instructed by dermatology
12. HELD- fluorouracil 5 % topical 2X/WEEK This medication was
held. Do not restart fluorouracil until instructed by
dermatology
13. HELD- Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
This medication was held. Do not restart Triamcinolone Acetonide
0.1% Ointment until instructed by dermatology
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
vascular dementia
afib
CKD
HTN
Discharge Condition:
Fair
Alert, only oriented to self (baseline)
Ambulatory with 1 person assist
Discharge Instructions:
You were admitted for another episode of pneumonia. It is likely
related to your poor swallow function. We have obtained a
swallow eval, and updated your diet to pureed nectar thick to
minimize aspiration risk. You will need another 3 days of
antibiotics in order to completely treat it.
Followup Instructions:
___
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2148-07-05 00:00:00
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2148-07-06 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of atrial
fibrillation on warfarin, vascular dementia, history of
aspiration pneumonia, who presented to the ___ ED from his
living facility (___) with fever and hypoxia. Patient
reportedly had a witnessed aspiration event earlier in the day
associated with coughing. EMS was called. Patient was febrile to
100.0, hypotensive into the 80's, hypoxic to 88%. On arrival to
the ED, he was oriented only to self, not to place or time,
which
per the patient's son, is close to the patient's baseline.
Overall, the patient is a limited historian due to mental status
and the majority of history is provided by the patient's son.
___, the patient has been admitted multiple times over the
past several years most recently ___ for aspiration with
subsequent pneumonias (requiring ICU admission on ___.
In the ED, initial vitals were:
97.8F HR:86 BP: 89/49 RR: 18 95% RA
- Exam:
End expiratory wheezes in the bilateral bases
- Labs:
Cr: 1.8
Mg: 1.5 (given Mg)
Lactate: 3.2 --> 1.3 (2L fluid)
WBC: 10.2
INR: 3.5
- Imaging:
___: Chest X-Ray: CHEST (PORTABLE AP)
-no distinct focal consolidation
(Most Recent):
___: LVEF: 60% (nl >=55%)
___: LVEDD: 4.4 cm (nl <= 5.6 cm)
___: LVESD: 2.7 cm
___: TR Gradient: 19 mm Hg (nl <= 25 mm Hg)
- Micro:
Blood cultures pending
UA pending
- Consults:
None
- EKG:
13:54 and 13:57 - Irregularly irregular bradycardia consistent
with rate controlled A-fib; no signs of ischemia
- Patient was given:
Vanc
Cefepime
Metronidazole
1L NS
1L LR
Mg sulfate 2g
Acetaminophen 1gm
Upon arrival to the floor, patient reports feeling well but has
a
coarse non-productive cough. Per the patient's son who is at the
bedside, the patient appears to be mentating at baseline and
notes that his cough is new. He denies current fever, chills,
nausea, vomiting, chest pain or diarrhea. The patient was
hypertensive upon arrival to the floor and was saturating well
on
room air.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 97.6F PO BP:181 / 103 HR: 65 97% Ra
___: Weight: 146.2
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. Nares patent, no drainage or sinus
tenderness. missing left incisor, gums normal.
EYES: PERRL, EOM intact, conjunctivae clear, no scleral
icterus.
NECK: No cervical lymphadenopathy. No JVD, no carotid bruit.
Neck supple, symmetrical, trachea midline.
LUNG: coarse breath sounds with ronchi in right and left lower
base, expiratory wheezes noted throughout all lung fields
HEART: RRR, Normal S1/S2, No ___ systolic murmur with radiation
to axilla
BACK: Symmetric, no curvature. ROM normal. No CVA tenderness.
ABD: Soft, non-tender, non-distended; nl bowel sounds; no
rebound or guarding, no organomegaly
GU: Not examined
EXTRM: Extremities warm, no edema, no cyanosis, positive ___
pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities,
strength, sensation equal and intact throughout. A&O1 oriented
to
self only, pleasant
PSYC: Mood and affect appropriate
DISCHARGE PHYSICAL EXAM
___ 1109 Temp: 97.5 PO BP: 159/80 R Lying HR: 70 RR: 18 O2
sat: 98% O2 delivery: Ra
GEN: Awake, no distress
HENT: NC/AT, MMM. missing left incisor
EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus
NECK: No elevated JVP, no carotid bruit.
LUNG: decreased BS in bases, mild wheezes
HEART: RRR, Normal S1/S2, ___ systolic murmur with radiation to
axilla
ABD: Soft, ntnd, normoactive bs
EXTRM: warm, no edema, symmetric
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities. AOx0
PSYC: pleasant
Pertinent Results:
ADMISSION LABS
___ 10:51AM BLOOD WBC-10.2* RBC-4.14* Hgb-11.8* Hct-38.0*
MCV-92 MCH-28.5 MCHC-31.1* RDW-14.6 RDWSD-48.3* Plt ___
___ 10:51AM BLOOD Neuts-55.5 ___ Monos-9.8 Eos-1.9
Baso-1.0 Im ___ AbsNeut-5.64 AbsLymp-3.19 AbsMono-0.99*
AbsEos-0.19 AbsBaso-0.10*
___ 10:51AM BLOOD ___ PTT-39.6* ___
___ 10:51AM BLOOD Glucose-130* UreaN-21* Creat-1.8* Na-140
K-4.0 Cl-100 HCO3-27 AnGap-13
___ 10:51AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.3* Mg-1.5*
___ 10:51AM BLOOD ALT-12 AST-21 AlkPhos-90 TotBili-0.6
___ 10:51AM BLOOD Lactate-3.2*
___ 03:30PM BLOOD Lactate-1.3
PERTINENT STUDIES
CHEST X-RAY ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes are stable.
There is calcification of the aortic knob. There may be mild
pulmonary vascular congestion. Mitral annulus calcification is
noted.
IMPRESSION: No definite focal consolidation.
DISCHARGE LABS
___ 07:41AM BLOOD WBC-8.6 RBC-3.78* Hgb-10.6* Hct-34.9*
MCV-92 MCH-28.0 MCHC-30.4* RDW-14.6 RDWSD-50.0* Plt ___
___ 07:41AM BLOOD ___ PTT-29.5 ___
___ 07:41AM BLOOD Glucose-100 UreaN-22* Creat-1.2 Na-145
K-4.4 Cl-107 HCO3-26 AnGap-12
___ 07:41AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
Brief Hospital Course:
SUMMARY STATEMENT:
==================
Pt is a ___ yo M with dementia (lives in ___
home), atrial fibrillation on warfarin, history of recurrent
admissions for pneumonia ___ aspiration who was admitted for
fever, hypoxia, shortness of breath, hypotension, and
leukocytosis following an aspiration event at his nursing home.
On admission had SBP to ___, responsive to fluids. Chest x-ray
showed no opacity. Was initiated on broad coverage with vanc,
cefepime, and flagyl initially. This was switched to ceftriaxone
and azithro due to concern for community acquired pneumonia.
Patient had MRSA swab return positive so received additional
dose of vanc and then switched to oral doxycycline prior to
discharge for 5 day course to end ___. Patient also found to
have UA concerning for UTI. He was treated empirically for
simple cystitis with a three day course of IV ceftriaxone.
#Aspiration pneumonitis vs community acquired pneumonia
Patient admitted for respiratory/systemic symptoms as above. SLP
was not consulted this admission, instead started pureed
solids/nectar prethickened liquids per recommendation from last
admission given that this is a recurring event for him and based
on goals of care discussion w/ patient and family he would not
want to cease eating regardless of SLP recommendation despite
knowing risks of aspiration.
#Supratherapeutic INR:
INR 3.5 on admission, warfarin was held for one day and INR then
became therapeutic and patient restarted on home 2.5 daily
warfarin. Can consider transition to DOAC as outpatient.
#Urinary retention
___ on CKD
#Bacteriuria
Patient has CKD w/ baseline Cr of 1.2. Presented with Cr 1.8
which downtrended to normal with fluids. Patient was retaining
urine and required intermittent straight cath.
==============
Chronic Issues
==============
#Atrial fibrillation
Warfarin as noted above. Continued home metoprolol.
#Prostate cancer
Continued home tamsulosin
#GERD
Continued home pantoprazole
#Neuropathy
Continued home gabapentin
TRANSITIONAL ISSUES
===================
[ ] 5 day course of doxycycline to continue through ___.
Please give after meals.
[ ] Continue pureed solids/nectar prethickened liquids as diet
as outpatient given history of multiple aspiration events. Can
liberalize diet pending decision regarding goals of care with
family.
[ ] Patient continues to take warfarin. Consider DOAC for this
patient to eliminate need for monitoring. Given Cr<1.5 and
weight>60 kg could receive 5 mg bid.
Contact:
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Second health care proxy is ___ ___ (cell)
___ (home).
Code status: DNR/DNI confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Tamsulosin 0.4 mg PO QHS
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 9 Doses
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12
hours Disp #*9 Tablet Refills:*0
2. Gabapentin 100 mg PO BID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Tamsulosin 0.4 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Community acquired pneumonia
Acute hypoxemic respiratory failure
Acute uncomplicated urinary tract infection
Atrial fibrillation
SECONDARY DIAGNOSES
Gastroesophageal reflux disease
Peripheral neuropathy
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 Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You came to the hospital because there was concern that you
aspirated while eating. You had fever, cough, and low blood
oxygen levels.
What happened while I was in the hospital?
- In the hospital, you were given IV antibiotics to treat a
presumed pneumonia. You were fed a modified diet as recommended
by the speech language pathology team during your last
admission.
What should I do once I leave the hospital?
- Be sure to finish your course of antibiotics, the last day
will be ___
We wish you the best!
Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10714768-DS-6
| 10,714,768 | 23,355,961 |
DS
| 6 |
2153-01-12 00:00:00
|
2153-01-13 16:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left arm numbness
Major Surgical or Invasive Procedure:
Brain biopsy and surgical debulking of tumor
History of Present Illness:
The pt is a ___ year-old R-handed woman with no significant PMHx
who presents with left arm numbness. She reports that she woke
up, went to the gym, felt normal then a few minutes before 8am
she went to reach into a top shelf of her closet for her sweater
and her arm felt numb. She brought it back down to her side and
tried to "shake it out", and it felt temporarily better.
However, about 5 minutes later she felt that the sensation was
still present and she called ___. When asked, she isn't sure if
the numbness actually improved or if she was just "trying to
convince myself it was getting better" during the 5 minutes
prior
to her calling 911. She was brought to the ED where a Code
Stroke was called. She had a NCHCT which showed vasogenic edema
in the right parietal lobe. Her NIHSS at the time of neurology
evaluation was 0. Her numbness had improved throughout her time
in the ED. Neurosurgery saw the patient in the ED and
recommended an MRI for further evaluation. She was admitted to
neurology for further workup of the cause of her vasogenic
edema.
Of note, on ___ she was at work and had the onset of right
eye "sparkles" and "wavy lines" for about 20 minutes, which then
self-resolved. She had a mild headache thereafter. She called
her doctor who said it was likely an ocular migraine. She then
saw her PCP the week of the ___ and "passed her
physical", and was sent to the eye doctor. She saw the eye
doctor
on ___ who felt her vision was fine except that she needed
reading glasses. Of note, she also had a mammogram that was
read
as normal last week.
On neuro ROS, the pt reports left arm numbness as above, but
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. 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:
___
Social History:
___
Family History:
her mother died of ___ (was a smoker) and her
father died of lung cancer (was a smoker). Her grandmother had
a
stroke in her late ___.
Physical Exam:
Vitals: T: 98.2 P: 76 R: 16 BP: 144/82 SaO2: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score was: 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5- 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. ___
absent.
Pertinent Results:
BLOOD LABS
Na:139
K:3.8
Cl:99
TCO2:24
Glu:112
Lactate:2.7
Cr: 0.8
6.0 >----< 362
37.9
___: 9.8 PTT: 31.7 INR: 0.9
IMAGING:
Non-Contrast CT of ___ (___): Focus of vasogenic edema in
the right
parietal lobe is more concerning for underlying tumor as opposed
to acute ischemia. No intracranial hemorrhage.
CT Torso (___):
1. Multiple hypodense lesions within the liver, which are
nonspecific. Although one of the lesions might be a hemangioma,
they are not clearly benign lesions. Recommend further
evaluation with a MRI and/or ultrasound for feasibility for
biopsy.
2. Multiple hypodense lesions extending off the uterus are
likely fibroids.
3. Indistinct thickened appearance of the cervical region,
which is
nonspecific. Given the search for primary malignancy, recommend
correlation with gynelogical exam and possible pelvic ultrasound
or MRI.
4. Two sub 4 mm pulmonary nodules. Given the suspected
malignancy, recommend follow-up with a CT of the chest in 3
months.
5. T8 vertebral body hemangioma and right acetabulum bone
island.
6. Cholelithiasis without evidence of cholecystitis.
MR ___ (___)
1. A 4-cm non-enhancing, FLAIR hyperintense lesion in the right
parietal
lobe, without restricted diffusion, concerning for a low-grade
glioma.
2. An 8-mm likely meningioma in the posterior falx.
MRS ___ with Spin ___ (___):
1. Increased ASL perfusion at the right parietal FLAIR
hyperintense lesions.
2. Increased choline/NAA ratio within the lesion.
3. Differential diagnosis is between a primary neoplasm and a
subacute
infarct. The ASL and spectroscopic findings favor a primary
neoplasm.
MRI ___ (___)
1. Increased ASL perfusion in the right parietal lobe,
corresponding to the FLAIR hyperintensity.
2. Single and multi-voxel MRS ___ elevated choline peak
at the right parietal lesion. Of note, the lesion did not
demonstrate any post-contrast enhancement in the ___
study.
MRI/MRA Abdomen (___)
1. Multiple lesions within the liver which are consistent with a
cavernous hemangiomas, flash filling hemangiomas or simple
cysts. No suspicious hepatic lesions.
2. Accessory left hepatic artery arising from the left gastric
artery.
3. Simple renal cyst.
4. Cholelithiasis.
Brief Hospital Course:
NEURO FLOOR COURSE (___):
Ms. ___ is a ___ RHwoman with no significant PMHx who
presents with left arm numbness and clumsiness lasting less than
an hour, with initial mild left neglect and perhaps subtle
oribiting, with a right parietal lesion seen on CT. MRI brain
shows a non-enhancing, slightly diffusion restricted mass with
minimal edema that involves the cortex; this is suggestive of a
low-grade glioblastoma or oligodendroglioma. MRS ___
elevated Choline:NAA ratio, suggestive of an old stroke vs.
tumor but arterial spin labelling indicates increased flow to
the area, more suggestive of a tumor. We also considered
metastasis, but she is otherwise healthy and is up-to-date with
all routine screening exams with no obvious source of metastatic
cancer. CT Torso did show some hypodense lesions of the liver
(?hemangiomas) but no other obvious masses and MRI of the liver
was suggestive of hemangiomas vs. cysts but not cancer. The
differential diagnosis was all discussed with the patient
throughout her stay.
We thought the cause of her left-arm numbness was likely from
the vasogenic edema in her right parietal lobe but also
considered seizure especially given the cortical involvement of
the lesion. Therefore, we started Keppra 500mg BID for seizure
prophylaxis and Decadron for swelling with GI prophylaxis. The
patient went to the OR on ___ for biopsy of this
lesion. Debulking was ultimately not done.
NEUROSURGERY COURSE (___)
Patient was taken to the OR on ___ with no intraoperative
complications. She was extubated post operatively and taken to
the ICU for recovery. Post operative ___ CT showed small amount
of acute hemorrhage in surgical bed, but no mass effect. She was
stable on exam. On ___, patient was intact on exam, her diet
was advanced and she was transferred to the floor. MRI ___ was
done which showed some ischemic changes in the operative bed,
which were thought to be the cause of the mild enhancement seen
post-operatively. They could not compare pre and post-operative
lesion burden as pre-operatively there was no enhancement but
felt that the compression of the lateral ventricles was
approximately the same.
NEUROLOGY FLOOR COURSE (___)
Ms. ___ was observed on the floor for an additional day. Her
exam was felt to be stable, with less graphesthesias on the
right hand compared to before surgery and her gait was normal.
She was discharged for follow-up with neuro-oncology for further
planning. Her pathology was pending at discharge. She was
discharged on Keppra and Decadron.
Medications on Admission:
- metrogel PRN
- advil PRN
Discharge Medications:
1. Dexamethasone 4 mg PO TID
RX *dexamethasone 2 mg ___ tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6 hrs PRN Disp #*15
Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R parietal lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with sutures/staples. You may wash
your hair only after sutures and/or staples have been removed.
**Your wound was closed with dissolvable sutures, you must
keep that area dry for 10 days.
You may shower before this time using a shower cap to cover
your ___.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion 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.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10715003-DS-17
| 10,715,003 | 20,924,297 |
DS
| 17 |
2111-12-22 00:00:00
|
2111-12-22 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:
weakness, fall, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a sig PMHx of COPD, AV block s/p PPM,
HTN, HLD, who presents from ___ s/p mechanical fall with
subarachnoid hemorrhage and new onset shortness of breath.
The patient was in his usual state of health until 2 weeks prior
to admission when he was feeling progressively weak and
fatigued.
He also had a new non productive cough and congestion. He called
his PCP who had ___ visiting PA evaluate him. He was diagnosed
with
a URI/bronchitis, for which he was prescribed levofloxacin for 7
days (___). Unfortunately, his symptoms did not improve
and he continued to feel lethargic and now with dyspnea at rest.
On the day of admission, he called his PCP once again to discuss
his symptoms. A visiting nurse/ PA came to evaluate him and
while
attempting to sit down, he tripped and fell backwards, striking
the back of his head on a chair. He denies any loss of
consciousness, or prodromal symptoms, including lightheadedness
or vision changes. He does note that he had been feeling
nauseous, denying any emesis. He was brought to ___ for
further evaluation.
Otherwise, the patient denied any fevers, chills, chest pain,
palpitations, changes in bowel or bladder function, changes in
vision or hearing, headaches, new rashes or lesions, ___ edema.
Past Medical History:
Coronary artery disease
Atrial Fibrillation s/p ablation
AV block s/p pacemaker
COPD
Type II diabetes
Gout
Hyperlipidemia
Chronic back pain
Anemia
Osteoarthritis
L acetabular fx s/p repair
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 99.9 PO 157 / 89 97 20 95 4L
GENERAL: pleasant, alert, and conversant. sitting upright in
bed.
able to state ___ forwards. AOX person, place. In no acute
distress.
HEENT: +ecchymosis on occiput. PERRL, EOMI. R conjunctival
injection. Sclera anicteric. dry mucous membranes.
NECK: No cervical lymphadenopathy. JVP 7cm at 45 deg.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. +ppm
in place.
LUNGS: diffuse crackles in posterior fields. dullness in lower
fields b/l R>L and scattered wheezes. No increased work of
breathing.
BACK: mild lumbar spinous process tenderness (chronic).
ABDOMEN: Normoactive bowels sounds. soft, mild distention.
non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: warm. no pitting or dependent edema. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait not assessed. no nystagmus.
DISCHARGE EXAM:
===============
VITALS: 24 HR Data (last updated ___ @ 2335)
Temp: 98.1 (Tm 99.2), BP: 125/67 (125-138/67-79), HR: 66
(63-80), RR: 20 (___), O2 sat: 93% (91-93), O2 delivery: 1L
(1l-2L)
GENERAL: Elderly gentleman sitting comfortably in chair, in no
acute distress.
HEENT: R conjunctiva red. Dry mucous membranes.
CARDIAC: Faint heart sounds. Normal rate and rhythm. Normal S1
and S2. No murmurs, rubs, or gallops appreciated. +ppm in place.
LUNGS: Faint bibasilar inspiratory crackles. No rhonchi or
wheezes. No increased work of breathing.
ABDOMEN: Normoactive bowel sounds. Soft, nontender, nondistended
EXTREMITIES: Warm, well perfused
NEUROLOGIC: AAOx3. Pupils equal and reactive, EOMI without
nystagmus. CN2-12 intact. Motor and sensory function grossly
intact throughout.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:43PM WBC-11.8* RBC-4.25* HGB-14.2 HCT-40.6 MCV-96
MCH-33.4* MCHC-35.0 RDW-11.9 RDWSD-41.2
___ 05:43PM NEUTS-72.9* LYMPHS-13.4* MONOS-10.1 EOS-1.8
BASOS-0.7 IM ___ AbsNeut-8.63* AbsLymp-1.59 AbsMono-1.19*
AbsEos-0.21 AbsBaso-0.08
___ 05:43PM PLT COUNT-238
___ 05:43PM GLUCOSE-138* UREA N-13 CREAT-0.8 SODIUM-129*
POTASSIUM-4.9 CHLORIDE-89* TOTAL CO2-25 ANION GAP-15
___ 05:43PM ___ PTT-30.3 ___
___ 06:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR*
___ 06:04PM URINE RBC-<1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 09:46PM LACTATE-2.3*
PERTINENT LABS:
===============
___ 05:43PM BLOOD cTropnT-0.02*
___ 05:43PM BLOOD proBNP-729
___ 01:00PM BLOOD Osmolal-264*
___ 05:45AM BLOOD TSH-0.57
___ 05:56AM BLOOD Cortsol-6.4
___ 06:50AM BLOOD Cortsol-20.2*
___ 09:46PM BLOOD Lactate-2.3*
___ 06:41AM BLOOD Lactate-1.6
___ 05:30AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-123*
K-5.3 Cl-87* HCO3-26 AnGap-10
DISCHARGE LABS:
===============
___ 05:12AM BLOOD WBC-7.6 RBC-3.67* Hgb-12.4* Hct-35.5*
MCV-97 MCH-33.8* MCHC-34.9 RDW-12.1 RDWSD-42.7 Plt ___
___ 05:12AM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-129*
K-4.6 Cl-93* HCO3-24 AnGap-12
IMAGING:
========
CHEST (PA & LAT) Study Date of ___
IMPRESSION:
Mild to moderate pulmonary edema. Difficult to exclude
underlying pneumonia. Follow-up to resolution.
CT CHEST W/O CONTRAST Study Date of ___
IMPRESSION:
-Extensive bilateral airspace opacities concerning for
multifocal pneumonia, may reflect sequelae of aspiration.
-Patulous upper esophagus containing debris also raises
concern/risk for
further aspiration.
-Small hiatal hernia.
-Extensive coronary artery disease with mild cardiomegaly.
CT C-SPINE W/O CONTRAST Study Date of ___
IMPRESSION:
1. Degenerative changes in the cervical spine without acute
fracture or
alignment abnormality.
2. Opacities at the lung apices better assessed on concurrently
performed CT of the chest.
3. Patulous upper esophagus containing debris may predispose to
aspiration.
VIDEO OROPHARYNGEAL SWALLOW Study Date of ___
IMPRESSION:
Aspiration with thin and nectar thick liquids.
MICROBIOLOGY:
=============
__________________________________________________________
___ 12:18 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:12 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 11:51 pm
URINE ADDED TO 65439F.
**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.
__________________________________________________________
___ 8:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:57 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:04 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Mr. ___ is a ___ with a sig PMHx of COPD, AV block s/p PPM,
HTN, HLD, who presents from ___ s/p mechanical fall with
subarachnoid hemorrhage and acute onset shortness of breath,
with CT evidence concerning for multifocal pneumonia, found on
labs to have hyponatremia concerning for SIADH.
ACUTE ISSUES:
=============
#Acute Hypoxemic Respiratory Failure
#Multifocal Pneumonia
#Sepsis
Patient had two week history of weakness, lethargy, and a
nonproductive cough prior to admission. Patient failed
outpatient treatment with levofloxacin x7 days (last day ___,
giving concern for resistant organism. Patient presented with
hypoxemia to 92% at ___, and CT chest with diffuse patchy
opacities suggestive of
a multifocal pneumonia. Influenza A/B PCR neg. Legionella
negative and strep pneumo negative. Given dysphagia (as
described below) aspiration PNA also differential. Patient was
started on IV vancomycin and ceftazidime for broad-spectrum
coverage. Of note, nasal MRSA swab was positive, but felt to not
correlate with MRSA pneumonia. Patient was narrowed PO augmentin
in setting of hyponatremia (see below) in attempt to reduce
excess free water administration with IV medications. He
completed a 7 day total course for pneumonia. He was also given
duonebs but did not exhibits signs/symptoms of COPD
exacerbation.
#Hyponatremia
#SIADH
Incidentally found to have serum sodium of 129 on admission.
Sodium worsened with fluid bolus. Patient had elevated urine
sodium and osmolarity, normal TSH, and normal cortisol response
to ACTH stimulation test, consistent with a diagnosis of SIADH.
Etiology of SIADH likely secondary to head trauma and SAH.
Patient was maintained on 1000mL daily fluid restriction and
high protein diet with Ensure supplements with meals.
#Oropharyngeal dysphagia
Unclear etiology, and unclear how much of a long-standing issue
this represents. ___ have contributed to pneumonia in setting of
possible aspiration. Speech and language pathology evaluated
swallowing function and recommended pureed solids and nectar
thickened liquids.
#Mechanical fall with headstrike
#Subarachnoid Hemorrhage
Patient had fall with headstrike at ___. Likely in
the setting of weakness and lethargy from underlying pneumonia.
No prior fall history. CT head showed evidence of right lateral
frontotemporal subarachnoid
hemorrhage and limited anterior right and left frontal cortical
contusions. Neurosurgery evaluated in ED and no acute surgical
indication. Neurologically stable throughout admission.
#Elevated Lactate, improved
Lactate of 2.3 on admission. Likely type B in the setting of
multifocal pneumonia and sepsis. Improved with fluid
administration and antibiotics.
CHRONIC ISSUES:
===============
#AV block s/p pacemaker
#CAD
Held home ASA in the setting of SAH
#HTN
Continued losartan while in house. Resumed home irbesartan on
discharge
#HLD
#DM
Held home metformin, glipizide and managed on insulin sliding
scale.
#BPH
Continued home oxybutynin, tamsulosin
#Anxiety/insomnia
Continued home trazodone QHS
#Chronic Pain
Continued home gabapentin
TRANSITIONAL ISSUES:
====================
[ ] Patient had fall with headstrike, with some concern for
post-concussive syndrome. He may benefit from follow up as
needed with the ___ clinic
[ ] Dysphagia during admission. Recommended by ___:
1. Diet: downgrade to PUREED solids and nectar thick liquids (pt
must CHIN TUCK w/ liquids).
2. Medications: whole in puree w/ several follow up bites of
puree to ensure clearance of pill through esophagus (VFSS ___
3. Aspiration precautions:
-Meals and Meds at full 90 degree angle. Encourage patient to
be out of bed to chair for meals when able.
-1:1 assist with meals
-*Nectar thick liquid: Small sips by cup; chin tuck; then
swallow. Please make sure he does not toss his head back or take
large sips. This strategy is crucial to avoid gross aspiration.
-No straws
-Encourage cough.
-Check mouth after meal to make sure there is no pocketing,
especially on the left.
4. Oral care: Q4
[ ] Aspirin held on discharge, because being used for primary
prevention and data from recent ASPREE Trial suggests higher
all-cause mortality in older adults receiving daily aspirin
compared to placebo. If patient develops new strong indication
for aspirin, this can be restarted in the outpatient setting.
[ ] On 1000mL daily fluid restriction due to hyponatremia and
SIADH. This should be continued until his sodium levels
normalize.
[ ] Patient should have serum sodium checked daily to ensure
hyponatremia does not worsen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. GlipiZIDE XL 2.5 mg PO DAILY
4. irbesartan 150 mg oral DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Oxybutynin 10 mg PO QHS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
8. Tamsulosin 0.4 mg PO QHS
9. TraZODone 25 mg PO QHS insomnia
10. TraZODone 25 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO TID
4. Senna 8.6 mg PO BID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
6. Gabapentin 100 mg PO TID
7. GlipiZIDE XL 2.5 mg PO DAILY
8. irbesartan 150 mg oral DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Oxybutynin 10 mg PO QHS
11. Tamsulosin 0.4 mg PO QHS
12. TraZODone 25 mg PO QHS insomnia
13. TraZODone 25 mg PO Q6H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
-Acute hypoxemic respiratory failure
-Sepsis secondary to multifocal pneumonia
-Syndrome of inappropriate ADH
-Mechanical fall with headstrike
-Right lateral frontotemporal subarachnoid hemorrhage
SECONDARY DIAGNOSES:
-Oropharyngeal dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
-You were admitted because you had pneumonia
-You were transferred to ___ because you fell and had a small
bleed in your head
What happened while I was in the hospital?
-You were evaluated by our neurosurgery team who felt the
bleeding in your head was stable and did not need any surgery
evaluation
-You were treated with antibiotics for your pneumonia
-You were found to have a low sodium level in your blood. You
were treated by limiting the amount of fluid you can drink every
day, and by eating a high protein diet and drinking Ensure with
each meal.
-You were evaluated by our speech pathologists because you had
trouble with your swallowing. They recommended you eat only
pureed solids and nectar thickened liquids to lower your risk
for choking while eating.
What should I do once I leave the hospital?
-You should keep your follow up appointments
-You should take your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10715202-DS-2
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|
2113-11-02 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old male with a PMHx of aortic
stenosis, T2DM, hypertension, atrial fibrillation, and HLD who
presents for worsening shortness of breath.
The shortness of breath started one month ago and has been
slowly worsening. Today, even manipulating the bed sheets in his
room causes shortness of breath. He has never had this problem
before. Denies orthopnea or PND. No chest pain. No
light-headedness or dizziness. No abdominal swelling. No fevers
of chills.
He will get short of breath if he quickly goes from sitting to
standing.
He noticed bruising on his R leg and foot about ___ days ago.
No trauma to the R leg. It was present one morning when he woke
up. It is not painful. It is swollen, especially the R ankle.
He also notes that he has not had a bowel movement in 20 hours.
In the ED, initial vitals were: T 99.1, HR 63, BP 135/50, RR
16, O2 100% RA.
Stool was guaiac negative.
Labs notable for: H&H ___, INR 3.9, Cr 1.7
Imaging notable for:
CXR:
IMPRESSION:
Findings suggestive of mild pulmonary edema and small bilateral
pleural effusions.
___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Probable hematoma within the subcutaneous tissues of the right
lateral lower extremity. Follow-up imaging suggested if area
does not resolve clinically.
On the floor, patient is pleasant and breathing comfortably.
Past Medical History:
Aortic stenosis
Type 2 Diabetes
Atrial fibrillation
HLD
Hypertension
Osteoarthritis
CKD stage ___ (baseline Cr 1.6)
Ventricular tachycardia
h/o rheumatic fever as child
Social History:
___
Family History:
No medical problems in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.0, 140/52, 66, 22, 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear and pale
NECK: No appreciable JVD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur best heard at ___
Lungs: Mild bibasilar crackles that improved with coughing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, small L pelvic mass that patient believed was
stool
GU: No foley
Ext: Warm, well perfused, RLE with bruising and non-pitting
edema around the ankle
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 98.2 145/67 69 18 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: No appreciable JVD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur best heard at ___
Lungs: On RA, no increased work of breathing, good air
exchange, no wheezes, rales or ronchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly.
Back: No hematoma or tenderness.
GU: No foley
Ext: Warm, well perfused, RLE with bruising and non-pitting
edema around the ankle.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:42PM BLOOD WBC-7.0 RBC-2.99* Hgb-6.0* Hct-21.2*
MCV-71* MCH-20.1* MCHC-28.3* RDW-18.0* RDWSD-46.0 Plt ___
___ 08:42PM BLOOD Neuts-75.2* Lymphs-11.3* Monos-10.7
Eos-2.1 Baso-0.3 Im ___ AbsNeut-5.25 AbsLymp-0.79*
AbsMono-0.75 AbsEos-0.15 AbsBaso-0.02
___ 08:42PM BLOOD Plt ___
___ 08:42PM BLOOD ___ PTT-54.3* ___
___ 08:42PM BLOOD Ret Aut-2.0 Abs Ret-0.06
___ 08:42PM BLOOD Glucose-118* UreaN-30* Creat-1.7* Na-138
K-3.9 Cl-101 HCO3-26 AnGap-15
___ 08:42PM BLOOD ALT-8 AST-15 LD(___)-251* AlkPhos-79
TotBili-0.6 DirBili-<0.2 IndBili-0.6
___ 08:42PM BLOOD cTropnT-<0.01 proBNP-5214*
___ 08:42PM BLOOD Albumin-4.4 UricAcd-8.4* Iron-18*
___ 08:42PM BLOOD calTIBC-459 Hapto-246* Ferritn-19*
TRF-353
___ 10:09PM BLOOD Lactate-1.4
PERTINENT LABS:
===============
___ 08:42PM BLOOD ALT-8 AST-15 LD(___)-251* AlkPhos-79
TotBili-0.6 DirBili-<0.2 IndBili-0.6
___ 08:42PM BLOOD cTropnT-<0.01 proBNP-5214*
___ 08:42PM BLOOD Albumin-4.4 UricAcd-8.4* Iron-18*
___ 08:42PM BLOOD calTIBC-459 Hapto-246* Ferritn-19*
TRF-353
PERTINENT IMAGING/STUDIES:
==========================
___ TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Quantitative (3D) LVEF = 56%. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
severely thickened/deformed. The mean LVOT gradient is 2 mmHg.
The aortic valve VTI = 120 cm. There is severe aortic valve
stenosis (valve area 0.6 cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is no mitral valve prolapse. Moderate (2+) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Severe aortic stenosis.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
___ CXR:
IMPRESSION:
Findings suggestive of mild pulmonary edema and small bilateral
pleural effusions.
___ ___:
No evidence of deep venous thrombosis in the right lower
extremity veins. Probable hematoma within the subcutaneous
tissues of the right lateral lower extremity. Follow-up imaging
suggested if area does not resolve clinically.
MICRO:
======
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 10:05 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
DISCHARGE LABS:
===============
___ 05:31AM BLOOD WBC-7.5 RBC-3.50* Hgb-7.9* Hct-25.9*
MCV-74* MCH-22.6* MCHC-30.5* RDW-20.5* RDWSD-54.2* Plt Ct-96*
___ 05:31AM BLOOD ___ PTT-44.4* ___
___ 05:31AM BLOOD Glucose-165* UreaN-22* Creat-1.5* Na-139
K-3.6 Cl-102 HCO3-27 AnGap-14
___ 05:31AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ with aortic stenosis and AFib presenting with
worsening shortness of breath and found to have a hemoglobin of
6. His dyspnea is likely due to worsening AS as well as severe
iron deficiency anemia from a bleed into his right lower
extremity in the setting of a supratherapeutic INR.
ACTIVE DIAGNOSES:
# Severe, symptomatic iron deficiency anemia: Likely due to
spontaneous hematoma in the right leg given supratherapeutic
INR. He improved with 2 units packed red cells. His iron studies
were significant for an iron deficiency anemia. His haptoglobin
was higher suggesting against hemolysis and LDH was only very
slightly elevated. 3 stool guaiac tests were negative. He was
started on Iron 325 mg daily with a bowel regimen.
He had no evidence of compartment syndrome due to the rt shank
lateral hematoma, spontaneous. This demonstrated some clinical
resolution with getting inr back to therapeutic range, becoming
less tense and less tender to palpation. There was no evidence
of clinical expansion of hematoma during hospitalization by
exam, symptoms, or measurement of cell counts.
# Severe Aortic Stenosis: Most recent echo on admission was in
Atrius system ___ showed severe AS with peak velocity
4.3m/s, peak gradient 75mmHg, mean gradient of 48mmHg, and ___
of 0.8cm2. Per Dr. ___ ___ note, plan was to have patient
evaluated by ___ team because of progression of dyspnea. ___
team was notified that he was inpatient and agreed with repeat
echocardiogram which showed slight worsening of his AS (valve
area 0.6) which may have contributed to his shortness of breath.
He had no evidence of volume overload except for mild pulmonary
edema and did not require diuresis. He was seen by the ___ NP
while admitted and will have a cardiac catheterization scheduled
in the near future for further pre-procedure workup. Of note, he
will require discontinuation of his warfarin prior to the
catheterization. His cardiologist will decide whether he needs a
Lovenox bridge. This will all be arranged as an outpatient.
# Atrial fibrillation: On admission, in sinus rhythm with
supratherapeutic INR. CHADS2VASC: 4 (HTN,DM,AGE). Home
metoprolol was continued. Warfarin was restarted when INR
decreased to 2.7 on ___. He will need a repeat INR on ___.
# Positive Urine Culture: Pt asymptomatic. Grew 10,000-100,000
ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp. No indication for treatment.
# Thrombocytopenia: Between 90-110's while inpatient. Appears
to be near baseline (117 in ___. Further work-up as
outpatient should be considered. Omeprazole may be a possible
etiology.
# Constipation: Resolved with bowel reigmen. Patient reports
that L inguinal mass is stool and typically resolves once he has
a BM. L inguinal mass appears to be hernia, easily reducible.
Could consider follow-up with general surgery if patient
amenable.
CHRONIC, INACTIVE DIAGNOSES:
# CKD: Patient's baseline Cr is 1.6 (as of ___. He remained
near baseline while inpatient.
# HTN: Continued on home amlodipine and chlorthalidone
# HLD: Continued home simvastatin (note that dose of 40 mg is
considered a drug-drug interaction with amlodipine, but pt seems
to be stabilized on regimen)
# T2DM: Held home metformin, was on Humalog sliding scale as
inpatient.
#Primary Pevention: Restarted Aspirin once HgB was stable. His
dose was decreased from 325 mg daily to 81 daily due to bleeding
risk.
Transitional Issues:
[ ] Started on Iron 325 PO daily
[ ] Switched from 325 mg PO Aspirin to 81 mg daily to decrease
bleeding risk.
[ ] Consider further work-up of thrombocytopenia
[ ] Consider appt with general surgery for L inguinal hernia.
[ ] Follow-up with structural heart team for cardiac
catherization (date to be determined- they will call him with
date/time).
[ ] Patient will need to stop warfarin before his
catheterization. The structural heart team will be in touch with
his cardiologist to determine whether he needs to be bridged
with Lovenox prior to the cath.
# CODE: Full Code
# CONTACT: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Warfarin 3 mg PO 3X/WEEK (___)
3. Chlorthalidone 12.5 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Omeprazole 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Warfarin 4 mg PO 4X/WEEK (___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
10. Psyllium Wafer 1 WAF PO DAILY
RX *psyllium 1 packet(s) by mouth once a day Disp #*30 Packet
Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
once a day Refills:*0
12. Warfarin 3 mg PO 3X/WEEK (___)
13. Warfarin 4 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Right Lower Extremity Hematoma
Supratherapeutic INR
Severe Aortic Stenosis
Iron Deficiency Anemia
Secondary:
Hypertension
Chronic Kidney Disease
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were having worsening
shortness of breath and some bruising on your right leg. You
blood level (hemoglobin) was low. We gave you some blood and
your shortness of breath improved. We believe you may have lost
some blood in your leg because your warfarin level was high.
The bleeding in your leg appears to have stopped because your
blood levels are stable. You will take iron pills on a daily
basis to help your body make more blood. We decreased your
aspirin dose to 81mg daily.
You should follow-up with the ___ team about your upcoming
cardiac catheterization. They will be calling you when the
catheterization has been scheduled. Please continue to take your
warfarin until they tell you to stop. You should also follow-up
with your primary care physician (listed below).
Please continue to take your medications as listed below.
Followup Instructions:
___
|
10716082-DS-2
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2184-03-12 19:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male past medical history of bladder ___, PE,
Waldonstroms macroglobulinemia presenting with rash. Patient
states that his pain left sided back pain began around 10 days
ago and gradually worsened after attempting to lift his wife and
assist her with her ADLs. He denies any trauma or falls. He
denies any weakness or numbness. He denies any saddle
anesthesia.
He denies any incontinence of urine or stool. He does state that
yesterday he noted a temperature of 100 degrees F and that has
been after taking fairly consistent NSAIDs. Several days ago he
noticed a small area of redness on left lower shin which he
thought was trauma then it worsened yesterday and spread down
his
whole left shin and later there were spots noted scattered on
his
back. Denies any pain or itching of the rash. Went out to urgent
care today who sent him here for concern for possible
disseminated varicella-zoster. Patient denies any chest pain,
cough, dysuria, vomiting, diarrhea.
Past Medical History:
PULMONARY EMBOLISM
BLADDER ___
WALDENSTROM'S MACROGLOBULNEMIA
HYPERLIPIDEMIA
BENIGN PROSTATIC HYPERTROPHY
DIABETES TYPE II
OSTEOARTHRITIS
HYPERPARATHYROIDISM
HEMORRHOIDS
CYST POSTERIOR NECK
DYSPNEA
COLONIC ADENOMA
EXCISION NECK CYST
BLADDER ___
CHOLECYSTECTOMY
RESECTION OF PARATHYROID ADENOMA
Social History:
___
Family History:
Mother had MI and CAD, Father AAA
Physical ___:
ADMISSION PHYSICAL EXAM:
VS:T97.7 PO BP111/64, HR 73, RR 18, SaO2 93%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, 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, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, extensive maculopapular rash on
anterior left shin, scattered popular lesions on back and chest.
DISCHARGE PHYSICAL EXAM:
VS Temp: 97.6 PO BP: 126/75 HR: 81 RR: 18 O2 sat: 96% O2
delivery: Ra
Skin: Zosteriform vesicles on an erythematous base on L leg,
L4-5
dermatomal distribution, almost all completely crusted with
exception of two vesicles on his superior shin. Scattered
erythematous papules along trunk in back, R leg, pubic area
which
have improved without any evidence of vesicles.
General: Well-appearing male in no acute distress
HEENT: PERRL, EOMI, no eye involvement
CV: regular rate, regular rhythm, no murmurs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
NEURO: A&Ox3, moving all 4 extremities with purpose
BACK: No paraspinal tenderness noted, no midline spinal
tenderness to palpation
EXT: Left lower extremity with nontender erythematous papules.
NO
edema.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:15AM WBC-5.5 RBC-4.32* HGB-13.1* HCT-38.9* MCV-90
MCH-30.3 MCHC-33.7 RDW-13.1 RDWSD-43.2
___ 12:15AM NEUTS-55.5 ___ MONOS-15.9* EOS-3.8
BASOS-0.7 IM ___ AbsNeut-3.03 AbsLymp-1.29 AbsMono-0.87*
AbsEos-0.21 AbsBaso-0.04
___ 12:15AM PLT COUNT-223
___ 12:15AM GLUCOSE-113* UREA N-26* CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
Urine: Unremarkable
___ 12:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:30AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:30AM URINE MUCOUS-RARE*
PERTINENT LABS:
===============
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final ___:
POSITIVE FOR VARICELLA ZOSTER.
Viral antigen identified by immunofluorescence.
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
___: Negative for Herpes simplex by
immunofluorescence.
___ 08:08AM BLOOD ALT-20 AST-19 AlkPhos-65 TotBili-0.7
___ 07:35AM BLOOD ALT-17 AST-16 LD(LDH)-135 AlkPhos-51
TotBili-0.4
___ 07:35AM BLOOD IgG-840 IgA-20* IgM-542*
DISCHARGE LABS:
===============
___ 08:25AM BLOOD Glucose-124* UreaN-22* Creat-1.1 Na-135
K-4.4 Cl-98 HCO3-23 AnGap-14
___ 08:25AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.4
IMAGING/STUDIES:
================
___ CXR: No acute intrathoracic process.
Brief Hospital Course:
___ male with history of bladder ___, PE, and current
Waldonstroms macroglobulinemia who is presenting with rash
consistent with disseminated shingles.
ACUTE ISSUES:
===============
# Disseminated Zoster: Patient presented with lesions that
appeared on his left anterior shin and scatterd along his back.
These lesions appeared one day prior to presentation and were
confirmed to be Zoster on this admission via DFA. Given his
immunocompromised status, he was treated with IV acyclovir with
good tolerance (___) and transitioned to oral valacyclovir
on discharge (1g TID for total 10 day course, to complete ___.
His shingles is complicated by neuropathic pain in his left leg
and back, for which he was given Tylenol and gabapentin.
# Back pain: Patient presented with lower back pain, which is
almost resolved. This occurred in the context of recent muscle
strain and is reproducible, and he had no systemic signs to
suggest abscess.
CHRONIC ISSUES:
===============
# Waldonstroms macroglobulinemia: Dx in ___, treatment started
in ___ when he received retuxin and dexamethasone. In ___ he
was found to have ophthalmologic signs of hyperviscosity, so he
received 4 cycles of bendamustine with the final 2 cycles
administered with rituximab (completed in ___. Apparently
maintenance therapy was deferred in light of his
hypogamaglobulinemia and recurrent admissions for sepsis. A
recheck of immunoglobulins shows high IgM but low IgA,
consistent with his prior records. There does not seem to be
progressive of his disease (IgM has increased, though), and he
will follow up soon with his hematologist/oncologist Dr.
___ on ___.
# History of bladder CA: Dx in ___ initially treated with BCG
and mitomycin. No concerns during this hospital stay.
#BPH: Continued tamsulosin
TRANSITIONAL ISSUES:
#CODE: Full
#CONTACT: ___ ___
NEW MEDICATIONS:
- Valcyclovir
- Gabapentin
- Voltaren gel--- previously prescribed for patient for other
pain and gave new prescription on discharge
STOPPED MEDICATIONS:
- Naproxen (due to risk of kidney injury while on acyclovir)
-- ___ resume as clinically indicated or at lower doses
[] Complete Valtrex ___ day total course (to complete ___
[] Follow up herpetic lesions on leg to ensure crusted over
[] Assess neuropathic pain and discontinue gabapentin as
clinically indicated. In his advanced age, gabapentin could
cause excessive drowsiness or confusion if continued without
need
[] Follow up immunoglobulins and status of macroglobulinemia
with outpatient hematologist, Dr. ___ at ___, who was
emailed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY:PRN GERD
2. Tamsulosin 0.4 mg PO QHS
3. Naproxen 500 mg PO Frequency is Unknown
Discharge Medications:
1. Gabapentin 100 mg PO TID:PRN Leg nerve pain
RX *gabapentin 100 mg 1 capsule(s) by mouth Three times daily
Disp #*30 Capsule Refills:*0
2. ValACYclovir 1000 mg PO TID Duration: 13 Doses
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Three times per
day Disp #*13 Tablet Refills:*0
3. Voltaren (diclofenac sodium) 1 % topical Q8H:PRN
Apply three times a day as needed for back pain
RX *diclofenac sodium [Voltaren] 1 % Three times a day
Refills:*0
4. Omeprazole 20 mg PO DAILY:PRN GERD
5. Tamsulosin 0.4 mg PO QHS
6. HELD- Naproxen 500 mg PO Frequency is Unknown This
medication was held. Do not restart Naproxen until your doctor
tells you to
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Disseminated zoster
SECONDARY:
___'s macroglobulinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___!
Why were you admitted?
- You were admitted for a rash and pain in your back and legs
- You were diagnosed with herpes zoster, which is also known as
shingles
What happened while you were in the hospital?
- We kept you on many precautions (air and contact) because of
the contagious nature of shingles
- Your rash improved significantly on IV acyclovir, a medication
that treats viral infections
What should you do when you leave the hospital?
- Some of your skin rash may still be contagious, so please do
not allow anyone to touch your leg without gloves on until the
rash is gone. Please wear pants whenever possible.
- Your doctor ___ tell you when this rash has completely
resolved.
- You will need to continue taking a pill version of the
antiviral you received in the hospital (it is called Valtrex).
Take this three times daily (8AM, 2PM, and 8PM) with the first
dose on ___ at 8PM. You will be given 13 pills to complete 10
days total of antiviral medication (including the IV you
received in hospital).
- You may have back or leg pain related to the shingles
(neuropathic pain). You can take Tylenol or gabapentin for this.
You can take the gabapentin as needed, up to three times daily.
Thank you for allowing us to care for you! We wish you all the
best.
- Your ___ Team
Followup Instructions:
___
|
10716082-DS-3
| 10,716,082 | 25,750,539 |
DS
| 3 |
2184-12-22 00:00:00
|
2184-12-22 11:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Pancytopenia, low-grade fevers, night sweats
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ hx Past s/p t/t Waldenstrom's,
Bladder Ca, PE, dissem zoster ( ___ presenting
with worsening dyspnea and referral from PCP to be admitted to
hospital for pancytopenia which seems to be worsening.
Patient and family offer detailed history of undulating fatigue
and weakness, fever (100-102)x 6 weeks since administration of a
shingles vaccine, that has been gradually worsening and now
states his lab counts according to his PCP warrant him coming
into the hospital.
Patient states that aside from fatigue and decreased appetite,
he
has no symptoms though occ feels DOE, denies cp, n/v/d, no
blurry
vision, UTI s/s, dysuria.
He saw Dr. ___ on ___ on the same day that he noted a
rash on his right abdominal wall. Dr. ___ that the
rash was consistent with shingles and he was begun on
valacyclovir. However, he describes the rash is fading without
any pain
or itching.
In ED
BP 116/54-134/60, Spo2 96-99%, T 97.9 - 98.8
WBC 2.2, Hb 9.7 plt 57
WBC 2.4, Hgb 11.8, Plt 75 on ___ at ___.
140 | 101 | 23 AGap=14
_____________/113
4.3 | 25 |1.1\
___: 12.2 PTT: 25.5 INR: 1.1
Ca: 9.0 Mg: 2.1 P: 3.4
ALT: 27 AP: 119 Tbili: 1.1 Alb: 3.8
AST: 35 LDH: Dbili: TProt:
___: Lip: 58
UA wnl
Pending BCx, UCx
Past Medical History:
PULMONARY EMBOLISM
BLADDER CANCER
___ MACROGLOBULNEMIA
HYPERLIPIDEMIA
BENIGN PROSTATIC HYPERTROPHY
DIABETES TYPE II
OSTEOARTHRITIS
HYPERPARATHYROIDISM
HEMORRHOIDS
CYST POSTERIOR NECK
DYSPNEA
COLONIC ADENOMA
EXCISION NECK CYST
BLADDER CANCER
CHOLECYSTECTOMY
RESECTION OF PARATHYROID ADENOMA
Social History:
___
Family History:
Mother had MI and CAD, Father AAA
Physical ___:
GENERAL: Alert and in no distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS:
======
___ 04:00PM BLOOD WBC-2.2* RBC-3.21* Hgb-9.7* Hct-29.6*
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.6 RDWSD-48.6* Plt Ct-57*
___ 04:00PM BLOOD Neuts-49.4 ___ Monos-22.9*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-1.10* AbsLymp-0.56*
AbsMono-0.51 AbsEos-0.01* AbsBaso-0.01
___ 06:35AM BLOOD WBC-1.8* RBC-3.12* Hgb-9.6* Hct-28.5*
MCV-91 MCH-30.8 MCHC-33.7 RDW-15.0 RDWSD-49.3* Plt Ct-54*
___ 06:35AM BLOOD WBC-2.1* RBC-2.93* Hgb-9.0* Hct-26.7*
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.9 RDWSD-49.6* Plt Ct-55*
___ 06:35AM BLOOD Neuts-41.9 ___ Monos-24.4*
Eos-0.5* Baso-0.5 Im ___ AbsNeut-0.86* AbsLymp-0.64*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.01
___ 06:30AM BLOOD WBC-2.3* RBC-3.38* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.2 MCHC-33.1 RDW-15.0 RDWSD-49.6* Plt Ct-61*
___ 06:30AM BLOOD Neuts-44 Bands-2 ___ Monos-23*
Eos-0* ___ Metas-2* AbsNeut-1.06* AbsLymp-0.67* AbsMono-0.53
AbsEos-0.00* AbsBaso-0.00*
___ 04:00PM BLOOD Glucose-113* UreaN-23* Creat-1.1 Na-140
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 04:00PM BLOOD Glucose-113* UreaN-23* Creat-1.1 Na-140
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 06:35AM BLOOD Glucose-139* UreaN-17 Creat-1.2 Na-137
K-4.5 Cl-98 HCO3-25 AnGap-14
___ 06:35AM BLOOD Glucose-127* UreaN-18 Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-26 AnGap-12
___ 04:00PM BLOOD ALT-27 AST-35 AlkPhos-119 TotBili-1.1
___ 06:35AM BLOOD ALT-26 AST-33 LD(LDH)-552* AlkPhos-111
Amylase-55 TotBili-1.1
___ 04:00PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-2.1
___ 06:35AM BLOOD TotProt-6.1* Albumin-3.5 Globuln-2.6
Calcium-8.7 Phos-3.5 Mg-2.3 Iron-80
___ 06:35AM BLOOD Mg-2.3
___ 06:35AM BLOOD calTIBC-263 VitB12-467 Folate-10
___ Ferritn-587* TRF-202
___ 12:50PM BLOOD VitB12-532 Folate-11
___ 06:35AM BLOOD ___ D-Dimer-3609*
___ 06:35AM BLOOD Ret Aut-2.4* Abs Ret-0.07
___ 04:00PM BLOOD Lipase-58
___ 06:35AM BLOOD HBsAg-NEG HBsAb-POS
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD PEP-AWAITING F IgG-906 IgA-32* IgM-75
IFE-PND
___ 12:50PM BLOOD IgG-941 IgA-22* IgM-244*
___ 06:35AM BLOOD EBV IgG-PND EBNA-PND EBV IgM-PND EBVI-PND
___ 06:35AM BLOOD HCV Ab-NEG
___ 06:35AM BLOOD CMV VL-PND
___ 06:35AM BLOOD HIV1 VL-PND
___ 06:35AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
___ 06:35AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
___ 06:35AM BLOOD IGG SUBCLASSES 1,2,3,4-PND
___ 06:35AM BLOOD B-GLUCAN-PND
___ 06:35AM BLOOD HISTOPLASMA ANTIGEN-PND
MICRO:
=======
___ 5:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:02 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:16 pm URINE ___.
**FINAL REPORT ___ URINE CULTURE (Final ___: <
10,000 CFU/mL.
___ 6:35 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
IMAGING:
========
___ CXR:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
unchanged. The
pulmonary vasculature is normal. Apart from minimal atelectasis
in the left
lung base, the lungs are clear. No pleural effusion or
pneumothorax is seen.
There are no acute osseous abnormalities. Mild degenerative
changes are seen
in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
___ ECG:
Sinus rhythm
Abnormal R-wave progression, early transition
compared to previous ECG no significant change
Brief Hospital Course:
___ w/ Waldenstrom's macroglobulinemia (last chemo/immunotherapy
___ years ago at ___), bladder cancer (BCG ___ years ago),
presented with 6 weeks of fever/fatigue and found to have
pancytopenia.
BRIEF HOSPITAL COURSE BY PROBLEM
=============================
# Pancytopenia, fevers
For the past month had evidence of progressively dropping counts
involving all lines that was concerning for malignancy versus
viral insult. An extensive infectious work-up was sent, focused
on potential viral etiologies, most of which is pending at
discharge. Patient endorsed feeling well during the
hospitalization, despite the prior concerns, and had no fevers.
Counts hit their nadir on ___ and then started rebounding.
Patient declined bone marrow ___ and given the improving
counts, after corresponding with his outpatient oncologist Dr.
___ from ___, it was determined that the
patient could be discharged and could pursue further evaluation
with Dr. ___ would schedule an appointment within a
week. At discharge, WBC 2.2 (ANC 980), Hgb 10.3, and patelet
count 71.
Studies Resulted Prior to Discharge:
LDH 552
Ferritin 587
HBsAg negative HBsAb positive
___ negative
IgG 941, IgA 22, IgM 244
IgG subclasses: 1 670, 2 127 (L), 3 27, 4 32.6
CMV VL not detected
Galactomannan negative
UCx negative
Pending studies at discharge:
___ 06:21 HEPATITIS A ANTIBODY
___ 06:21 ANAPLASMA PHAGOCYTOPHILUM DNA, QUALITATIVE
___ 06:21 PARVOVIRUS B19 DNA
___ 06:35 EBV PCR, QUANTITATIVE, WHOLE BLOOD
___ 06:35 B-GLUCAN
___ 06:35 HISTOPLASMA ANTIGEN
___ 07:47 BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE; BLOOD/AFB CULTURE
___ 18:13 BLOOD CULTURE Blood Culture, Routine
___ 18:12 BLOOD CULTURE Blood Culture, Routine
# ___ macroglobulinemia
Successfully completed chemo/immunotherapy ___ years ago at ___
___. Will follow up with outpatient hematologist-oncologist
Dr. ___.
# BPH
Continued home tamsulosin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because your blood counts were
going low. You also have had weeks of low-grade fevers and night
sweats.
While in the hospital we felt well and did not have fevers.
Tests including for infections were ordered. None of the results
are so far concerning or demonstrate the cause of your symptoms
or blood count changes.
We proposed a bone marrow biopsy but given that your blood
counts have since improved, we think it is safe for you to be
discharged and have this done with your regular oncologist. We
have corresponded with him and they will schedule you to be seen
in the next week.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10716312-DS-20
| 10,716,312 | 24,611,658 |
DS
| 20 |
2143-03-16 00:00:00
|
2143-03-17 22:42:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Ilotycin / Flagyl /
Percocet
Attending: ___.
Chief Complaint:
fatigue, diarrhea
Major Surgical or Invasive Procedure:
pacemaker placement
History of Present Illness:
___ year old gentleman with a history of hypertension, IBS s/p
colectomy for chronic diarrhea, and parkinsonism with chronic
bladder stimulator who presents with 2 weeks of generalized
lethargy and weakness, associated with one day of nonbloody
watery diarrhea. He states that the fatigue/lethargy has been
constant and progressive (not associated with time of day,
activity). The patient is able to ambulate with a walker. No
recent falls or loss of consciousness. He denies chest pain,
dyspnea, nausea, vomiting, abdominal pain. No recent med
changes.
.
The patient also states that this morning, he has had to empty
his colostomy bag 6 times (at baseline, empties 4 times daily).
Denies nausea, hematochezia, melena. No fevers or chills. He
states that his mouth is always dry.
.
In the ED, initial vitals were 36 145/50 100%. The patient was
found on EKG to be in SR at 40 with 2nd degree block with 2:1
A-V block. He remained normotensive, alert, mentating well,
chest pain free. Labs and imaging significant for a creatinine
of 1.7 (baseline 1.3). Vitals on transfer were 97 37 18 156/53
96% room air.
.
On arrival to the floor, patient is comfortable, without
complaints. He continues to feel fatigued. Cardiac review of
systems is notable for chronic ankle edema. No chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He denies recent fevers, chills or rigors. Patient does have a
bladder stimulator in place. He states that he does experience
difficulty with initiating urination and slowed stream. No
dysuria, frequency, urgency. All of the other review of systems
were negative.
Past Medical History:
ANEMIA
ANXIETY/DEPRESSION
AORTIC REGURGITATION
ASTHMA
BENIGN PROSTATIC HYPERPLASIA
CERVICAL SPINAL STENOSIS
CHRONIC SCROTAL DERMATITIS
CHRONIC DIARRHEA
DIZZINESS
GASTROESOPHAGEAL REFLUX DISEASE
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM - S/P THYROIDECTOMY IN ___LOCK ___
NOCTURNAL LEG CRAMPS
LOW BACK PAIN
PANCREATIC LESION
PARKINSONISM ___
SLEEP APNEA ON CPAP
RECURRENT BASAL CELL CA
S/P COLECTOMY WITH END COLOSTOMY
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: T 97.8 BP 150/69 HR 47 RR 20 O2 sat 94%RA
GENERAL: WDWM in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. MM slightly dry. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, bradycardic S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, slight kyphosis. Resp
unlabored, no accessory muscle use. CTAB, no crackles, wheezes
or rhonchi.
ABDOMEN: + normoactive bowel sounds; abdomen with opaque
colostomy bag in LLQ. Abdomen soft, non-distended. Mildly
tender to palpation in suprapubic region.
EXTREMITIES: trace edema to mid-calf
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
Discharge Physical Exam:
VS: 100.2 TMax; 147/74 80 18 93%RA 700+ out
Gen: Pleasant gentleman laying comfortably in bed; alert and
oriented x 3, but occasionally makes non-sensical statements
HEENT: MMM
Neck: No JVD
Card: Normal S1, S2, ___ systolic ejection murmur; no rubs or
gallops; Pacemaker in place on left chest covered in bandage;
bandage CDI; no surrounding erythema
Lungs: Clear to auscultation bilaterally
Abdomen: Colostomy in LLQ; abdomen soft, non-tender,
non-distended
Ext: Trace non-pitting ankle edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
Admission Labs:
___ 10:10AM BLOOD WBC-6.4 RBC-3.96* Hgb-12.4* Hct-36.3*
MCV-92 MCH-31.2 MCHC-34.1 RDW-12.7 Plt ___
___ 10:10AM BLOOD Neuts-68.1 ___ Monos-8.1 Eos-2.8
Baso-0.4
___ 10:10AM BLOOD Glucose-104* UreaN-43* Creat-1.7* Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
___ 10:10AM BLOOD CK(CPK)-97
___ 10:10AM BLOOD cTropnT-0.04*
___ 10:10AM BLOOD CK-MB-4
___ 10:10AM BLOOD Calcium-9.9 Phos-2.8 Mg-2.3
.
Discharge Labs:
___ 07:40AM BLOOD WBC-10.1 RBC-3.86* Hgb-11.9* Hct-35.3*
MCV-91 MCH-30.7 MCHC-33.6 RDW-12.7 Plt ___
___ 07:40AM BLOOD Glucose-98 UreaN-23* Creat-1.2 Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
___ 07:40AM BLOOD Calcium-9.0 Phos-2.2* Mg-1.8
Cardiac enzymes x 3:
___ 10:10AM BLOOD CK-MB-4
___ 10:10AM BLOOD cTropnT-0.04*
___ 09:30PM BLOOD CK-MB-3 cTropnT-0.04*
___ 07:10AM BLOOD CK-MB-3 cTropnT-0.04*
Brief Hospital Course:
___ year old gentleman with a history of hypertension w/ chronic
LBBB, IBS s/p colectomy for chronic diarrhea and parkinsonism
who presents with 2 weeks of generalized lethargy and weakness,
found to have symptomatic bradycardia with 2nd degree AV block
with 2:1 conduction.
.
# RHYTHM/BRADYCARDIA: Patient presented to the hospital with
significant fatigue, and was found to be bradycardic to 30, in
2nd degree AV block with 2:1 conduction. Patient has a left
bundle branch block, first discovered in ___. With carotid
massage, the sinus rate slowed markedly, and a junctional rhythm
with left anterior fascicular block emerged, indicating that the
site of conduction block is likely to be intra-His, with the
escape rhythm originating lower in the bundle of His. The
patient underwent ___ pacemaker placement. Chest X-ray
and device interrogation confirmed appropriate positioning and
functionality of the device. The patient was placed on Keflex
to complete a 3 day course for infection prophylaxis. He should
follow up in device clinic on ___.
.
# VENTRICULAR FUNCTION: Last ECHO in ___ with EF 50-55% (low
normal EF). No history or evidence of heart failure. The
patient was continued on aspirin throughout admission.
.
# HYPERTENSION: The patient has a history of hypertension. On
admission, he was continued on home AMLODIPINE 10 mg by mouth
once a day. His diuretics were held on admission, as the
patient was in acute kidney injury. Diuretics were resumed at
discharge on return of his creatinine to baseline.
.
# CORONARIES: The patient does not report chest pain or anginal
equivalents. Troponin slightly elevated at 0.04 x3, likely
secondary to poor renal clearance.
.
# DIARRHEA: Patient has chronic diarrhea (changes colostomy bag
4x daily) with negative infectious workup multiple times in the
past. On admission, the patient complained of an acute
exacerbation - had to empty his bag 8 times on day of admission.
He had no evidence of bacterial infectious diarrhea (no nausea,
no blood in stools, WBC count normal and anemia around
baseline). The patient received a bolus of 250 cc IVF for mild
dehydration. Stool cultures and C. Difficile returned negative.
The patient's diarrhea resolved without intervention.
.
# ACUTE ON CHRONIC KIDNEY INJURY: Patient with elevation in
creatinine from baseline of 1.2-1.4 to 1.7. Likely pre-renal
azotemia secondary to dehydration from diarrhea. The patient
received a 250 cc bolus, resulting in improvement of his
creatinine to 1.2.
.
# PARKINSONISM: Chronic, with indwelling bladder stimulator.
Patient able to ambulate with walker, without reported falls or
LOC. The patient was continued on cinemet throughout admission.
He was seen by physical therapy who recommended rehabilitation.
.
# HYPOTHYROIDISM: Chronic. The patient was continued on
levothyroxine throughout admission.
.
# GERD: Chronic. The patient was continued on omeprazole
throughout admission.
.
# ANXIETY/DEPRESSION: Chronic. Patient states that he has been
in good spirits; no SI/HI. He was continued on bupropion and
fluoxetine. He was continued on trazodone for sleep.
.
CODE: DNR/DNI - Confirmed with patient and health care proxy
___ on ___:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - ___ puffs(s) by
mouth every four (4) to six (6) hours as needed for
cough/wheezing
AMLODIPINE [NORVASC] - 10 mg Tablet - 1 Tablet(s) by mouth once
a
day
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - One
Tablet(s) by mouth every day
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth every
morning
CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 1.5 Tablet(s) by
mouth
three times daily
FLUOXETINE [PROZAC] - 20 mg Capsule - 1 Capsule(s) by mouth
every
day
LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - 1 Tablet(s) by mouth
once a day Brand name only
MOMETASONE [NASONEX] - 50 mcg Spray, Non-Aerosol - 2 puffs(s)
nostrils once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
TRAZODONE - 75 mg Tablet - 1 Tablet(s) by mouth before sleep
TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5 mg-25 mg Tablet - Take one
Tablet(s) by mouth daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. carbidopa-levodopa ___ mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for
wheezing/SOB.
10. Keflex ___ mg Capsule Sig: One (1) Capsule PO twice a day
for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
11. triamterene-hydrochlorothiazid 37.5-25 mg Tablet Sig: One
(1) Tablet PO once a day.
12. mometasone 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
puffs Nasal once a day: to each nostril.
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis: Type II atrioventricular Block; now status
post pacemaker placement
Secondary Diagnosis: Chronic diarrhea; Hypertension, Chronic
kidney disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Father ___,
.
You were admitted to the hospital for fatigue and one day of
diarrhea. In the emergency department, you were found to have a
slow heart rhythm that may be the source of your fatigue. You
underwent ___ pacemaker placement and were discharged to
your home at ___. You were discharged on Keflex to
complete a 3-day course.
.
We found that you were dehydrated, likely related to your
diarrhea, on admission. We gave you a small amount of fluids
and your dehydration improved. Your diarrhea resolved after one
day of admission. We performed tests to examine for infection
of your stool. They are negative to date.
.
You should follow up with your primary care physician ___ 1
week of discharge. You should follow up in cardiac device
clinic on ___. You have an appointment with Dr. ___ on
___.
.
MEDICATIONS CHANGED THIS ADMISSION:
START Keflex ___ mg every 12 hours by mouth for 2 days
Followup Instructions:
___
|
10716372-DS-11
| 10,716,372 | 20,297,014 |
DS
| 11 |
2169-02-15 00:00:00
|
2169-02-15 12:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motorvehicle collision with polytrauma (hip dislocation, left
open distal and proximal tibial fractures)
Major Surgical or Invasive Procedure:
___ - L hip closed reduction, LLE ex-fix and VAC placement
___ - LLE ex-fix revision and VAC change
___ - ORIF L acetabulum, ORIF L tibial plateau
___ - L pilon antibiotic spacer placement and free flap
___ - Removal of residual ex-fix hardware
History of Present Illness:
HPI: This is a ___ M s/p MCC approximately one week ago (___)
with multiple traumatic orthopaedic injuries, including left
open severely-comminuted tib-fib shaft fracture with
intra-articular extension and segmental bone loss, as well as
native left hip dislocation and closed left tibial plateau
fracture. He has been taken to the OR several times by
orthopaedics ___: closed hip reduction, tibial ex-fix and
medial tibial wound vac; ___ I&D of tibial wound, ex-fix
revision, wound vac change). To OR with ortho today for ORIF
acetabular fracture, ORIF tibial plateau fracture, and I&D of
open tibial wound and cement spacer placement for segmental bone
loss associated with tibial shaft/pilon fracture. Plastic
surgery was consulted intraoperatively for recommendations
regarding future coverage of open medial tibial wound overlying
tibial shaft and pilon fracture.
Past Medical History:
Hyperlipidemia, hernia repair
Social History:
___
Family History:
noncontributory
Physical Exam:
CURRENT
Vitals: T:97.8 P:69 BP: 118/63 RR:18 SaO2: 100%/RA
GEN: NAD, AOx3, calm, responsive
HEENT: PERRL, EOMI
CV: RRR
LUNGS: CTA B/L
ABD: soft, nontender, nondistended
EXT: RLE +2 DP pulse, 15 cm clean, dry, intact, nonerythemetous,
surgical incision closed by staples. LLE: minimal distal
sensation, +2 DP pulse, flap clean, dry, intact, viable,
well-healing, triphasic doppler signal. minimal movement of
toes, sensation intact in lower and upper leg.
Pertinent Results:
___ 05:17AM BLOOD WBC-12.5* RBC-2.19* Hgb-6.5* Hct-20.0*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.9 Plt ___
___ 05:48AM BLOOD ___ PTT-26.2 ___
___ 12:39AM BLOOD ___ 05:17AM BLOOD Glucose-87 UreaN-13 Creat-0.5 Na-136
K-3.7 Cl-102 HCO3-20* AnGap-18
___ 02:30PM BLOOD CK(CPK)-5884*
___ 02:15AM BLOOD CK(CPK)-5698*
___ 08:30PM BLOOD CK(CPK)-2919*
___ 02:20AM BLOOD CK(CPK)-2563*
___ 07:10PM BLOOD CK(CPK)-1820*
___ 05:48AM BLOOD Albumin-2.1* Calcium-7.3* Phos-3.9 Mg-1.9
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have multiple injuries including a dislocated L native hip, a
L acetabulum fracture, a L tibial plateau fracture, a L open
comminuted midshaft tib/fib fracture, and a L pilon fracture and
was admitted to the acute care surgery service. The patient was
taken to the operating room emergently on ___ for L hip CR
and LLE ex-fix and VAC placement, which the patient tolerated
well (for full details please see the separately dictated
operative report). The patient was taken from the OR to the PACU
in stable condition and after recovery from anesthesia was
transferred to the TSICU. Anticoagulation was held at this point
due to concerns for active bleeding. The patient remained
intubated and was taken back to the OR on ___ for LLE ex-fix
revision and VAC change. On ___, the patient was taken to the
OR for ORIF of his L acetabulum and L tibial plateau fracture.
On ___, the patient was taken to the OR for placement of an
antiobiotic spacer through his highly comminuted tibia fracture
/ pilon fracture and free flap by the plastic surgeons.
Following the final surgery, the patient was transferred to the
plastic surgery team for continued flap management. On ___
the remainder of external fixation hardware was removed. The
patient was given perioperative antibiotics and anticoagulation
per routine. It was noted that post operatively his hematocrit
was in the ___ range. This number remained stable throughout
his course even while on coagulation. This anemia was entirely
asymptomatic and it was decided that the risks of transfusion
currently outweighted the beneffit. He was started on oral
ferrous gluconate to support hematopoesis. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the left lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin Dose is Unknown PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC QD Duration: 30 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneously twice a day
Disp #*56 Syringe Refills:*0
2. Aspirin 325 mg PO DAILY
Take for 30 days.
RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*120 Tablet Refills:*1
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*1
5. Ferrous GLUCONATE 324 mg PO DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO Q3H severe pain Duration: 60
Doses
Do not drive or operate heavy machinery on this medicine.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 3
hours as needed Disp #*60 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*60 Tablet Refills:*1
8. Senna 1 TAB PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice daily Disp #*60
Tablet Refills:*1
9. Atorvastatin 0 unknown PO DAILY
10. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Capsule Refills:*3
11. Morphine SR (MS ___ 15 mg PO Q12H
Do not drive or operate heavy machinery.
RX *morphine 15 mg 1 tablet extended release(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L native hip dislocation
L acetabulum fracture
L tibial plateau fracture
L open comminuted midshaft tib/fib fracture
L pilon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Ambulation to be limited initially according to
dangle protocol included in discharge packet.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 4 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing in left lower extremity
Followup Instructions:
___
|
10716479-DS-11
| 10,716,479 | 23,119,305 |
DS
| 11 |
2142-08-29 00:00:00
|
2142-08-29 11:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Percocet / Lyrica / dexamethasone
Attending: ___.
Chief Complaint:
pain and swelling at spinal stimulator site
Major Surgical or Invasive Procedure:
___ Lumbar puncture at interventional radiology
___: Explant of Spinal Cord Stimulator Lead and IPG
History of Present Illness:
___ year old woman with history of lumbar disc herniation s/p
spinal stimulator placement on ___ ___ she
has an unsuccessful L4-L5 surgery prior and wanted to come off
medication who presents with increased back pain, fever and
leukocytosis. Pt repot L4-L5 herniation in ___ which did not
improve with conservative treatment. Pt had L4-L5 discectomy
(Dr. ___) with post-op imaging showing no
hernation. However, her pain worsened following surgery - she
reports lower back pain, achy in nature, radiating down legs to
feet, numb and tingling in nature. Due to ongoing pain whe had a
tiral of spinal stimulator which improved the pain. Her pain
clinic (Pain Care, ___, Dr. ___ and Dr. ___
___ referred her to Dr. ___ at ___ who placed spinal
stimulator ___. Pt reports pain well controlled prior to
this week on stimulator and current pain regimen. However, 2
days ago she developed severe burning, fire-like pain on her
back from her neck to lower back below where the stimulator is
implanted. The pain is worse with touch and movement. ___
days ago, currently ___. She reports swelling at the
implantaion site. Yesterday morning her temp was 101.5 and she
present to ___. She also reports recent
headache and some neck pain.
At OSH pt found to have WBC 27,000 was cleared for the flu, and
received Vanc PTA. She was transferred to ___ since she had
her surgery at ___.
Reports continued intermittent subjective fevers. Denies
increased numbness or tingling, weakness, or incontinence.
Denies significant cough, dysuria, chest pain, abomdinal pain,
SOB, diarrhea. No recent travel. Son had headache recently but
otherwise no recent sick contacts.
In the ED, initial vital signs were: T 98 HR 103 BP 107/59 RR 16
Sat 98%RA. Labs were notable for negative UCG, K 3.4, Cr 0.7,
lactate 1.4, WBC 25.2 with 85% PMN. CXR did not show pneumonia.
UA not suggestive of UTI. CT T-L spine with contrast showed (WET
READ) no drainable abcess or fluid collection with limited
assessment at T10 and T11 demonstrates mild fat stranding along
catheter in subcutaneous tissues posterior to the spine with
associated skin induration and absence of enhancement suggesting
post procedural change however infection cannot be excluded. No
evidence of osteomylitis. Neurosurgery was consulted and thought
that it's unlikely to be from stimulator site. Given CT is
suggestive of post-op changes, patient is being admitted to
MEDICINE for leukocytosis and fever work up. Patient was given
in the ED IV valium and PO diazepam. Urine and blood culture
drawn and pending.
On Transfer Vitals were: 97.6 125 124/78 16 99% RA.
Past Medical History:
-L4-L5 herniation s/p surgery (___) and spinal stimulator
implantation (___)
-Hypothyroidism
-Cholecystectomy
-Carpal tunnel surgery
-C-section x 2
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- able to move flex and rotate, not rigid, mildly tender
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Back: Incision over thoracic spine without drainage, edematous
to L of incision without erythema, back tender to palpation from
slightly below neck to inferior lumbar spine, incision over L
superior buttocks - surrounding area mildly tender to palpation,
mildly erythematous
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- no clubbing, cyanosis or edema
Neuro- alert, oriented x 3, CNs2-12 intact, motor function
grossly normal, strength ___ throughout
On discharge:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present
Ext- no clubbing, cyanosis or edema, no atrophy
Neuro- alert, oriented x 3, CNs2-12 intact, motor function
grossly normal, strength ___ throughout, incision is c/d/i with
sutures in place
Pertinent Results:
========================
Labs:
========================
Admission labs:
-----------------
___ 01:48AM BLOOD WBC-25.2* RBC-4.01* Hgb-13.1 Hct-40.1
MCV-100* MCH-32.5* MCHC-32.6 RDW-12.5 Plt ___
___ 01:48AM BLOOD Neuts-85.2* Lymphs-9.5* Monos-4.3 Eos-0.9
Baso-0.3
___ 07:40PM BLOOD ___ PTT-30.9 ___
___ 01:48AM BLOOD Glucose-111* UreaN-5* Creat-0.7 Na-138
K-3.4 Cl-102 HCO3-25 AnGap-14
___ 06:00AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2
___ 01:53AM BLOOD Lactate-1.4
Urine:
-----------------
___ 02:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:30AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:30AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 02:30AM URINE Mucous-RARE
___ 02:30AM URINE UCG-NEGATIVE
CSF:
-----------------
___ 02:14PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* Polys-0
___ Macroph-16
___ 02:14PM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-70
========================
Micro:
========================
___ blood cultures x 2: no growth
___ 9:59 am CSF;SPINAL FLUID Source: LP TUBE 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 2:00 pm FOREIGN BODY
SPINAL CORD STIM BATTERY FOR CULTURE.
WOUND CULTURE (Pending):
___ 2:00 pm FOREIGN BODY
SPINAL NERVE STIM ELECTRODE FOR CULTURE.
GRAM STAIN (Final ___:
TEST CANCELLED, PATIENT CREDITED.
INAPPROPRIATE SPECIMEN FOR TESTING.
Reported to and read back by ___ ___.
WOUND CULTURE (Preliminary):
___ 6:30 pm SWAB
INCISION ON L SUPERIOR BUTTOCKS WHERE BATTERY LOCATED.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 2:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
========================
Imaging:
========================
CHEST (PA & LAT) Study Date of ___ 3:09 AM
IMPRESSION: No acute cardiopulmonary process.
CT L-SPINE W/O CONTRAST Study Date of ___ 6:43 AM
IMPRESSION:
1. Limited assessment at T10 and T11 demonstrates induration and
mild
stranding around the catheter coiled in subcutaneous tissues
posterior to the spine. Findings may represent postprocedural
change/inflammation, however infection cannot be entirely
excluded. No drainable abscess or fluid collection.
CT T-SPINE W/ CONTRAST Study Date of ___ 6:44 AM
IMPRESSION:
1. Limited assessment at T10 and T11, particularly of the
central canal
demonstrates some induration/fat stranding around the cathetern
which is
coiled in the subcutaneous tissues posterior to the spine.
There is no
enhancement and findings may be due to post procedural change
however
infection cannot be excluded. No drainable abscess or fluid
collection.
No cortical destruction seen.
US EXTREMITY NONVASCULAR LEFT Study Date of ___ 7:43 ___
IMPRESSION: No evidence of abscess. These findings are
concordant with the CT of the lumbar spine performed on the same
day.
LUMBAR PUNCTURE (W/ FLUORO) Study Date of ___ 1:18 ___
IMPRESSION:
Successful fluoroscopically guided lumbar puncture at L2-L3
level. Samples were taken to the laboratory for analysis.
CHEST PORT. LINE PLACEMENT Study Date of ___ 12:10 ___
IMPRESSION: AP chest compared to ___:
Tip of the new right PICC line is in the right atrium at a level
nearly 7 cm above the carina. Tube reposition low in the SVC,
it should be withdrawn 3 cm. Findings discussed by telephone
with IV nurse, ___, at 12:30 p.m. Lungs clear. Heart size
normal. No pleural abnormality
CHEST (PORTABLE AP) Study Date of ___ 11:24 AM
FINDINGS: As compared to the previous radiograph, the PIC line
has been
pulled back. The tip now projects over the mid SVC. The spinal
stimulator is in unchanged position. The lung volumes remain
low. However, no evidence of acute pulmonary disease is seen.
No pneumonia, no pneumothorax. No pleural effusion. No
pulmonary edema.
Brief Hospital Course:
___ year old woman with history of lumbar disc herniation s/p
spinal stimulator placement on ___ who presents with back
pain, fevers, and leukocytosis, concerning for infection of
spinal stimulator hardware.
# Spinal stimulator/battery infection: Pt met SIRS criteria on
admission with suspected infection as well as leukocytosis (WBC
25 on admission) and tachycardia. Concern for infection of
spinal stimulator/ battery pack (not MRI-compatible) given pain,
edema, erythema, and drainage from battery site. Pathogen most
likely MSSA, which grew from wound culture (vs skin flora) from
battery site incision. There was initially concern for
meningitis given communication of device with epidural space,
but LP studies (after antibiotics started) not consistent with
infection. Other infectious workup negative: CXR, urine culture,
blood cultures. Initially started ceftriaxone and vanc,
ceftriaxone d/c'ed after unremarkable LP studies, vanc changed
to cefazolin ___ after wound grew MSSA. ID recommended at least
2 weeks of antibiotics after hardware removal, and PICC placed
___. Neurosurgery removed spinal stimulator on ___. Hardware
sent for culture which showed staph aureus.
For pain control, patient remained on home regimen of dilaudid,
diazepam, cyclobenzaprine, morphine, tramadol, acetaminophen
prior to spinal stimulator removal. Post-op was treated with
Dilaudid PCA which on ___ was discontinued and PO dilaudid was
returned
# Hypothyroid: Continued on home levothyroxine.
# Asthma: On albuterol inhaler at home. Written for albuterol
neb prn.
# Tobacco use: Treated with nicotine patch.
======================
Transitional issues:
======================
# Code: Full
# Emergency Contact: Husband ___ cell: ___
NEUROSURGERY COURSE:
Patient was taken to the operating room on ___ for explant of
her spinal cord stimulator IPG and lead. Both the lead and the
IPG were sent for culture during the case. She tolerated the
procedure well and went to the PACU post-operatively. She
remained stable overnight on a dilaudid PCA for pain. The PCA
was discontinued on the early afternoon of ___ and she was
restarted on PO Dilaudid. She was awaiting culture results. A
PICC was placed in routine fashion and CXR confirmed placement.
On ___, patient remained stable for discharge. At the time of
discharge she was tolerating a regular diet, ambulating without
difficulty, afebrile with stab;e vital signs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) 4 mg PO Q4H
2. Diazepam 5 mg PO QID
3. Amrix (cyclobenzaprine) 30 mg oral qhs
4. Morphine SR (MS ___ 30 mg PO QAM
5. Morphine SR (MS ___ 15 mg PO QHS
6. Acetaminophen 1000 mg PO TID
7. TraMADOL (Ultram) 50 mg PO BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Tizanidine 4 mg PO TID
10. Clobetasol Propionate 0.05% Cream 1 Appl TP Frequency is
Unknown
11. Allegra-D 24 Hour (fexofenadine-pseudoephedrine) 180-240 mg
oral unknown
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown prn
Discharge Medications:
1. Amrix (cyclobenzaprine) 30 mg oral qhs
2. Clobetasol Propionate 0.05% Cream 1 Appl TP Q12H:PRN rash
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*100 Tablet Refills:*0
4. Senna 8.6 mg PO BID constipation
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Nicotine Patch 14 mg TD DAILY
7. Docusate Sodium 100 mg PO BID
8. CefazoLIN 2 g IV Q8H Duration: 4 Weeks
9. Allegra-D 24 Hour (fexofenadine-pseudoephedrine) 180-240 mg
oral unknown
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown prn
11. Acetaminophen 1000 mg PO TID
12. Diazepam 5 mg PO QID
RX *diazepam [Diazepam Intensol] 5 mg/mL 5 mg by mouth Q6 hours
Disp #*60 Tablet Refills:*0
13. Levothyroxine Sodium 75 mcg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Morphine SR (MS ___ 30 mg PO QAM
16. Morphine SR (MS ___ 15 mg PO QHS
17. TraMADOL (Ultram) 50 mg PO BID
RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have beeing diagnosed with infected wound from your spinal
cord stimulator. You will be on Antibiotics for 4 weeks.
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool swimming
for two weeks from your date of surgery.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best if
taken in the morning when you wake-up for morning stiffness, and
before bed for sleeping discomfort.
- You may not drive while takin gnarcotics
- You will need to take stool softeners while on narcotics to
prevent constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of bowl
or urine control).
Followup Instructions:
___
|
10716756-DS-6
| 10,716,756 | 23,094,962 |
DS
| 6 |
2184-10-02 00:00:00
|
2184-10-02 20:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fosaprepitant
Attending: ___.
Chief Complaint:
Low grade fevers at home.
Major Surgical or Invasive Procedure:
ERCP with stent placement ___
History of Present Illness:
In brief, this is a ___ woman with history of metastatic
neuroendocrine carcinoma of the gallbladder with mets to the
liver and periportal nodes s/p cisplatin/etoposide (completed
___, s/p lymph node & liver segment resection ___, and
s/p splenectomy who initially presented for fever to 100.9 and
malaise.
She started feeling feverish over the weekend, with a temp of
100.5. She had another fever on ___ and was referred to the
ED. Otherwise, no n/v/d, abdominal pain, dysuria, sore throat,
sick contacts. She does endorse a dull back pain that is present
when she lies down; this pain has been there since her surgery.
She underwent CT torso which showed what was initially thought
to
be a biloma vs hepatic abscess and patient was admitted to
transplant surgery. Subsequent
ultrasound and ___ evaluation found collection to instead be
expected post-operative changes, possibly hematoma, but in
either
case was decided no indication or need for evacuation.
ID was consulted, given ongoing fevers, recommended broad
spectrum antibiotics (vanc/cefepime/flagyl), MR spine ___
evidence of abscess), and repeat of CT A/P (not yet completed).
They raised the possibility of subacute p
Transplant surgery recommended transfer to medicine for
furtherworkup of fever and infection in an immunocompromised
patient. No plans for additional chemotherapy at this time.
Past Medical History:
PMH:
GB carcinoma
esophagitis
GERD
GIST
Cervical dysplasia
Elevated prolactin level
PSH:
Distal pancreatectomy ___
Splenectomy ___
Social History:
___
Family History:
MotherINNER EAR TUMOR
FatherALZHEIMERS
BrotherCHRONIC KIDNEY DISEASE
STROKE
DIABETES MELLITUS
HEPATITIS C
Physical Exam:
ADMISSION EXAM
==============
98.9 96 120/83 16 98% RA
GEN: NAD
CV: RRR
Pulm: nonlabored breathing on room air
Abd: soft, nontender, nondistended; well-healed midline surgical
scar
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 2318)
Temp: 98.8 (Tm 99.3), BP: 107/65 (107-116/60-65), HR: 112
(110-120), RR: 20, O2 sat: 94%, O2 delivery: Ra
GENERAL: Laying in bed, appears comfortable but tired, NAD.
EYES: PERRLA, sclera icteric.
HEENT: OP clear, MMM.
LUNGS: CTA b/l, no wheezes/rales/rhonchi
CV: RRR, normal S1 and S2. no m/r/g
ABD: soft, mild distention, normoactive BS, tympanitic, no
rebound or guarding.
EXT: normal muscle bulk and tone. Trace pedal edema.
SKIN: warm, dry, no rash. Jaundiced
NEURO: AOx3, fluent speech
Pertinent Results:
ADMISSION LABS:
===============
___ 06:15PM WBC-12.6* RBC-3.20* HGB-9.0* HCT-28.3* MCV-88
MCH-28.1 MCHC-31.8* RDW-14.6 RDWSD-47.1*
___ 06:15PM NEUTS-72.9* LYMPHS-17.2* MONOS-8.4 EOS-0.5*
BASOS-0.6 IM ___ AbsNeut-9.17* AbsLymp-2.17 AbsMono-1.06*
AbsEos-0.06 AbsBaso-0.07
___ 06:15PM PLT COUNT-345
___ 06:15PM ___ PTT-31.6 ___
___ 06:15PM calTIBC-255* FERRITIN-1039* TRF-196*
___ 06:15PM GLUCOSE-165* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 06:15PM ALT(SGPT)-18 AST(SGOT)-25 LD(LDH)-225 ALK
PHOS-92 AMYLASE-39 TOT BILI-0.2
___ 06:15PM ALBUMIN-3.7 IRON-18*
___ 06:22PM LACTATE-1.6
___ 06:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM*
___ 06:27PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
DISCHARGE LABS:
==============
___ 05:41AM BLOOD WBC-22.9* RBC-2.95* Hgb-8.3* Hct-24.2*
MCV-82 MCH-28.1 MCHC-34.3 RDW-17.7* RDWSD-50.4* Plt Ct-39*
___ 05:41AM BLOOD Neuts-77* Bands-2 Lymphs-5* Monos-10
Eos-1 Baso-0 Atyps-4* Metas-1* Myelos-0 NRBC-2* AbsNeut-18.09*
AbsLymp-2.06 AbsMono-2.29* AbsEos-0.23 AbsBaso-0.00*
___ 05:41AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-1+* Tear
Dr-1+* How-Jol-OCCASIONAL
___ 05:41AM BLOOD ___ PTT-35.3 ___
___ 05:41AM BLOOD Plt Smr-VERY LOW* Plt Ct-39*
___ 05:13AM BLOOD ___
___ 12:10PM BLOOD Fact II-PND
___ 11:15AM BLOOD Fact ___ FactVII-13* FacVIII-453*
___ 06:59AM BLOOD Lupus-NEG
___ 05:41AM BLOOD Glucose-199* UreaN-35* Creat-1.2* Na-132*
K-4.8 Cl-98 HCO3-23 AnGap-11
___ 05:41AM BLOOD ALT-11 AST-18 LD(LDH)-304* AlkPhos-157*
TotBili-3.6* DirBili-2.3* IndBili-1.3
___ 05:39AM BLOOD GGT-36
___ 05:05AM BLOOD proBNP-300*
___ 05:41AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.2
___ 08:15AM BLOOD %HbA1c-6.7* eAG-146*
___ 08:15AM BLOOD Triglyc-169* HDL-15* CHOL/HD-8.3
LDLcalc-76 LDLmeas-45
___ 05:41AM BLOOD Osmolal-284
___ 08:15AM BLOOD TSH-0.50
___ 07:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:56AM BLOOD RheuFac-16* ___
___ 05:25AM BLOOD CRP-271.7*
___ 06:52AM BLOOD IgG-1571 IgA-210 IgM-47
___ 06:59AM BLOOD C3-154 C4-36
___ 06:59AM BLOOD HIV Ab-NEG
___ 07:00AM BLOOD HCV Ab-NEG
MICRO:
======
Blood cultures ___
- negative
Urine cultures ___ - negative
Monospot ___: negative
___ CMV IgG+, CMV IgM-
___ EBV VCA-IgG AB+, EBNA IgG Ab+, VCA-IgM Ab-
Blood culture ___: pending, no growth to date
Urine culture ___: URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>___ R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
KEY IMAGING AND STUDIES:
=======================
___: CT Chest/abd/pelvis with contrast:
1. Status post open cholecystectomy and segment ___ wedge
resection, with a
new 3.1 x 2.1 x 2.4 cm nonenhancing hypodensity within the right
hepatic lobe
associated with a surgical clip likely a postsurgical hematoma
less likely an
abscess given lack of peripheral enhancement.
2. There is periportal edema. Mild focal narrowing of the main
portal vein at
the porta hepatis without an associated thrombus.
___ NIVS: No DVT
___ CT abd and pelvis w contrast:
1. Interval appearance of partial thrombosis in the right portal
vein.
Unchanged appearance of small fluid collection in the hepatic
segment ___
surrounding a surgical clip, likely a postoperative small
hematoma.
No other significant interval change compared to prior study.
___ MR ___ w and w/o contrast:
1. No acute intracranial process.
___ MRI Liver w/ and w/o contrast:
1. 2.5 cm fluid collection in the right hepatic lobe containing
debris and
associated with a surgical clip, likely postoperative seroma.
Superimposed
infection cannot be entirely excluded.
2. 2 cm right hepatic fluid collection containing heterogeneous
material on
the prior study may represent an area of fat necrosis.
3. Multiple suspicious hepatic masses primarily within the
hepatic hilum with
scattered satellite lesions in the left hepatic lobe are highly
suspicious for
recurrent malignancy, increased in size and number from prior
studies.
4. Similar near occlusive thrombus involving the main and right
portal veins.
5. Filling defect in the proximal celiac axis with possible
low-level
___ MRCP:
1. Increased sizes of dominant hepatic hilar mass and
hepatic/regional
metastases with extensive necrotic components.
2. New extrahepatic biliary stricture associated with this
appearance
including obliteration of the duct over a segment of nearly 2.5
cm. Moderate
new intrahepatic biliary dilatation upstream.
3. Slight decrease in postoperative collection at the hepatic
resection site
near the gallbladder fossa. Mild increase in a collection along
the falciform
ligament which is very unlikely to represent an infectious
process.
4. Similar occlusive thrombosis of the central portal venous
system aside
from mildly increased proximal extension of bland component.
5. Continued patency of hepatic arterial system with similar
nonocclusive
filling defect along the celiac axis.
enhancement worrisome for tumor thrombus within the celiac
artery.
Brief Hospital Course:
SUMMARY:
=========
___ w/ metastatic gallbladder adenocarcinoma now C1D6 on FOLFOX,
PMHx of metastatic neuroendocrine carcinoma of the GB s/p 8
cycles of cisplatin/etoposide (___) and open
resection of gallbladder and liver segment 5 (___), admitted
for FUO with hospitalization c/b partial R portal vein
thrombosis now on Lovenox and atypical chest pain during ___
infusion, now s/p successful ___ challenge, with course further
complicated by thrombocytopenia and hyperbilirubinemia, found to
have biliary stricture, now s/p ERCP with fully covered metal
stent to common hepatic duct on ___.
ACUTE ISSUES:
=============
# Acute kidney injury
Cr rose from 0.7 to 1.3 between ___ and ___. This was
attributed to dehydration given limited PO intake, though the
patient was also noted to be edematous in the setting of
hypoalbuminemia. She was diuresed with lassie 40 PO, which did
not improve Cr. Albumin was given. Discharge creatinine 1.2.
# Direct hyperbilirubinemia
# Common hepatic duct stricture
Transaminitis from early this admission resolved, and
hyperbilirubinemia was most consistent with an obstructive
process. However, repeat RUQUS on ___ showed no obstruction,
and right portal vein occlusion. ___ MRCP showed new
extrahepatic biliary stricture, obliteration of the duct over a
segment of nearly 2.5 cm, Mod new intrahepatic biliary
dilatation upstream. She underwent ERCP on ___ due to common
hepatic duct stricture, with placement of fully covered stent.
Afterward her bilirubin began to downtrend. CMP, LFTs and
fractionated bili were trended. Cefepime and Flagyl were started
prior to ERCP but discontinued afterward as she had no signs of
infection. Her diet was advanced to regular and her PO intake
was adequate.
# Coagulopathy
INR was noted to be rising throughout the admission, and was 2.3
on ___. Unclear whether this is vitamin K deficiency (could be
secondary to chemo) vs liver function impairment (more likely,
due to malignancy). S/p IV 10mg IV vit K on ___, and
___. Factors V, VII, VIII were checked to help elucidate
etiology. Factor V normal, Factor VII low (13), Factor VIII high
(453). This is consistent with factor VII inhibitor presence vs
low factor VII level. A mixing study was sent and pending at the
time of discharge.
# Thrombocytopenia
Noted in the setting of FOLFOX, though without significant other
cytopenia initially. Plts fell <20k with some clinical signs of
bleeding (hemorrhoidal), s/p plt transfusion ___, given
bleeding. At time of discharge, platelets were uptrending with
no further s/s bleeding. Lovenox was held or administered at
half dose for platelets <25 and <50, respectively. Platelets 39
on the day of discharge. She was discharged with half-dose (70mg
daily) lovenox because of the degree of thrombocytopenia.
#Fever related to malignancy
Due to fever of unknown origin, the patient was started on broad
spectrum antibiotics for presumptive infection in the setting of
immunocompromise. She was given vancomycin, cefepime, flagyl. CT
imaging of the torso revealed a 3.1 x 2.1 x 2.4 cm nonenhancing
hypodensity within the right hepatic lobe, initially thought to
be a hematoma, bilioma or abscess. Repeat imaging showed no
evolution of the lesion, consistent with a hematoma. MRI imaging
of the lumbar spine was unrevealing for infectious source.
Repeat blood cultures were negative for growth. An extensive
infectious/inflammatory workup without obvious causes.
Infectious Disease and Rheumatology evaluated the patient and
signed off. Fever thought to be ___ malignancy in light of
necrotic lymph nodes seen at porta hepatis, pathology from ___
showing adenocarcinoma. The patient's fever was managed
symptomatically with Tylenol ___ per pt preference, limited to
2g/day. Metoprolol tartrate 6.25 Q6H was trialed ___ with
improvement of sinus tachycardia that was thought to be
resulting from fevers. She again developed fever with
leukocytosis on ___ because she had no other localizing
symptoms and felt well, this was attributed to malignant fevers
recurring. Blood cultures pending at the time of discharge.
#Metastatic gallbladder adenocarcinoma
The patient has history of metastatic neuroendocrine carcinoma
of the gallbladder (s/p 8 cycles of cisplatin/etoposide, ending
___, s/p open choley, lymph node dissection, segment ___
wedge resection and splenectomy (___), found to have ypT2N2
adenocarcinoma in resection), as well as history of mucinous
cystic neoplasm of pancreatic tail s/p distal
pancreatectomy/splenectomy. Repeat MRI Liver ___ was initially
read as unchanged, but further review showed multiple
heterogeneously peripherally enhancing masses, larger than on
prior CT ___. Given her presentation, these are thought to be
most consistent with malignancy. Patient has histologic evidence
of both NEC and adenocarcinoma, likely a mixed tumor. Biopsy of
LN on ___ is consistent with adenocarcinoma. C1D1 FOLFOX
started ___ via PICC. As above, ___ infusion was stopped on
___ due to development of atypical chest pain, but the patient
subsequently underwent successful ___ challenge as above while
on isordil. Her next chemotherapy is scheduled for ___. She
will need port placement before then, which must be done 2 weeks
after antibiotic use (first day eligible to get port: ___.
currently scheduled for ___ port placement ___. She will have a
flush on ___ and then have treatment on ___.
#Occlusive thrombosis of the central portal venous system
Bland, partially occlusive thrombus noted on ___ CT (part of
fever work up). Patient was initiated on a heparin drip and then
transitioned to Lovenox. RUQUS on ___ shows occlusion but no
direct evidence of thrombus, but MRCP on ___ demonstrated
occlusive thrombosis. This is likely secondary to extrinsic
compression caused by malignancy. She was discharged with
half-dose lovenox at 70mg daily because of thrombocytopenia. She
will continue to take Enoxaparin Sodium 70 mg and if the
platelets increase above 50 then increase the dose to SC Q12H
following discharge.
# Asymptomatic Bacteriuria
___ urine culture growing GNRs. No s/s cystitis. Leukocytosis
downtrended. She was monitored closely but not initiated on
antibiotics for urinary tract infection.
CHRONIC/RESOLVED ISSUES:
========================
# Atypical chest pain
Onset during ___ transfusion on ___, which was held. ACS was
unlikely given ECG without ischemic changes and trop x3
negative. CXR with no acute process. This could be coronary
vasospasm in the setting of ___ transfusion, though unclear.
The patient has no known cardiac history. Isordil 10 mg Q8H was
started, and the patient underwent successful ___ challenge on
___ while on telemetry with no CP recurrence and no ECG
changes. Cardiac risk factor workup was obtained, which revealed
dyslipidemia and diabetes (A1c 6.7), which will need outpatient
follow up. Isordil was stopped and the patient was transitioned
to ___ ER 30 mg PO daily. Her chest pain recurred once,
raising concern for ___ cardiotoxicity. She was continued on
___ ER 30 daily with holding parameters. It was felt that she
may benefit from coronary CT, attempted to do this ___, though
patient's HRs remained ___ despite metoprolol IVP, will need to
have HRs 50-60s for this study. This study was deferred to the
outpatient setting. given her multiple reasons to have
tachycardia (fevers, anemia, active malignancy).
# Rectal bleeding - resolved
Patient complaining of new rectal bleeding ___, has a
history of both internal/external hemorrhoids. Last colonoscopy
reportedly at ___ ___, s/p polypectomy with hemorrhoids
noted. No dyschezia. Transfused 1U plts ___ and gave IV vit K.
No evidence of ongoing bleeding. Continued to monitor and to
trend CBC qday.
#Transaminitis - resolved
Unclear etiology, although likely due to metastatic involvement.
Not currently on hepatotoxic drugs. RUQ u/s was stable. FOLFOX
was chosen instead of FOLFIRI due to Tbili elevation. LFTs were
trended during the admission.
#DM2
A1C obtained as part of cardiac risk stratification evaluation
was found to be 6.7 this admission. BG 100s-220s this admission.
She will need PCP follow up for diabetes and likely metformin
initiation.
# Dyslipidemia
Lipid panel was obtained this admission as part of cardiac risk
stratification evaluation. She will need PCP follow up and
likely statin initiation eventually, when no longer on
chemotherapy.
#Normocytic Anemia
Thought to be due to anemia of chronic inflammation. Followed
with daily CBCs, active type and screen maintained. Received 1U
pRBCs ___ and ___.
#Inadequate Oral Intake
Pt only able to eat about ___ of a meal per day. NG tube and
tube feeds were discussed with patient but ultimately decided
against. Nutrition was consulted and their recommendations were
followed, including supplements with meals, high calorie fraps,
and multivitamins.
#GERD
Continued on home PPI.
TRANSITIONAL ISSUES:
====================
[] Labs (Chem 7, CBC, LFTs) should be obtained on ___.
[] Follow platelet count and increase lovenox to full dose if
platelets increase to greater than 50.
[] Next chemotherapy is scheduled for ___. Port placement is
scheduled for ___. She will have the port remain accessed and
have it flushed on ___ in the ___ clinic - this is scheduled.
[] f/u factor levels and mixing study results given elevated ___
during this admission
[] Monitor creatinine, thought to be hypovolemia, encourage PO
intake.
[] PCP follow up for possible metformin initiation for newly
diagnosed T2DM (A1C = 6.7%)
[] Dyslipidemia diagnosed this admission, but deferred starting
statin at this time given her metastatic cancer and active
chemotherapy. PCP should reassess at future visits.
[] Coronary CT could be considered in the outpatient setting to
determine the patient's burden of coronary disease.
[] If patient is symptomatic from fevers, options for treatment
include: Tylenol up to 2g/day, ibuprofen/naproxen as needed, and
dexamethasone 2mg PO QAM.
#HCP/Contact: ___ (sister: ___
#Code: Full confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Acyclovir 400 mg PO 5X/D
3. Vitamin D 1000 UNIT PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q24H
RX *enoxaparin 300 mg/3 mL 70 mg SC Daily Disp #*7 Vial
Refills:*3
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth Daily Refills:*3
5. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tab by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. Acyclovir 400 mg PO 5X/DAY:PRN Herpes outbreak
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Common hepatic duct stricture
Occlusive thrombosis of the central portal venous system
Metastatic gallbladder adenocarcinoma
Fever related to malignancy
SECONDARY DIAGNOSES:
====================
Coagulopathy
Normocytic anemia
Thrombocytopenia
Dyslipidemia
Type 2 Diabetes Mellitus
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 recurrent fevers
What was done for me while I was in the hospital?
- You were treated with broad spectrum antibiotics while we
searched for a cause of your infection.
- Your fevers were determined to be caused by your cancer.
- A CT scan of your belly revealed a blood clot in one of your
veins. You were started on a blood thinner to help treat the
clot.
- You had an endoscopic biopsy of your lymph nodes to help guide
your chemotherapy regimen.
- You were started on FOLFOX chemotherapy.
- You were treated with stunting for a blockage in your biliary
drainage system.
- You improved and were ready to leave the hospital. You did
have a fever and elevated white blood cell count before you
left, but we believe this is related to your cancer rather than
a new infection.
What should I do when I leave the hospital?
- Take your medications as prescribed and go to the follow up
appointments that we have arranged for you.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10716890-DS-10
| 10,716,890 | 28,990,313 |
DS
| 10 |
2146-07-22 00:00:00
|
2146-07-22 20:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o female with hx CAD, COPD, sCHF (EF 65%), HTN,
dementia, who presents as a transfer from ___ with
acute dyspnea and hypoxia.
She was recently hospitalized at ___ for sigmoid
diverticulitis s/p colostomy and was discharged to rehab.
According to her son, she was discharged from rehab yesterday to
her assisted living facility and transferred back to the
hospital today for her shortness of breath.
At ___, CXR showed vascular redistribution suggesting
vascular congestion and mild coarse bibasilar markings.
She was treated with Vanc, Levaquin, Zosyn, and given 80mg IV
Lasix. Foley placed. Trop < 0.03. There was concern of possible
ST changes, so patient was started on BiPAP, heparin gtt,
nitropaste.
She was tried off BiPAP but became more tachypneic and increased
work of breathing. She also had 500 cc UOP.
The patient is full code but would not want prolonged intubation
if there was no evidence of improvement/recovery per her son.
- In the ED, initial vitals: T 98 BP 121/49 RR 32 O2sat 91%
BiPAP
- Exam notable for: increased work of breathing
- Labs were notable for: WBC 20.9 with 92% PMNs, Cr 1.4
(baseline 0.9-1.1), normal coags, VBG, 7.34/56 (off BiPAP), trop
0.01
- Patient was given: nothing
CXR IMPRESSION:
1. Opacification in the left lower lung, which may represent
pleural effusion and/or consolidation, concerning for
atelectasis, aspiration or pneumonia.
2. The lungs are hyperexpanded.
- Consults: none
On arrival to the MICU, patient reports that she was feeling
short of breath and feels better now.
Past Medical History:
CAD
CHF
HTN
Diagnostic laparoscopy with diverting colostomy ___, ___
___
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITALS: HR 90, BP 134/64, RR 20, O2sat 98% on RA.
GENERAL: Awake, alert, oriented x 3
HEENT: AT/NC, EOMI, PERRL
NECK: no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: diffuse rhonchi in mid and lower lung fields
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
===========================
Vitals: 97.7 BP:112/57 HR:58 18 97 RA
Sitting in chair in NAD
HEENT: MMM
Lungs: Crackles at left base
___: RRR S1 S2 present, no murmurs
Abdomen: Soft, NT, ND
Ext: No edema
Neuro: Moving all extremities, AAOx3
Pertinent Results:
ADMISSION LABS:
====================
___ 07:55PM BLOOD WBC-20.9* RBC-4.20 Hgb-11.7 Hct-38.5
MCV-92 MCH-27.9 MCHC-30.4* RDW-15.0 RDWSD-50.7* Plt ___
___ 07:55PM BLOOD Neuts-92* Bands-2 Lymphs-3* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-19.65*
AbsLymp-0.63* AbsMono-0.63 AbsEos-0.00* AbsBaso-0.00*
___ 07:55PM BLOOD ___ PTT-25.1 ___
___ 07:55PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-139
K-3.7 Cl-97 HCO3-27 AnGap-19
___ 07:55PM BLOOD cTropnT-0.01
___ 08:07PM BLOOD ___ pO2-26* pCO2-56* pH-7.34*
calTCO2-32* Base XS-1
___ 08:00PM URINE Color-Straw Appear-Clear Sp ___
___ 08:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:00PM URINE RBC-4* WBC-27* Bacteri-NONE Yeast-NONE
Epi-0
___ 08:00PM URINE CastHy-4*
___ 08:00PM URINE Hours-RANDOM Creat-16 Na-108
___ 08:00PM URINE Osmolal-322
OTHER RELEVANT LABS:
======================
___ 03:11AM BLOOD WBC-29.9* RBC-3.87* Hgb-10.7* Hct-34.2
MCV-88 MCH-27.6 MCHC-31.3* RDW-15.1 RDWSD-48.9* Plt ___
___ 03:11AM BLOOD Glucose-121* UreaN-32* Creat-1.5* Na-136
K-3.8 Cl-97 HCO3-26 AnGap-17
___ 03:11AM BLOOD ALT-7 AST-16 LD(LDH)-215 AlkPhos-49
TotBili-0.6
___ 03:11AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.7* Mg-1.7
___ 03:19AM BLOOD Type-ART pO2-74* pCO2-48* pH-7.42
calTCO2-32* Base XS-5
IMAGING
========
___ CXR
1. Opacification in the left lower lung, which may represent
pleural effusion and/or consolidation, concerning for
atelectasis, aspiration or pneumonia.
2. The lungs are hyperexpanded.
MICROBIOLOGY
============
___ 8:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS
================
___ 06:20AM BLOOD WBC-6.3 RBC-3.94 Hgb-10.8* Hct-35.4
MCV-90 MCH-27.4 MCHC-30.5* RDW-14.9 RDWSD-49.2* Plt ___
___ 06:20AM BLOOD Glucose-80 UreaN-24* Creat-1.1 Na-140
K-3.8 Cl-99 HCO3-33* AnGap-12
___ 06:20AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.3
___ 03:11AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-6941*
Brief Hospital Course:
BRIEF SUMMARY
===============
___ y/o female with hx of CAD, COPD, HFpEF (EF 65%), HTN,
dementia, who presents as a transfer from ___ with
acute dyspnea and hypoxia, requiring brief MICU stay and BiPAP.
ACTIVE ISSUES
============
# Acute hypoxemic respiratory failure ___ mild volume overload
and
# Healthcare associated pneumonia:
Patient initially admitted with acute hypoxemic respiratory
requiring brief BiPAP. CXR showed infiltrate in LLL concerning
for pneumonia. At ___, she received 80 mg IV Lasix with
good urine output given elevated BNP to 6941 (baseline ~3000).
She was also started on vancomycin and ceftazidine. She was
quickly weaned to nasal cannula in the MICU and transferred to
the floor. MRSA swab was sent and returned negative and
Vancomycin was discontinued. The patient was transitioned to
oral levaquin to complete a ___cute on chronic HFpEF- Patient with an EF of 65% on recent
TTE at ___. As mentioned BNP was elevated. She received
Lasix as above with rapid improvement in her oxygen saturations,
suggesting some component of heart failure contributing to her
respiratory failure. She was resumed on home Lasix and her home
metoprolol. Her Isosorbide was resumed once BP improved.
# Acute kidney injury: Patient with creatinine of 1.4 on
admission with baseline at 0.8-1.1 in last few months at ___
___. With diuresis, her creatinine improved to 1.1 on
discharge.
#Constipation
The patient developed constipation during her hospitalization
with no output from her ostomy. She was given milk of mag with
resolution of constipation.
CHRONIC ISSUES
==============
# COPD: No evidence of reactive airway disease on exam. She was
continued on nebs.
# CAD, HTN: She was continued on aspirin 81 mg and metoprolol.
Home imdur was initially held and resumed prior to discharge
Transitional issues
- consider repeat CXR to asses resolution of infiltrate/effusion
in ___ weeks
- continue to check daily weights and adjust Lasix accordingly
- Code status: Full- confirmed with patient
- HCP: Son ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48hrs Disp #*2
Tablet Refills:*0
2. Milk of Magnesia 30 mL PO Q6H:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Respiratory failure
Pneumonia
Diastolic congestive heart failure exacerbation
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with shortness of breath
which is likely due to pneumonia and congestive heart failure.
You were treated with antibiotics and diuretics and your
symptoms improved. You also developed constipation which was
treated with milk of magnesia. You were seen by the physical
therapists who recommended you continue home physical therapy.
Your metoprolol was changed to 50mg twice daily. You will be
discharged on Levaquin, an antibiotic which you should take
every other day for 2 doses.
Please follow up with your PCP in the next ___ weeks.
Followup Instructions:
___
|
10717400-DS-14
| 10,717,400 | 23,711,811 |
DS
| 14 |
2182-02-18 00:00:00
|
2182-02-19 15:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
succinylcholine
Attending: ___.
Chief Complaint:
dysarthria
Major Surgical or Invasive Procedure:
___ x4 days
History of Present Illness:
___ is a ___ old right-handed man with a history
of hypertension and hyperlipidemia who presents with two days of
gait insecurity and bilateral hand parasthesias and one day of
alteration in his voice.
He was last in his normal state of health two days ago.
Yesterday
he felt "off" all day, with a mild malaise but no fevers. His
walking felt unsteady although he did not fall. He was able to
complete a full day of work. In the evening he started to notice
parasthesias in the fingertips of both hands bilaterally. He
went
to bed and slept well. The next morning he noticed that the
parasthesias were now present in the palms though the
fingertips.
He also felt a little tingling in his toes. This did not bother
him much. However, around 9:30 AM he spoke aloud for the first
time and noticed that his voice sounded very different. He
looked
in the mirror and did not see any facial droop. He had been able
to eat and drink during breakfast without difficulty. He
shoveled
snow for about 45 minutes, which was no more difficult than
usual. He then drove to the airport to pick up his girlfriend;
while he was driving he recited words to test out his voice and
felt that "b" and "d" sounds gave him the most trouble. When he
picked her up, she agreed immediately that his voice was very
different from usual, and so they went to ___
together.
Upon presentation to ___ he was afebrile and mildly
hypertensive.
His examination was notable for a nasal voice. Labs, CT head and
CTA head and neck were normal. Given the concern for
___ GBS or myasthenia, GQ1B and Anti AChR antiboties
were sent and he was transferred to ___ for further workup.
These symptoms have never occurred before. The symptoms of
dysarthria have not significantly worsened since their onset
earlier today. He has not eaten or drunk anything since
breakfast. He did have ___ glasses of wine last night but this
is
normal for him and he did not feel unusually intoxicated.
He has had two recent illnesses. He had a gastrointestinal
illness ___ days ago, with subjective fever, vomiting, diarrhea
and malaise. This has since resolved completely. He also had an
upper respiratory infection earlier this month with fever,
malaise, myalgias, and URI symptoms which have resolved with the
exception of a mild cough.
Neurologic review of systems was notable as above, as well as
for
a mild headache which is starting now; mild blurriness of vision
while driving. Otherwise, he denies visual loss or diplopia. He
denies dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness. No bowel or bladder
incontinence or retention.
General review of systems was notable as above. Otherwise, he
denies recent fever or chills. No night sweats or recent weight
loss or gain. Denies shortness of breath. Denies chest pain or
tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias. Denies
rash.
Past Medical History:
hypertension
hyperlipidemia
Social History:
___
Family History:
Adopted, does not know details.
Physical Exam:
==============
ADMISSION EXAM
==============
HR 71; BP 129/82; RR 16; SpO2 97% RA
General: Thin man, appears stated age, appears slightly anxious,
sitting up in NAD.
HEENT: NC/AT. No scleral icterus. No rash noted on face or in
oropharynx.
Neck: Supple, no nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated. Counts to 32 on
one breath.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Thin, soft, nontender, nondistended
Extremities: Mo lower extremity edema
Skin: Cat scratch on R anterior thigh; trauma from nail biting
on hands. Otherwise no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive to examination.
Able to relate history without difficulty. Language is fluent
and intact to repetition, comprehension, reading, writing and
naming of high and low frequency objects. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm, both directly and consentually; brisk
bilaterally. VFF to confrontation with finger counting.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. No ptosis
on sustained upgaze. No Cogan's twitch.
V: Facial sensation intact to light touch. Detects lash
stimulation bilaterally. ___ strength noted bilateral in
masseter VII: Forehead elevates symmetrically, strength of eye
closure is full bilaterally. Can overcome cheek puffing, but
face appears to activate symmetrically without obvious weakness.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Minimal palate elevation bilaterally. Uvula midline. Gag
present bilaterally.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor or asterixis. Strength is full in upper
and lower extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 2
R 3 2 3 2 2
- Plantar response was flexor bilaterally.
-Sensory: Decrease in sensation to temperature and vibration
over the feet bilaterally. No deficits to temperature or
vibration in upper extremities. No deficits to light touch,
pinprick or proprioception throughout. No extinction to DSS.
Graphesthesia is intact.
-Coordination: Finger tapping brisk, accurate with normal
cadence. FNF without dysmetria or intention tremor. Overshoot on
finger following bilaterally. HKS is normal without ataxia or
dysmetria. No truncal ataxia.
-Gait: Good initiation. Slightly wide-based, normal stride
length and arm swing. Turning radius is wide. Could not walk in
tandem without taking a lateral step. Able to heel and toe walk
although he was initially unsteady. On Romberg, swayed without
taking a step.
==============
DISCHARGE EXAM
==============.
III, IV, VI: EOMI without nystagmus. Normal saccades. No ptosis
on sustained upgaze. No Cogan's twitch. Had double vision on far
L and R lateral gaze and far left downward gaze, none on far
left or right upward gaze.
IX, X: palate elevation more than on admission. Uvula midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor or asterixis. Strength is full in upper
and lower extremities.
-DTRs: 1 throughout, no jaw jerk reflex
- Plantar response was flexor bilaterally.
-Gait: Good initiation. Narrow based pigeon-toed gait. Normal
stride length and arm swing.
Pertinent Results:
ADMISSION LABS: ___
WBC-10.9 Hgb-14.2 Hct-42.8 MCV-91 Plt ___
Neuts-70.1 ___ Monos-7.6 Eos-1.2 Baso-0.6 Im ___
AbsNeut-7.64* AbsLymp-2.17 AbsMono-0.83* AbsEos-0.13
AbsBaso-0.06
Glucose-84 UreaN-12 Creat-0.8 Na-138 K-4.2 Cl-102 HCO3-25
AnGap-15
Calcium-8.9 Phos-3.3 Mg-2.3
Serum/Urine tox: negative
UA: bland
Workup:
TSH-2.0
CRP-2.6 SED RATE-6
IgA-146
Lumbar Puncture: ___
WBC-1 RBC-1* Polys-0 ___ Monos-22
TotProt-43 Glucose-56
HERPES SIMPLEX VIRUS PCR-PND
Imaging:
MRI Brain w/wo contrast ___
IMPRESSION:
1. No abnormal enhancement or lesion of the brainstem and
cranial nerves.
2. No acute infarct. No brain parenchymal FLAIR abnormality.
3. Fluid signal in the bilateral mastoid air cells. Clinical
correlation with otomastoiditis and patient's clinical symptoms
is recommended.
EMG: ___
Clinical Interpretation: Essentially normal study, performed
about three days after symptom onset. The mildly reduced median
and ulnar sensory amplitudes with normal sural responses may be
seen in acute inflammatory demyelinating polyneuropathy (AIDP).
A repeat study in about a week may show evolving abnormalities
of AIDP. There is no electrophysiologic evidence for a
post-synaptic disorder of the neuromuscular junction, as in
myasthenia ___. Single fiber electromyography may be
performed if clinical suspicion for myasthenia is high.
Brief Hospital Course:
Mr. ___ is a ___ man with succinylcholine
sensitivity who was admitted ___ with unsteady gait and
dysarthria after having diarrhea 1 week prior concerning for
Guillion ___, ___ Variant. On exam, his speech was
hypernasal, diminished palate elevation, bilateral CN VI palsy,
no nystagmus, no jaw jerk, diminished ___ reflexes compared to
admission, and diminished vibration sense. LP was bland. Head
imaging was normal. Differential diagnosis includes GBS and its
many variants, infectious/post-infectious, inflammatory or
neoplastic process causing cranial nerve palsies, or myasthenia
___. Most likely diagnosis is ___ Variant of GBS
given his bilateral ___ nerve palsies, ataxia, and diminished
reflexes.
He was empirically started on a 5 day course of IVIg but
developed bad headaches during his third dose of IVIg. They only
happen during the infusions, and he does not have headaches at
baseline. Headache worsened after the 4th dose of IVIg. Due to
the concern for chemical meningitis, the 5th dose of IVIg was
held. Even so, his speech greatly improved as did his gait. On
discharge, he walked normally, was able to say the word
"cracker" that he was unable to say before, speech much less
nasal, and had a mild bilateral lateral rectus palsy causing
diplopia.
Prior to discharge, he was counseled on alcohol cessation as he
was drinking ___ glasses of wine/night.
TRANSITIONAL ISSUES
1. Unsteady gait, nasal speech, and CN VI palsy concerning for
___ variant GBS s/p 4 days IVIg
- f/u CSF cytology, Gq1B, AChR, blocking and modulating
antibodies from ___
Medications on Admission:
lisinopril 10 mg daily
pravastatin 40 mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Lisinopril 10 mg PO DAILY
3. Pravastatin 40 mg PO QPM
4. Outpatient Physical Therapy
ICD-10: G61.0 ___
Outpatient physical therapy
Balance training
5. Outpatient Speech/Swallowing Therapy
ICD-10: G61.0 ___
Outpatient speech therapy
Discharge Disposition:
Home
Discharge Diagnosis:
___ Syndrome, ___ Variant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: speech nasally but better, has diplopia on far lateral
gaze, palate elevation diminished but better than previously
Discharge Instructions:
Dear Mr. ___,
You were admitted for unsteady gait and dysarthria after having
diarrhea 1 week prior concerning for Guillion ___ Syndrome,
___ Variant. You were given 4 days of IVIg, and you
symptomatically improved. Because of your headaches that were
concerning for chemical meningitis and your symptoms were
already much improved after 4 days of IVIg, the 5th dose was
held. We would like to see you back in clinic ___ at 1pm with
Dr. ___.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10717448-DS-14
| 10,717,448 | 25,638,862 |
DS
| 14 |
2174-03-05 00:00:00
|
2174-03-05 13:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pt found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female w/ PMH HTN,
hypothyroidism, mood disorder with sleep issues, constipation,
history of breast cancer who presents after she was found down.
She was found down for an unknown time. She was found to have an
elevated CK and was started on IV hydration for rhabdomyolysis.
She had an episode of chest pain while in the ED with first
troponin negative and normal EKG. Chest pain resolved without
intervention. Second troponin was pending on transfer. She was
given full dose aspirin.
In the ED she received 1.5L IVF.
CT head, C-spine were negative for pathology of fracture.
Gleno-humeral shoulder X-ray showed no fracture of dislocation.
CXR showed no acute process, hiatal hernia.
On arrival to the floor, she is very tired and is upset that I
have woken her. She asks if "we can do this tomorrow" and says
she has bad heart burn. She told the nurse she knew she was in
the hospital but she isn't answering my question now and goes
back to sleep.
She does respond that she doesn't remember any of the events of
today's fall but does have a history of falls.
She can't confirm her medications.
Past Medical History:
HTN
Hypothyroidism
Mood disorder with sleep issues
Constipation
History of breast cancer s/p surgery and radiation
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Sleeping, doesn't want to wake up
EYES: Anicteric, pupils equally round
CV: Heart regular, ___ systolic murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: unable to assess
PSYCH: tired, not wanting to engage in interview
Pertinent Results:
Admission Data
WBC 15.3, Hgb 13, Cr 0.9, bicarb 21, AST 80, CK 4960, CK-MB 29,
trop negative x 1, lactate 2.6
EKG: sinus rhythm, normal axis, normal rate, normal QRS. T wave
flat in V2,
III, inverted T wave aVF.
Telemetry: no events
CTH
No acute intracranial process. Chronic small vessel disease.
CT C Spine
No fracture or alignment abnormality. Degenerative changes as
stated without critical stenosis.
CXR: No acute intrathoracic process, hiatal hernia.
Discharge labs:
___ 06:49AM BLOOD WBC-6.0 RBC-3.68* Hgb-11.4 Hct-35.7
MCV-97 MCH-31.0 MCHC-31.9* RDW-13.5 RDWSD-48.7* Plt ___
___ 06:49AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140
K-5.8 (hemolyzed)* Cl-101 HCO3-25 AnGap-14
___ 06:49AM BLOOD CK(CPK)-153
___ 03:35PM BLOOD Lipase-15
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:04AM BLOOD Phos-3.0 Mg-1.9
___ 07:50AM BLOOD TSH-5.5*
___ 04:37PM BLOOD Lactate-2.6* K-4.3
Brief Hospital Course:
#Found down: Patient with history of falls and dizziness and has
been evaluated by Gerontology at ___ for this. Concern was for
POTS disease because her HR increased >30 with standing. Has not
been worked up for arrhythmia. She is on many medications that
can cause hypotension, will however she was hypertensive on
admission. She also has a murmur on exam that is known but has
not had a recent echo, so one was ordered. It was notable for
mild-mod aortic stenosis. EKG was nonischemic and telemetry not
notable for any arrhythmias. Orthostatics were normal throughout
the admission but the patient felt dizzy with sitting up.
Physical and occupational therapy were consulted and recommended
rehab. On discharge, carvedilol and aldactone were stopped and
her amlodipine and lisinopril were uptitrated, with good control
of BPs.
#Mild Rhabdomyolysis: No evidence of ___, levels elevated to ~5K
on admission.
IVF were continued until CK downtrended to normal.
#Leukocytosis: likely due to stress reaction. No evidence of
infection. Downtrended on recheck.
#Chest pain: Had chest pain episode in ED. On arrival to the
floor she complained of heart burn. Trop neg x 1. ___ trop 0.02
but could be elevated due to rhabdo. No evidence of ischemia on
EKG. Was given Tums and protonix for heartburn.
CHRONIC/STABLE PROBLEMS:
#HTN: On discharge, carvedilol and aldactone were stopped and
her amlodipine and lisinopril were uptitrated, with good control
of BPs.
#Hypothyroidism: continued levothyroxine 75 mcg. TSH 5.5
#GERD: continued pantoprazole
#Psych: held escitalopram, divalproex, doxepin, trazodone but
restarted on admission. Stopped ambien, which pt takes
intermittently.
#Urinary incontinence: held finasteride and vesicare for now
TRANSITIONAL ISSUES
[ ] ___ stopped all pills for insomnia (VPA, trazodone, doxepin)
and started ramelteon. Aviod ambien
[ ] for incontinence and hair loss: stopped finasteride,
vesicare as these cause dizziness.
[ ] may benefit from follow up in an ENT dizzy clinic
[ ] wants to follow up with a new gerontologist from rehab, Dr.
___ ___
[ ] ___ cardiology clinic to call and set up follow up for
mild-mod AS. Pt is preload dependent due to this and needs
serial TTEs.
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 30 mg PO DAILY
2. Finasteride 2.5 mg PO DAILY
3. Vesicare (solifenacin) 10 mg oral DAILY
4. Doxepin HCl 10 mg PO HS
5. CARVedilol 3.125 mg PO BID
6. TraZODone 100 mg PO QHS:PRN insomnia
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Divalproex (EXTended Release) 250 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. meloxicam 15 mg oral DAILY
11. Escitalopram Oxalate 20 mg PO DAILY
12. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Ramelteon 8 mg PO QHS:PRN insomnia
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. meloxicam 15 mg oral DAILY
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall, altered mental status
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital after a fall and presumed loss
of consciousness. We evaluated you for causes of your frequent
falls, including arrhythmias, heart attacks, deconditioning, and
low blood pressure. Ultimately we were not able to find a
single unifying reason for your falls, however a condition
called orthostatic hypotension may be contributing, as well as
being on multiple sedating medications.
Followup Instructions
Please follow-up with your new geriatrician Dr. ___. You
will need to call his office from rehab to set up the
appointment when you have a better idea of your discharge date.
The BI cardiology office will call you to set up follow up as
well.
Followup Instructions:
___
|
10717565-DS-22
| 10,717,565 | 29,422,467 |
DS
| 22 |
2170-07-10 00:00:00
|
2170-07-11 15:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lamictal / Bactrim
Attending: ___.
Chief Complaint:
unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with a history of
unprovoked DVT, primary generalized epilepsy on 3 AEDs who
presents for evaluation of worsening slurred speech, dizziness,
and unsteady gait.
Her epilepsy history will be reviewed in brief, but for more
complete course please see Dr. ___ clinic note from
___.
Per Dr. ___, "she first began to have absence seizures
at
___ years old, described as brief loss of awareness in the middle
of a conversation. During these events she would often come to
and realize she was in a different part of the room that prior.
She was evaluated at ___, diagnosed with
epilepsy and strated on a medication (unknown). At the age of
___,
she had her first GTC, with her second roughly ___ years later.
Since this time she has been having ___ perhaps yearly.
Currently, she has been experiencing roughly 10+ absence
seizures
per day. She has been on multiple different AEDs (as below) and
is currently on a three-drug regimen (Levetiracetam, Lacosamide
and Perampanel plus PRN lorazepam) with persistently poor
seizure
control.
Prior admissions to the ___ EMU have captured episodes of
behavioral
arrest associated with ___ Hz generalized spike-and-wave
discharges, as well as interictal generalized spike-and-wave
discharges.
Of note, she has recently developed a new type of spell in ___ consisting of twitching movements on the right side of her
face. After several minutes, the twitching resolved and she then
had numbness in her right face which spread down to her right
hand over the course of ~1 minute. The numbness persisted
through
the rest of the day until she went to bed. When she awoke the
next morning, it had
completely resolved."
She called her OSH Neurologist and told him about this new type
of seizure episode, and he asked her to taper off quickly from
Acetazolamide. The following day she has recently had 2 ___ on
___ and was admitted to ___, where she states
she
had a ___. She was started on Fycompa at that time and has
uptitrated from 2 mg to 6 mg over the past 3 weeks, with plan to
increase to 8 mg on ___. Per Dr. ___, "Since starting
Fycoma and frequent "muscle spasms" which she describes as
jerking movements in her bilateral shoulders, or unilaterally in
her hands or feet. These are very brief. She feels she has been
more clumsy as well - dropped a coffee cup and a Christmas
ornament recently, which felt as if they were being "pushed out
of my hand". She denies a history of myoclonic jerks during
childhood or at any point in the past, although one ___
discharge summary from ___ does report a complaint of
sporadic
twitching movements at times."
Dr. ___ the patient last week and noted bilateral
direction
changing nystagmus, asterixus, and R end point tremor. She had
planned to get a repeat MRI brain to rule out a structural
lesion
such as stroke which could have caused this new type of episode
as described above, and then admit to the EMU for medication
titration. It was felt that medication toxicity from Fycompa was
contributing to her asterixus and slurred speech.
However, this weekend the patient had worsening of her symptoms
on and off throughout the weekend. Her symptoms tended to be
worst around dinner time after taking her medications, and
better
in the mornings. She described slurred speech and drooling. No
facial droop. There was an increase in the jerking movements as
described above. This weekend, her hands seemed even clumsier,
and she recalls trying to brush her teeth with her R hand and
completely missing her teeth and making a mess. In the evenings
she has also had some episodes of dizziness which she describes
as "head spinning" and "unbalanced." When this happens she has
to
lean over and hold her head, and feels nauseous and terrible.
She
also noted worsening gait this weekend, and kept falling into
walls (not one side more than another). Her legs also felt like
they were giving way, on both sides equally. Her father noted
that she seemed "lethargic" and "out of it."
Per Dr. ___ and confirmed with patient:"
SEIZURE TYPES:
FIRST CLINICAL SEIZURE TYPE: absence seizures. Began at age ___.
Described as loss of time (will be having a conversation, then
suddenly lose awareness for a few seconds and return to
consciousness in a different part of the room). Described by her
daughter and father as spells where she stops speaking and
stares
ahead, unable to speak or interact.
-Frequency: currently at least 10/day (possibly more, as pt only
aware of them when they interrupt conversations)
-Postictal symptoms: none
-Seizure free interval: none. Has been having multiple events
per
day since onset in teens.
SECOND CLINICAL SEIZURE TYPE: generalized tonic-clonic seizures.
Began at age ___, and have occurred ~once/year since then. They
are occasionally preceded by aura of smelling a "wet dog". Then
has tonic stiffening and generalized tonic-clonic convulsions.
+Tongue bite with every seizure, no urinary incontinence.
-Frequency: ~one/year. Several years ago, had four in 1 day
(with
full return of consciousness between each). Most recently, had 2
___ in one day on ___.
-History of status epilepticus: NO
-Post-ictal symptoms: fatigue, confusion, nausea.
THIRD CLINICAL SEIZURE TYPE: ?focal motor seizure (vs. complex
migraine?) which occurred only once on ___. Right facial
twitching for several minutes, followed by numbness that began
in
the right face and spread rapidly into the right hand,
persisting
for at least 12 hours and resolving completely by the following
morning. No speech arrest or altered awareness with the event.
Did have a stabbing right-sided headache throughout the day of
the event, possibly preceding seizure onset.
- Frequency: only one (___)
FOURTH CLINICAL SEIZURE TYPE: ?myoclonic jerks (versus
asterixis). Started after most recent GTC on ___. Describes
sudden, random twitches in her bilateral shoulders, hands and
feet. Also increased clumsiness and dropping things (coffee cup
felt like it "flew out of her hand"). No history of morning
myoclonus or sleep twitches earlier in life. Possibly a side
effect of Perampanel?
---> Possible lateralizing signs by history are: right facial
twitching suggests possible new seizure focus in right motor
cortex. "Wet dog smell" preceding ___ raises question of mesial
temporal lobe aura.
SEIZURE TRIGGERS: sleep deprivation, stress, flashing lights
(cause her to feel sick "like I have emptiness in my head")
RISK FACTORS FOR SEIZURES: Paternal aunt with epilepsy (___)
and
has a son with generalized epilepsy. Has another paternal aunt
with ___ who died at age ___ from a seizure. Had two minor head
injuries as a child (fell off bike with head strike, and
collided
with a dog, neither clearly with LOC). Highest level of
education
was high school; had trouble in grade school due to frequent
absence seizures causing poor attention. No meningitis or
encephalitis, no developmental delays.
"
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Dysarthria as described
above but denies aphasia, and speech improved today per patient
and family. Denies focal weakness, numbness, parasthesiae. No
bowel or bladder incontinence or retention. Endorses gait
instability.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Endorses
SOB with walking up stairs, no cough. Endorses some stuffy nose
and allergy symptoms. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain.
Past Medical History:
- Epilepsy (as above)
- Headaches
- h/o unprovoked LLE DVT ___, negative hypercoag workup,
treated with Coumadin/Lovenox for 6 months then discontinued)
- Hyperlipidemia
- Obesity
- Renal stones
- Benign renal mass
- Splenomegaly
- Anxiety
- Depression
- Palpitations (___) -- Holter monitor showed one
supraventricular premature beat and 19 PVCs, TTE was normal.
Treated briefly with Zebeta (Bisoprolol) with good effect."
Social History:
___
Family History:
Family Hx:
Per above, has 2 paternal aunts and a paternal
cousin with generalized epilepsy (one aunt passed away at ___
due to a seizure)."
Physical Exam:
Admission Physical Exam:
Vitals:
98.6 101 149/94 18 100 %RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Ext: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Patient and family state that speech is baseline
and no longer dysarthric. Pt was able to name both high and low
frequency objects. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with bilateral
endgaze nystagmus to the L and the R, no nystagmus on center, up
or downgaze. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: L eye ptosis which patient and family state is baseline, L
hemiface appears slightly smaller than the R.
VIII: Hearing grossly intact.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Mild asterixus R>L with arms outstretched.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 0 1 1 1 0
R 0 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: Difficult with FNF on the R, ? end point tremor.
No cerebellar findings on rebound, overshoot, or mirroring.
-Gait: Narrow based but falls to the R, then to the L. Able to
catch herself. Unable to tandem. When marching with eyes closed
almost falls.
====================================================
Pertinent Results:
ADMISSION LABS (___):
-WBC-7.1 RBC-4.85 Hgb-14.0 Hct-40.8 MCV-84 MCH-28.9 MCHC-34.3
RDW-11.4 RDWSD-34.2* Plt ___
-Glucose-89 UreaN-16 Creat-0.8 Na-138 K-4.3 Cl-102 HCO3-23
AnGap-19
-Calcium-9.0 Phos-3.9 Mg-2.0
-ALT-34 AST-34 AlkPhos-78 TotBili-0.3
-cTropnT-<0.01
-BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
STUDIES:
___ - ECG - Sinus rhythm. Normal ECG. Compared to the
previous tracing of ___ the ECG is now normal.
___ - CXR - Cardiomediastinal silhouette is normal. There
is no pleural effusion or pneumothorax. There is no focal lung
consolidation.
___ - 1. No acute intracranial abnormality. 2. Patent
intracranial and neck vasculature without occlusion, dissection,
significant stenosis, or aneurysm.
___ - MRI - Unremarkable MRI of the brain without any
acute intracranial abnormality.
___ - EEG -
Brief Hospital Course:
Ms. ___ is a ___ year old right-handed woman with a history of
idiopathic generalized epilepsy who presented to the ___ ED
with worsening slurred speech, myoclonic jerking, dizziness, and
unsteady gait following changes to her antiepileptic medication
regimen in ___. In the ED, CTA imaging of her head and neck
did revealed patent vessels, but a ? pons hypodensity. Her MRI
was negative for acute intracranial abnormality. Ms. ___ was
subsequently admitted to the epilepsy service for long-term
monitoring on video-EEG and optimization of her antiepileptic
medications. She was tapered off perampanel with subsequent
improvement of presenting symptoms and no electrographic
seizures. She was tapered off of vimpat and gabapentin were
discontinued, because both AEDs can worsen idiopathic
generalised epilepsy. Onfi was started. There were no
electrographic seizures, but her EEG was notable for subclinical
generalized epileptiform discharges. She improved to discharge
home with epilepsy followup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Keppra (levETIRAcetam) 1,000 mg oral 2 tablets by mouth twice
a day
3. Lorazepam 0.5 mg PO BID:PRN seizure/anxiety
4. LACOSamide 200 mg PO BID
5. Gabapentin 200 mg PO QHS
6. Omeprazole 20 mg PO BID
7. Fycompa (perampanel) 6 mg oral QHS
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Pravastatin 40 mg PO QPM
3. Keppra (levETIRAcetam) 1,000 mg oral 2 tablets by mouth twice
a day
4. Lorazepam 0.5 mg PO BID:PRN seizure/anxiety
5. Clobazam 5 mg PO BID
RX *clobazam [Onfi] 10 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Generalized Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for slurred speech, unsteadiness and myoclonic
jerks, which were concerning for Fycompa toxicity. Your brain
imaging was normal. Your Fycompa and Vimpat were tapered off.
You had no seizure. You were started on clobazam (Onfi) a new
medication which you are tolerating well. You will take Onfi
___ tablet in the morning and at night. Dr. ___ will uptitrate
this if you are having further seizures. Please continue to
take lorazepam (Ativan) if you are have seizures at home. If
you need to take lorazepam, please call Dr. ___ office as she
may want to adjust your medications.
Please follow up with Neurology and take your medications as
prescribed.
Sincerely,
YOUR ___ Neurology Team
Followup Instructions:
___
|
10717708-DS-7
| 10,717,708 | 21,849,575 |
DS
| 7 |
2183-11-02 00:00:00
|
2183-11-02 08:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
open cholecystectomy
History of Present Illness:
HPI: ___ with history of diabetes c/b retinopathy and neuropathy
with recent admission for cholecystitis s/p percutaneous
cholecystostomy who now presents with several hours of
non-radiating epigastric pain. He was recently seen ___ ___
clinic
on ___. At the time he was feeling well and the
percutaneous cholecystostomy tube was removed with interval
cholecystectomy planned for ___ with Dr. ___. Today he
denies fevers, nausea, vomiting, and diarrhea and is moving his
bowels regularly.
___ ED, patient's glucose was ___ the high 200s. He received
morphine and zofran with some mild improvement ___ pain control.
Past Medical History:
IDDM c/b retinopathy, A1c is above 10
HTN
HL
Neuropathy
GERD
MRSA osteo/ulcer Pt completed ___bx
toe amputation
Social History:
___
Family History:
History of DM, heart disease, biliary disease
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.4 HR: 99 BP: 141/85 Resp: 18 O(2)Sat: 100
Constitutional: awake, alert and oriented
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Normal
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, tender to palpation ___ RUQ
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
___ 04:50AM BLOOD WBC-14.6* RBC-3.93* Hgb-11.0* Hct-33.3*
MCV-85 MCH-28.1 MCHC-33.1 RDW-14.3 Plt ___
___ 04:55AM BLOOD WBC-13.7* RBC-3.92* Hgb-11.0* Hct-33.3*
MCV-85 MCH-28.0 MCHC-33.0 RDW-14.1 Plt ___
___ 04:40AM BLOOD WBC-15.0* RBC-4.05* Hgb-11.6* Hct-33.9*
MCV-84 MCH-28.7 MCHC-34.4 RDW-14.2 Plt ___
___ 03:45PM BLOOD Neuts-89.9* Lymphs-7.0* Monos-2.7 Eos-0.3
Baso-0.1
___ 04:50AM BLOOD Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-149* UreaN-12 Creat-0.7 Na-132*
K-3.5 Cl-96 HCO3-26 AnGap-14
___ 04:40AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-134
K-3.3 Cl-98 HCO3-25 AnGap-14
___ 03:45PM BLOOD Glucose-285* UreaN-24* Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-24 AnGap-16
___ 04:55AM BLOOD ALT-165* AST-160* AlkPhos-196*
TotBili-0.3
___ 04:40AM BLOOD ALT-116* AST-36 AlkPhos-63 Amylase-168*
TotBili-0.5
___ 03:45PM BLOOD ALT-514* AST-611* AlkPhos-130 TotBili-0.5
___ 04:55AM BLOOD Lipase-30
___ 04:40AM BLOOD Lipase-70*
___ 03:45PM BLOOD Lipase-6870*
___ 04:50AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.8
___ 04:55AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.8
___: Ultrasound of gallbladder:
IMPRESSION:
1. Thickened gallbladder with echogenic shadowing material,
consistent with cholecystitis.
2. Suggestion of pneumobilia, which may be related to recent
transhepatic
approach cholecystostomy drainage. CT could be performed for
further
evaluation.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Acute pancreatitis without evidence of necrosis,
pseudoaneurysm, or
vascular complications.
2. Acute cholecystitis with persistent gallbladder wall
thickening and
hyperemia, now status post transhepatic cholecystostomy
decompression, with hyperdense intraluminal material.
3. Mild pneumobilia ___ the left biliary tree, likely related to
recent
transhepatic approach for cholecystostomy.
4. Trace apparent extraluminal air along the superior greater
curve of the
stomach, ___ likely venous distribution and trace ___ volume, of
unclear
etiology or clinical significance.
___: MRI of abdomen:
IMPRESSION:
1. Pancreatitis, likely hemorrhagic given the T1 hyperintense
fluid ___ the
peripancreatic mesentery. No evidence of organized fluid
collection.
2. Thick walled gallbladder which is not distended. This may be
due to
chronic cholecystitis; recent presence of an indwelling
cholecystostomy tube may contribute.
3. Small bilateral pleural effusions with associated compressive
atelectasis.
___: chest x-ray:
Low lung volumes are redemonstrated. Bibasilar atelectasis is
present.
Minimal vascular engorgement is seen but no overt edema is
present. Bilateral pleural effusions are most likely small and
bilateral. There is no evidence of pneumothorax.
___: chest x-ray:
Bilateral mild, left side more than right, lower lung
atelectasis and minimal left pleural effusions persist,
unchanged since ___. Upper lungs are clear, no
discrete opacities concerning for pneumonia. Top normal heart
size, mediastinal and hilar contours are stable.
___: chest xray:
IMPRESSION: Persistent bilateral pleural effusions, with
associated bibasilar atelectasis. No evidence of pneumonia.
___:
___ 8:50 pm FLUID,OTHER GALL BLADDER CULTURE.
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___. ___ @ 1425,
___.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
PREVIOUSLY REPORTED AS (___).
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): BUDDING YEAST.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
SECOND MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S 2 S
VANCOMYCIN------------ 1 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
___ year old gentleman admitted to the acute care service with
abdominal pain. Upon admission, he was made NPO, given
intravenous fluids, and underwent radiographic imaging. He was
reported to have a thickened decompressed gallbladder with high
attenuation material within the lumen. Extensive pancreatitis
without necrosis or pseudocyst was also visualized. He was also
reported to have mildly elevated liver enzymes. As part of his
work-up, he underwent an MRCP which showed acute pancreatitis
and gallbladder wall thickening.
He was taken to the operating room ___ HD # 5 where he underwent
a cholecystectomy. A laparoscopic approach was attemtped, but
converted to open because of increased inflammation and multiple
stones ___ the gallbladder. A ___ drain was placed ___ the right
upper quadrant. The operative course was stable. He required
an intermittent infusion of neosynephrine for blood pressure
support intra-op. He was extubated ___ the recovery room.
His post-operative course has been stable. He did have a mild
elevation of his white blood cell count, but his liver function
tests have been decreasing. He was started on a regular diet.
His vital signs are stable and he is afebrile.
On POD #5, he was still reported to have an elevation of his
white blood cell count. His antibiotic course was changed to
unasyn. His fluid culture from his gallbladder grew staph and
his antibiotic was changed to vancomycin. Infectious disease
was consulted and made recommendations for management of this
finding. Despite vancomycin coverage, he continued to an
increase ___ his white blood cell count. He was afebrile, and
tolerating a regular diet. His vancomycin was discontinued on
___ and his white blood cell count was monitored. Patient
white count continued to decrease on ___ and patient remained
afebrile.
Patient was discharged to home with stable VSS, afebrile,
toleating a regular diet with appropriate urine output and good
pain control at time of discharge. Staples were removed and
steri-strips were placed over wound. Pateint was instructed as
to follow up plans.
Medications on Admission:
___: Gabapentin 600'', hydrochlorothiazide 25', novolog and
lantus (40U qAM, 38U qPM), omeprazole 20', simvastatin 20',
valsartan 320', aspirin 81'
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP <110.
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain: avoid driving while on this
medication, may cause drowsiness.
Disp:*30 Tablet(s)* Refills:*0*
8. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 5 days: started ___.
Disp:*8 Tablet(s)* Refills:*0*
9. insulin glargine 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous breakfast: please monitor blood sugar.
10. insulin glargine 100 unit/mL Cartridge Sig: 38 units
Subcutaneous at bedtime: please monitor blood sugar.
11. Novolog 100 unit/mL Solution Sig: as per sliding scale
Subcutaneous breakfast, lunch, dinner, and bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
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 epigastric pain. You were
found on imaging to have an inflammation of your pancreas
related to gallstones. You were given a course of antibiotics.
You were taken for an MRI of your abdomen which showed a
thickened gallbladder and pancreatitis. You were taken to the
operating room where you had your gallbladder removed. You are
slowly recovering and you are now ready to be discharged home
with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep ___ 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change ___ your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10717732-DS-11
| 10,717,732 | 23,165,015 |
DS
| 11 |
2194-11-22 00:00:00
|
2194-11-22 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / atenolol
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ -
1. Coronary artery bypass grafting x1, with the left
internal mammary artery to left anterior descending
artery.
2. Aortic valve replacement with a 19 mm ___
mechanical valve. Serial number is ___ reference
number is ___.
3. Annular enlargement with a bovine pericardial patch.
___ Left VATS for hemothorax
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of diabetes
mellitus type I and end-stage renal disease on peritoneal
dialysis. She was recently admitted with cough, dyspnea,
malaise. She was found to have pneumonia and she was treated
with antibiotics. She was discharged to home. Following
discharge, she developed chest pain radiating to her back. She
developed severe back
pain and per her husbandm, she had loss of conciousness and was
apneic for a period of time. She was taken to the emergency
department where her initial troponin was 0.85. A CTA of the
chest showed no evidence of disection with poor evaluation for
PE given inadequate timing of contrast. Echocardiogram revealed
severe aortic stenosis. She was transferred to ___ for
surgical evaluation.
Past Medical History:
DM Type 1, diagnosed in ___
ESRD on nightly PD
Diabetic retinopathy
Renal artery stenosis with left RA angioplasty
Hypertension
Hyperlipidemia
Bilateral carotid stenosis
Anemia in chronic kidney disease
Aortic stenosis
Tinnitus
Depression
Carpal tunnel syndrome
PD catheter placed ___
Left Renal artery angioplasty
Left left fracture s/p rod placement
C-section x 2
Social History:
___
Family History:
Diabetes Type II in Maternal Grandmother
Lung Cancer, ___ Infarction in Maternal Grandfather
___, Gout in Father (deceased)
___ in Father and Sister
___ in Mother
No family history of kidney disease
Physical Exam:
Admission PE:
HR: 80 BP: 98/49 RR: 18 O2 sat: 100% 3L
Height: 62" Weight: 63.5 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs crackles bilaterally, rhoncorhous upper sounds []
Heart: RRR [x] Irregular [] Murmur [x] ___
Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds +
[]PD Dwell in place at time of exam, PD RLQ CDI
Extremities: Warm [x], well-perfused [x]; no edema
Varicosities: None [x]
Neuro: very mild right sided weakness, otherwise intact []
Pulses:
Femoral Right: +1 Left: +1
DP Right: trace Left: trace
___ Right: trace Left: trace
Radial Right: Trace Left: Trace
Carotid Bruit: None
Pertinent Results:
Chest CTA ___ at ___
1. No aortic dissection. Evaluation for PE limited due to bolus
timing.
2. Pulmonary edema and abdominal ascites.
3. Confluent opacities at the lung bases, right greater than
left concerning for pneumonia.
4. Small right and trace left pleural effusions.
5. Severe coronary artery and aortic valvular calcifications.
6. Prominent mediastinal lymph nodes, most likely reactive.
Transthoracic Echocardiogram ___
LEFT ATRIUM: Severely increased LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severe global LV hypokinesis.
RIGHT VENTRICLE: Normal RV chamber size. TASPE normal (>=1.6cm)
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Very
severe AS (Vmax ___ or mean gradient >=60mmHg; valve area
<1.0cm2) Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. ___ (2+) MR.
___ VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrial volume index is severely increased. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber
size is normal. Tricuspid annular plane systolic excursion is
normal (1.8 cm; nl>1.6cm) consistent with normal right
ventricular systolic function. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are mildly thickened (?#). There is very severe aortic
valve stenosis (Vmax ___ or mean gradient >=60mmHg; valve area
<1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Severe global LV systolic dysfunction with normal RV
size and function. Very severe aortic stenosis with moderate
aortic regurgitation. Moderate mitral regurgitation. Compared
with the prior study (images reviewed) of ___, the
severity of aortic stenosis and MR has progressed. New onset of
severe global LV dysfunction.
Cardiac Catheterization ___
___: no stenosis
LAD: 50% proximal stenosis at origin and sequential 50% stenosis
before D1.
LCX: no significant disease
RCA: small, non-dominant vessel with diffuse disease and
proximal subtotal occlusion.
Carotid Ultrasound ___
ReportRight ICA <40% stenosis. Left ICA <40% stenosis.
LABS:
___ 06:10AM BLOOD WBC-20.0* RBC-2.66* Hgb-8.2* Hct-26.2*
MCV-99* MCH-30.8 MCHC-31.3* RDW-16.3* RDWSD-54.7* Plt ___
___ 02:42AM BLOOD WBC-11.8* RBC-3.46* Hgb-10.8* Hct-30.3*
MCV-88 MCH-31.2 MCHC-35.6* RDW-16.7* Plt ___
___ 02:07PM BLOOD WBC-9.3 RBC-2.71* Hgb-8.3* Hct-26.0*
MCV-96 MCH-30.7 MCHC-31.9 RDW-17.2* Plt ___
___ 05:45AM BLOOD ___ PTT-66.6* ___
___ 02:07PM BLOOD ___ PTT-29.7 ___
___ 06:10AM BLOOD Glucose-364* UreaN-41* Creat-7.3* Na-132*
K-3.8 Cl-91* HCO3-29 AnGap-16
___ 03:12AM BLOOD Glucose-160* UreaN-34* Creat-6.4* Na-134
K-3.2* Cl-93* HCO3-28 AnGap-16
___ 02:07PM BLOOD Glucose-170* UreaN-61* Creat-11.8* Na-134
K-5.4* Cl-91* HCO3-27 AnGap-21*
___ 06:15AM BLOOD ALT-9 AST-15 LD(LDH)-544* AlkPhos-172*
Amylase-57 TotBili-0.2
___ 08:18PM BLOOD ALT-17 AST-16 AlkPhos-100 TotBili-0.2
___ 06:15AM BLOOD Lipase-34
___ 08:00AM BLOOD CK-MB-12* MB Indx-8.3* cTropnT-1.25*
___ 01:03AM BLOOD CK-MB-15* MB Indx-7.9* cTropnT-1.47*
___ 09:30AM BLOOD CK-MB-16* MB Indx-7.7* cTropnT-1.49*
___ 06:10AM BLOOD Calcium-8.1* Phos-4.3 Mg-1.6
___ 02:07PM BLOOD Calcium-9.9 Phos-7.8* Mg-2.8*
___ 08:18PM BLOOD Albumin-3.0*
___ 03:55AM BLOOD %HbA1c-7.7* eAG-174*
___ 07:13AM BLOOD TSH-4.3*
___ 02:19AM BLOOD PTH-515*
___ 07:13AM BLOOD Free T4-0.95
___ 05:55AM BLOOD PTH-285*
___ 06:10AM BLOOD 25VitD-PND
___ CT abd and pelvis
LOWER CHEST:
Limited evaluation of the lung bases demonstrates a artificial
aortic and
mitral valve. There are dense coronary artery vascular
calcifications. There is a a loculated left hydro pneumothorax.
Empyema cannot be excluded. Bibasilar atelectasis.
ABDOMEN: Small amount of abdominal ascites.
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
There is dense material within the gallbladder which may
represent vicarious excretion of IV contrast. PANCREAS: The
pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic stranding. SPLEEN: Wedge-shaped hypodensity in
the spleen compatible with a splenic
infarct.. ADRENALS: The right and left adrenal glands are
normal in size and shape. URINARY: Dense atherosclerotic disease
at the origin of the bilateral renal arteries. The bilateral
kidneys are small and atrophic in appearance.. GASTROINTESTINAL:
No evidence of bowel obstruction.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy. VASCULAR: There is no abdominal aortic
aneurysm. There is heavy calcium burden in the abdominal aorta
and great abdominal arteries. PELVIS: There is a right lower
quadrant approach dialysis catheter coiled within the left lower
quadrant. The urinary bladder and distal ureters are
unremarkable. There is no evidence of pelvic or inguinal
lymphadenopathy. Small amount of pelvic free fluid.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Stable peripherally
sclerotic
lesions in T7-T8 which may represent Schmorl's nodes. Rounded
lucencies in the superior endplate of the T12 vertebral body,
also likely representing a benign lesion such as a Schmorl's
node. Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Limited evaluation of the lung bases demonstrates a
loculated left
hydropneumothorax. Underlying infection cannot be excluded.
2. New wedge-shaped hypodensity in the spleen compatible with
splenic
infarct. 3. Small amount of abdominal ascites with peritoneal
dialysis catheter coiled in the left lower quadrant.
___ CXR
There has been interval removal of the enteric tube. Heart size
and
mediastinal contours are stable. Left pleural effusion has
improved, now
trace. Right lung is clear and the left lung persistently
demonstrates
considerable parenchymal abnormality and atelectasis.
IMPRESSION:
Small left pleural effusion.
Diffuse left pulmonary parenchymal abnormality as before.
Brief Hospital Course:
She was admitted on ___ and underwent routine preoperative
testing and evaluation. The ___ team was consulted to aid in
the perioperative management of her diabetes mellitus. She was
evaluated by the dental service and cleared for surgery. She was
taken to the operating room on ___ and underwent aortic
valve replacement and coronary artery bypass grafting. Please
see operative note for full details. She tolerated the procedure
well and was transferred to the CVICU in stable condition for
recovery and invasive monitoring. She was slow to wake and
removed intubated for several days post op. She was weaned off
epinephrine and remained hemodynamically stable. She was given
one dose of Coumadin and INR increased to 13, requiring Vitamin
K. She had POD 2 she was extubated without incidence. She had
ongoing issues with nausea and vomiting, thought to be due to
gastroparesis. She also had multiple issues with glucose control
and was followed by ___ and ___ on an insulin drip for
several days post op. Post op course also complicated by
leukocytosis - WBC count peaked at 47.5. ID was consulted. She
had a CT which showed left sided colitis. Cdiff was negative at
that time, but the decision was made to proceed with treatment
for 14 days with po vancomycin. On POD 14, she began to drop her
Hematocrit, became hypotensive and short of breath and required
multiple transfusions. She was transferred back to the CVICU and
CXR showed large left hemothorax and thoracic surgery was
consulted. She underwent a Left VATs procedure on ___ for
hemaothorax evacuation. She remained stable and was transferred
to the telemetry floor and anticoagulation was resumend. On ___
she began to have bloody stools with a dropping Hematocrit
again. She was transferred back to the CVICU and GI was
consulted. They recommended CT, repeat C diff ___ - negative)
and ultimately she will need a colonoscopy once her clinical
status improves. This can be done in the next 6 ___ year as
an outpatient per GI and anticoagulation was approved to be
restarted. Heparin was restarted for mechanical AVR and low dose
Coumadin was initiated. Renal continued to follow for PD
exchanges. She was once again transferred to the telemetry floor
for further recovery. She was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD ___ she was ambulating, the wound was
healing, and pain was controlled. She was discharged home with
services with plan to follow up with ___ as needed for blood
glucose management, and to restart cycling PD at home and follow
up with outpatient renal provider in next ___ hours
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Cinacalcet 30 mg PO QOD
4. CloniDINE 0.1 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
8. Calcium Acetate ___ mg PO TID W/MEALS
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Gabapentin 200 mg PO BID
11. Torsemide 40 mg PO BID
12. Nephrocaps 1 CAP PO DAILY
13. Levofloxacin 750 mg PO Q48H
14. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.7 units/hr
Basal rate maximum: 0.83 units/hr
Bolus minimum: 1:13 units
Bolus maximum: 1:13 units
Target glucose: ___
Fingersticks: QAC and HS, Q6H, if NPO
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Cinacalcet 60 mg PO DAILY
RX *cinacalcet [Sensipar] 60 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. Glargine 24 Units Breakfast
Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Sertraline 25 mg PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN pain, fever
6. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Calcitriol 0.5 mcg PO DAILY
RX *calcitriol 0.5 mcg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*1
8. Nephrocaps 1 CAP PO DAILY
9. Gabapentin 200 mg PO BID
10. HYDROmorphone (Dilaudid) 0.5 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 0.25 tablet(s) by mouth q3h
Disp #*25 Tablet Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
12. ___ MD to order daily dose PO DAILY
Goal INR 2.5-3.5 mech AVR dose varies from 0.5-5 mg based on INR
RX *warfarin [Coumadin] 2 mg vary tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*1
13. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
14. Gentamicin 0.1% Cream 1 Appl TP DAILY:PRN pain
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Aspirin 81 mg PO DAILY
17. Outpatient Lab Work
___ for coumadin mechanical valve (V43.3) as needed
Please call results to cardiac surgery ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aortic Stenosis s/p aortic valve replacement
Coronary Artery Disease s/p Coronary revascularization
Leukocytosis no clear etiology
Hemothorax s/p VATS
Hard of Hearing
Diabetes mellitus type 1 uncontrolled
Renal Failure on peritoneal dialysis
Secondary Diagnosis
Carotid Artery Stenosis
Diabetic Retinopathy
Hyperlipidemia
Hypertension
MDD
Pneumonia
Renal Artery Stenosis with left RA angioplasty
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid and acetaminophen
Sternal Incision - mild erythema distal end with slight
separation with eschar no drainage
Edema none
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10717732-DS-15
| 10,717,732 | 25,628,080 |
DS
| 15 |
2196-10-01 00:00:00
|
2196-10-02 17:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / atenolol / tetanus & diphtheria toxoids
Attending: ___.
Chief Complaint:
bradycardia during colonoscopy
Major Surgical or Invasive Procedure:
His bundle pacemaker placement ___
screening colonoscopy ___
History of Present Illness:
Ms. ___ is a ___ year-old female with a history of type I DM
(on insulin pump), ESRD on PD, CAD s/p CABG x1 with mechanical
AVR (for severe AS), who presented with bradycardia during
anesthesia for colonoscopy.
The patient was seen in the GI suite for planned colonoscopy as
part of renal transplant evaluation. She was given fentanyl and
propofol prior to colonoscopy, and her HR dropped to ___, with
SBP in the ___, as well as SpO2 to ___ prior to initiating the
colonoscopy. She was given 0.5 mg atropine twice with
improvement in HRs. She was then transferred to the ___ for
further evaluation.
Of note, 3 weeks ago, her nephrologist increased her metoprolol
from 12.5 mg qd to 25 mg qd. She was found to be bradycardic at
phlebotomy 1 week ago, and the dose was decreased again to 12.5
mg daily.
In the ED initial vitals were: 97.2 42 144/42 16 100% RA
- EKG: sinus brady, HR 43, NA, PR 280, new STD I + II, TWI
V1-V3, STD V4-6
- Labs/studies notable for: leukocytosis of 11.8, hypokalemia
of 2.7, trop of 0.4 (baseline 0.6-0.7). CXR showed mild
interstitial pulmonary edema.
- Patient was given: 1L NS, 80 mEq KCl, and started on heparin
drip
On the floor, she is feeling well & without complaints.
REVIEW OF SYSTEMS: Positive per HPI, otherwise 10 point ROS was
negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes mellitus, type 1
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: 1-vessel LIMA-LAD ___
- Severe AS s/p AVR
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Diabetic retinopathy
- ESRD on PD
- Carpal tunnel syndrome
- Depression
- Anemia of chronic disease
- Parkinsonism
- Depression
- Insomnia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission
VITALS - 97.6 | 181/67 initially, then 163/49 | 43 | 16 | 97%/RA
| 66.8 kg
GENERAL - pale, but well appearing, in no distress
HEENT - no scleral icterus, PERRL (pupils 8 mm, reactive to 6
mm, bilaterally)
NECK - no JVD or AJR
CARDIAC - regular, bradycardic, normal S1, loud S2, no murmurs
audible
LUNGS - clear to auscultation
ABDOMEN - soft, non-tender, non-distended, PD catheter in place
& appears clean; insulin pump in place, appears clean
EXTREMITIES - no edema, warm, pulses 2+
SKIN - dry
NEUROLOGIC - face symmetric, oriented x4, sits in bed
unassisted
Discharge
VITALS - 98.9 120s-150s/60s 91 24 97%RA
GENERAL - well appearing, in no distress
HEENT - no scleral icterus, nc/at
CARDIAC - regular rate and rhythm, normal S1, loud S2, no
murmurs audible. PPM site (L chest) nontender, dressing
clean/dry/intact
LUNGS - clear to auscultation bilaterally
ABDOMEN - soft, non-tender, non-distended, PD catheter in place
& appears clean; insulin pump in place, appears clean
EXTREMITIES - no edema, warm, +femoral bruit bilaterally, some
bruising at cath site
SKIN - dry, no significant rash
NEUROLOGIC - grossly intact
Pertinent Results:
Labs:
=====
___ 01:00PM BLOOD WBC-11.8* RBC-2.83* Hgb-8.7* Hct-27.2*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.0 RDWSD-45.2 Plt ___
___ 06:20AM BLOOD WBC-12.8* RBC-2.48* Hgb-7.8* Hct-24.1*
MCV-97 MCH-31.5 MCHC-32.4 RDW-13.2 RDWSD-46.9* Plt ___
___ 06:10AM BLOOD WBC-14.9* RBC-2.27* Hgb-7.1* Hct-22.3*
MCV-98 MCH-31.3 MCHC-31.8* RDW-13.3 RDWSD-47.6* Plt ___
___ 01:00PM BLOOD Neuts-75.4* Lymphs-8.8* Monos-9.9 Eos-4.8
Baso-0.5 Im ___ AbsNeut-8.91* AbsLymp-1.04* AbsMono-1.17*
AbsEos-0.57* AbsBaso-0.06
___ 01:00PM BLOOD ___ PTT-35.7 ___
___ 05:15AM BLOOD ___ PTT-84.1* ___
___ 06:20AM BLOOD ___ PTT-79.2* ___
___ 05:50AM BLOOD ___ PTT-68.1* ___
___ 05:42AM BLOOD ___ PTT-42.4* ___
___ 12:50PM BLOOD ___ PTT-40.0* ___
___ 06:10AM BLOOD ___ PTT-42.6* ___
___ 01:00PM BLOOD Glucose-116* UreaN-39* Creat-10.7* Na-142
K-2.8* Cl-96 HCO3-26 AnGap-23*
___ 06:20AM BLOOD Glucose-80 UreaN-40* Creat-11.9* Na-136
K-4.3 Cl-97 HCO3-25 AnGap-18
___ 06:10AM BLOOD Glucose-255* UreaN-36* Creat-11.8* Na-137
K-4.1 Cl-94* HCO3-25 AnGap-22*
___ 01:00PM BLOOD CK(CPK)-166
___ 01:00PM BLOOD cTropnT-0.40*
___ 06:55PM BLOOD cTropnT-0.37*
___ 01:00PM BLOOD Calcium-8.5 Phos-6.6* Mg-1.9
___ 06:10AM BLOOD Calcium-8.8 Phos-8.3* Mg-1.9
___ 06:20AM BLOOD TSH-3.4
___ 06:55PM BLOOD K-2.9*
STUDIES
=======
CXR ___
IMPRESSION:
Mild interstitial pulmonary edema.
Left heart cath ___:
Single vessel CAD with ostial total occlusion of the LAD and a
patent LIMA to LAD bypass graft. There is
angiographically moderate, non-obstructive disease of the ostial
LCx. A non-dominant RCA is chronically
occluded.
TTE ___:
The left atrial volume index is mildly increased. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>65%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The estimated cardiac index is normal (>=2.5L/min/m2).
A bileaflet aortic valve prosthesis is present.The aortic valve
prosthesis appears well seated, with normal disc motion and
transvalvular gradients. The effective oriface area index is
moderately depressed (0.8 cm2/m2; nl > 0.9 cm2/m2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no anatomic or functonal mitral stenosis.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Well seated bileaflet aortic valve prosthesis
with normal gradient and no aortic regurgitation. Moderate
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is now much higher. Inferior
dysfunction is not seen on review of the prior study.
R femoral vascular US ___:
IMPRESSION:
Normal sonographic appearance of the groin, without evidence of
hematoma,
pseudoaneurysm, or AV fistula.
Brief EP Procedure Report ___:
Success dual chamber pacemaker implant with His bundle pacing
via the left cephalic vein without complications.
We were able to achieve pure His bundle pacing by pacing the
lead fairly proximally in the
His bundle.
- continue with coumadin
- Vancomycin total of 72hrs
- PA/Lat CXR tomorrow
- f/u at ___ device clinic with me on ___
CXR ___:
IMPRESSION:
No pneumothorax.
Small left pleural effusion or thickening, similar.
Mildly increased heart size, pulmonary vascularity.
Interstitial prominence
is similar to prior, may represent edema or inflammatory.
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a history of type I DM
(on insulin pump), ESRD on PD, CAD s/p CABG x1, and severe AS
with mechanical AVR, admitted for bradycardia I/s/o anesthesia
for scheduled outpatient colonoscopy and found to have 2:1 heart
block.
# Sinus bradycardia: EKGs with 2:1 AV block, with others
suggesting higher level heart block. Onset with anesthesia for
colonoscopy on ___ but continued during admission. TSH was
normal and Lyme titers negative. Beta blocker was stopped on
admission. Underwent placement of His bundle pacemaker on
___. Device interrogated on ___ and functioning
appropriately. Due to specific bleeding risk into pacemaker
pocket with heparin, patient is not to receive heparin for 3
weeks after procedure. Restarted home metop xl on ___. Given 1
dose cephazolin on ___ overnight, discharged to complete 2 days
of PO cephalexin.
# History of CAD s/p 1-vessel CABG:
# Need for left heart cath:
as part of pre-transplant workup. Showed patent LIMA-LAD,
chronic RCA occlusion, and non-occlusive disease in ostial LCX.
Recommended medical management and showed no contraindication
for renal transplant.
# Need for screening colonoscopy: as part of pre-transplant
workup. No polyps identified, and ___ year follow up is
recommended.
# History of severe AS s/p mechanical AVR: goal INR 2.0-3.0.
Anticoagulation adjusted during admission. She was initially on
heparin drip as her INR was subtherapeutic after warfarin had
been held prior to colonoscopy ___. INR supratherapeutic on ___
and rec'd 1U FFP prior to colonoscopy that day. INR was 4.4 on
___ (possibly secondary to abx) and so warfarin was held on
___. Patient should have INR drawn on ___.
# Diabetes mellitus, type I: managed with insulin pump and
followed by ___. Labile during stay I/s/o NPO for Cath and
bowel prep for c-scope.
# ESRD, on PD: undergoing renal transplant evaluation.
Continued PD in house.
# Hypertension: Continued amlodipine, valsartan & furosemide.
Held home metoprolol as above, and restarted on ___.
TRANSITIONAL ISSUES
===================
-continue renal transplant workup. S/p L heart cath recommending
medical mgmt and negative screening colonoscopy
-INR 4.4 on day of discharge, pt instructed to hold warfarin on
day of discharge. Please draw INR on ___ and adjust dosing
accordingly
-concern for obstructive sleep apnea. please consider referral
for outpatient sleep study
-Cardiology, Nephrology, Endocrinology follow up needed
# CODE: Full, confirmed, but does not want long course of life
sustaining measures if futile
# CONTACT: HCP: daughter, ___, ___ son, ___,
alternate ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 18.9 units/hr
Bolus maximum: 15 units
Target glucose: ___
Fingersticks: QAC and HS
3. Gabapentin 200 mg PO BID
4. Sertraline 25 mg PO DAILY
5. Warfarin ___ mg PO DAILY16
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Gentamicin 0.1% Cream 1 Appl TP DAILY
11. amLODIPine 5 mg PO DAILY
12. Valsartan 320 mg PO DAILY
13. Cinacalcet 30 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q12H Duration: 2 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*3
Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Cinacalcet 30 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 200 mg PO BID
8. Gentamicin 0.1% Cream 1 Appl TP DAILY
9. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 18.9 units/hr
Bolus maximum: 15 units
Target glucose: ___
Fingersticks: QAC and HS
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Sertraline 25 mg PO DAILY
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Valsartan 320 mg PO DAILY
14. HELD- Warfarin ___ mg PO DAILY16 This medication was held.
Do not restart Warfarin until Instructed to do so per your
___ clinic
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Second Degree Heart Block
Secondary: End stage renal disease, type 1 diabetes mellitus
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 ___ after an episode of slow heart rate
after getting sedation medication for your scheduled
colonoscopy.
WHILE YOU WERE IN THE HOSPITAL
-You continued to have a slow heart rate, and your EKG showed
signs of "heart block." You received a pacemaker for this.
-You had a "cardiac cath" that did not show any heart disease
requiring intervention.
-You had a colonoscopy that did not show any concerning
findings.
-You continued peritoneal dialysis.
-Your blood sugar was difficult to control.
-Your INR was elevated to 4.4 on day of discharge, you should
not take your Coumadin today (___) and you need to have your
INR checked ___.
-You should take 2 days of oral antibiotics.
WHAT YOU SHOULD DO NOW
-Have your INR drawn at the ___ clinic TOMORROW ___
___. Do NOT take your dose of warfarin tonight.
-Follow up with Dr. ___ for your pacemaker as
scheduled below.
-Follow up with the kidney and diabetes doctors as ___.
-There was concern you suffer from "obstructive sleep apnea."
You should follow up with a sleep doctor and consider sleep
studies as an outpatient.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10717732-DS-6
| 10,717,732 | 22,348,690 |
DS
| 6 |
2191-07-03 00:00:00
|
2191-07-04 21:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
dizziness, nausea and vomiting
Major Surgical or Invasive Procedure:
Peritoneal dialysis
Surgical peritoneal dialysis catheter repositioning
History of Present Illness:
___ with h/o DMI c/b neuropathy, retinopathy and stage 5 CKD,
RAS s/p angioplasty, HTN and HL presented to outpatient dialysis
center this AM with malaise, fatigue, nausea & dizziness when
standing and was found to be orthostatic. Dialysis nephrologist
decreased her labetolol from TID to BID, stopped amlodipine, and
referred her to the ___ ED for admission for urgent PD given
worsening uremic symptoms of decreased appetite,
nausea/vomiting, cloudy thinking and itchy skin.
.
Pt was admitted to ___ MICU ~2 weeks ago as an OSH transfer
for hypertensive emergency and flash pulmonary edema, requiring
intubation. At ___, she was diuresed & extubated; peritoneal
catheter was placed by transplant surgery with plan for
initiation of PD as an outpatient 4 weeks thereafter. Since
discharge, she reports worsening orthostatic symptoms including
palpitations. Reports similar symptoms when taking labetolol
previously.
.
In the ED today, her VS were T 98.2 HR 64 BP 112/53 RR 16 O2
98%. Reported some discomfort when PD catheter was flushed today
at outpatient nephrology appt, but otherwise no symptoms besides
the constitutional symptoms described above. No fever/chills, no
CP/SOB. EKG showed NSR @59, prolonged qTC 459 w/diffeuse TVI in
V2-V6 & inferior/lateral leads more prominent than prior EKGs.
___ showed
Renal consult saw the patient in the ED and agreed w/admission
for early initiation of PD. Also seen by transplant surgery
whose attending ok'd use of PD catheter on ___.
Transfer VS T 97.9 HR 72 RR 16 BP 145/57 O2sat 100/RA.
.
On the floor the patient confirms history as above. Not
currently nauseated but continues to feel malaised and itchy
everywhere. Reports that her current symptoms have been
worsening over the past ___ days. She spends most of the day in
bed.
Past Medical History:
- IDDM Type 1, diagnosed in ___
- ESRD V, GFR < 15ml/min, thought to be due to DM
- Diabetic retinopathy
- MDD
- renal artery stenosis with left RA angioplasty
- Hypertension
- Hyperlipidemia LDL
- Bilateral carotid stenosis
- Anemia in chronic kidney disease
Social History:
___
Family History:
Diabetes Type II in Maternal Grandmother
Lung Cancer, ___ Infarction in Maternal Grandfather
___, Gout in Father (deceased)
___ in Father and Sister
___ in Mother
No family history of kidney disease
Physical Exam:
ADMISSION
VS 98.4 160/62 81 18 100/RA
GEN AOX lying in bed conversing in NAD, skin slightly flushed
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: CTAB no r/rw
CV: RRR, ___ systolic murmur throughout precordium, loudest LUSB
ABD soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; PD catheter
RLQ
no surrounding erythema/tenderness, dressing c/d/i
Ext: no edema, chonic anterior LLE white macules w/well-defined
borders
.
DISCHARGE
VS Tm 100 Tc 98.2 BP 120-154/50-70s HR 60-70s RR 18 ___ RA
GEN AOX lying in bed conversing in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: CTAB no r/rw
CV: RRR, ___ systolic murmur throughout precordium, loudest LUSB
ABD soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; PD catheter
RLQ
no surrounding erythema/tenderness, dressing c/d/i
Ext: no edema, LLE well-healed white macule w/defined borders
Pertinent Results:
ADMISSION LABS
___ 01:58PM BLOOD WBC-7.8 RBC-3.02* Hgb-9.2* Hct-27.8*
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.5 Plt ___
___ 01:58PM BLOOD Neuts-79.3* Lymphs-9.9* Monos-3.5
Eos-6.3* Baso-0.9
___ 01:58PM BLOOD ___ PTT-27.2 ___
___ 01:58PM BLOOD Glucose-73 UreaN-58* Creat-8.6* Na-137
K-5.4* Cl-97 HCO3-26 AnGap-19
___ 01:58PM BLOOD ALT-8 AST-21 AlkPhos-82 TotBili-0.1
___ 01:58PM BLOOD Lipase-37
___ 01:58PM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.9*# Mg-2.3
___ 02:13PM BLOOD Lactate-2.4* K-4.9
.
DISCHARGE LABS
___ 08:00AM BLOOD WBC-9.2 RBC-2.88* Hgb-8.9* Hct-27.4*
MCV-95 MCH-30.8 MCHC-32.4 RDW-14.0 Plt ___
___ 08:00AM BLOOD Glucose-218* UreaN-48* Creat-7.6* Na-137
K-4.4 Cl-94* HCO3-32 AnGap-15
___ 08:00AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.0
.
URINALYSIS
___ 02:36PM URINE Color-Straw Appear-Clear Sp ___
___ 02:36PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:36PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-4
.
DIALYSATE ANALYSIS
___ 12:49PM OTHER BODY FLUID WBC-33* RBC-15* Polys-12*
Lymphs-12* Monos-0 Eos-10* Basos-1* Mesothe-2* Macro-63* (FIBRIN
STRANDS VISIBLE)
.
MICROBIOLOGY
___ DIALYSIS FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE - PRELIMINARY
___ URINE CULTURE-FINAL
___ BLOOD CULTURE-FINAL
.
TRANSPLANT WORKUP LABS
___ HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE
___ BLOOD PEP-WNL F IgG-834 IgA-206 IgM-85 IFE-NO
MONOCLONAL
___ BLOOD HIV Ab-NEGATIVE
___ BLOOD HCV Ab-NEGATIVE
___ TOXOPLASMA IgG ANTIBODY-FINAL
___ Blood (EBV) ___ VIRUS VCA-IgG AB-FINAL;
___ VIRUS EBNA IgG AB-FINAL; ___ VIRUS VCA-IgM
AB-FINAL
___ Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM
ANTIBODY-FINAL
___ SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-FINAL
___ SEROLOGY/BLOOD Rubella IgG/IgM Antibody-FINAL
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
___ SEROLOGY/BLOOD RUBEOLA ANTIBODY, IgG-PENDING
.
IMAGING
___ KUB
FINDINGS: Supine and upright views of the abdomen and pelvis
were provided.
A catheter projects over the right lower abdomen with its tip
extending into the right mid abdomen. The bowel gas pattern is
unremarkable without definite signs of ileus or obstruction.
There is no free air below the right hemidiaphragm. Bony
structures appear intact.
IMPRESSION: Peritoneal dialysis catheter positioned in the right
mid abdomen. No signs of bowel obstruction or free air.
.
___ KUB
SUPINE AND UPRIGHT RADIOGRAPHS OF THE ABDOMEN: A peritoneal
dialysis catheter is identified in unchanged position in the
right lower quadrant. There is equivocal small focus of air
under the right hemidiaphragm, though this is not unexpected in
a patient receiving peritoneal dialysis. There is no large free
air, and no bowel wall thickening or pneumatosis. There is no
radiographic evidence of obstruction. Lung bases are clear, the
osseous structures are unremarkable.
IMPRESSION: No evidence of obstruction or large free air.
Equivocal small
focus of air under the right diaphragm is not unexpected in a
patient on
peritoneal dialysis.
Brief Hospital Course:
___ with hx DMI c/b neuropathy, retinopathy and stage 5 CKD; RAS
s/p angioplasty; HTN; and HL admitted via outpatient ___
clinic for early initiation of PD in the context of worsening
orthostatic hypotension and uremic symptoms.
.
# ESRD on PD
Indications for early initiation of PD were symptomatic uremia
(N/V/abd pain/decreased appetitite, pruritis), and mild
hyperkalemia. No e/o AMS. Transplant surgeon agreeable to
initiation of PD in ___ using catheter placed 2 weeks ago
despite initial surgical plan to try to wait 4 weeks before
using it. She underwent 1.5d unremarkable PD when nurses noted
difficulty instilling and draining dialysate, with no
improvement despite heparin dwells in the PD catheter. Trial of
tPA in line triggered an episode of cramping, abdominal pain,
nausea and vomiting. Given these difficulties and non-ideal
positioning of PD catheter in mid-abdomen by ___, she underwent
surgical PD catheter repositioning by transplant surgery on
___. Peritoneal dialysis restarted thereafter x2d with no
further complications. Some small amount of blood in dialysate
(light pink) was noted post-operatively. Uremic symptoms
resolved. Renal service arranged for her to attend formal PD
training at ___ the morning after discharge.
.
# Hypertension w/symptomatic orthostatic Hypotension
History was suggestive of orthostatic hypotension since recent
discharge; she attributed lightheadedness and dizziness to
recent initiation of labetolol given similar intolerance of
labetolol ___ year prior. 60-point BP drop was documented here
even after decreasing labetolol from 300 TID to ___ BID and then
200 BID; she was only able to maintain pressures without
orthostasis at 100 labetolol BID. She did need additional blood
pressure control agents, however, because of systolic readings
of 180-200, so 10 amlodipine QD, 40 lisinopril QD, and 50
hydralazine QID were added to the labetolol 100 BID & home
clonipine patch. The discharge blood pressure regimen maintained
pressures of 120-140s/50-70s for 2 days without orthostasis
prior to discharge. Of note, home torsemide was also decreased
from 40 to 20 QD. HR stable throughout. Discussed with renal
consult team that her BP meds will likely need to be further
down-titrated over the next few weeks as she fully adopts a
peritoneal dialysis regimen.
.
# Hx CHF
Decreased torsemide from 40 to 20 QD on admission in the setting
of orthostatic hypotension. No signs/symptoms volume overload.
.
# DM1
Continued home insulin sliding scale; some high fingersticks
noted in-house once she started eating again - she may need
sliding scale monitoring/adjustment as an outpatient once eating
habits stabilize.
.
TRANSITIONAL ISSUES
1. MONITOR BP, ADJUST MEDS PRN (MAY NEED DOWNTITRATION IN
COORDINATION W/PD PLAN
2. MONITOR FOR ORTHOSTATIC SYMPTOMS
3. MONITOR BLOOD SUGAR, MAY NEED INSULIN SCALE ADJUSTMENT
4. FOLLOW-UP ANY ISSUES WITH HOME PERITONEAL DIALYSIS, RECENT
CATHETER ADJUSTMENT
Medications on Admission:
torsemide 20 mg x2 tabs (40 mg) DAILY
amlodipine 10 mg QD (dc'd right before admission)
labetalol 600 mg TID* (decr to BID right before admission)
clonidine 0.2 mg/24 hr Patch qWED
aspirin 81 mg QD
atorvastatin 20 mg QD
sodium bicarbonate 650 mg TID
B complex-vitamin C-folic acid 1 mg (nephrocaps) QD
calcium acetate 667 mg TID
sevelamer carbonate 800 mg TID
glargine 12U qHS
Humalog sliding scale
oxycodone-acetaminophen ___ mg Tablet ___ Tablets q6h prn (PD
pain)
vitamin D QD (not taking)
MV (not taking)
Discharge Medications:
1. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal once a week.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
10. Humalog 100 unit/mL Solution Sig: AS DIRECTED Subcutaneous
QACHS.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
15. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: PD pain.
16. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. epoetin alfa Injection
18. labetalol 100 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension
Symptomatic Uremia
Type 1 diabetes
End-stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for dizziness and to start
peritoneal dialysis.
We found that your blood pressure dropped 40-60 points when you
stood up. Because this had been attributed to labetolol in the
past, we tapered down your labetalol and started other blood
pressure medications. Your pressures had improved so that you
were no longer having lightheaded/dizzy episodes by the time you
left the hospital.
We started peritoneal dialysis through your new catheter. You
had to undergo catheter adjustment by transplant surgery. The
catheter worked fine for dialysis for 2 days thereafter. The
renal fellow set you up for a full-day training session at
___ on ___, where you will be trained to do
peritoneal dialysis at home. You will also need to exchange the
gauze dressing at the catheter site regularly.
We made the following changes to your medications:
1. DECREASED LABETOLOL to 100 mg twice daily
2. DECREASED TORSEMIDE to 20 mg daily
3. STOPPED SODIUM BICARBONATE
4. RE-STARTED AMLODIPINE, 10 MG PER DAY
5. RE-STARTED HYDRALAZINE, 50 MG EVERY 6 HOURS
6. STARTED LISINOPRIL 40 MG PER DAY
7. RECOMMEND TYLENOL, UP TO 1000 MG EVERY 4 HOURS AS-NEEDED FOR
PAIN
Please review the attached medication list with your doctors at
your next appointment.
Followup Instructions:
___
|
10717732-DS-7
| 10,717,732 | 29,099,793 |
DS
| 7 |
2192-02-11 00:00:00
|
2192-02-12 20:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
Left foot swelling, erythema, and pain
Major Surgical or Invasive Procedure:
Incision and drainage
History of Present Illness:
___ F with a h/o TIDM c/b ESRD on PD who p/w left foot
swelling, pain, and erythema. Pt reports that 4 days prior to
admission, she returned home from work and noticed that her left
foot appeared swollen up to her ankle. The next afternoon, she
also noticed redness and pain over the distal and lateral aspect
of her L foot, which progressed to her ankle over the course of
the day. The following day, pt had an appointment with her
orthopedic surgeon, as she had been experiencing sharp pain over
her L leg for several weeks where she had a fibular fracture and
repair many years ago. Her surgeon told her that she had
developed cellulitis over her foot, and started her on bactrim
and augmentin (two days prior to admission). Pt reports that
after starting the antibiotics, erythema decreased to involve
only her toe, but toe became extremely red and painful. She
reports that she could not walk on her foot due to the extreme
pain. Swelling has remained constant during this time.
Pt denies fevers, chest pain, palpitation, or calf swelling. She
denies having had prior episodes of cellulitis. Does not recall
any cuts or scratches over her foot, and denies new shoes or
footwear.
In the ED, initial VS were 98 80 158/56 18 100% RA. Exam notable
for redness and swelling over dorsum of her L foot. A plain film
of the foot was unremarkable. Labs showed a leukocytosis and
hyperkalemia. Seen by podiatry in the ED who attempted I&D but
without purulent return. Started on vanc and unasyn and admitted
to medicine.
On the floor patient appears well. Temp 99.2 BP 166/54 91 18 98%
RA.
ROS: (+) as per HPI. A 12-point ROS is otherwise unremarkable.
Past Medical History:
- IDDM Type 1, diagnosed in ___, last A1c 10.3 in ___
- ESRD on nightly PD
- Diabetic retinopathy
- MDD
- Renal artery stenosis with left RA angioplasty
- Hypertension
- Hyperlipidemia LDL
- Bilateral carotid stenosis
- Anemia in chronic kidney disease
Social History:
___
Family History:
Diabetes Type II in Maternal Grandmother
Lung Cancer, ___ Infarction in Maternal Grandfather
___, Gout in Father (deceased)
___ in Father and Sister
___ in Mother
No family history of kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 99.2, BP 166/57, HR 91, RR 18, 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no LAD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, systolic ejection
murmur
LUNGS - CTAB, no r/rh/wh, good air mvmt, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, PD exit site covered by dressing c/d/i, no
surrounding eythema
EXT - No ___ edema, area of warmth and erythema extending ___ up
L foot that is extremely TTP, most prominent over lateral 3 toes
NEURO - CNs III-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout
SKIN - No rashes or lesions
DISCHARGE PHYSICAL EXAM:
VS - T 98.8, BP 125/46, HR 83, RR 18, O2 96% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no LAD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, systolic ejection
murmur
LUNGS - CTAB, no r/rh/wh, good air mvmt, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, PD exit site covered by dressing c/d/i, no
surrounding eythema
EXT - No ___ edema, interval decrease in L foot erythema, no TTP,
sensation intact over distal toes bilaterally
NEURO - CNs III-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout
SKIN - No rashes or lesions
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-18.6*# RBC-3.62*# Hgb-11.2*#
Hct-34.6*# MCV-95 MCH-31.0 MCHC-32.5 RDW-12.8 Plt ___
___ 04:15PM BLOOD WBC-17.4* RBC-3.56* Hgb-11.1* Hct-33.4*
MCV-94 MCH-31.1 MCHC-33.1 RDW-12.8 Plt ___
___ 02:00PM BLOOD Neuts-87.2* Lymphs-4.4* Monos-4.8 Eos-3.2
Baso-0.4
___ 04:15PM BLOOD Neuts-84.6* Lymphs-6.6* Monos-5.5 Eos-3.1
Baso-0.3
___ 02:00PM BLOOD Plt ___
___ 04:15PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-93 UreaN-77* Creat-8.5* Na-135
K-6.1* Cl-95* HCO3-22 AnGap-24*
___ 04:15PM BLOOD Glucose-115* UreaN-77* Creat-8.6* Na-136
K-5.7* Cl-96 HCO3-25 AnGap-21*
___ 02:07PM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-10.1 RBC-3.27* Hgb-10.2* Hct-31.2*
MCV-95 MCH-31.0 MCHC-32.6 RDW-12.8 Plt ___
___ 05:35AM BLOOD Neuts-69.6 Lymphs-16.2* Monos-9.5
Eos-4.3* Baso-0.5
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-324* UreaN-60* Creat-8.7* Na-135
K-4.9 Cl-95* HCO3-24 AnGap-21*
___ 05:35AM BLOOD Calcium-8.9 Phos-8.7* Mg-2.3
MICROBIOLOGY:
___ BLOOD CULTURE x 2: Pending
IMAGING:
FOOT AP,LAT & OBL LEFT Study Date of ___
IMPRESSION: No radiographic findings of acute osteomyelitis.
Brief Hospital Course:
This is a ___ female with a h/o TIDM complicated by ESRD on
nightly peritoneal dialysis who p/w left foot swelling, pain,
and erythema concerning for cellulitis.
ACTIVE ISSUES:
# Cellulitis - Patient presented with area of cellulitis over
her distal left foot. There was no clear portal of entry.
Patient was initially treated with IV vancomycin and unasyn and
oral ciprofloxacin. Her WBC trended downward, and cellulitis
improved on this regimen. Patient did report that she had
difficulty ambulating due to the pain, and she was seen by
Physical Therapy while in house who fit her with crutches on
discharge. Patient was discharged on oral regimen of bactrim and
ciprofloxacin for a total 10 day course.
# Type I DM - Patient has a history of poorly controlled TIDM.
Her most recent HgA1c prior to admission was 10.3 in ___.
HgA1c was obtained in hospital and was 10.5 in house. Patient's
sugars ranged from 100s to 400s while in house. Patient was
maintained on home insulin regimen of insulin glargine 20 units
per night plus sliding scale. She will need close follow-up of
insulin regimen as outpatient.
# ESRD on PD - Patient was continued on peritoneal dialysis
while in house. She was continued on her phophate binder, and
maintained on a low K/Phos diet. She was followed by renal
fellow while in hospital. She was also kept on fluconazole 100
mg q48 hours for prevention of fungal peritonitis.
# Blood pressure - Patient has a long history of poorly
controlled HTN. She was hypertensive on admission and was
initially continued on all home BP medications and ASA. Patient
had several episodes of hypotension (systolics dropping into
___ in the setting of decreased PO intake, change in PD
regimen, and emesis. Patient received gentle fluids and
torsemide was temporarily held, with resolution of hypotension.
CHRONIC ISSUES:
# HL - Patient was continued on home statin during
hospitalization.
TRANSITIONAL ISSUES:
# Follow-up of L foot cellulitis to monitor for resolution and
to ensure that patient is able to ambulate well without
crutches.
# Given uncontrolled sugars during hospitalization, patient will
need close follow-up of insulin regimen as an outpatient.
# Per renal team, patient should continue on fluconazole 100 mg
qd for 7 days after discharge for prevention of fungal
peritonitis. Continuation after 7 days should be decided by the
patient's outpatient peritoneal dialysis nurse.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Gabapentin 100 mg PO DAILY
3. Lisinopril 40 mg PO BID
4. Torsemide 40 mg PO QAM
5. Torsemide 20 mg PO QPM
6. Ciprofloxacin HCl 250 mg PO Q24H
7. Nystatin Oral Suspension 5 mL PO TID
8. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
9. Labetalol 100 mg PO BID
10. Atorvastatin 20 mg PO DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Amlodipine 10 mg PO DAILY
13. HydrALAzine 50 mg PO Q6H
14. Docusate Sodium 100 mg PO BID:PRN Constipation
15. Acetaminophen 500 mg PO Q6H:PRN Pain
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Daily Disp
#*8 Tablet Refills:*0
6. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
7. Nystatin Oral Suspension 5 mL PO TID
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*16 Tablet Refills:*0
9. Fluconazole 100 mg PO Q24H
Continue for 7 days.
RX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth Daily
Disp #*7 Tablet Refills:*0
10. Torsemide 20 mg PO QPM
11. Torsemide 40 mg PO QAM
12. sevelamer CARBONATE 2400 mg PO TID W/MEALS
13. Lisinopril 40 mg PO BID
14. Labetalol 100 mg PO BID
15. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
16. HydrALAzine 50 mg PO Q6H
17. Gabapentin 100 mg PO DAILY
18. Docusate Sodium 100 mg PO BID:PRN Constipation
19. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Three times daily Disp
#*15 Tablet Refills:*0
20. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 tablet(s) by mouth TID before meals
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Cellulitis
secondary diagnoses: diabetes, end stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at the ___!
You were admitted due to foot redness, swelling, and pain due to
an infection. Your foot improved with intravenous antibiotics.
You will go home with oral antibiotics and follow-up with your
primary care physician. You also had elevated sugars while in
the hospital, and will need follow-up with your primary doctor
and endocrinologist. The details of these appointments are
included below. However, you should try to call your primary
care office on ___ to get an earlier appointment if possible
to evaluate your blood sugars and to ensure that it is safe for
you to return to work.
You were evaluated by physical therapy who felt that you were
safe to return home.
If you have any concerns regarding your dialysis, please call
your PD nurse.
Please start the following medications:
- Bactrim
- Ciprofloxacin
- PhosLo
- fluconazole
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10717791-DS-10
| 10,717,791 | 29,221,831 |
DS
| 10 |
2187-03-15 00:00:00
|
2187-03-16 19:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
agitation/insomnia
REASON FOR MICU: Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubated at outside hospital
History of Present Illness:
Mr. ___ is an ___ y/o man with a PMH of CKDIV (baseline
Cr ~3.0), COPD, HFpEF, HTN, T2DM, transferred from ___
with hypoxic respiratory failure and NSTEMI.
He was recently admitted to ___ from ___ to
___ for worsening dyspnea, lower extremity edema, and
agitation at home, which was thought to be due primarily to
volume overload from renal failure, partly from decompensated
heart failure, as well as possible COPD exacerbation. He was
treated with a course of cefazolin for cellulitis. For his
agitation, he was switched from olanzapine to haloperidol, and
geriatric psychiatry placement was attempted, but unsuccessful
on this admission. He did have EEG monitoring that was
consistent with episodic sharp beta wave activity, for which
valproic acid was initiated. MRI at ___ demonstrated
age-related involution, small vessel ischemic
leukoencephalopathy and old stroke. He was discharged home.
He presented to ___ on ___ for geriatric-psychiatry
evaluation for agitation and insomnia as well as increased leg
swelling. He was seen by his nephrologist Dr. ___ the day
prior, where he was noted to have no change in kidney function.
He continued to be agitated, for which he was given olanzapine
and lorazepam. Serial EKGs were monitored, at which point he was
found to have lateral ST depressions and an elevated troponin,
which resolved. He was initiated on a heparin gtt. He did,
however, become acutely hypoxic to the ___, reportedly, for
which he was intubated and transferred.
On arrival to the ___ ED, his vitals were: T 96.8F BP 125/88
mmHg P 76, RR 20, O2 100% on ventilator. Labs were notable for
Na 138, K 5.5, Cl 100, HCO3 14, BUN 78, Cr 2.9, Gluc 104, Trop
0.47, MB 37, Ca 8.9, Mg 2.5, Phos 7.1, ___ 10899. VBG:
7.20/___, lactate 1.9. INR 1.1. WBC 7.4, H/H 9.1/29.1, PLT 282.
Cardiology evaluated the patient in the ED, and a bedside TTE
demonstrated normal ejection fraction and no focal wall-motion
abnormalities. His presentation was thought consistent with
demand NSTEMI and acute pulmonary edema in the setting of volume
overload from renal failure. He was continued on his heparin gtt
and admitted to the MICU.
On arrival to the MICU, he was intubated and sedated. On
speaking with his family, they reported that he has had multiple
admissions over the last several months for swelling in his legs
and agitation. Each time, the agitation appears to improve after
placement of the Foley catheter. They noted that he did not have
any fevers, chills, cough or chest pain and that his primary
problem was insomnia and agitation.
Past Medical History:
- CKDIV (baseline Cr ~3.0) ___ diabetic nephropathy
- COPD
- HFpEF
- HTN
- T2DM (last A1c 9.7% ___
- spinal stenosis
- hx of R eye blindness ___ accident
Social History:
___
Family History:
- father died of unknown causes
- mother passed away from "old age"
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 97.9F BP 107/44 mmHg P 68 RR 15 O2 97% on PSV ___/100%
FiO2
General: Intubated and sedated.
HEENT: R pupil non-reactive; L pupil pinpoint and reactive.
Anicteric sclerae.
Neck: JVP elevated to mandible at 30 degrees.
CV: RRR, no MRGs; normal S1/S2.
Pulm: Intubated; crackles L>R. No wheezes appreciated.
Abd: Soft, non-tender, non-distended. NABS.
GU: Foley in place, draining clear urine.
Ext: Warm, well-perfused. Bilateral, pink appearing shins with
anterior pitting. 2+ DP pulses.
Neuro: Sedated.
DISCHARGE PHYSICAL EXAM
=======================
VS - 98.0 PO 152 / 53 53 18 98 Ra
General: Elderly gentleman, Alert to name, named hospital as
___, year ___
HEENT: Blind in R eye with large, irregularly shaped pupil
Neck: supple, JVP difficult to assess
CV: Irregularly irregular, tachycardic
Lungs: faint bibasilar crackles, good air movement
Abdomen: distended, soft, normoactive bowel sounds
GU: foley in place
Ext: no erythema, trace edema
Skin: bilateral shins with linear scabs, dry without purulence
Pertinent Results:
ADMISSION LABS
==============
___ 07:49AM BLOOD WBC-7.4 RBC-2.77* Hgb-9.1* Hct-29.1*
MCV-105* MCH-32.9* MCHC-31.3* RDW-13.6 RDWSD-52.9* Plt ___
___ 07:49AM BLOOD Neuts-80.8* Lymphs-9.4* Monos-8.7
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.96 AbsLymp-0.69*
AbsMono-0.64 AbsEos-0.02* AbsBaso-0.02
___ 07:49AM BLOOD ___ PTT-38.6* ___
___ 07:45AM BLOOD Glucose-104* UreaN-78* Creat-2.9* Na-138
K-5.5* Cl-100 HCO3-14* AnGap-30*
___ 07:45AM BLOOD CK-MB-37* MB Indx-4.2 cTropnT-0.47*
___
___ 07:45AM BLOOD Albumin-3.0* Calcium-8.9 Phos-7.1* Mg-2.5
___ 01:07AM BLOOD VitB12-928* Folate-4
___ 01:15PM BLOOD %HbA1c-8.1* eAG-186*
___ 12:44PM BLOOD Osmolal-325*
___ 01:07AM BLOOD TSH-1.2
___ 08:27AM BLOOD ___ pO2-110* pCO2-44 pH-7.20*
calTCO2-18* Base XS--10 Comment-GREEN TOP
___ 08:27AM BLOOD Lactate-1.9
CARDIAC ENZYMES
===============
___ 07:45AM BLOOD CK-MB-37* MB Indx-4.2 cTropnT-0.47*
___
___ 12:44PM BLOOD CK-MB-54* cTropnT-0.73*
___ 12:10AM BLOOD CK-MB-50* cTropnT-1.20*
___ 04:21AM BLOOD CK-MB-39* cTropnT-1.29*
___ 02:00PM BLOOD CK-MB-24* cTropnT-1.75*
___ 02:19AM BLOOD CK-MB-6 cTropnT-2.55*
___ 05:45AM BLOOD CK-MB-4 cTropnT-3.07*
PERTINENT INTERVAL LABS
========================
___ 02:19AM BLOOD VitB12-944*
___ 01:07AM BLOOD VitB12-928* Folate-4
___ 01:15PM BLOOD %HbA1c-8.1* eAG-186*
___ 01:07AM BLOOD TSH-1.2
MICROBIOLOGY
============
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 11:21 am SPUTUM
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
All Urine and Blood Cultures: No growth
IMAGING/STUDIES
===============
CHEST (PORTABLE AP) (___):
FINDINGS:
ET tube terminates 5.5 cm above the carina. NG tube with tip
and side hole below the diaphragm.
There is moderate to severe pulmonary edema. Complete
silhouetting of the
left hemidiaphragm likely due to a combination of pleural fluid
and left lower lobar collapse. An underlying pneumonia cannot
be excluded. Moderate
cardiomegaly. No pneumothorax.
IMPRESSION:
1. Appropriate position of lines and tubes.
2. CHF exacerbation with cardiomegaly, moderate pulmonary edema,
and a large left pleural effusion.
3. Left lower lobar atelectasis/collapse. An underlying
pneumonia cannot be excluded.
RENAL U.S. (___):
FINDINGS:
The right kidney measures 11.5 cm. The left kidney measures 10.6
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally. There is moderate edema within the adjacent
perinephric fat. No focal fluid collection is seen.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
No hydronephrosis.
ECHO (___):
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - ventilator.
Conclusions
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 number of aortic valve leaflets cannot be determined. There
is no aortic valve stenosis. No aortic regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Limited study.
CHEST (PORTABLE AP) (___):
FINDINGS:
Moderate, somewhat asymmetrical edema is minimally improved from
the prior
examination. There there is no pneumothorax. There may be a
small left
pleural effusion. The cardiomediastinal and hilar contours are
unchanged.
IMPRESSION:
Moderate edema is minimally improved from the prior examination.
Likely small left pleural effusion.
___ CT Head w/o Contrast
IMPRESSION:
I
m
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e
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.
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or recent infarction. Partial opacification of the left mastoid
air cells.
___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of a slower than typical and poorly modulated background. This
finding can be seen in patients with widespread areas of
subcortical or deeper midline
dysfunction such as can be seen with subcortical dementias
and/or with mild
encephalopathies. Interval findings were conveyed to the
treating team
intermittently during this recording period.
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-5.6 RBC-2.75* Hgb-9.0* Hct-28.2*
MCV-103* MCH-32.7* MCHC-31.9* RDW-14.5 RDWSD-54.0* Plt ___
___ 06:45AM BLOOD Glucose-129* UreaN-59* Creat-2.7* Na-142
K-4.3 Cl-105 HCO3-24 AnGap-17
___ 06:45AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2
Brief Hospital Course:
for Outpatient Providers: **Anticipated rehab stay < 30 days.**
___ man with history of Stage CKD (baseline Cr ~ 3), COPD,
diastolic CHF, HTN, DMII, progressive dementia and multiple
recent admission for fluid over load attributed to ___
exacerbtion +/- worsening renal failure and requiring aggressive
diuresis (IV bumetanide and metolazone previous OSH admission).
Transferred on ___ from ___ to ___ MICU with acute
hypoxemic respiratory failure due to acute diastolic CHF in the
setting of NSTEMI.
Hospital course: At OSH required intubation (extubated ___.
TTE showed normal EF without WMA. EKG showed lateral ST
depressions and elevated toponin. In MICU managed for demand
NSTEMI and acute pulmonary edema. Course complicated by atrial
fibrillation currently rate controlled on PO metoprolol + dilt
and anticoagulated with warfraine. On vanc/ceftazidime ___
for suspected aspiration pneumonia. Diuresed initially with
120mg IV Lasix + chlorothiazide, transitioned on ___ to PO
torsemide. Delirium managed with riperidal 2.5mg TID with 2.5mg
PRN agitation.
Problem Summary:
- Delirium: likely multifactorial in setting of acute illness
and underlying dementia. In resolution
- Acute on Chronic Diastolic CHF: euvolymic currently after
aggressive diuresis and stable on home torsemide
- NSTEMI: significant trop elevation (>3.0) and ST depressions.
Thought to be type II per cards.
- New onset Afib w/RVR in ICU, converted spontaneously to sinus
after transfer to medical floor. In sinus HR is in the 50's on
currently metoprolol + dilt. At anticoagulation goal on
warfarine for CHADS-VASC 6
- Acute on diabetic CKD Stage IV: thought to be cardiorenal +/-
possible obstruction.
- Urinary retention: s/p failed voiding trial on ___. Currently
on foley with plan for outpatient voiding trial. Discharged on
doxazosine.
- DMII: home glimepiride held given renal failure and
possibility that mau have contributed to fluid retention.
Discharged on Lantus + ISS. (HbA1c 8.1 ___
- HTN: Initially held home labetalol and hydralazine.
Hydralazine was restarted before discharge, but labetalol was
not given initiation of Metoprolol as above. Doxazosin 2mg was
initiated for treatment of HTN and urinary retention. RAS
inhibitors not used given renal failure.
- macrocytic anemia - normal B12, Folate 4 (low end normal).
- Spinal steonsis
- Apiratin risk: evaluated by speach and swallow service in
house. recommended dysphagia diet.
- Nutrition: Nepro TID (thickened to nectar thick consistency) +
Daily MVI w/Minerals
- Goals of care: DNR, ok for intubation per family meeting
(medicine team + nephrology) on
___ with patient's wife (hc proxy) and two sons.
===================
TRANSITIONAL ISSUES
===================
[ ] ongoing BP /HR monitoring and management by rehab physician
[ ] monitor CBC abd renal functions + electrolytes
[ ] Discharged with foley in place due to failed voiding trial.
Will need repeat voiding trial. Pt has scheduled urology
followup.
[ ] Pt discharged on home dose of Torsemide 20mg daily. Please
obtain daily standing weights. If weight increases by more than
3lbs or pt develops O2 requirement, please call PCP or have pt
seen by ___ MD for diuretic adjustment
[ ] Mental status: Pt AAOx1 on discharge, knows name, knew he
was in a hospital (but not which one), could not consistently
state correct year
[ ] Please check INR on ___ along with chem 7; adjust warfarin
dose as needed for INR goal ___
[ ]CONTACT: Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. glimepiride 4 mg oral DAILY
2. Torsemide 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Fentanyl Patch 12 mcg/h TD Q72H
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. TraZODone 50 mg PO QHS:PRN insomnia
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Omeprazole 20 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
12. Nicotine Patch 21 mg TD DAILY
13. HydrALAZINE 50 mg PO BID
14. Labetalol 200 mg PO BID
15. Divalproex (DELayed Release) 250 mg PO DAILY
16. sevelamer HYDROCHLORIDE 800 mg oral TID W/MEALS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Doxazosin 2 mg PO HS
6. Escitalopram Oxalate 5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheeze
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
13. RisperiDONE 0.25 mg PO QHS
14. Senna 8.6 mg PO BID Constipation
15. Warfarin 4 mg PO DAILY16
16. Acetaminophen 1000 mg PO Q8H
17. Lidocaine 5% Patch 2 PTCH TD QAM
18. Polyethylene Glycol 17 g PO DAILY constipation
19. Divalproex (DELayed Release) 250 mg PO DAILY
20. Docusate Sodium 100 mg PO BID
21. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
22. HydrALAZINE 50 mg PO BID
23. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
24. Nicotine Patch 21 mg TD DAILY
25. sevelamer CARBONATE 800 mg PO TID W/MEALS
26. Torsemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnoses: Acute on chronic heart failure, acute kidney
injury, NSTEMI
Secondary Diagnoses: Delirium, urinary retention, AFib,
diabetes, hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were transferred to ___ from ___ with heart failure
that was making it difficult for you to breathe, as well as a
mild heart attack.
WHAT HAPPENED WHILE YOU WERE HERE?
You were first in the ICU because you required a tube and
machine to help you breathe. We used IV diuretic medications to
help get extra fluid off of your lungs. Your kidneys were
injured because of your heart problems, so we adjusted some
medications to help with this. You also had some problems with
confusion and agitation, for which we adjusted some of your
medications.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
We are discharging you to rehab. You should work on getting your
strength back, and be sure to follow up with all of your
doctors. ___ continue to take all of your medications as
directed.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10717791-DS-11
| 10,717,791 | 25,824,787 |
DS
| 11 |
2187-07-14 00:00:00
|
2187-07-15 19:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ y/o man with PMH notable for COPD not
on home O2, HFpEF, urinary retention, chronic back pain on
high-dose opioid therapy, presenting with acute-on-chronic
abdominal pain and constipation.
The patient was recently admitted to ___ between
___ for a similar issue. During that hospitalization,
work-up included negative CT scan, negative blood work for
infection, and evaluation by GI as well as psychiatry. Overall
impression as that his pain was manifestation of constipation.
He was treated with increased bowel regimen and also underwent
multiple other medication changes, including discontinuation of
Haldol and Depakote (?medication intolerance vs. lack of
therapeutic benefit). He was started on marinol for agitation as
well.
Subsequently, after discharge, he presented again to the ___ on
___ (2 days prior to admission) for the same constellation of
symptoms. He again had negative work-up, this time in the ___,
and was discharged home, per report after passing BM and noting
some improvement in symptoms.
Since discharge from the ___, the patient states that
he has had ongoing abdominal pain localized to this LUQ and LLQ.
He states that the pain comes in waves, occurring every few
minutes, and is craming in nature. He feels like he needs to
make a BM, but can't. He is passing gas regularly and small BM's
almost daily. His last BM was on day of presentation to the ___
and he describes it as small and black without evidence of
blood. He has taken his prescribed pain mediations and he thinks
other medications as well for these symptoms with little relief.
He has been unable to eat for at least the past 24 hour ___
pain.
ROS otherwise negative for any N/V, chest pain/pressure, SOB,
increased abdominal swelling, ___ swelling, fevers, chills,
dysphagia.
In the ___, initial VS were .
-98.6 55 164/48 18 100% RA
Exam notable for:
-Alert, pleasant, conversant, oriented x3, c/o abdominal pain
-Lungs CTABL, no wheeze or crackle
-RRR +S1S2
-No spinal tenderness, no CVAT
-Abd soft, nd, ttp LLQ mod, ttp RUQ/RLQ mild
-BLE without edema, wwp
Labs showed:
-CBC notable for Hg 8.7 (baseline 9), Plt 137 (baseline 160)
-Chem10 with BUN/Cr 54/2.5 (lower than prior recorded values,
ranging from 2.6-4.1), Bicarb 20, AG 12
Imaging showed
-CT as below without evidence of diverticulitis
-ECG per my read: sinus bradycardia with ventricular rate of 57,
left atrial abnormality; ?prior anterior wall infarction;
compared with prior on ___, overall similar
Received:
-1L NS
-morphine 4mg IV x1
Decision was made to admit to medicine due to multiple recent
admissions for similar problem.
Transfer VS were:
-97.6 55 118/63 16 95% RA
On arrival to the floor, patient endorses ongoing waves of pain,
stating "my rectum is on fire." He endorses the above history
and states that he needs to go to the bathroom, but does not
think he will be able to.
REVIEW OF SYSTEMS: 10-point review of system negative except as
stated above.
Past Medical History:
- pAF (diagnosed ___, CHADS2 4, previously on warfarin,
currently not)
- CKD, stage IV (baseline Cr ~3.0) ___ diabetic nephropathy
- COPD not on home O2
- HFpEF (LVEF >55% ___
- HTN
- T2DM (last A1c 9.7% ___
- spinal stenosis
- hx of R eye blindness ___ accident
- Chronic abdominal pain
- Depression c/b history of agitation, especially while
hospitalized
Social History:
___
Family History:
- father died of unknown causes
- mother passed away from "old age"
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.4 189/47 55 22 93 RA
GENERAL: Lying in bed on his left side initially. Alert,
interactive. Looks uncomfortable ___ abdominal pain
HEENT: AT/NC, EOMI, R pupil significant larger than left with
intact but very sluggish response to light (baseline per patient
___ traumatic injury to right eye), anicteric sclera, pink
conjunctiva, MMM, missing teeth, small ulceration in upper hard
palate; tongue midline on protrusion; unable to smile given his
discomfort, but symmetric eyebrow raise
NECK: nontender supple neck, no LAD appreciated, JVP unable to
be visualized as patient lying on his side in pain and breathing
heavily ___ pain
HEART: RRR, S1/S2, unable to appreciate any m/r/g over the
patient's loud, rapid breathing ___ abdominal discomfort
LUNGS: CTAB, no crackles; + mild end-expiratory wheeze; mild
rhonchorous breath sounds diffusely
ABDOMEN: nondistended, +BS, TTP in LLQ and LUQ, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing; 1+ edema in b/l ankles; warm
well perfused
GU: foley in place; rectal exam with intact tone, empty vault,
trace stool was guaiac negative, not melanotic or bloody
PULSES: 2+ DP pulses bilaterally
NEURO: strength ___ in b/l UE; able to lift both legs up against
gravity; sensation to light touch grossly intact and symmetric
in bilateral UE, torso, and ___
SKIN: warm, dry
DISCHARGE PHYSICAL EXAM
=======================
VS: 97.8 171/64 53 18 94% Ra
GENERAL: Lying in bed on his left side. Alert, interactive,
oriented x2. Looks uncomfortable
HEENT: AT/NC, EOMI, R pupil significant larger than left with
intact but very sluggish response to light (baseline per patient
___ traumatic injury to right eye)
HEART: RRR, S1/S2, no appreciable m/r/g
LUNGS: Mildly decreased breath sounds at left lung base with
patient laying on left side.
ABDOMEN: nondistended, +BS, non-tender, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing; 1+ edema in b/l ankles; warm
well perfused
GU: foley in place draining yellow urine
PULSES: 2+ DP pulses bilaterally
NEURO: strength ___ in b/l UE; able to lift both legs up against
gravity; sensation to light touch grossly intact and symmetric
in bilateral UE, torso, and ___
SKIN: warm, dry
Pertinent Results:
ADMISSION LABS
==============
___ 10:32PM BLOOD WBC-7.1 RBC-2.54* Hgb-8.7* Hct-26.5*
MCV-104* MCH-34.3* MCHC-32.8 RDW-13.8 RDWSD-52.5* Plt ___
___ 10:32PM BLOOD Neuts-60.3 ___ Monos-10.6 Eos-4.2
Baso-0.4 Im ___ AbsNeut-4.26 AbsLymp-1.71 AbsMono-0.75
AbsEos-0.30 AbsBaso-0.03
___ 06:54AM BLOOD ___ PTT-31.0 ___
___ 10:32PM BLOOD Glucose-133* UreaN-54* Creat-2.5* Na-135
K-4.4 Cl-103 HCO3-20* AnGap-16
___ 06:54AM BLOOD ALT-21 AST-16 LD(LDH)-146 AlkPhos-78
TotBili-0.4
___ 06:54AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.7 Mg-2.1
___ 10:42PM BLOOD Lactate-1.6
MICRO
=====
___ 10:32 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:39 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=======
CT ABD/PELVIS W/O CONTRAST ___:
IMPRESSION:
1. Mild pericholecystic stranding. No evidence of a gallstone.
Clinical
correlation for acute cholecystitis is recommended.
2. Intermediate density rounded focus measuring 3.7 cm in
maximal diameter in the right lobe of the liver (series 2:22)
which is indeterminate. MRI is recommended for further
characterization.
3. Bilateral renal lesions which may reflect cysts but can be
evaluated by
MRI.
4. Colonic diverticulosis without evidence of diverticulitis.
HIDA SCAN ___:
FINDINGS: Serial images over the abdomen show homogeneous
uptake of tracer into the hepatic parenchyma.
At 7 minutes, the gallbladder is visualized with tracer activity
noted in the small bowel at 44 minutes.
IMPRESSION: Normal hepatobiliary scan.
CXR ___:
FINDINGS:
PA and lateral views of the chest provided.
There has been interval decrease in size of a left pleural
effusion.
Atelectatic changes at the left base are also slightly improved.
Atelectasis at the right base is stable. Mild pulmonary
vascular congestion is not significantly changed. There is no
definite focal consolidation. There is no pneumothorax. Mild
cardiomegaly stable.
IMPRESSION:
Interval improvement of small left-sided pleural effusion.
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-5.1 RBC-2.67* Hgb-9.1* Hct-28.2*
MCV-106* MCH-34.1* MCHC-32.3 RDW-14.2 RDWSD-54.4* Plt ___
___ 06:10AM BLOOD Plt ___
___ 02:39PM BLOOD Glucose-126* UreaN-46* Creat-2.9* Na-138
K-3.6 Cl-105 HCO3-23 AnGap-14
___ 02:39PM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ y/o man with PMH notable for dementia
(A&Ox1 at baseline), COPD not on home O2, HFpEF, urinary
retention, chronic back pain, admitted for management of
acute-on-chronic abdominal pain and self-reported constipation.
He had an extensive workup including infectious workup,
abdominal CT, HIDA scan with no evidence of infection or acute
pathology causing his symptoms. He did have a significant stool
burden and was treated with an aggressive bowel regimen to
relieve his constipation. He was also volume overloaded in the
setting of holding his home diuretics and received IV furosemide
with improvement in his oxygenation. He was discharged at a
weight of 117.8kg. He was also delirious during his
hospitalization and was started on mirtazapine to help with
sleep. Speech and swallow evaluated him for aspiration risk and
recommended 1:1 observation of meals to reduce aspiration risk,
regular food, thin liquids, and meds whole in pureed foods.
ACTIVE:
---------
# Acute-on-Chronic Abdominal Pain: The patient presented with
his ___ medical visit to an ___ facility over past 2 weeks
for sx of colicky abdominal pain. He was initially benign
appearing on exam but after eating he developed RUQ pain and
nausea/vomiting. His CT abdomen was relatively unremarkable but
did show some pericholecystic stranding so he underwent HIDA
scan which was normal and did not show any evidence of
hepatobiliary pathology. The rest of his workup was unrevealing
for infectious etiology including no evidence of UTI. Ultimately
his pain was attributed to constipation and he was treated with
an aggressive bowel regimen including Colace, senna, BID
miralax, dulcolax and was able to have a bowel movement. He was
additionally thought to have bladder spasms and required
placement of a foley catheter given urinary retention. He should
continue an aggressive bowel regimen as an outpatient to help
prevent constipation.
# Acute on chronic heart failure with preserved ejection
fraction (LVEF >55% ___: Diuretics were initially held
given concern for infection and patient became volume overloaded
requiring 2L NC. He was diuresed with IV furosemide and was
oxygenating well on room air prior to discharge. His home
diuretics were restarted prior to discharge. He was continued on
his home calcium channel blocker and beta blocker. Discharged at
a weight of 105kg.
# Medication reconcilitation: The patient has also been in
multiple different hospitals with multiple medication changes
made recently. Med reconciliation was performed with son and
daughter-in-law, updated as per their report; was not on
fentanyl patch or sevelamer at home; has not been on Coumadin in
the past and is diet controlled for diabetes.
- Discontinued Ativan during this hospitalization as not optimal
medication (deliriogenic) given dementia
- not on anticoagulation for his ___ need outpatient
discussion
- not on antihyperglycemics, with lenient A1c goal; however did
not require insulin sliding scale while inpatient
- not on bicarbonate for chronic acidosis in CKD; will need
outpatient discussion
- For COPD he is on Advair, but could consider transition to
___ per ___ COPD guidelines
# Goals of care: Per attending discussion with patient and
family, DNR/Ok to intubate. Given aspiration risk and recurrent
hospitalizations, it will be important to continue to address
goals of care as an outpatient.
# Non-anion gap metabolic acidosis: mild, Bicarb of 20, likely
___ CKD however patient is not on any bicarbonate as an
outpatient. Should consider initiation of bicarbonate for
chronic acidosis as an outpatient.
# Anemia, chronic: macrocytic, with mild thrombocytopenia as
well. He does have recent B12 level that is normal in ___. No
recent iron labs. Could be ___ combination of CKD and primary
marrow insufficiency with advance age. Consider further
outpatient workup.
CHRONIC:
--------
# pAF: patient with pAF noted on prior discharge summary,
controlled with beta blockade and calcium channel blockers. He
has CHADS2 of 4 though per family has not been on warfarin in
the past. Needs outpatient discussion regarding potential
initiation of anticoagulation.
- continued home BB and CCB
# CKDIV (baseline Cr ~3.0) ___ diabetic nephropathy: Cr 3.0
prior to discharge, relatively stable throughout admission. Not
taking sevelamer at home.
# COPD not on home O2:
- continued home advair
- albuterol nebs PRN
- Needs consideration of ___ per ___ COPD guidelines
# HTN:
- continued home diltiazem, metoprolol, and hydralazine
# T2DM (last A1c 9.7% ___: Diet controlled at home per
family. Continued aspirin and atorvastatin for cardiovascular
protection. Did not require sliding scale insulin while
in-house.
# BPH/chronic urinary retention: Has long history of difficulty
with urinary retention, perhaps related to BPH. He had foley
replaced this admission as he was retaining urine. Home
finasteride was continued. Tamsulosin dose was increased and he
was instructed to follow up with urology for voiding trial.
# History of tobacco abuse: continued nicotine patch
# H/o agitation with possible contribution from underlying
depression: Patient became delirious during hospitalization. He
was started on mirtazapine while in-house and required extra
trazodone on top of his home trazodone for intermittent
agitation. His home citalopram was continued. Ativan was
discontinued as it is potentially deliriogenic.
# Gastroesophageal reflux disease: continued home pantoprazole
TRANSITIONAL ISSUES
===================
[ ] Patient with aspiration risk, will need 1:1 supervision for
meals to reduce risk, seen by speech & swallow while inpatient;
also recommended regular food with thin liquids, meds whole in
pureed foods
[ ] Continue to monitor constipation and increase bowel regimen
as needed
[ ] Consider initiation of ___ for COPD instead of advair
per ___ COPD guidelines as clinically indicated
[ ] Discontinued Ativan as potentially deliriogenic
[ ] Ensure follow up with urology for urinary retention, foley
was placed and will need voiding trial
[ ] Consider initiation of bicarbonate for chronic acidosis with
CKD as clinically indicated
[ ] Consider initiation of systemic anticoagulation for atrial
fibrillation with CHADsVASC of 4 as clinically indicated
[ ] Discharge weight: 105kg
#CODE: ___/ok to intubate
#CONTACT: ___: ___
___, wife: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Torsemide 20 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Dronabinol 2.5 mg PO BID
7. HydrALAZINE 50 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Escitalopram Oxalate 20 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Docusate Sodium 100 mg PO BID
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Nicotine Patch 21 mg TD DAILY
15. Aspirin 81 mg PO DAILY
16. LORazepam 0.5 mg PO BID:PRN agitation
17. Polyethylene Glycol 17 g PO DAILY
18. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
19. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tablets by mouth DAILY Disp #*60
Tablet Refills:*0
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
TID W/MEALS Disp #*90 Tablet Refills:*0
5. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 0.5 (One half) tablets by mouth QID:PRN
Disp #*90 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by
mouth twice a day Refills:*0
7. Tamsulosin 0.8 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 2 capsule(s) by mouth at bedtime
Disp #*60 Capsule Refills:*0
8. TraZODone 50 mg PO DAILY:PRN agitation
9. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Dronabinol 2.5 mg PO BID
15. Escitalopram Oxalate 20 mg PO DAILY
16. Finasteride 5 mg PO DAILY
17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
18. HydrALAZINE 50 mg PO BID
19. Lidocaine 5% Patch 1 PTCH TD QPM
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Nicotine Patch 21 mg TD DAILY
22. Pantoprazole 40 mg PO Q24H
23. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Abdominal pain
Acute on chronic heart failure with preserved ejection fraction
Delirium
SECONDARY DIAGNOSIS
===================
Chronic kidney disease stage IV
Chronic obstructive pulmonary disease
Hypertension
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were experiencing abdominal
pain. You had an extensive workup for causes of your abdominal
pain and did not have any evidence of serious infection or
life-threatening causes of your pain. Your abdominal pain was
likely from a combination of constipation and bladder spasms.
You had tests for your gallbladder that showed it was normal
with no infection.
You had a foley catheter placed because you were having
difficulty urinating. You will need to follow up with urology in
1 week to have the foley removed and make sure you can urinate
on your own.
It is important that you continue taking medications to help
treat your constipation to prevent your abdominal pain from
worsening. If you are starting to get constipated, you should
take miralax more frequently, up to three times a day to help
relieve your constipation.
You were started on a new medication mirtazapine to help you
sleep.
It was a pleasure taking care of you and we wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10717791-DS-12
| 10,717,791 | 22,902,908 |
DS
| 12 |
2187-08-29 00:00:00
|
2187-08-31 19:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left hip pain and agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ with PMH notable for dementia, COPD not on home O2, HFpEF,
urinary retention, chronic back pain on ?fentanyl patch,
presenting after a witnessed fall 2 days prior to presentation
to
the hospital. Since the fall patient has had difficulty bearing
weight on the left leg is complaining of L hip pain has had
difficulty ambulating around the house. Fall was witnessed by
his
son who denies any head strike. Patient lives with his wife and
his 2 sons who care for him on a daily basis. There is no new
urinary incontinence or stool incontinence and the patient is
not
complaining of numbness, tingling or weakness.
In the ED, initial VS were: 97.5 90 166/90 18 100% RA.
Labs showed: WBC 7.3, Hb 8.7, Cr 2.8, K 5.2, UA negative.
Imaging showed: CT head and C-spine severely limited by motion
artifact but no definite fracture, no obvious intracranial
hemorrhage or ischemia. Unable to obtain plain films of hip or
chest due to agitation.
Patient was increasingly agitated in the ED limiting ability to
perform work-up and imaging. He received: morphine 4mg IV x1,
olanzapine 2.5mg PO x1, olanzapine 5mg IV x1, Haldol 5mg IM with
improvement in his agitation. Of note, he has been increasingly
difficulty to care for at home according to his son due to
worsening dementia and agitation. Given agitation and
significant
pain, patient was admitted to medicine.
Transfer VS were: 59 142/35 16 95% RA.
On arrival to the floor, patient is agitated that he is woken up
at 4AM. Unable to provide further history. Not complaining of
pain currently.
Past Medical History:
- pAF (diagnosed ___, CHADS2 4, previously on warfarin,
currently not)
- CKD, stage IV (baseline Cr ~3.0) ___ diabetic nephropathy
- COPD not on home O2
- HFpEF (LVEF >55% ___
- HTN
- T2DM (last A1c 9.7% ___
- spinal stenosis
- hx of R eye blindness ___ accident
- Chronic abdominal pain
- Depression c/b history of agitation, especially while
hospitalized
Social History:
___
Family History:
- father died of unknown causes
- mother passed away from "old age"
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T96.8 BP154/52 HR66 RR22 9%RA
GENERAL: Alert and agitated. Intermittently screaming/swearing.
Wants to be able to sleep.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. Lying on L hip but
will not allow palpation or ROM of LLE.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose.
MENTAL: agitated, knows year is ___, thinks he is at CHA.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission:
___ 09:07PM BLOOD WBC-7.3 RBC-2.55* Hgb-8.7* Hct-26.6*
MCV-104* MCH-34.1* MCHC-32.7 RDW-14.5 RDWSD-54.7* Plt ___
___ 09:07PM BLOOD Neuts-60.0 ___ Monos-11.4 Eos-4.0
Baso-0.3 Im ___ AbsNeut-4.37 AbsLymp-1.74 AbsMono-0.83*
AbsEos-0.29 AbsBaso-0.02
___ 06:05PM BLOOD Glucose-122* UreaN-54* Creat-2.8* Na-139
K-5.7* Cl-103 HCO3-17* AnGap-19*
___ 09:07PM BLOOD Glucose-114* UreaN-55* Creat-2.8* Na-139
K-4.8 Cl-104 HCO3-20* AnGap-15
___ 11:10AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.2
IMAGING and STUDIES: Reviewed in ___
CT HEAD WITHOUT CONTRAST IMPRESSION:
1. The study is significantly degraded by motion artifact.
Within these limitations, there is no obvious large acute
intracranial hemorrhage or acute large vascular territorial
infarct.
2. Partial opacification of the left mastoid air cells and
similar to the prior study in ___.
3. Age related global atrophy and chronic microangiopathy.
CT C-SPINE IMPRESSION:
1. Of note, the study is significantly suboptimal due to motion
artifact, particularly at the C5-T1 levels limiting evaluation
at
these vertebrae. Within these limitations, no definite acute
fracture is identified from the C1-C4 levels. A repeat study
can
be obtained for further evaluation of the C5-T1 levels, if there
is high clinical concern.
2. A left pleural effusion is partially imaged.
CT PELVIS IMPRESSION:
1. No evidence of fracture or dislocation in the pelvis or
bilateral hips.
Brief Hospital Course:
___ with PMH notable for dementia, COPD not on home O2, HFpEF,
urinary retention, chronic back pain presenting after a
witnessed fall 2 days prior to presentation to the hospital c/o
L hip pain without e/o fracture with ED
complicated by significant agitation.
ACUTE PROBLEMS
==============
#Acute Encephalopathy:
Likely secondary to constipation, urinary tract infection, pain,
and advancing dementia. Per family, patient has been having
worsening agitation related to worsening depression/anxiety and
dementia at home. Difficult to care for by family. Patient is at
risk for acute delirium given: age, pre-existing neurologic
condition, and medications. Agitation likely worsened by pain
and constipations at admission. Patient was having severe neck
pain and headache likely from anxiety as patient had spastic
muscles on exam. His muscle pain and delirium improved with
administration of low dose Flexeril. Patient was on an
aggressive bowel regimen with goal of 1 BM per day. Psychiatric
team was following the patient during hospitalization and he was
started on standing Seroquel. His escitalopram, mirtazapine and
quetiapine were continued.
In terms of his advancing dementia, he currently lives at home
with his wife and receives help from their sons and a ___ once
weekly. His worsening dementia made it very difficult for him to
go home as he became agitated, making it unsafe for him and his
wife to be left alone. It was recommended that he go to a locked
dementia unit, geriatric psychiatric unit, or receive 24 hour
care at home. The family refused all of this and he will be
discharged home with ___ +/- private help at home but only for a
few hours every day.
#Left HIP PAIN S/P FALL
CT pelvis at admission without evidence of worrisome osseous
lesions or acute fracture. Patient seemed to have an improvement
of his hip pain during hospitalization. Pain was managed with
standing acetaminophen for pain, lidocaine patch PRN to left hip
and tramadol PRN. Patient was seen by ___ who recommended home ___
following discharge.
#SHOULDER PAIN
Patient reported shoulder pain. X ray showing moderate bilateral
AC joint arthropathy, mild to moderate bilateral glenohumeral
osteoarthritis and possible small focus of calcific tendinitis
of the right rotator cuff. Pain likely from muscle spasms as he
was pain free with flexiril.
#CONSTIPATION:
Chronic issue with aggressive home bowel regimen that is likely
causing an acute decline in mental status. Possibly related to
chronic narcotic use. It was managed with lactulose enema,
lactulose PRN and standing senna/Colace/miralax/bisacodyl with 1
bowel movement every day. Family was informed that patient needs
to have a BM every day to prevent constipation.
#UTI
Urine culture with final report with growth for enterococcus.
Patient did not report urinary symptoms but did present with
changes in mental status. He was treated with augmentin for 7
days.
#HYPERTENSION
Patient was hypertensive during hospitalization. Blood pressure
medications adjustments were needed, with increase hydralazine
to 100 mg BID and amlodipine 10 mg daily and metoprolol.
# pAF: On home beta blockers and CCB. He has CHADS2 of 4 though
per family has not been on warfarin in the past (would likely
have high bleeding risk). We initially held his rate control
given HR 50-60s. However, he was later in the hospitalization in
the ___, therefore, metoprolol and titrated to HR 60's.
CHRONIC PROBLEMS
================
#MACROCYTIC ANEMIA: At baseline hemoglobin. Persistently
macrocytic in previous labs. Possibly nutritional deficiency. No
current ETOH use. B12 and TSH levels were normal. Stable during
hospitalization. He receives EPO as outpatient.
#HFpEF: previous discharge weight 117.5 kg. Appear euvolemic
during hospitalization. Continued home torsemide.
# CKDIV (baseline Cr ~3.0) ___ diabetic nephropathy: Cr 2.8 on
admission and stable. Continued sevelamer CARBONATE 800 mg PO
TID W/MEALS.
#HLD: Continued Aspirin 81 mg PO DAILY and Atorvastatin 80 mg PO
QPM
# COPD: not on home O2. Continued home advair. Continued duonebs
nebs PRN.
# T2DM (last A1c 9.7% ___: Diet controlled at home per
family. No current meds. Placed him on HISS while hospitalized.
# BPH/chronic urinary retention: Continued home finasteride and
tamsulosin
# GERD: Continued home pantoprazole
TRANSITIONAL ISSUES
--------------------
[] Urinary Tract Infection: Patient was started on augmentin for
urinary tract infection for 7 days from ___. He will have 1
more day of antibiotics when he leaves the hospital.
[] Worsening Dementia: Patient's family refused 24 hour care but
there is significant concern over patient and wife's safety with
worsening mental status. Currently only discharged with ___.
Please follow up family support.
[] QTc Monitoring: Patient is now on Seroquel standing three
times a day. Please check EKG at next appointment. Discharge QTc
was 455.
[] Hypertension: Blood pressure medications were adjusted and
were increased to hydralazine to 100 mg BID and amlodipine 10 mg
daily and metoprolol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Escitalopram Oxalate 20 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. HydrALAZINE 50 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Nicotine Patch 21 mg TD DAILY
11. Pantoprazole 40 mg PO Q24H
12. Tamsulosin 0.8 mg PO QHS
13. Torsemide 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO BID
15. Bisacodyl 10 mg PO/PR DAILY constipation
16. Mirtazapine 7.5 mg PO QHS
17. Senna 17.2 mg PO DAILY
18. sevelamer CARBONATE 800 mg PO TID W/MEALS
19. Simethicone 40-80 mg PO QID:PRN gas pain
20. TraZODone 50 mg PO BID:PRN agitation
21. Dronabinol 2.5 mg PO BID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO BID Duration: 9 Doses
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*2 Tablet Refills:*0
3. Cyclobenzaprine 5 mg PO QHS:PRN Pain
Do not take if sedated
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every night Disp
#*7 Tablet Refills:*0
4. Lactulose 15 mL PO DAILY
RX *lactulose [Enulose] 10 gram/15 mL 15 mL by mouth daily
Refills:*0
5. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth before bed Disp #*30
Tablet Refills:*0
6. QUEtiapine Fumarate 12.5 mg PO DAILY Give at 2 ___
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
7. QUEtiapine Fumarate 50 mg PO QHS
8. QUEtiapine Fumarate 25 mg PO QAM
RX *quetiapine 25 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
9. HydrALAZINE 100 mg PO BID
RX *hydralazine 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
12. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Bisacodyl 10 mg PO/PR DAILY constipation
16. Docusate Sodium 100 mg PO BID
17. Dronabinol 2.5 mg PO BID
18. Escitalopram Oxalate 20 mg PO DAILY
19. Finasteride 5 mg PO DAILY
20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
21. Mirtazapine 7.5 mg PO QHS
22. Nicotine Patch 21 mg TD DAILY
23. Pantoprazole 40 mg PO Q24H
24. Polyethylene Glycol 17 g PO BID
25. sevelamer CARBONATE 800 mg PO TID W/MEALS
26. Simethicone 40-80 mg PO QID:PRN gas pain
27. Tamsulosin 0.8 mg PO QHS
28. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
--------
Dementia/Delirium
Chronic pain
Constipation
Urinary Tract Infection
Secondary:
Hypertension
COPD
HFpEF
Afib
CKD
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 Mr. ___,
It was a pleasure taking care of you at ___.
What brought you into the hospital?
You came into the hospital because you were confused and
agitated. You had a fall before you came in and was complaining
of severe pain. You had a CT scan of your hip which did not show
a fracture.
You were likely confused because you were very constipated and
had a urinary tract infection.
What was done for you at the hospital?
Your received medications to control your pain and treat your
constipation. We also had a psychiatrist see you who gave you
medications to help with your agitation. Lastly, we gave you
medications for your urinary tract infection.
What should you do after leaving the hospital?
You should follow up with your doctors below and continue to
take your medications. You need to have a bowel movement every
day and should take all of the medications given to you.
We wish you the best,
your care team at ___
Followup Instructions:
___
|
10717791-DS-13
| 10,717,791 | 27,258,866 |
DS
| 13 |
2189-02-27 00:00:00
|
2189-03-02 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx CKD (baseline Cr ~4.5), HFpEF (EF 55%), COPD, DM,
HTN, HLD, CAD, advanced dementia, recent admission for
UTI/pneumonia who presents for hypoxemic respiratory failure.
Pt recently admitted to ___ ___ for weakness. He was
treated for presumed UTI given symptoms of dysuria, urgency, and
frequency, and hx of multiple UTI although Ucx were negative.
Additionally thought to have a pneumonia given O2 requirement
and cough, possible RLL consolidation, and therefore pt was
treated with unasyn transitioned to augmentin on discharge to
complete 10 day course (last day ___. Additionally pt had ___
on CKD, Cr of
5.5 on admission, received IVF and improved to baseline Cr of
4.5 on discharge. Will note that pt has longstanding penile pain
and agitation and had a TURP a couple months ago.
He was at rehab for 1 day but had progressive O2 requirement and
was sent to ___ on ___ for shortness of breath. He was
initially saturating in low ___ on room air and was placed on
NRB. First documented vitals were 98, 165/52, HR 89, O2 100%
NRB. His weight was 116.2kg. Exam notable for diffuse wheezing
bilaterally, no edema, and an alert, conversant but disoriented
man. CXR was consistent with volume overload. He was placed on
Bipap and given 40 mg IV Lasix with 1L urine output. Due to
agitation given 0.5 Ativan x2 and then transferred to ___ ED
due to lack of ICU beds.
___ labs:
Trop T 0.08
Hgb 9.1
WBC 4.2
Plt 134
Cr 4.5
BUN 82
Na 141
K 4.7
Cl 105
CO2 22
Ca 8.3
In the ED, initial vitals were: 68 172/69 17 100% RA
- Labs notable for:
8.2
___ 82
--------------<112
4.6 20 4.8
VBG: 7.34/41
Lactate 0.9
- Imaging was notable for:
CXR:
Mild pulmonary edema, perhaps minimally improved, with small
bilateral pleural effusions and bibasilar compressive
atelectasis.
- Patient was given: furosemide 80mg IV
Upon arrival to the ICU, patient is on BiPAP, but uncomfortable.
BiPAP was stopped and patient placed on 4LNC with good O2 sats.
He is tired, and asking to go home. Denies any pain. Unable to
obtain other history.
Spoke to patient's son ___ who reports that patient lives at
home with his wife and son. Patient has been mostly bedbound and
has repeated hospitalizations for weakness. Also gets
agitated/anxious and receives Seroquel. He notices that he has
been progressively declining at home and wonders if patient
needs to be at an assisted living facility. He states patient
has not had fevers, chills, N/V, chest pain, diarrhea. Has been
coughing.
Review of systems was unable to be performed due to mental
status.
Past Medical History:
- pAF (diagnosed ___, CHADS2 4, previously on warfarin,
currently not)
- CKD, stage IV (baseline Cr ~3.0) ___ diabetic nephropathy
- COPD not on home O2
- HFpEF (LVEF >55% ___
- HTN
- T2DM (last A1c 9.7% ___
- spinal stenosis
- hx of R eye blindness ___ accident
- Chronic abdominal pain
- Depression c/b history of agitation, especially while
hospitalized
Social History:
___
Family History:
- father died of unknown causes
- mother passed away from "old age"
Physical Exam:
ADMISSION
=========
VITALS: Reviewed in MetaVision.
GENERAL: obese, lethargic, hard of hearing, in no acute distress
HEENT: PERRL. EOMI.
CARDIAC: RRR. S1, S2. No mrg
PULMONARY: No accessory muscle usage. Rhonchorous breath sounds
diffusely
ABDOMEN: Soft, nontender, nondistended. +BS
EXTREMITIES: warm, well perfused. No ___ edema
NEURO: CN II-XII grossly intact. Moving all extremities.
Discharge
=========
PHYSICAL EXAM
24 HR Data 24 HR Data (last updated ___ @ 607)
Temp: 98.4 (Tm 98.4), BP: 145/62 (125-145/46-74), HR: 65
(54-68), RR: 18 (___), O2 sat: 96% (92-98), O2 delivery: Ra,
Wt: 239.42 lb/108.6 kg (225.9-239.42)
GENERAL: sitting up in bed, moaning and agitated
NECK: No cervical lymphadenopathy. JVP 7cm
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse wheezes no signs of increased work
of breathing
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis. Trace ___ edema
NEUROLOGIC: AOx1
Pertinent Results:
ADMISSION
=========
___ 09:05PM ___ PTT-34.0 ___
___ 09:05PM PLT COUNT-115*
___ 09:05PM NEUTS-58.5 ___ MONOS-11.4 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-2.81 AbsLymp-1.29 AbsMono-0.55
AbsEos-0.10 AbsBaso-0.02
___ 09:05PM WBC-4.8 RBC-2.48* HGB-8.2* HCT-26.1* MCV-105*
MCH-33.1* MCHC-31.4* RDW-14.0 RDWSD-53.5*
___ 09:05PM ALBUMIN-3.0*
___ 09:05PM ___
___ 09:05PM cTropnT-0.08*
___ 09:05PM LIPASE-120*
___ 09:05PM ALT(SGPT)-12 AST(SGOT)-22 ALK PHOS-121 TOT
BILI-0.4
___ 09:05PM estGFR-Using this
___ 09:05PM GLUCOSE-112* UREA N-82* CREAT-4.8*#
SODIUM-142 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-20* ANION
GAP-13
___ 09:19PM LACTATE-0.9
___ 09:19PM ___ PO2-50* PCO2-41 PH-7.34* TOTAL
CO2-23 BASE XS--3
___ 10:55PM URINE MUCOUS-RARE*
___ 10:55PM URINE RBC-81* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-0
___ 10:55PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 10:55PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 10:55PM URINE UHOLD-HOLD
Important Imaging
=================
CXR ___
IMPRESSION:
Mild pulmonary edema, perhaps minimally improved, with small
bilateral pleural effusions and bibasilar compressive
atelectasis.
Discharge Labs
===============
___ 01:37PM BLOOD WBC-4.4 RBC-2.53* Hgb-8.3* Hct-26.6*
MCV-105* MCH-32.8* MCHC-31.2* RDW-14.1 RDWSD-55.0* Plt ___
___ 01:37PM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-30.0 ___
___ 01:37PM BLOOD Glucose-128* UreaN-69* Creat-5.0* Na-146
K-3.8 Cl-106 HCO3-24 AnGap-16
___ 01:37PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8
Brief Hospital Course:
SUMMARY
=======
___ with PMHx CKD (baseline Cr ~4.5), HFpEF (EF 55%), COPD, DM,
HTN, HLD, CAD, advanced dementia, recent admission for
UTI/pneumonia who presents for hypoxemic respiratory failure
concerning for heart failure exacerbation.
ACUTE ISSUES
============
#Acute Hypoxemic Respiratory Failure
#Acute on chronic diastolic heart failure
Worsening O2 requirement likely ___ volume overload given CXR
with pulmonary edema, BNP 10k, weight up 14 lbs (from 242 lbs on
recent discharge). Overload in setting of being discharged off
diuretic and fluid resuscitation during previous admission.
Unlikely COPD exacerbation given no evidence of retention on
VBG. O2 requirement improved with diuresis. He was continued on
his home heart failure medications. Patient was responsive to
IV Lasix 60 mg boluses, and was transitioned 120mg Lasix to at
discharge.
#UTI
Diagnosed during recent hospitalization. UA on admission here
with significant pyuria. He was treated with CTX.
#Community Acquired Pneumonia
Diagnosed with CAP at recent hospitalization, s/p augmentin 5
day course. Given CTX/azithro in ED for CAP, narrowed to CTX for
UTI, no antibioitics for pneumonia given low suspicion for
infectious lung process / COPD exacerbation, likely more CHF
exacerbation.
#Macrocytic anemia
At baseline hemoglobin. Persistently macrocytic in previous
labs. Possibly nutritional deficiency. No current EtOH use.
CHRONIC/STABLE ISSUES
=====================
#COPD: not on home O2. - Continued home advair and gave
Duonebs nebs PRN
#CKD (baseline Cr ~4.5) ___ diabetic nephropathy:
- Continued sevelamer and calcitriol
#CAD: - Continued home ASA, atorvastatin
#HTN: - Continued amlodipine, hydralazine, metoprolol as above.
Hold home clonidine for now.
#T2DM
Not on insulin or oral DM management at home. Was given insulin
sliding scale during admission, blood glucose between 100-160.
Discharged off insulin.
#BPH/chronic urinary retention: - continued home finasteride and
tamsulosin
#GERD: - continue home pantoprazole
#Advanced Dementia -Continued home Seroquel
#Chronic pain
Has pain in the neck, receives trigger point injection as
outpatient -Continued Tylenol PRN
TRANSITIONAL ISSUES
===================
[]follow up with nephrology about worsening renal function
[]follow up hgb on ___
[]patient will need daily weights as he has heart failure. He
was discharged on Lasix 120mg, please monitor volume status and
consider adjustment to diuretic dose.
[]Please check electrolytes and renal function on ___ to
ensure within normal limits.
Discharge weight 108.6KG
Discharge Cr 5.0
MEDICATION CHANGES:
- Lasix 120mg p.o. daily
- Held Seroquel PRN and Gabapentin
#CODE STATUS: DNR/DNI (MOLST FILLED OUT DURING HOSPITALIZATION)
#CONTACT: ___ (son): ___ (c), ___
Next of Kin: ___
Relationship: WIFE
Phone: ___
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY constipation
5. Finasteride 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. HydrALAZINE 100 mg PO TID
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO BID
11. Senna 17.2 mg PO BID
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Tamsulosin 0.8 mg PO QHS
14. amLODIPine 10 mg PO DAILY
15. QUEtiapine Fumarate 75 mg PO QHS
16. QUEtiapine Fumarate 50 mg PO BID
17. Simethicone 40-80 mg PO QID:PRN gas pain
18. QUEtiapine Fumarate 6.25 mg PO Q4H:PRN agitation
19. Ramelteon 8 mg PO QHS:PRN insomnia
20. Thiamine 100 mg PO DAILY
21. Nicotine Patch 14 mg/day TD DAILY
22. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
23. Calcitriol 0.25 mcg PO DAILY
24. FoLIC Acid 1 mg PO DAILY
25. Gabapentin 300 mg PO DAILY
26. CloNIDine 0.1 mg PO DAILY
Discharge Medications:
1. Furosemide 120 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Bisacodyl 10 mg PO/PR DAILY constipation
8. Calcitriol 0.25 mcg PO DAILY
9. CloNIDine 0.1 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. FoLIC Acid 1 mg PO DAILY
13. HydrALAZINE 100 mg PO TID
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Nicotine Patch 14 mg/day TD DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO BID
18. QUEtiapine Fumarate 75 mg PO QHS
19. QUEtiapine Fumarate 50 mg PO BID
20. Ramelteon 8 mg PO QHS:PRN insomnia
21. Senna 17.2 mg PO BID
22. sevelamer CARBONATE 800 mg PO TID W/MEALS
23. Simethicone 40-80 mg PO QID:PRN gas pain
24. Tamsulosin 0.8 mg PO QHS
25. Thiamine 100 mg PO DAILY
26. HELD- Gabapentin 300 mg PO DAILY This medication was held.
Do not restart Gabapentin until you see your PCP
27. HELD- QUEtiapine Fumarate 6.25 mg PO Q4H:PRN agitation This
medication was held. Do not restart QUEtiapine Fumarate until
You see your primary doctor and obtain an ecg
28. HELD- QUEtiapine Fumarate 6.25 mg PO Q4H:PRN agitation This
medication was held. Do not restart QUEtiapine Fumarate until
You see your pcp and obtain an ecg
29. HELD- QUEtiapine Fumarate 6.25 mg PO Q4H:PRN agitation This
medication was held. Do not restart QUEtiapine Fumarate until
you see your PCP and obtain an ecg
30. HELD- QUEtiapine Fumarate 6.25 mg PO Q4H:PRN agitation This
medication was held. Do not restart QUEtiapine Fumarate until
you see your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Acute Hypoxemic Respiratory Failure
Acute on chronic diastolic heart failure
Urinary tract infection
SECONDARY DIAGNOSES:
=====================
Chronic obstructive pulmonary disease
Chronic kidney disease
Type 2 diabetes
Advanced dementia
Hypertension
Hyperlipidemia
Coronary artery disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you are feeling
short of breath.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were found to have fluid in your lungs and required an
oxygen mask in the ICU.
- Given water pills through the IV to remove the extra fluid in
your lungs
- You were given antibiotics to treat a urinary tract infection
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Please maintain a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10717970-DS-15
| 10,717,970 | 28,818,329 |
DS
| 15 |
2155-02-05 00:00:00
|
2155-02-05 14:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
Duodenal Stent Placement - ___
History of Present Illness:
___ yo male with a history of newly diagnosed adenocarcinoma who
is admitted with ___ and nausea and vomiting. The patient
reports
greater than 2 weeks of abdominal pain, nausea, and vomiting. He
is unable to keep anything down. He has lost approximately 15
pounds. He has had workup done at an OSH and found to have a
pancreatic mass with duodenal compression and a FNA positive for
adenocarcinoma. He was supposed to be seen in the pancreatic
___ clinic today but when presented for his CT
scan
was found to have ___ and nausea and vomiting so he was
referred to the ED. He denies any recent fevers, shortness of
breath, dysuria, or rashes. He has been moving his bowels
regularly, sometimes they are watery.
In the ED he was given IV fluids and nausea.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
Adenocarcinoma (Duodenal vs. Pancreatic primary)
(Per surgery notes)
CT A/P on ___ showed an ___ 3 cm hypodense
mass in the pancreatic uncinate which appeared to invade D3 with
some adjacent borderline RP lymphadenopathy.
He was discharged with planned EUS as outpatient, but
represented
to ED on ___ with intractable nausea and vomiting x 3 days
with
burning in his esophagus and dysphagia. Repeat CT showed
dilated
CBD w/o obstruction (nml LFTs), mildly elevated lipase w/o e/o
pancreatitis on CT, and KUB confirmed constipation. EGD/EUS
performed on ___ by Dr. ___ revealed severe esophagitis
and a 3.8 cm uncinate mass and 1.1 cm celiac LN. No definite
vascular involvement noted. Given symptoms of severe N/V with
CT
findings of D3 invasion, careful inspection of D3 was performed
(unable to pass standard endoscope or enteroscope). Pediatric
colonoscope was able to help maneuver around region, but
rigidity
limited inspection. Overall, there was no large mass lesion
within the lumen or ulceration noted. Mild erythema was noted
at
the area of narrowing only. FNA of pancreatic mass returned
positive for adenocarcinoma.
Social History:
___
Family History:
- Married, retired ___, two sons. ___ one glass of wine
per day, history of tobacco use for ___ years, quit 4 months
ago.
Physical Exam:
ADMISSION
General: NAD
VITAL SIGNS: T 98.4 BP 130/70 HR 67 RR 18 O2 93%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, Tenderness to palpation greatest in midepigastric,
no
masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE
VS: 98.1 122/68 74 20 94%RA
Gen - sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, nontender, no rebound/guarding, neg ___
normoactive bowel sounds; improved from day prior
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:15AM BLOOD ___
___ Plt ___
___ 11:15AM BLOOD ___
___
___ 11:15AM BLOOD ___
DISCHARGE
___ 07:40AM BLOOD ___
___ Plt ___
___ 07:30AM BLOOD ___
___
ERCP ___
Stricture of the third part of the duodenum -- a 9cm by 22mm
metal stent was placed successfully (stent placement) Otherwise
normal EGD to third part of the duodenum
Test Result Reference
Range/Units
PREALBUMIN 18 L ___ mg/dL
Test Result Reference
Range/Units
CA ___ 1129 H <34 U/mL
Brief Hospital Course:
This is a ___ year old male with past medical history of
hypertension and hyperlipidemia, recent outside hospital
diagnosis of adenocarcinoma of pancreatic vs duodenal origin,
initially scheduled for outpatient ___ but admitted
___ with ___, vomiting and abdominal pain secondary to
duodenal obstruction and dehydration, now status post duodenal
stent placement, tolerating mechanical soft solids, able to be
discharged home.
# Duodenal Obstruction / Adenocarcinoma of Duodenal vs
Pancreatic Primary - Patient with a recent diagnosis of
adenocracinoma of pancreatic vs duodenal origin, who had
originally been planned to establish with ___ Oncology and
Hepatbiliary Surgery as an outpatient, who presented with pain,
nausea and vomiting. Workup was notable for duodenal
obstruction, prompting advanced endoscopy evaluation and
placement of duodenal stent. Patient subsequently had diet
slowly advanced, was able to tolerate clears, then full liquids
and then a modified soft diet, as per advanced endoscopy
instructions. Nutrition met with patient and educated him on
dietary modifications to prevent stent occlusion. He received
prn Tylenol for pain.
# ___ - Secondary to dehydration / prerenal state. Had a Cr of
2.8 on admission in the setting of above PO intolerance;
resolved to baseline with IV fluids over subsequent 48 hours.
Held lisinopril. Did not restart given subsequent normal blood
pressures. Can consider restarting at ___ visit
# Esophagitis / Abnormal Esophagus/Stomach Finding - As part of
malignancy staging, patient underwent a CT chest that showed a
"possible primary carcinoma is the lower esophagus upper
stomach, with circumferential wall thickening." Per review of
imaging with advanced endoscopy service, this area correlated
with area of esophagitis / gastritis seen on endoscopy. They
recommended continued PPI with repeat EGD for reassessment in 6
weeks.
# Hyperlipidemia - continued home Atorvastatin
# Hypertension - Held lisinopril in setting of ___. Given
normotensive, did not restart at discharge. Can reassess at PCP
___.
Transitional Issues
- Discharged home with multidisciplinary pancreas clinic
___ scheduled for ___
- Held lisinopril given initial ___ with subsequent
normotension; can reassess regarding restarting at PCP ___
- As part of malignancy workup, a CT scan incidentally found
possible primary carcinoma in the lower esophagus upper stomach,
with circumferential wall thickening---this corresponded with an
area of esophagitis / gastritis seen on endoscopy. He is
recommended for repeat EGD in 6 weeks to ___ the GE
junction after severe esophagitis has healed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Atorvastatin 20 mg PO QPM
3. Ondansetron 4 mg PO Q8H:PRN Nausea
4. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Atorvastatin 20 mg PO QPM
3. Ondansetron 4 mg PO Q8H:PRN Nausea
4. Pantoprazole 40 mg PO Q12H
5. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
# Duodenal obstruction secondary to adenocarcinoma of pancreas v
duodenum
# Acute renal failure
# Abnormal Esophagus/Stomach Finding / Esophagitis
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with nausea, vomiting and abdominal pain. You underwent testing
that showed this was from a blockage in your intestines due to
cancer. You were seen by specialists who performed a procedure
where they placed a stent (tube) to open up the blockage in your
intestine. You are now ready for discharge home.
You are scheduled for an appointment with the surgeons and
oncologists for ___. It is very important that you make
this appointment.
Your CT scan showed an abnormal area in your esophagus. The GI
specialists reviewed your CT scan, and recommended you have a
repeat endoscopy with Dr. ___ in 6 weeks.
It is important that you keep to a special diet to prevent
blockage of the stent:
- smooth or pureed foods including pasta, mashed potatoes, soft
bread, cereals, pudding/jello, yogurt, ice cream
- Soft fruit, Poultry, fish, minced beef, eggs, cooked
vegetables, baked or canned fruits.
Take drinks during and after each meal. Drink plenty of fluids.
Cut food into small pieces. Sit upright at meal times and for
___ hours afterwards
AVOID: fresh fruits and vegetables (ie celery, carrots, corn,
lettuce, pineapple), foods with seeds (oranges, watermelon,
tomatoes), Fruits or vegetables with skin (potatoes skins); nuts
(peanuts, popcorn etc), tough meat ie steak
Followup Instructions:
___
|
10718588-DS-9
| 10,718,588 | 25,733,444 |
DS
| 9 |
2160-01-06 00:00:00
|
2160-01-07 06:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall w/ Right Pontine Intraparenchymal Hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old ___ speaking right handed woman
with past history of hypertension, hyperlipidemia, and mild
cognitive impairment who presented from ___ with imaging
concerning for a pontine bleed, found during workup of an
unwitnessed fall. The patient was noted to be in her usual
state
of health earlier in the day on ___ at which time she left
to go to the kitchen to wash a plate off at which time she
endorses vertiginous symptoms which were sudden onset and
impacting the posterolateral right side of her head on a flat
surface. Her grandson and daughter who she lives with rushed to
her aid after hearing the fall and noted that she was confused
as
to what had happened and remained dizzy. She was taken to
___ where she was found to be oriented only to self which
per the family is her baseline and was still dizzy. She was
found to have labwork concerning for a urinary tract infection
and NCHCT which demonstrated a small pontine hemorrhage for
which
she was transferred to ___ for further evaluation.
They noted the patient has been having a significant number of
falls over the course of the past few months and had taken worse
impacts than the one noted to have happened today. She was
noted
to have had a laceration ___ months ago which was treated at
___ with negative imaging.
When questioned about her mental status, the family noted that
she does have some impairment with date and place noting that on
her best days she has trouble with these; also, they noted that
her speech was appropriate; however, it seemed like she is
slurring more of her words.
ROS was difficult to obtain ___ language barrier and patients
lethargy, however, she denies headache, loss of vision, but
notes
some blurring of vision with no diplopia. She notes dysarthria,
but denies dysphagia. She endorses worsening vertigo, but denies
any tinnitus or hearing difficulty. Denies difficulties
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Multiple falls noted by family over the past months.
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:
- Hyperlipidemia
- Hypertension
Social History:
___
Family History:
- Negative for any Aneurysmal disease, AVM, stroke, migraine, or
other neurologic illness
Physical Exam:
ADMISSION PHYSICAL EXAM:
T= 98.8F, BP=109/61-144/90, HR=92, RR=22, SaO2= 96% 2L
General: Awake, cooperative, but requiring some redirection and
translation.
HEENT: NC/AT, eyes injected with some crusting on lids
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated, pain elicited on the
right hip with passive motion and palpation (impact site)
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self which is baseline per
family. Able to relate some history but required prompting and
continued stimulation. Language was dysarthric per the family
who interpreted for the patient. There was no evidence of
apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with saccadic intrusions, no nystagmus seen
however, poor cooperation by patient keeping eyes in end gaze.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No obvious facial droop, facial musculature symmetric and
___ strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Could not fully assess palate secondary to compliance.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and patient did not comply
with
tongue-in-cheek testing.
-Motor: Decreased bulk, normal tone throughout. Could not assess
pronator drift as patient would not cooperate. No adventitious
movements, such as tremor, noted. No asterixis noted. Patient
did
not cooperate with exam but was at least anti-gravity in all,
with no evident deficits bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 2 2
R 2 1 1 2 2
- Plantar response was extensor on left and mute on right.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick. Did not
cooperate with extinction to DSS testing or proprioception
testing
-Coordination/Gait: Did not cooperate with testing
DISCHARGE PHYSICAL EXAM:
Gen: NAD
HEENT: nc/at, mucosa moist and pink, oropharynx clear
CV: irregularly irregular, loud splitting of S1, II-III/VI
systolic ejection murmur at LLSB, systolic hyperexpansion of
jugular veins
Pulm: CTAB
Abd: soft, NT, ND
MSK: 1+ pretibial edema
-Mental Status: Alert, oriented to self which is baseline per
family. Able to relate some history but required prompting and
continued stimulation. Language was dysarthric per the family
who interpreted for the patient. There was no evidence of
apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with saccadic intrusions, no nystagmus seen
however, poor cooperation by patient keeping eyes in end gaze.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No obvious facial droop, facial musculature symmetric and
___ strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: palatal elevation symmetric.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline
-Motor: Decreased bulk, normal tone throughout. No pronator
drift
Delt Bic Tri ECR FEx FFI IO IP Quad Ham TA Gas ___
L 4 ___ 4+
R 4+ 4+ 4+ 4+ 4+
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 2 2
R 2 1 1 2 2
- Plantar response was extensor on left and mute on right.
-Sensory: No deficits to light touch, pinprick. Did not
cooperate with extinction to DSS testing or proprioception
testing
-Coordination/Gait: Did not cooperate with testing
Pertinent Results:
LABS:
___ 10:50AM BLOOD WBC-6.3 RBC-4.78 Hgb-13.4 Hct-42.1 MCV-88
MCH-28.1 MCHC-31.8 RDW-14.4 Plt ___
___ 04:50AM BLOOD WBC-5.5 RBC-4.74 Hgb-13.6 Hct-40.1 MCV-85
MCH-28.7 MCHC-33.8 RDW-13.9 Plt ___
___ 09:15PM BLOOD Neuts-86.4* Lymphs-6.7* Monos-6.7 Eos-0.1
Baso-0.1
___ 10:50AM BLOOD ___ PTT-29.6 ___
___ 10:50AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-141
K-3.4 Cl-104 HCO3-31 AnGap-9
___ 04:35AM BLOOD Glucose-98 UreaN-11 Creat-0.5 Na-136
K-4.5 Cl-99 HCO3-28 AnGap-14
___ 10:50AM BLOOD Albumin-3.7 Phos-2.8 Mg-1.7 Cholest-146
___ 04:35AM BLOOD Calcium-10.0 Phos-2.7 Mg-1.8
___ 10:50AM BLOOD %HbA1c-5.3 eAG-105
___ 10:50AM BLOOD Triglyc-95 HDL-56 CHOL/HD-2.6 LDLcalc-71
___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CTA HEAD/NECK ___: IMPRESSION:
1. Stable small right pontine hemorrhage without associated
mass effect. No evidence of new intracranial abnormalities
compared to one day earlier.
2. Significantly motion-limited head CTA, without evidence for
an
intracranial aneurysm or arteriovenous malformation.
3. Atherosclerosis at the origins of the right and left
internal carotid
arteries without evidence of hemodynamically significant
stenoses.
Atherosclerosis at the origins of the right and left vertebral
arteries with possible mild stenoses.
4. Enlarged main pulmonary artery, indicating pulmonary
hypertension.
5. Diffusely heterogeneous and multinodular thyroid gland. The
enlarged
right thyroid lobe deviates the trachea to the left without
associated
compression.
An addendum to this report may be issued when the
three-dimensional and curved reformatted images are finalized by
the imaging lab.
CXR ___: IMPRESSION: Improved pulmonary congestion with no
focal consolidations concerning for pneumonia.
MR HEAD W/O CONTRAST ___: IMPRESSION:
1. Evolving right pontine hemorrhage which could be related to
hypertension, underlying cavernoma, and less likely due to
developmental venous anomaly. No MR evidence of underlying
amyloid. Follow up MRI with contrast is advised if clinically
warranted.
2. Nonspecific numerous foci of T2/FLAIR white matter
hyperintensities likely related to chronic microangiopathy.
1. Mild global cerebral volume loss.
KNEE, AP, LAT & OBLIQUE ___: IMPRESSION: Severe
degenerative disease involving the right knee joint, with
moderate joint effusion as described.
VIDEO SWALLOW STUDY ___: IMPRESSION: Trace aspiration with
thin liquids.
Brief Hospital Course:
___ ___ w hx of HTN, HLD, cognitive decline, and
multiple recent falls who presented ___ after experiencing
vertigo leading to a fall to her right-side with head strike. CT
head at ___ revealed small pontine hemorrhage. Relevant
hospital course, by system, as follows:
1) Neuro: Presented with small pontine hemorrhage seen on ___
CT head at ___ in setting of recent fall with head
strike. CTA head performed ___ at ___ did not show vascular
malformation or aneurysm. MRI on ___ confirmatory of evolving
hemorrhage. MRI w/ contrast to rule out cavernoma/vascular
malformation deferred during this admission given patient's age
and prognosis. Observed irregular heart rhythm shortly after
arrival, confirmed a.flutter on EKG. Deferred starting
anticoagulation given hemorrhagic nature of stroke. Patient
unlikely to benefit from systemic anticoagulation (CHADS2 equal
to 3), given her advanced age, frequent falls, and now primary
cerebral hemorrhage. Modifiable risk factors, including
cholesterol levels and HbA1c, evaluated showing a LDL of 71 and
A1c of 5.3. Speech and swallow evaluation performed ___
revealed significant dysphagia, though improved by ___ and
was at that time tolerating a pureed diet. Discharged home with
pureed diet teaching to family. Of interest, patient likely to
benefit from ___ but unable to discharge to rehab given
payment restrictions (patient is not a ___. citizen and does not
have insurance, unable to pay out of pocket).
2) CV: Hx of HTN. Allowing BP to autoregulate with goal SBP <
160 (goal SBP 140-160s). Observed irregular heart rhythm shortly
after arrival, confirmed a.flutter on EKG. Deferred starting
anticoagulation given hemorrhagic nature of stroke. Patient
unlikely to benefit from systemic anticoagulation (CHADS2 equal
to 3), given primary hemorrhagic cerebral event, advanced age,
and frequent falls. Started metoprolol for rate control on
___.
3) GI: Patient failed initial swallowing eval on ___, though
improved slowly since. Tolerating pureed diet by day of
discharge.
5) ID: Treated UTI (diangosed with screening urinalysis shortly
after admission) with 3 days of ceftriaxone (___).
TRANSITIONAL ISSUES:
- CODE STATUS: Patient DNR/DNI throughout hospitalization.
- ANTICOAGULATION: Patient observed to be in atrial flutter
during this hospitalization. Deferred starting systemic
anticoagulation given the hemorrhagic nature of her stroke, as
well as her propensity to fall (several falls at home in months
prior to admission).
- DISPO: Patient without health insurance, is not a ___.
citizen. Limited options for ___ rehab. Per
discussion with patient's daughter (who is HCP), patient will be
cared for at home and provided with a pureed diet. Discharged
home after procurement of home hospital bed and instructions for
pureed diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
Hold for sBP <90, HR <60
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID
4. Hospital Bed
Home Hospital Bed
ICD-9: 432.9
Please fax questions to Dr. ___ ___
5. Aspirin 81 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Acetaminophen 500 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth q6hrs Disp #*120
Tablet Refills:*0
8. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- intraparenchymal cerebral hemorrhage
- hypertension
SECONDARY:
- recurrent falls at home
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. ___,
Thank you for choosing ___ for your medical care. You were
admitted after a recent fall, caused by a stroke in your brain.
The brain is the part of your body that controls and directs all
the other parts of your body, so damage to the brain from
disruption of the blood supply can result in a variety of
symptoms.
Please take your medications as ___
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 ___
- 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 ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10718657-DS-17
| 10,718,657 | 22,008,262 |
DS
| 17 |
2189-04-25 00:00:00
|
2189-04-25 17:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
==================================
HMED ADMISSION NOTE
___
==================================
PCP: ___
HPI:
Ms. ___ is a ___ year old female with a pmh of COPD on
home oxygen with multiple admissions for COPD exacerbations at
___, never intubated, recently diagnosed lung cancer (RLL),
HTN, DMII, and inflammatory arthritis, who presents with 1 week
of cough, fatigue, and shortness of breath.
Her symptoms have slowly worsened over the past week, and today
got to the point with coughing fits that it induced vomiting.
She had 3 episodes of non-bloody emesis today. No nausea. No
fevers at home. Her cough is dry, hacking. Very occassionally is
it productive.
Of note, a RLL mass was noted on imaging in ___ which was
recently confirmed to be ___ stage IIIA confirmed on biopsy two
weeks ago. Scheduled to see rad onc tomorrow at ___.
In the ED
Initial vitals: 98 100 101/71 20 93%
Transfer vitals: 98.2 89 121/74 16 92% Nasal Cannula
Meds given: Albuterol 0.083% Neb Soln 0.083%, Ipratropium
Bromide Neb 2.5mL, OxycoDONE (Immediate Release) 10mg,
Azithromycin 500 mg, PredniSONE 60 mg, Benzonatate 100mg
Capsule.
Fluids: NS
Access: PIV in left hand
Labs: Significant for Creatinine 1.6, HCT 29
On the floor she feels much better. SOB is improved since
treatment. Cough persists. No fevers.
ROS: (+) and pertinent (-) per HPI. 10 system ROS otherwise
negative.
Past Medical History:
Small Cell Lung CA stage IIIA - per signout, no documentation -
diagnosed ___
HTN
HLD
DMII
COPD on home oxygen (2L now 3.5L - oxygen started in ___)
Arthritis (inflammatory, unknown subtype)
Depression
Radiculopathy
Social History:
___
Family History:
Family history of breast cancer in her sister (deceased)
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.3, BP 138/78, HR 92, RR 20, sats 97%
Gen: Chronically ill
HEENT: Moist MM, anicterica sclera
CV: Normal rate, regular rhythm, distant heart sounds
Resp: CTAB, with intermittent coughing, mild crackles at the
bases
GI: Soft, NT, ND
Skin: No rashes on limited exam
Neuro: AOx3, easy speech
Psych: mood/affect appropriate
Vasc: 2+ pulses radial
Pertinent Results:
ADMISSION LABS
--------------
___ 01:00PM BLOOD WBC-6.2 RBC-3.22* Hgb-8.9*# Hct-29.7*#
MCV-92# MCH-27.7# MCHC-29.9* RDW-17.2* Plt ___
___ 01:00PM BLOOD Neuts-51.5 ___ Monos-9.8 Eos-4.6*
Baso-0.8
___ 02:04PM BLOOD ___ PTT-27.7 ___
___ 01:00PM BLOOD Glucose-89 UreaN-26* Creat-1.6* Na-139
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 01:00PM BLOOD proBNP-400*
___ 01:07PM BLOOD Lactate-1.1
DISCHARGE LABS
--------------
___ 04:00AM BLOOD WBC-7.9 RBC-3.22* Hgb-9.0* Hct-30.9*
MCV-96 MCH-27.9 MCHC-29.2* RDW-17.2* Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-100 UreaN-22* Creat-1.2* Na-142
K-4.8 Cl-105 HCO3-26 AnGap-16
___ 04:00AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2
IMAGING
-------
CXR:
IMPRESSION:
Right lower lobe opacity may correspond to patient's known lung
cancer. Correlate with prior imaging.
MICROBIOLOGY
------------
Blood culture x ___: pending at discharge
Urine culture ___ 3:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ year old female with history of COPD on home oxygen with
multiple admissions for COPD exacerbations at ___, with
recent diagnosis of lung cancer (RLL), who presents with one
week of cough, fatigue, and shortness of breath consistent with
a COPD exacerbation.
ACTIVE ISSUES
-------------
# COPD: She had a CXR that did not demonstrate pneumonia. She
was treated for a COPD exacerbation with azithromycin (completed
5 days), prednisone (40mg x4 days, 20mg x2 days), and
albuterol/ipratropium nebulizers. Her symptoms improved. She
was continued on advair. She was given tessalon and guaifenesin
for cough. She was continued on supplemental oxygen at ___
liters nasal cannula. She was discharged with two days of
prednisone 20mg daily and will follow up with her oncologist on
day #3 to determine if therapy needs to be continued.
# Non-small cell Lung cancer: She was seen by radiation Oncology
during her admission and underwent simulation treatment to Lung
field on ___. She will follow up with her oncologist on
___. She will follow up with radiation oncology on ___.
MRI brain performed on ___ at ___ demonstrated small
vessel ischemic disease without evidence of metastasis.
#Diabetes: The Januvia was held during the hospitalization but
was restarted at discharge. She was maintained on an insulin
sliding scale during the hospitalization. Blood sugars were in
the 100s-200s while on prednisone 20mg. She will continue to
monitor blood sugars at home while on prednisone.
INACTIVE ISSUES
---------------
# Anemia, normocytic: Most likely anemia of chronic disease. Her
hematocrit was trended during her admission and remained stable
___. Would consider iron studies as an outpatient.
# Hypertension: patient was continued on her home amlodipine
# Depression: patient was continued on her home citalopram and
bupropion.
# Arthritis: patient was continued on her hydroxychloroquine and
leflunomide. Patient is unsure of what type of arthritis she
has.
TRANSITIONS OF CARE
-------------------
[ ] follow up with oncology ___
---[ ] consider more prolonged steroid taper at that time
[ ] follow up with radiation oncology ___
[ ] consider iron studies to further evaluate anemia
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 600 mg PO DAILY
2. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Januvia (sitaGLIPtin) 100 mg oral daily
6. Amlodipine 10 mg PO DAILY
7. leflunomide unkown mg oral daily
8. BuPROPion 200 mg PO BID
9. Citalopram 10 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
14. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
16. Albuterol 0.083% Neb Soln 1 NEB IH BID
17. Ipratropium Bromide Neb 1 NEB IH Q6H
18. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH BID
2. Amlodipine 10 mg PO DAILY
3. Calcium Carbonate 600 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
15. BuPROPion (Sustained Release) 200 mg PO BID
16. Januvia (sitaGLIPtin) 100 mg oral daily
17. leflunomide 0 mg ORAL DAILY
18. Simvastatin 20 mg PO DAILY
19. Acetaminophen 1000 mg PO Q8H:PRN pain
20. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
21. Albuterol 0.083% Neb Soln 1 NEB IH Q8
22. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
23. PredniSONE 20 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
24. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Right lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of shortness of breath. It was determined
that you likely have a COPD exacerbation, which improved with
nebulizers, prednisone, and azithromycin. You symptoms
improved. You will continue to take prednisone for the next two
days. You will follow up with your oncologist ___ to make
sure you continue to improve.
You also have a known right lung mass. You were seen by
Radiation Oncology while you were admitted - you were seen by
radiation oncology for simulation treatment. An appointment was
scheduled with your oncologist this week. An appointment was
scheduled for radiation oncolgoy this week. It is important
that you continue to take your medications as prescribed and
follow up with the appointments listed below.
Please continue monitor your blood sugars while you are taking
prednisone as this can raise blood sugar. If your blood sugars
are >400, please contact your primary care physician.
Followup Instructions:
___
|
10718657-DS-18
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| 18 |
2189-05-23 00:00:00
|
2189-05-24 00:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Failure to Thrive, Odynophagia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This patient is a ___ year old womanw with metastatic SCC lung CA
on chemo/XRT ___ ___ fractions)who
presented from clinic due to failure to thrive. She endorsed
feeling worsening fatigue, nausea, and anorexia but is starting
to feel better since admission. But does c/o feeling "sick"
continued odynophagia, weakness, abdominal pain, and mid-sternum
pain.
Past Medical History:
Small Cell Lung CA stage IIIA - per signout, no documentation -
diagnosed ___
HTN
HLD
DMII
COPD on home oxygen (2L now 3.5L - oxygen started in ___)
Arthritis (inflammatory, unknown subtype)
Depression
Radiculopathy
Social History:
___
Family History:
Family history of breast cancer in her sister (deceased)
Physical Exam:
Initial Physical Exam
General- Alert, oriented, moderate distress
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- decreased breath sounds b/l, expiratory wheezes
CV- Regular rate and rhythm, II/VI murmur throughout the
precordium
Abdomen- soft, tender at b/l upper quadrants, non-distended,
bowel sounds present,
GU- no foley
Ext- warm, well perfused, no edema
Neuro- motor function grossly normal
Discharge Physical Exam
Vitals: Tm 98.2 Tc 97.8 ___ P ___ R 20 O2 Sat 98%
3L
General- Alert, oriented, NAD
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- decreased breath sounds b/l, CTAB
CV- Regular rate and rhythm, II/VI murmur throughout the
precordium
Abdomen- soft, diffusely tender to palpation, no guarding, no
rigidity, non-distended, bowel sounds present
GU- no foley
Ext- warm, well perfused, no edema
Neuro- motor function grossly normal
Pertinent Results:
Initial Lab Results
___ 01:00PM BLOOD WBC-3.0*# RBC-3.32* Hgb-9.4* Hct-30.9*
MCV-93 MCH-28.2 MCHC-30.3* RDW-17.5* Plt ___
___ 01:00PM BLOOD Glucose-111* UreaN-19 Creat-1.3* Na-138
K-4.9 Cl-105 HCO3-22 AnGap-16
___ 01:00PM BLOOD ALT-9 AST-14 AlkPhos-115* TotBili-0.3
___ 11:00AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.6
___ 01:02PM BLOOD Lactate-1.0
Discharge Lab Results
___ 07:25AM BLOOD WBC-2.7* RBC-3.60* Hgb-10.1* Hct-33.9*
MCV-94 MCH-28.1 MCHC-29.8* RDW-18.2* Plt ___
___ 07:25AM BLOOD Glucose-122* UreaN-9 Creat-1.0 Na-138
K-4.4 Cl-100 HCO3-23 AnGap-19
___ 07:25AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9
EGD ___
A focal area of mild erythema and very superficial ulceration
with an area directly opposite to it with mild erythema at the
upper esophagus. This finding could be consistent with pill
esophagitis. Cold forceps biopsies were performed for histology
at the esophagus.
Follow-up biopsy results
Continue PPI therapy
Can start carafate slurry 1gm QID
Brief Hospital Course:
ASSESSMENT & PLAN: ___ with metastatic lung ca presenting with
new onset odynophagia, orthostasis and failure to thrive, found
to have acute DVT with EGD showing possible pill esophagitis
ACUTE ISSUES
#) Odynophagia/dysphagia:
Patient presented with new odynophagia. The GI service was
consulted and performed an EGD which showed erythema and
findings consistent with pill esophagitis. Biopsies were also
taken of the stomach and were pending at discharge. EGD also
showed debris at the vocal cords prompting a speech and swallow
evaluation. This evaluation showed no concerns for aspiration
and patient was cleared to eat a regular diet. The patient's
symptoms were managed with a PPI, maalox swish and swallow,
Carafate 1gm QID, and anti-emetics including zofran and reglan.
An out-patient follow up appointment with ENT was also arranged
for the patient on discharge.
#) Abdominal Pain
The patient's abdominal pain was of unclear etiology. Pain was
mostly in the epigastric region, and may have been secondary to
GERD vs her right lower lung mass vs gas. A CT A/P negative for
any acute process. She received XRT during admission and her
symptoms were managed with a bowel regimen, reglan, oxycodone,
and oxycontin.
# DVT:
Patient was found to have a DVT likely in the setting of
malignancy. She was started on a heparin drip and then
transitioned to therapeutic dosing of Lovenox. Her creatinine
was monitored closely and she was discharged with Lovenox for
continued treatment of DVT. She received instructions and
information regarding how to give herself Lovenox injections.
# Failure to thrive:
Patient presented with failure to thrive in the setting of
odynophagia, abdominal pain, and receiving XRT for lung cancer.
As described above, she underwent EGD and speech and swallow
evaluation to evaluate her odynophagia. Nutrition was also
consulted and their recommendations were implemented.
Symptomatic control of her nausea and abdominal pain was managed
with reglan, oxycodone, oxycontin, Carafate, and a PPI.
# Positive UA:
Patient presented with a positive UA and completed a 3 day
course of treatment with Ceftriaxone.
CHRONIC ISSUES
# Metastatic non-small cell lung cancer:
Patient has a known diagnosis of lung cancer. She received XRT
during admission and her out-patient oncologist was notified of
her admission by the medical team.
# COPD: On home O2 at this time.
Patient was managed with her home nebulizers,
Fluticasone-Salmeterol, and cough syrup.
# Depression:
Patient was continued on her home buproprion and citalopram.
#Diabetes:
Her diabetes was managed with an insulin sliding scale
# Hypertension:
Amlodipine 10 mg PO DAILY
# Arthritis:
-held home leflunomide and hydroxychloroquine
TRANSITIONAL ISSUES
-recommend out-patient ENT evaluation for odynophagia
-please monitor patient's creatinine given Lovenox treatment for
DVT
-please ensure patient feels comfortable and is administering
her Lovenox properly, at 70mg BID. She needs to waste 10mg from
the 80mg vial. Teaching was provided during admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH BID
2. Amlodipine 10 mg PO DAILY
3. Calcium Carbonate 600 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
15. BuPROPion (Sustained Release) 200 mg PO BID
16. Januvia (sitaGLIPtin) 100 mg oral daily
17. leflunomide 10 mg ORAL DAILY
18. Simvastatin 20 mg PO DAILY
19. Albuterol 0.083% Neb Soln 1 NEB IH Q8
20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
21. Benzonatate 100 mg PO TID:PRN cough
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH BID
2. Amlodipine 10 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO BID
4. Calcium Carbonate 600 mg PO DAILY
5. Citalopram 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
7. FoLIC Acid 1 mg PO DAILY
8. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
per pt, takes Q3-4hr pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
RX *oxycodone [OxyContin] 30 mg 1 tablet extended release 12
hr(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
14. Simvastatin 20 mg PO DAILY
15. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
16. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth once a day Disp #*14 Capsule Refills:*0
17. Januvia (sitaGLIPtin) 100 mg oral daily
18. Benzonatate 100 mg PO TID:PRN cough
19. Albuterol 0.083% Neb Soln 1 NEB IH Q8
20. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 70 mg subcutaneous twice a day Disp
#*28 Syringe Refills:*0
21. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN burning
sternal pain
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL 15 ml by mouth four times a day Disp #*1 Bottle
Refills:*0
22. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*56 Tablet Refills:*0
23. Simethicone 40-80 mg PO QID:PRN gas, dyspepsia
RX *simethicone 80 mg ___ tablet by mouth four times a day
Disp #*56 Tablet Refills:*0
24. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*56 Tablet Refills:*0
25. leflunomide 10 mg ORAL DAILY
26. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. Esophagitis
2. Deep Venous Thrombosis
3. Urinary Tract Infection
Secondar Diagnosis
1. Metastatic Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
It was a pleasure caring for you at ___. You were admitted
because you had difficulty swallowing and abdominal pain. The GI
doctors used ___ to look inside your esophagus and stomach
and found irritation of your stomach and esophagus. The speech
and swallow specialists evaluated you and did not find any risk
of aspirating food when you swallow. You were started on
medications to help relieve the irritation in your stomach, as
well as your nausea and gas.
Please follow up with your oncologist Dr. ___. Please also
see the primary care doctor who will help make an appointment
for you to see the Ear Nose and Throat doctors ___ they ___
further evaluate your swallowing.
Of note, when using your new prescription for
enoxaparin/lovenox, only use 70 mg of each dose and waste the
last 10 mg.
Thank you for choosing ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10718657-DS-19
| 10,718,657 | 26,743,687 |
DS
| 19 |
2189-10-14 00:00:00
|
2189-10-14 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
nausea, vomiting, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo woman with a history of NSCLC, HTN, HLD, DM2, COPD, and
depression presenting with several days of nausea, vomiting,
inability to tolerate PO, abdominal pain, and headache.
She has NSCLC originally in the right lung, with 9mm cerebellar
metastasis, s/p chemotherapy and radiation last in ___, and
recently underwent stereotactic radiosurgery (cyberknife) at
___ (___). Reportedly she has had increased nausea and
vomiting since her Cyberknife procedure.
History obtained over the phone with patient's sister ___
___ (___) and niece/HCP ___
(___). They reported that following Cyberknife
procedure ___, patient was tired and "not feeling up to
par." Early on ___ morning (___) patient began vomiting
(at least 10 times over the course of the day) yellowish-brown
fluid in small volumes interspersed with frequent dry heaving.
She was reportedly complaining of a slight headache, but
collateral sources are not able to provide additional
information, and the patient did not mention abdominal pain.
Around mid-day on ___, per patient's sister and
niece, the patient was noticed to be more confused and
disoriented, not answering questions in a relevant/appropriate
fashion.
On interview today, Ms ___ is confused and answers questions
slowly and with difficulty. She is unable to recall the events
leading to her hospitalization. When prompted about symptoms
such as headache, nausea, vomiting she verifies that she has had
these problems in the last few days but is unable to provide any
qualifying or quantifying information. She states that her
headache has resolved, but is unable to localize or describe her
headache in any detail. She states that her nausea has resolved
but cannot provide additional details about episodes of
vomiting. She reports poor appetite and does not think she
could currently tolerate food or medications. Denies abdominal
pain. No shortness of breath, cough, chest pain, palpitations.
No lightheadedness, dizziness, or visual changes.
Of note, patient has visiting nurse who comes 3x per week. Due
to physical limitations, she is unable to do household chores.
Meds are organized by ___. Unable to make meals
on her own. All this is new in the last 3 months.
Past Medical History:
Small Cell Lung CA stage 4, metastatic to brain, diagnosed
___
HTN
HLD
DMII
COPD on home oxygen (2L now 3.5L - oxygen started in ___)
Arthritis (inflammatory, unknown subtype)
Depression
Radiculopathy
Social History:
___
Family History:
Family history of breast cancer in her sister (deceased)
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================================
Vitals: T:98.4 BP: 155/99 P:116 R:20 O2: 100 on 3L NC
General: Alert, awakes to voice, but oriented to name only, in
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. Unlabored breathing on 3L O2 per NC
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: macular hyperpigmentation on arms and upper central chest.
No rashes or other lesions.
Neuro: Alert and awake, oriented to name only. Answers ___
when asked to name the year. Unable to describe events leading
to hospitalization. Prolonged speech latency. Speech slow,
monotone. Does not answer when asked to perform calculations,
serial 7s or 3s. No overt hallucinations or delusions.
Cranial Nerves: difficulty following commands, but EOMI. PERRL
3->2mm. Facial sensation intact, face symmetric, equal movements
to smile/frown. Palate elevates symmetrically. Tongue Midline
Strength: ___ strength in upper and lower extremities
bilaterally.
Sensation: grossly intact to light touch in distal extremities
Gait: slow, somewhat unsteady.
DISCHARGE PHYSICAL EXAM:
=================================
Vitals T 97.6 BP 110/81 HR 127 RR 20 SPO2 96 on RA
GENERAL: Awake in NAD lying in veil appears comfortable. Speech
spontaneous, conversant.
HEENT: Bald. NC/AT, sclerae anicteric and white,
LUNGS: Unlabored breathing on RA
HEART: Regular pulse with occasional premature beats. No JVD
ABDOMEN: refused exam
EXTREMITIES: WWP, moving all extremities well.
Neuro: Alert and awake, oriented to ___ and date. No overt
hallucinations or delusions.
Gait: not tested today
Pertinent Results:
ADMISSION LABS:
=====================================
___ 05:00PM BLOOD WBC-4.4# RBC-3.39* Hgb-10.6* Hct-34.6*
MCV-102*# MCH-31.4# MCHC-30.8* RDW-20.1* Plt ___
___ 05:00PM BLOOD Neuts-65.7 ___ Monos-5.4 Eos-1.5
Baso-0.2
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-148* UreaN-18 Creat-1.2* Na-138
K-4.2 Cl-105 HCO3-16* AnGap-21*
___ 05:00PM BLOOD ALT-8 AST-15 AlkPhos-123* TotBili-0.2
___ 05:00PM BLOOD Lipase-22
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Albumin-3.7
___ 11:35PM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
___ 06:10AM BLOOD TSH-0.91
___ 11:35PM BLOOD HBsAg-NEGATIVE
___ 11:35PM BLOOD HIV Ab-NEGATIVE
___ 05:03PM BLOOD Lactate-2.4*
PERTINENT LABS:
=======================================
___ 06:10AM BLOOD WBC-7.9# RBC-3.24* Hgb-10.2* Hct-32.7*
MCV-101* MCH-31.6 MCHC-31.3 RDW-20.1* Plt ___
___ 07:25AM BLOOD ___ PTT-32.0 ___
___ 06:10AM BLOOD Glucose-134* UreaN-12 Creat-1.0 Na-137
K-3.9 Cl-100 HCO3-19* AnGap-22*
___ 06:10AM BLOOD Glucose-161* UreaN-17 Creat-1.1 Na-135
K-3.7 Cl-98 HCO3-17* AnGap-24*
___ 11:35PM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
___ 06:10AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.7
___ 06:10AM BLOOD Calcium-9.8 Phos-2.8 Mg-1.8
___ 05:36PM BLOOD ___ Temp-37 pO2-68* pCO2-16*
pH-7.58* calTCO2-15* Base XS--2 Intubat-NOT INTUBA
___ 05:36PM BLOOD Glucose-216* Lactate-2.5* Na-136 K-3.0*
Cl-106
DISCHARGE LABS:
=========================================
___ 07:25AM BLOOD WBC-4.2 RBC-3.60* Hgb-10.9* Hct-36.0
MCV-100* MCH-30.3 MCHC-30.3* RDW-20.0* Plt ___
___ 07:25AM BLOOD Glucose-202* UreaN-19 Creat-1.3* Na-137
K-3.4 Cl-103 HCO3-18* AnGap-19
___ 07:25AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.9
IMAGING
========================================
#CT head w/o contrast ___
A 9 mm hypodensity within the right cerebellum corresponds to
the previously seen ring enhancing lesion on MRI, compatible
with a metastasis (2:9). There is no acute intracranial
hemorrhage, new mass effect, or vascular territorial infarction.
Periventricular and deep white matter hypodensities are likely
sequela of chronic small vessel ischemic disease. Left basal
ganglia lacunar infarct is re- demonstrated. There is
preservation of normal gray-white matter differentiation.
Prominence of the sulci and ventricles is compatible with age
appropriate atrophy. No fracture is identified.
#Chest XR ___
Cardiac silhouette size remains within normal limits. The aorta
is tortuous. Previously seen right lower lobe mass has
substantially decreased in size from the previous exam with
residual right infrahilar opacity likely reflective of
post-treatment change and/or residual disease. There is no
pulmonary edema. The lungs are hyperinflated with emphysematous
changes again demonstrated. Small right pleural effusion is
noted with interval decrease in extent of lateral pleural
thickening as seen on the prior study. Patchy opacities in the
lung bases may reflect atelectasis. No pneumothorax is
identified. Multilevel degenerative changes are seen in the
thoracic spine. Bilateral shoulder arthroplasties are partially
imaged.
#CT A/P w contrast ___
1. Dominant mass at the right base is essentially resolved,
however there is residual ground-glass opacity which may reflect
residual disease or post-treatment changes. Slight worsening in
pleural thickening and enlarging pericardial nodule may reflect
metastatic disease. 2. Small right pleural effusion. 3. No
evidence of bowel obstruction.
#ECHO ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality due to premature
discontinuation of the test at the patient's request. Normal
biventricular cavity sizes with preserved global biventricular
systolic function. No definite valvular disease identified. No
pericardial effusion.
Brief Hospital Course:
#Altered mental status: Patient initially presented with poor
attention, disorientation, slow and irrelevant speech,
difficulty following commands, unable to articulate specific
complaints. Differential diagnosis for encephalopathy
initially consisted of new brain metastases or leptomeningeal
spread vs toxic/metabolic (infection) vs medication-induced.
CT Head showed no signs of ICH, stroke, or mass effect.
Medications were withheld that may have had worsening effect on
confusion (bupropion, oxycodone, oxycontin, anticholinergics).
She demonstrated no localizing signs of infection (no fever,
cough, infiltrate on CXR), and no evidence of
cardiac/renal/hepatic dysfunction or electrolyte abnormality.
She has no history of seizure disorder or movements suggestive
of seizure. Due to agitation and inability to consent, no MRI
or lumbar puncture was done to assess for leptomengeal
carcinomatosis or worsening burden of cerebral metastases. No
clear etiology of her altered mental status was definitively
established. However, her symptoms of anxiety and agitation were
treated with haloperidol and lorazepam, and around hospital day
5 her mental status began to improve gradually. Haldol was held
for one night and she again became delirious and attempted to
get out of bed unsupervised, so haldol was restarted. On
discharge she is able to carry on normal conversations and is no
longer hypervigilant or anxious.
#Tachycardia: For the duration of her hospitalization, she had
tachycardia of HR 110-130, of unclear etiology. Differential
diagnoses for this problem consisted of infections, pulmonary
embolism (given history of DVT, treated wtih lovenox), or
anxiety/delirium. No V/Q scan or CTA was done to assess for PE
given her agitation and anxiety, and she denied shortness of
breath, chest pain, and had normal O2 saturation even off of O2
which she uses at home. Her acute confusional state resolved yet
she remained tachycardic.
#history of DVT:
Patient was found to have a left common femoral vein DVT at prio
admission (___), discharged on lovenox, which was
continued this hospitalization.
-Con't lovenox
# COPD: On home 2L O2, but did not require supplemental oxygen
in hospital, nor did she have shortness of breath.
She was continued on home ipratropium, albuterol, and
fluticasone/salmeterol.
# Depression: Citalopram was continued this hospitalization,
bupropion was held in the setting of intracranial metastasis as
it decreases the seizure threshold
#Diabetes: Her blood glucose was often elevated in high 100s,
low 200s, but insulin was withheld in order to minimize painful
stimuli.
# Hypertension: She was continued on home amlodipine for most of
the hospitalization, but this was discontinued on discharge. BP
remained within normal limits.
#Goals of care:
Family meeting held ___ to discuss patient's goals of care.
Attendants were ___ MD, ___ MD, patient's
niece and HCP ___, patient's sister ___, and
family member ___. Patient's family acknowledged her mental
status was changed from baseline, and that she was "Not ___
that they know. Discussed patient's discomfort and anxiety
provoked by painful investigations/treatments such as blood
draws, ABG, and blood draws. Discussed care team's impression
that her altered mental status is suspected to be due to brain
metastases or leptomeningeal carcinomatosis, which carries a
prognosis of several months. Discussed tests required to
establish or rule out these diagnoses, including MRI and LP,
which would likely require sedation and/or intubation given her
discomfort/anxiety and expected refusal. Proposed that goals of
care shift away from invasive or anxiety-provoking diagnostic
testing and chemotherapy or radiation, and towards management of
pain, anxiety, confusion, and agitation. Family in agreement.
Palliative care was consulted, and helped establish plan to
discharge patient to home with family supervision and assistance
as well as hospice care. She was made DNR/DNI.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH BID
2. Amlodipine 10 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO BID
4. Calcium Carbonate 600 mg PO DAILY
5. Citalopram 10 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
10. Ipratropium Bromide Neb 1 NEB IH Q6H
11. Hydroxychloroquine Sulfate 200 mg PO DAILY
12. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
13. Simvastatin 20 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Omeprazole 40 mg PO DAILY
16. Januvia (sitaGLIPtin) 100 mg oral daily
17. Benzonatate 100 mg PO TID:PRN cough
18. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
19. Metoclopramide 10 mg PO QIDACHS
20. Simethicone 80 mg PO QID:PRN gas, dyspepsia
21. Sucralfate 1 gm PO QID
22. leflunomide 10 mg ORAL DAILY
23. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 nebulizer inh
Q4H:PRN Disp #*15 Vial Refills:*0
2. Citalopram 10 mg PO DAILY
RX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 neb
inh Q6H:PRN Disp #*5 Inhaler Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30
Tablet Refills:*0
6. Haloperidol 1 mg PO BID
RX *haloperidol 1 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Lorazepam 1 mg PO BID
RX *lorazepam 1 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
8. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID:PRN Disp #*90
Capsule Refills:*0
9. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60mg subcutaneously Q12hours Disp
#*30 Syringe Refills:*0
RX *enoxaparin 60 mg/0.6 mL 60mg subcutaneously Q12 hours Disp
#*30 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Nausea, vomiting, abdominal pain NOS
- Toxic/metabolic encephalopathy NOS
- Stage IV NSCLC with CNS metastasis
Secondary:
- Left lower extremity proximal DVT ___
- COPD
- Hypertension
- Inflammatory arthritis NOS
- Diabetes mellitus type II
- Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted to ___ on
___ after becoming nauseated and vomiting multiple times.
When you were admitted, you showed signs of confusion, agitation
and delirium, and you were not acting like your normal self.
There were no infections or problems with your lungs, heart,
kidneys, or liver that could explain why you were confused.
Some of your medication were stopped to avoid potential negative
side-effects that would worsen your confusion. Due to confusion
and attempting to get out of bed overnight, you spent several
nights in a protective bed. Fortunately, your confusion
resolved on its own.
Several family discussions were held to make plans for you when
you left the hospital. Ultimately, the decision was to stop
aggressive treatments to try to cure your lung cancer, but
rather to provide medications to make your feel as good as
possible. Doctors from the ___ care team evaluated you
and helped set up hospice care at home.
We wish you the very best of luck and trust that you will be
well taken care of at home with the support of your family and
friends.
With warm regards,
Your ___ team
Followup Instructions:
___
|
10718710-DS-5
| 10,718,710 | 21,321,929 |
DS
| 5 |
2132-02-06 00:00:00
|
2132-03-04 22:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
double vision
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o R-handed man w/ HTN, hyperlipidemia,
prediabetes, and factor V Leiden; presented for acute painless
binocular horizontal diplopia.
Presented to ED. Evaluated by Neurology. Found to have signs of
L CN VI palsy; remainder of exam unremarkable. Admitted due to
concern for stroke and need for further w/up.
Past Medical History:
HTN, hyperlipidemia, prediabetes, and factor V Leiden
Social History:
___
Family History:
factor V ___
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, . No nuchal rigidity
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 3mm and brisk, no changes in pupil
sizes in light room or dark room. No ptosis noted.
Slight L eye esodeviation on primary gaze. On cover-uncover test
L eye moves slightly outwards. On EOM, patient reports
horizontal
diplopia on L lateral gaze consistently. The double vision
disappears when either eye is closed. When the L eye is closed
the "outside" image goes away.
VFF to confrontation. Visual acuity ___ bilaterally.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: Bilateral mild intention tremor. Normal
finger-tap
bilaterally. No dysmetria on FNF
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty
Pertinent Results:
___ 05:30AM BLOOD WBC-6.2 RBC-4.37* Hgb-13.5* Hct-40.9
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.2 RDWSD-45.2 Plt ___
___ 05:30AM BLOOD Neuts-50.1 ___ Monos-9.4 Eos-3.1
Baso-1.0 Im ___ AbsNeut-3.11 AbsLymp-2.24 AbsMono-0.58
AbsEos-0.19 AbsBaso-0.06
___ 05:30AM BLOOD ___ PTT-27.9 ___
___ 05:30AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-137
K-4.7 Cl-99 HCO3-29 AnGap-9*
___ 02:24PM BLOOD ALT-24 AST-27 AlkPhos-75 TotBili-0.4
___ 02:24PM BLOOD Lipase-27
___ 05:30AM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.1
___ 02:24PM BLOOD %HbA1c-6.4* eAG-137*
___ 02:24PM BLOOD Triglyc-159* HDL-50 CHOL/HD-3.4
LDLcalc-86
___ 05:30AM BLOOD TSH-2.5
___ 02:24PM BLOOD CRP-1.1
Brief Hospital Course:
Mr. ___ is a ___ y/o R-handed man w/ HTN, hyperlipidemia,
prediabetes, and factor V Leiden; presented for acute painless
binocular horizontal diplopia.
Presented to ED. Evaluated by Neurology. Found to have signs of
L CN VI palsy; remainder of exam unremarkable. Admitted due to
concern for stroke and need for further w/up.
CTA head/neck and MRI brain negative.
Likely CN VI palsy due to acute nerve ischemia, given pt's
vascular risk factors.
OT evaluated pt and cleared him for D/C.
Pt discharged in stable condition.
Medications on Admission:
ALLOPURINOL - Dosage uncertain - (Prescribed by Other Provider)
ALLOPURINOL - allopurinol ___ mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
BETAMETHASONE, AUGMENTED - betamethasone, augmented 0.05 %
topical ointment. apply to eczema daily with saran wrap
CLOBETASOL - clobetasol 0.05 % scalp solution. Apply to scalp
daily for 2 weeks then 2 times weekly
ERYTHROMYCIN - erythromycin 5 mg/gram (0.5 %) eye ointment.
apply
gid - (Not Taking as Prescribed)Entered by MA/Other Staff
FLUOCINOLONE AND SHOWER CAP - fluocinolone 0.01 % scalp oil and
shower cap. Apply to scalp 1 time per week
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. ___
tablet(s) by mouth once a day
HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. use for
psoriasis on skin folds (neck, bellybutton, inner elbows and
groin) twice a day
LISINOPRIL - lisinopril 5 mg tablet. TAKE 1 TABLET BY MOUTH
DAILY
NEOMYCIN-POLYMYXIN-HC - neomycin-polymyxin-hydrocort 3.5
mg/mL-10,000 unit/mL-1 % ear solution. ___ gtts three times a
day
SIMVASTATIN - simvastatin 40 mg tablet. 1 tablet(s) by mouth
daily at bedtime
SIMVASTATIN - simvastatin 20 mg tablet. TAKE ONE TABLET BY MOUTH
EVERY EVENING
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth once a day - (Prescribed by Other Provider)
GLUCOSAMINE-CHONDROITIN - Dosage uncertain - (Prescribed by
Other Provider)
OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
idiopathic L CN VI palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You developed acute-onset double vision and were admitted due
to concern for stroke. MRI of your brain was normal; it did not
show any evidence of stroke.
You have a left cranial nerve 6 palsy that we believe is due
to lack of blood flow to that nerve. The problems that put you
at risk for this are high blood pressure, high cholesterol, and
pre-diabetes mellitus. To better treat these problems, you
should improve your diet and increase exercise.
Your double vision will likely get better with time.
You should follow-up with your primary care physician in
clinic.
It was a pleasure taking care of you.
- Your ___ Neurology team
Followup Instructions:
___
|
10718726-DS-14
| 10,718,726 | 26,625,494 |
DS
| 14 |
2177-10-05 00:00:00
|
2177-10-05 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F hx Afib on ASA 325mg who fell from sitting today and
sustained cervical fractures. Per patient she was doing
colonoscopy prep when she became lightheaded yesterday morning,
went into the kitchen, sat at the table and put her head down.
The next thing she remembers is waking up on the floor with
significant neck pain. She got herself up off the floor and
into
bed however the pain worsened and so she went to OSH ED
wherehead CT was negative, CT Cspine showed C2 and C3 fx, CXR
showed 8th rib fx and she was transferred to ___ for further
eval. She complains of significant neck pain that worsens with
movement and right flank pain that worsens with movement.
Denies numbness, weakness or tingling.
Past Medical History:
paroxysmal Afib (only on asa)
HTN
s/p sigmoidectomy for diverticulitis
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
=========================
O: HR: 59 BP: 100/37 RR: 17 Sat: 94%
Gen: WD/WN, comfortable, NAD. In Cervical Hard collar
HEENT: normocephalic, atraumatic
Neck: C-Collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R pain w/movement; ___ in UE 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
No ___
No Clonus
Toes downgoing bilaterally
DISCHARGE EXAM:
===================
VS: T= 98.4 BP=81/40-136/56 HR= 85(65-156) RR=18 O2 sat= 92% 2L
GENERAL:comfortable in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: C-collar in place, unable to assess JVP
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Poor inspiratory effort ___ to collar/fracture. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+
Left: DP 2+
Pertinent Results:
ADMISSION LABS:
========================
___ 09:40AM GLUCOSE-115* UREA N-29* CREAT-1.1 SODIUM-140
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-17
___ 09:40AM CALCIUM-9.7 PHOSPHATE-4.7* MAGNESIUM-2.1
___ 09:40AM WBC-11.9* RBC-4.05* HGB-11.2* HCT-34.9*
MCV-86 MCH-27.6 MCHC-32.0 RDW-14.3
___ 09:40AM PLT COUNT-276
___ 09:40AM ___ PTT-27.2 ___
IMAGING:
===================
___ MRI C-spine
IMPRESSION: 1. C2 and C3 acute nondisplaced fractures. No
ligamentous injury or epidural hematoma.
2. Superior endplate fractures of the T1 and T2 vertebral bodies
without loss of height. Annular tear in the anterior T1-2 disc.
___ MRI/MRA of neck IMPRESSION:
1. No evidence of vertebral or carotid artery dissection.
2. Approximately 50% stenosis of the proximal left internal
carotid artery.
MICRO: NONE
===================
DISCHARGE:
=====================
___ 04:45AM BLOOD WBC-9.2 RBC-3.61* Hgb-9.9* Hct-31.0*
MCV-86 MCH-27.6 MCHC-32.1 RDW-14.2 Plt ___
___ 04:45AM BLOOD Glucose-102* UreaN-23* Creat-0.9 Na-138
K-3.6 Cl-98 HCO3-32 AnGap-12
___ 04:45AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 04:45AM BLOOD TSH-PND
Brief Hospital Course:
___ year old female with HTN, AFib (on ASA), HLD, who was
intially admitted for ACS service for c2/3 fracture who was
transferred to cardiology for further management of afib w/ rvr.
ACTIVE ISSUES:
=====================
# C2/C3 fracture: On ___, the patient was admitted from the
ED after a syncopal episode related likely to dehydration in the
setting of colonoscopy prep. She had an MRI which showed a C2
and C3 fracture, but without evidence of ligamentous damage. A
hard collar was fitted which was to be worn at all times. She
was transferred to the floor for evaluation and treatment.
# Paroxysmal A.fib with RVR: She developed AFib with RVR which
failed to resolve with IV metoprolol 5mg x2 doses, IV metoprolol
10mg x1 dose, and 10mg IV diltiaziam x1 dose, therefore she was
transferred to the TSICU for a diltiazem gtt. On hospital day 2
she converted to sinus rhythm so the dilt gtt was stopped, she
was restarted on her home dose of metoprolol 50mg BID, and she
was transferred to the floor under the neurosurgery service. On
hospital day 3, she again went into AFib with RVR. She received
75mg PO metoprolol, 5mg IV metoprolol x3, and 15mg IV diltiazem
and converted to SR. She was transferred to the cardiology
service for further management of her AFib. While on tele, the
patient remained in sinus rhythm in the ___ and was discharged
to rehab on her home dose of metoprolol 50mg BID. The patient
reported that her cardiologist and her discussed anticoagulation
and recommended that she be on aspirin 325 as opposed to
coumadin. With her paroxysmal atrial fibrillation, it should be
considered if she would benefit from an anti-arrhthymic.
CHRONIC ISSUES:
=====================
# HTN: Has been well controlled this admission on her home
medications. No epsisodes of hypotension during afib with RVR.
She was maintained on home valsartan, and HCTZ.
#HLD: she was maintained home pravastatin.
TRANSITIONAL ISSUES:
===========================
# TSH pending at the time of discharge
# With the patient's paroxysmal a.fib, she may benefit from
chemical cardioversion
# Anti-coagulation: would recommend re-considering starting
coumadin for anti-coagulation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Pravastatin 80 mg PO DAILY
3. Valsartan 80 mg PO DAILY
Hold for SBP<100
4. Metoprolol Tartrate 50 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
9. Pravastatin 80 mg PO HS
10. Senna 1 TAB PO BID:PRN constipation
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
12. Valsartan 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: C2 and C3 non-displaced fractures, T1 and T2 superior
endplate fractures, paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Gait is steady, but has impaired activity tolerance.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you here at ___
___! You came to the hospital after you
fell while preparing for your colonoscopy. Our imaging studies
showed that you had a fracture of your neck, more specifically
the vertebrae labeled, C2-C3 and upper back, the vertebrae
labeled T1-T2.
While you were in the hospital, you intermittently had a fast
irregular heart rate called atrial fibrillation. While you were
having the a.fib, you did not have any symptoms of chest pain or
palpitations. We did not change your medications for fear that
your heart rate would be too slow. From talking with you, you
seemed to have talked with your cardiologists about coumadin to
thin your blood because atrial fibrillation puts you at
increased risk for stroke. We continued you on aspirin 325.
The following are recommendations from the neurosurgeons who saw
you while in the hospital.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
You are required to wear your cervical collar at all times.
You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
10719746-DS-20
| 10,719,746 | 26,389,426 |
DS
| 20 |
2121-12-22 00:00:00
|
2121-12-22 11:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / ceftriaxone / iodine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 10:36PM BLOOD WBC-9.7 RBC-3.97* Hgb-11.5* Hct-37.1*
MCV-94 MCH-29.0 MCHC-31.0* RDW-13.8 RDWSD-47.2* Plt ___
___ 09:05AM BLOOD ___
___ 10:36PM BLOOD Glucose-107* UreaN-45* Creat-1.7* Na-141
K-5.0 Cl-103 HCO3-26 AnGap-12
___ 10:36PM BLOOD ALT-74* AST-63* CK(CPK)-24* AlkPhos-241*
TotBili-0.4
___ 06:50AM BLOOD cTropnT-0.04*
___ 10:36PM BLOOD Lipase-36
___ 10:36PM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.1 Mg-2.3
RUQUS:
IMPRESSION:
1. Mild circumferential gallbladder wall thickening and trace
pericholecystic
fluid, with gallbladder sludge at the gallbladder neck.
Although no definite
stones are identified, in the setting of a positive sonographic
___ test,
these findings raise the possibility of acute cholecystitis. A
HIDA scan
could be considered for further evaluation.
2. Thick-walled, cystic lesion within the upper pole of the left
kidney,
measuring 4.9 cm, incompletely characterized. A nonemergent
renal MRI or
multiphasic CT may be obtained for further assessment.
RECOMMENDATION(S): Thick-walled, cystic lesion within the upper
pole of the
left kidney, measuring 4.9 cm, incompletely characterized. A
nonemergent renal
MRI or multiphasic CT may be obtained for further assessment
HIDA
IMPRESSION: Findings consistent with acute cholecystitis.
___ 08:38AM BLOOD WBC-9.8 RBC-4.17* Hgb-11.8* Hct-38.3*
MCV-92 MCH-28.3 MCHC-30.8* RDW-14.1 RDWSD-47.7* Plt ___
___ 08:38AM BLOOD Glucose-95 UreaN-27* Creat-1.2 Na-146
K-4.6 Cl-106 HCO3-23 AnGap-17
___ 08:38AM BLOOD ALT-24 AST-15 AlkPhos-172* TotBili-0.8
Brief Hospital Course:
___ is a ___ M with sCHF EF ___, CAD/PVD, HTN/HL, s/p
CVA after CEA ___, CKD III, who presented from SNF with RUQ
pain, US showing GB thickening and distention consistent with
acute cholecystitis.
# Acute cholecystitis:
Dx based on RUQ pain with mild hepatitis, and classic findings
on imaging. No clear stones appreciated but rather sludge
although ? small stone seen on RUQ US from OSH. No evidence of
bile obstruction. HIDA +. He improved on antibiotics alone.
Surgery did not feel he was safe for CCY and recommend perc
chole. Radiology wanted to watch him clinically to see how he
responded with antibiotics first. Overall he remained stable.
Long discussion was had with patient and daughter and
significant review of case with surgery and ___. At this time he
was clinically completely improved. Without drainage he was at
high risk for recurrence. However, the goal was to minimize
invasive procedures if possible. The timing of tube placement
will depend on his clinical condition going forward. We
discussed continuing to monitor with full diet and antibiotics
for 2 weeks (to end ___, and then re-image then to see if his
gallbladder inflammation has resolved
- Cont Cipro/Flagyl through ___
- If pain or symptoms recur at any point then will need perc
chole
- Given that he has remained entirely asymptomatic we discussed
discharge and then repeat RUQ US at end of antibiotic treatment
(the week of ___ to monitor for resolution of gallbladder
inflammation. Should inflammation persist, he will need a
referral to general surgery.
- Plavix resumed on discharge given no imminent surgical
intervention
# L shoulder Pain:
new since admission. Given weakness in arm he is at risk for fx
or dislocation with significant movement. Likely MSK related.
Xray negative for fx and dislocation
#Chronic systolic CHF
CAD/PVD:
CAD is per history. CHF confirmed by PCP on recent ___. He
was compensated with no edema on imaging or exam.
- Cont ASA, Plavix
- Cont metoprolol, atorvastatin
- Resumed Lasix
- Resumed lisinipril
- daily wts, fluid status assessments
#R forearm induration ___ local trauma from accidentally
striking it on bed rail. No evidence of purulence, flutuance or
drainage. Recommend warm compress and bacitracin ointment.
#QTc prolongation:
Mild Qtc prolongation. He was on Cipro serial EKG monitored
with QTc at 488 (<500) at time of discharge)
#AFib
prior CVA:
CVA apparently after CEA and not embolic. L sided weakness Not
on systemic anticoagulation.
- Continued ASA, Plavix
# ___ III:
Baseline per PCP ___ ___
# Glaucoma:
Cont eye drops
Transitional issues
[] Cont Cipro/Flagyl through ___ for acute cholecystitis
[] If pain or symptoms recur at any point then will need urgent
perc chole
[] Given that he has remained entirely asymptomatic we discussed
discharge and then repeat RUQ US at end of antibiotic treatment
(the week of ___ to monitor for resolution of gallbladder
inflammation. Should inflammation persist, he will need a
referral to general surgery. This should be coordinated through
his PCP
___ than 40 mins were spent in discharge planning and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Metoprolol Tartrate 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
7. Clopidogrel 75 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Furosemide 20 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
11. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID
Last dose in ___ of ___. MetroNIDAZOLE 500 mg PO TID
Last dose in ___ of ___. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Baclofen 10 mg PO QHS
7. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
8. Clopidogrel 75 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Furosemide 20 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Lisinopril 10 mg PO DAILY
14. Metoprolol Tartrate 25 mg PO DAILY
15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First
Line
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Chronic systolic CHF
CAD
prior DVA
CKD III
HTN
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:
Patient was admitted for inflammation in his gallbladder
(cholecystitis). He was started on antibiotics and he improved.
The decision was made not to drain his gallbladder. He will
need close monitoring for recurrence of symptoms. He will
complete a 14 day course of antibiotics (Cipro/Flagyl) with his
last dose on ___. He will need close follow up with his PCP to
coordinate ___ repeat ultrasound of his gallbladder to monitor for
ongoing inflammation.
It was a pleasure taking care of you.
Your ___ team
Followup Instructions:
___
|
10719901-DS-2
| 10,719,901 | 21,219,852 |
DS
| 2 |
2189-09-12 00:00:00
|
2189-09-12 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of hypertension,
severe neuropathy associated with multiple myeloma, and upcoming
surgery for hip replacement, who presents from ___ with chest pain.
Patient reports going in for preop visit and had to walk quite a
distance across several long hallways. He developed ___ chest
tightness. No radiation. No worsening or alleviating factors.
Associated with lightheadedness without syncope. Denied any
diaphoresis, nausea, vomiting, numbness or weakness in
extremities, palpitations.
Code green was called. Patient was given nitroglycerin
sublingual
x3, aspirin and Plavix and transferred for further evaluation or
cath. Initial troponin negative. Patient does report history of
chest pain yesterday that occurred at rest.
On presentation, he still endorses mild ___ chest pressure. No
history of exertional chest pain. He reports a history of a
stress test ___ years ago, but patient does not know the result.
(On review of chart, there is a pharm stress test with nuclear
imaging in ___ showing normal myocardial perfusion and no
evidence of infarction). No cardiac cath history. Reportedly
with
ST segment changes that improved with nitro.
No smoking. No family history of cardiac disease.
EKG: NSR, nl intervals, nl axis, no signs of ischemia
Baseline Cr between 1.3 and 1.6.
In the ED, initial VS were:
T 98.6 HR 72 NP 140/92 RR 18 O2 Sat 100% RA
Exam notable for: No murmurs, no pertinent physical exam
findings
EKG: NSR, nl intervals, nl axis, no signs of ischemia
Labs showed:
Baseline Cr between 1.3 and 1.6.
UA unremarkable
Trop < 0.01 at 8PM
CBC with mild anemia Hgb 12.9
Consults:
Cardiology was consulted and recommended admission to ___ under
Atrius service. Echo at ___ supposedly normal per family, will
need to request report in AM. Continue nitroglycerin and heparin
drip for now for management of presumed unstable angina.
Patient received:
Nitroglycerin SL
Heparin IV gtt
Nitroglycerin gtt
Of note, patient was called for a code stroke after a bolus of
heparin and a needle stick. Patient had witnessed episode of
unresponsiveness lasting ___ seconds, accompanied by
bradycardia to ___. He then had right-sided weakness that
rapidly
resolved.
Imaging showed:
CT head did not show any acute process. CTA showed some stenosis
of the bilateral carotids, without occlusion. Perfusion is
negative.
Neurology was consulted and thought was most likely vasovagal.
Patient back to baseline.
Transfer VS were:
HR 51 BP 140/70 RR 14 O2 Sat 99% RA
On arrival to the floor, patient reports continued chest
pressure, greater on the left than on the right. It seems to
radiate across both sides of his chest to his axilla. He denies
any nausea or vomiting and reports that it is not painful. He
does not have any shortness of breath. He has good appetite and
requests a sandwich. He does not feel that the nitroglycerin has
really helped with his pain (nitro drip is currently at 0.1). He
feels comfortable enough to rest and go to sleep.
Multiple myeloma in remission for about ___ years. Treated at ___.
REVIEW OF SYSTEMS:
Positive for chest pressure.
Positive for significant neuropathy (numbness and paresthesias),
dry skin, back pain.
Positive for blurred vision.
Positive for occasional abdominal cramping and constipation.
Positive for progressive left hip stiffness
Negative for nausea, vomiting, shortness of breath, diaphoresis,
fever, chills, sweats.
Otherwise, 10 point ROS reviewed and negative except as per HPI
Past Medical History:
History of POEMS syndrome ___
GERD
Neuropathy associated with multiple myeloma
History of seizure
Anemia
Osteoarthritis
Sickle cell trait
Hypertension
Social History:
___
Family History:
Mother- stomach cancer
Sister- hematologic malignancy
Brother- ___
Brother- HTN
Brother- diabetes
Has three daughters and five grandchildren
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 96.3 BP 150 / 83 HR 61 RR 20 O2 Sat 97 RA
GENERAL: No acute distress, well-developed male
HEENT: EOMI, PERRL, normal dentition, sclera anicteric. Moist
mucous membranes
NECK: nontender supple neck, no LAD, no JVD
CV: Regular rate, no murmurs, normal S1/S2
Chest pressure not reproducible with palpation, cough, or
inspiration
LUNGS: CTAB, no wheezes, breathing comfortably without use of
accessory muscles
ABDOMEN: Normoactive bowel sounds. Abdomen is soft,
nondistended, nontender in all quadrants, with no
rebound/guarding.
EXTREMITIES: Cold in distal extremities, prominent along
bilateral lower extremities. He has foot drop in R foot > L. No
edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Moves all extremities but cannot wiggle
toes on the R foot.
SKIN: Smooth and dry.
DISCHARGE PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 419)
Temp: 97.6 (Tm 98.3), BP: 156/78 (112-156/59-78), HR: 56
(56-77), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: RA
Fluid Balance (last updated ___ @ 1620)
Last 8 hours No data found
Last 24 hours Total cumulative 511ml
IN: Total 511ml, PO Amt 270ml, IV Amt Infused 241ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: WDWN older man in NAD
HEENT: NCAT, sclerae anicteric
NECK: Supple, JVP not elevated
CV: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, no increased work of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Cool distal extremities (unchanged from prior),
prominent along bilateral lower extremities. DP pulses 2+
bilaterally. No edema.
NEURO: A&Ox3, CN grossly intact, spontaneously moving all
extremities
Pertinent Results:
Admission labs:
============
___ 08:18PM BLOOD WBC-5.8 RBC-4.72 Hgb-12.9* Hct-38.5*
MCV-82 MCH-27.3 MCHC-33.5 RDW-15.0 RDWSD-45.2 Plt ___
___ 08:18PM BLOOD Plt ___
___ 08:45PM BLOOD ___ PTT-150* ___
___ 08:18PM BLOOD Glucose-88 UreaN-21* Creat-1.2 Na-140
K-4.7 Cl-106 HCO3-22 AnGap-12
___ 03:33AM BLOOD ALT-9 AST-13 AlkPhos-75 Amylase-62
TotBili-0.4
Discharge labs:
============
___ 09:15AM BLOOD WBC-5.6 RBC-4.89 Hgb-13.1* Hct-41.0
MCV-84 MCH-26.8 MCHC-32.0 RDW-15.2 RDWSD-46.1 Plt ___
___ 09:15AM BLOOD Plt ___
___ 09:15AM BLOOD Glucose-140* UreaN-23* Creat-1.4* Na-145
K-4.3 Cl-108 HCO3-26 AnGap-11
___ 09:15AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
Pertinent labs:
==========
___ 03:33AM BLOOD ALT-9 AST-13 AlkPhos-75 Amylase-62
TotBili-0.4
___ 03:33AM BLOOD Lipase-18
___ 08:18PM BLOOD cTropnT-<0.01
___ 03:33AM BLOOD cTropnT-<0.01
___ 08:18PM BLOOD Triglyc-119 HDL-33* CHOL/HD-4.7
LDLcalc-99
___ 08:24PM BLOOD %HbA1c-4.6 eAG-85
Imaging:
=======
Stress test
INTERPRETATION: ___ yo man with HL and HTN was referred to
evaluate
an atypical chest discomfort. The patient was administered 0.4
mg
Regadenoson IV bolus over 20 seconds. No chest, back, neck or
arm
discomforts were reported during the procedure. No significant
ST
segment changes were noted. The rhythm was sinus with no ectopy
noted.
The hemodynamic response to the infusion was appropriate.
Post-infusion,
the patient was administered 60 mg caffeine IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Nuclear
report sent separately.
FINDINGS: Left ventricular cavity size is normal
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 67%
IMPRESSION: 1. No reversible cardiac defect. 2. Estimated
ejection fracture of
67%.
CTA NEURO
IMPRESSION
1. Possible ischemia without definite infarct in the posterior
left temporal
lobe, more likely artifactual given additional apparent multiple
small regions
with increased T-max not aligning with a particular vascular
distribution. No
evidence of left temporal lobe hypoattenuation or decreased
arborization of
left middle cerebral artery branches to suggest infarct or
hypoperfusion.
2. Otherwise no evidence of an acute intracranial abnormality.
3. No evidence of arterial occlusion, stenosis, or aneurysm
formation.
4. Asymmetry at the left fossa of ___ may reflect an
underlying
lesion. Recommend correlation with symptoms and visual
inspection.
RECOMMENDATION(S): Asymmetry at the left fossa of ___
may reflect an underlying lesion. Recommend correlation with
symptoms and visual inspection.
Brief Hospital Course:
Mr. ___ is a ___ male with history of hypertension,
severe neuropathy associated with multiple myeloma, and upcoming
surgery for hip replacement, who presents from ___ with chest pain vs pressure.
# Non-Cardiac Chest Pain
Patient presented with chest pressure initially concerning for
unstable angina given its exertional component. Negative
regadenoson stress test in ___. TTE at OSH on ___ showed EF
>55%, normal LV size, wall thickness, systolic function, no WMA,
aortic root dilatation to 41mm. Normal CXR. Transferred to ___
for further management of possible unstable angina. He has no
known CAD; he has hypertension but no prior history of
hypercholesterolemia or diabetes (last Hgb A1c 4.8 in ___,
lipid panel was within normal limits in ___. He does not take
daily aspirin, has no EKG changes or positive cardiac biomarkers
so far, ultimately giving him a TIMI score of 2 points.
Troponins were negative x2, and repeat EKG showed no concerning
changes. Lipid panel notable for HDL 33. Patient weaned off
nitro gtt without worsening of chest pain. pMIBI completed this
admission and negative. Hepatic and pancreatic labs WNL. Started
H2 blocker for possible GI source given negative cardiac work-up
and low suspicion for pulmonary or musculoskeletal etiology.
# Syncope
Patient had episode of passing out during blood draw in
emergency department, associated with bradycardia to ___ with
rapid return to normal heart rate and regained consciousness.
Code stroke called and patient evaluated by neurology. CT head
negative, CTA head and neck with non-occlusive stenosis. Per
neurology evaluation, low suspicion for stroke, seizure, or
neurologic etiology of syncope, likely vasovagal. Patient
monitored on telemetry for duration of admission with no
evidence of arrhythmia, negative cardiac work-up as above.
# Glaucoma
Continued home brimonidine, timolol and latanoprost eye drops.
# Indolent IgA myeloma versus MGUS:
Patient has hx of monoclonal gammopathy complicated by
peripheral neuropathy symptoms. Followed at ___ with Dr.
___. He has been on observation for years and has not had
any evidence of disease progression by IgA levels. His
neuropathy symptoms were stable on the current regimen while
admitted. He was continued on home amitriptyline 50mg.
TRANSITIONAL ISSUES
[ ] Re-check Hgb, consider further work-up for anemia Hgb 11.7
[ ] Syncope experienced this admission likely vasovagal, please
be cautious if adding any anti-HTN medications
[ ] Consider referral for cognitive evaluation/ MOCA
[ ] Asymmetry at the left fossa of ___ may reflect an
underlying lesion. Recommend correlation with symptoms and
visual inspection.
New Medications:
Ranitidine 150MG BID
Atrovastatin 40mg qPM
Changed Medications:
None
Stopped/Held Medications:
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. lidocaine 4 % topical DAILY:PRN
6. Vitamin D 1000 UNIT PO DAILY
7. Amitriptyline 50 mg PO QHS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
2. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth every day Disp
#*30 Tablet Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Amitriptyline 50 mg PO QHS
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. lidocaine 4 % topical DAILY:PRN
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==================
Non-Cardiac Chest Pain
Vasovagal Syncope
Secondary diagnosis
===================
HLD
multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain
and an episode of passing out in the emergency department.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You underwent testing for heart disease which showed no
evidence of heart attack, irregular heart beat, or other heart
disease. Your stress test was normal.
- You were evaluated by the neurology team and had head imaging,
which showed no evidence of stroke.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10719998-DS-11
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2119-08-25 00:00:00
|
2119-08-26 22:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
metoclopramide / prochlorperazine / mesalamine / erythromycin
base
Attending: ___.
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a ___ year old woman
with a history of recent subdural and intraparenchymal
hemorrhage
requiring hemicraniectomy for clot evacuation, who presents to
the ED from ___ for evaluation of
altered mental status. Neurology is consulted to rule out
seizure
activity as a cause of her encephalopathy.
She was recently admitted on ___ after presenting to an
outside hospital with worst headache of her life. INR previously
that day was apparently 4.0, but was 2.7 on arrival to the
outside hospital. Coagulapathy was reversed. On arrival to ___
her exam deteriorated, therefore patient was intubated for
airway
protection. A CT/CTA was obtained on arrival and was negative
for
aneurysm, yet showed interval increase in IPH and SDH. Patient
was taken emergently to the OR for right craniectomy for SDH
evacuation. Etiology of her hemorrhage was thought to be due to
coagulopathy from Coumadin administration. On ___, she spiked a
fever, prompting cultures to be drawn. These showed a UTI, and
P.
aeruginosa eventually grew in the urine. This was treated with
Zosyn. On ___, she was noted to have some twitching activity of
the left had. EEG was applied and showed focal status
epilepticus. She was eventually treated with a regimen of
Levetiracetam 1500mg BID and Lacosamide 150mg BID. Although EEG
still showed periodic lateralized epileptiform activity, no
further seizures were seen. She was discharged to ___ on ___. Her daughter notes that although she
was being intermittently catheterized at ___, a Foley catheter
was placed on arrival to ___.
Her daughter visited both days over the weekend. She noted that
Ms ___ was able to speak in ___ word sentences, which were
generally appropriate. She was able to recall major aspects of
her recent hospitalization. She could follow simple commands.
She
remains dependent on others for all ADLs, and is fed via a PEG
tube. She is wheelchair bound, but has reportedly just started
to
move her left leg.
When her daughter visited yesterday (___), her mother was
sitting in a wheelchair with her eyes closed. She was not
speaking and would not follow any commands. Her daughter was
worried that she "was relapsing", but attributed it to her being
very tired from ___.
Today, Ms ___ was apparently again very lethargic.
Documentation from ___ states that she was awake, with her
eyes open, but she did not follow commands, and was not
responding to questions. Due to concern for worsening
intracranial hemorrhaged. She was transferred to ___.
On my arrival, her daughter reports that she seems to be getting
a bit better. Whereas she was not taking or interacting at all
earlier today, she is now able to say a few words, and was able
to identify her daughter and son-in-law.
Unable to obtain further review of systems due to her mental
status.
Past Medical History:
Recent right sided subdural and intraparenchymal hemorrhage
R lung cancer s/p radiation diagnosed in ___
Colitis
Hyperlipidemia
Hypertension
Chronic Kidney disease
Barretts esophagus
Broken shoulder - left
Fibromyalgia
Shingles
Recurrent thrombosis-alternately described as DVT as well as
arterial thrombus in prior notes. Was on Coumadin until recent
hospitalization
Past Surgical History:
R Craniectomy for subdural/clot evacuation
C-section
Ovarian cyst removal
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Exam
==============
Physical Examination:
Vitals: T: 97.7 P: 54 R: 16 BP: 115/68 SaO2: 99% RA
General: Awake, NAD.
HEENT: skull deformity on right, no scleral icterus noted, dry
mucous membranes, 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: PEG site clean/dry/intact.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, no acute distress. Eyes open and briefly
track examiner, though not consistently. Does not follow any
commands. Minimal spontaneous speech, mostly consisting of
___. Occasionally obeys daughter's instructions to stop
scratching, etc.
-Cranial Nerves:
Pupils equal and reactive 4 to 2mm. Gaze midline, with intact
oculocephalics. Slight left nasolabial fold flattening. Tongue
and palate midline. Cough/gag not tested.
-Motor: Tone is spastic in the left arm and leg. She moves the
right arm and leg spontaneously and purposefully, and can
sustain
against gravity for at least 5 seconds. No spontaneously
movement
of the left arm or leg, though they do withdraw in the plane of
the bed from a pinch.
-Sensory: Grimaces to pinch in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 2
R 2 2 2 2 2
Plantar response was mute bilaterally. ___ beats clonus present
in each ankle.
-Coordination: Unable to test
-Gait: Unable to test
Discharge Exam
===============
Physical Examination:
24 HR Data (last updated ___ @ 805)
Temp: 98.2 (Tm 99.4), BP: 138/68 (108-146/55-76), HR: 70
(69-76), RR: 20 (___), O2 sat: 95% (95-99), O2 delivery: RA
General: Awake, eyes open, says "not bad" following commands
HEENT: skull deformity on right, no scleral icterus noted, MMM,
no lesions noted in oropharynx
Cardiac: warm and well perfused
Abdomen: PEG site clean/dry/intact.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake and alert, says her name, oriented to
___,
says she's "still in the hospital" unable to say which hospital,
following commands
-Cranial Nerves:
Pupils equal and reactive 3 to 2mm. Midline gaze. Intact
oculocephalics. Slight left nasolabial fold flattening.
-Motor: Tone is rigid in the left arm and leg.
RUE briefly antigravity
LUE Plegic
LLE plegic
RLE spontaneous movement, antigravity
-Sensory: Grimaces to pinch in all extremities
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 2
R 2 2 2 2 2
Plantar response was mute bilaterally. no clonus
-Coordination: Unable to test
-Gait: Unable to test
Pertinent Results:
Admission Labs
===============
___ 12:22PM BLOOD WBC-8.2 RBC-3.25* Hgb-10.3* Hct-32.8*
MCV-101* MCH-31.7 MCHC-31.4* RDW-15.8* RDWSD-58.1* Plt ___
___ 12:22PM BLOOD Glucose-100 UreaN-22* Creat-0.7 Na-134*
K-5.1 Cl-97 HCO3-24 AnGap-13
___ 04:40PM BLOOD ALT-27 AST-39 LD(LDH)-375* AlkPhos-143*
TotBili-0.3
___ 12:22PM BLOOD Calcium-10.7* Phos-3.8 Mg-2.0
___ 04:40PM BLOOD calTIBC-274 Ferritn-347* TRF-211
___ 12:43PM BLOOD freeCa-1.33*
Important Interval Labs
=========================
___ 06:08AM BLOOD PTH-40
___ 04:50AM BLOOD 25VitD-40
___ HbA1c 5.2
___ LDL 60
Discharge Labs
===============
___ 05:20AM BLOOD WBC-6.9 RBC-2.66* Hgb-8.7* Hct-26.6*
MCV-100* MCH-32.7* MCHC-32.7 RDW-15.9* RDWSD-57.5* Plt ___
___ 05:20AM BLOOD Glucose-116* UreaN-36* Creat-0.7 Na-141
K-4.4 Cl-101 HCO3-29 AnGap-11
___ 06:01PM BLOOD freeCa-1.29
Micro
======
Urine culture: Yeast
Blood cultures: NGTD
Imaging
========
___ CT
Exam is slightly limited secondary to motion despite repeated
image
acquisition.
Right frontoparietal hemicraniectomy is again visualized with
appropriate
postsurgical changes. Interval decrease of brain parenchymal
herniation
through the defect. There has been interval evolution and
decrease density of right frontotemporal intraparenchymal
hematoma. There is no evidence of new hemorrhage, or large
territory infarction. There has been interval resolution of
leftward midline shift and decreased mass effect on the right
lateral ventricle. Previously seen intraventricular and
subarachnoid blood is no longer visualized.
Paranasal sinuses are grossly clear though significantly limited
by motion. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Limited exam secondary to motion. Expected evolution of
right
temporoparietal parenchymal hemorrhage with decreased mass
effect and right hemi craniectomy changes. No evidence of new
hemorrhage or large territory infarction.
2. Interval resolution of leftward midline shift, and decreased
mass effect on the right lateral ventricle.
___ MRI
There is a new diffusion abnormality in the posteromedial left
basal ganglia consistent with acute infarct (series 402, image
15). There is no evidence of acute infarct or new hemorrhage.
Seen again is the intraparenchymal hemorrhage in the
temporoparietal lobe which has undergone evolutional changes.
There continues to be mild left midline shift there is grossly
unchanged from prior. There are mild involutional changes of
the ventricles with no evidence of hydrocephalus.
IMPRESSION:
1. New acute infarction of the posteromedial thalamus.
2. No evidence of new hemorrhage.
3. Previous intraparenchymal hemorrhage in the temporoparietal
lobe shows no interval change.
EEG ___
IMPRESSION: This is an abnormal cvEEG due to:
(1) nearly continuous moderate to high voltage right frontal
lateralized
periodic discharges (LPDs) with frequency up to 2Hz suggestive
of an increased risk for seizures, and represents the
interictal-ictal continuum.
(2) Generalized slowing background is indicative of moderate
encephalopathy which is a nonspecific finding and can be seen
with medications, infection, toxic or metabolic derrangements.
(3) Higher amplitude seen in right hemisphere is indicative of
underlying
known skull defect (breach rhythm).
There are no pushbutton activations or electrographic seizures.
Compared with
prior day's recording there is no significant change.
Brief Hospital Course:
___ year old woman with a recent subdural and intraparenchymal
hemorrhage with a course complicated by a UTI and NCSE now on
keppra and lacosamide, who returned from rehab with decreased
level of consciousness.
Encephalopathy
-Most likely waxing and waning in setting of recent intracranial
hemorrhage complicated by NCSE. CT head showed interval
improvement in
mass effect and midline shift. MRI showed new thalamic infarct
but this was felt to be incidental and due to increased ICP. She
was monitored on EEG and showed right lateral transient
discharges that were consistent with prior EEG studies in
addition to diffuse background slowing; there were no
electrographic seizures. Her AEDs were weaned as these were felt
to be possibly causing encephalopathy. EEG was unchanged with
taper of Keppra to 750mg BID and Lacosamide 100mg BID. She was
also found to be slightly hypercalcemic due to hypovolemia. PTH
and Vit D were checked and were normal. Calcium improved with
fluids. There was not evidence of infection. Family refused LP
for complete infectious workup but this was felt to be very low
likelihood. She improved back to baseline. She is at high risk
for delirium given her age, recent intracranial hemorrhage and
prolonged hospitalization, presence of Foley catheter, etc.
#Right IPH/SDH s/p right craniectomy complicated by right
posterior parietal infarcts
#c/b focal status epileptics
- Patient was continued on home atorvastatin 20, losartan 50,
amlodipine 10 (d/c dose was 5). Metoprolol tartrate decreased
from 25mg q6 to BID. Prior admission developed fine tremors LUE
and chest. EEG showed focal status epileptics. She was started
on keepra and Vimpat. On this admission EEG did not show any
electrographic seizures but did show frequent lateral discharges
that were similar to prior. Weaning AEDs did not change EEG. Her
exam improved and she was kept at 750mg BID of Keppra, and 100mg
BID of vimpat.
#FEN
-Continued on TF through PEG
#ID
-Infectious work-up was negative. She was afebrile, no
leukocytosis. CXR improved from prior; but RLL consolidation
still visualized. Urine cx showed yeast; Blood cx negative. CSF
was not sent as family refused. Given low suspicion and
improvement in exam LP was deferred.
Transitional Issues:
=====================
[] Pt has wound on gluteal area, please monitor and have wound
care follow
[] Please avoid straight catheterization if able. Had had
frequent UTIs in the past
[] Continue AEDs: Keppra 750mg BID, l00mg BID
[] Goal SBP <160
[] Continue ___ as tolerated by symptoms- Degree of hemorrhage is
severe causing headaches that are worse with activity
[] follow-up with neurosurgery
[] Tube feed recs: Jevity 1.2; Full strength
Tube Type: Percutaneous gastrostomy (PEG); Placement confirmed.
Starting rate: 60 ml/hr; Do not advance rate Goal rate: 60
ml/hr
Residual Check: Q4H Hold feeding for residual >= : 200ml
Flush w/ 30 mL water Per standard
Free water amount: 100 mL; Free water frequency: Q6H
#Code:Full, discussed with daughter
#Contact: ___
Relationship: OTHER
Phone: ___
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
( ) Yes - (X) No. If not, why not? Pt. recently had ICH, ___ &
___
4. LDL documented? (x) Yes (LDL = 60) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - (x) unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
6. LACOSamide 150 mg PO BID please assess daily PR interval
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. LevETIRAcetam 1500 mg PO Q12H
9. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Heparin 5000 UNIT SC BID
2. Metoprolol Tartrate 25 mg PO BID
3. amLODIPine 10 mg PO DAILY
4. LACOSamide 100 mg PO BID
5. LevETIRAcetam 750 mg PO BID
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
8. Atorvastatin 20 mg PO QPM
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Toxic Encephalopathy
Acute Ischemic Thalamic Infarct
Secondary Diagnosis
=====================
HTN
Right IPH/SDH s/p right craniectomy complicated by right
posterior parietal infarcts
Focal Status Epilepticus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of lethargy and
unresponsiveness. We think this may have been because of a few
different factors including a new acute ischemic stroke and too
high doses of your seizure medications.
You were monitored on EEG and your seizure medications were
weaned down. Your mental status improved and you were back to
your baseline at discharge.
An ACUTE ISCHEMIC STROKE, is 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:
- IPH with cerebral edema
We are changing your medications as follows:
- Decrease dose of Keppra to 750mg BID
- Decrease dose of Vimpat to 100mg BID
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:
___
|
10720041-DS-11
| 10,720,041 | 20,231,711 |
DS
| 11 |
2132-08-31 00:00:00
|
2132-09-03 13:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with IV heroin and cocaine use disorder recently
admitted for acute hepatitis (discharged ___ with ALT/AST >
1000, Tbili 7.3, and INR 1.4, found to be due to acute hepatitis
C, now presenting from ___ with worsening jaundice.
Recent hospital course notable for: Patient remained clinically
stable with no encephalopathy or liver failure and was
discharged at baseline. HCV antibody was positive and VL was
positive, consistent with HCV as the etiology. Other viral and
toxin screens were negative. Autoimmune testing was pending at
discharge. Plan was to follow up with PCP for repeat LFTs and
Hepatology in 1 month to discuss HCV treatment options if
indicated. Labs at discharge: ALT 1348 AST 709 AP 330 TBili
8.6. Other notable labs - HCV VL 7.7, IgM elevated, ___ neg,
anti sm pos at 1:80. EBV IgM neg, CMV neg, Cr 0.7.
Since discharge he was feeling relatively well, though did
report two episodes of clear non-bloody, non-bilious vomiting on
___. Patient went to PCP for follow up yesterday and was found
to have increasing jaundice with worsening LFTs and bilirubin
(ALT 2200, AST 1347, T. bili 18.8, AP 333, INR 1.1). He was sent
to ___ for follow up, where he endorsed ongoing IV drug use, and
was transferred to ___. He reported that he last used IV
opiates ___, and that he has been using IV heroin over the past
few days since discharge, as well as smoking cigarettes ~1ppd.
He denies fevers, chills, confusion, chest pain, SOB, abdominal
pain, weakness, diarrhea, constipation, lower extremity
swelling, easy bruising. He also denies taking Tylenol or
ibuprofen containing medications since discharge, and denies
taking any dietary supplements or herbal medications in the time
leading up to his initial admission or in the time since
discharge.
In the ED, initial vitals: 98.7 98/63 74 16 99% RA
Exam notable for jaundice with scleral icterus, A&Ox3, no
asterixis, benign abdominal exam, no edema.
Labs were significant for:
wbc 12.7 hgb 11.2 hct 33.0 plts 291
INR 1.1 (down from 1.4 at last admission)
Na 130 K 4 Cl 96 bicarb 25 BUN 10 Cr 0.9
LFTs: alt 1771 ast 1252 ap 267 ldh 391 tbili 19.0
Serum tox negative
UA large bili, Urine tox negative
Imaging: RUQ US showed patent main portal vein, no ascites,
persistent GB wall thickening improved from prior, and mild
splenomegaly
In the ED, pt received:
___ 09:04 IVF NS ___ Started
___ 11:15 IVF NS 1 mL ___ Stopped (2h ___
Currently, patient reports that his jaundice appears improved
from yesterday and he has no other complaints.
Past Medical History:
IV heroin use: On previous admission reported ~6months of use,
currently reports over ___ of use
Occasional cocaine use (~once per month)
Social History:
___
Family History:
Sister with HCV (due to blood transfusion as a child)
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.6 95/58 68 19 99% RA
GEN: Alert, sitting in bed, jaundiced, no acute distress
HEENT: MMM, icteric sclerae, EOMI, PERLL, no conjunctival pallor
NECK: Supple, no LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, no appreciable fluid wave
EXTREM: Warm, well-perfused, no edema
NEURO: A&Ox3, CN II-XII grossly intact, strength and sensation
grossly intact bilaterally, no asterixis
DISCHARGE PHYSICAL EXAM
Vitals: 98.0 103/63 60 18 98% RA
GEN: Alert, lying in bed, jaundiced, no acute distress
HEENT: MMM, icteric sclerae, EOMI, PERLL, no conjunctival pallor
NECK: Supple, no LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, no appreciable fluid wave
EXTREM: Warm, well-perfused, no edema
NEURO: A&Ox3, CN II-XII grossly intact, strength and sensation
grossly intact bilaterally, no asterixis
Pertinent Results:
ADMISSION LABS
___ 08:45AM BLOOD WBC-12.7* RBC-3.89* Hgb-11.2* Hct-33.0*
MCV-85 MCH-28.8 MCHC-33.9 RDW-18.3* RDWSD-54.3* Plt ___
___ 08:45AM BLOOD Neuts-54.4 ___ Monos-8.9 Eos-4.4
Baso-1.0 Im ___ AbsNeut-6.89*# AbsLymp-3.88* AbsMono-1.13*
AbsEos-0.56* AbsBaso-0.13*
___ 08:54AM BLOOD ___ PTT-30.7 ___
___ 08:45AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-130*
K-4.0 Cl-96 HCO3-25 AnGap-13
___ 08:45AM BLOOD ALT-1771* AST-1252* LD(LDH)-391*
AlkPhos-267* TotBili-19.0* DirBili-13.4* IndBili-5.6
___ 08:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
LFTs TREND
___ 08:45AM BLOOD ALT-1771* AST-1252* LD(LDH)-391*
AlkPhos-267* TotBili-19.0* DirBili-13.4* IndBili-5.6
___ 05:23PM BLOOD ALT-1601* AST-1103* LD(LDH)-319*
AlkPhos-239* TotBili-18.0*
___ 06:09AM BLOOD ALT-1752* AST-1330* LD(LDH)-419*
AlkPhos-236* TotBili-19.4*
___ 06:20AM BLOOD ALT-1751* AST-1274* LD(LDH)-354*
AlkPhos-219* TotBili-18.4*
CHEM TREND
___ 08:45AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-130*
K-4.0 Cl-96 HCO3-25 AnGap-13
___ 05:23PM BLOOD Glucose-57* UreaN-10 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-28 AnGap-13
___ 06:09AM BLOOD Glucose-86 UreaN-10 Creat-0.7 Na-138
K-4.8 Cl-103 HCO3-25 AnGap-15
___ 06:20AM BLOOD Glucose-86 UreaN-10 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-25 AnGap-14
___ 05:23PM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.8 Mg-2.3
___ 06:09AM BLOOD Albumin-3.2* Calcium-8.0* Phos-2.8 Mg-2.3
___ 06:20AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.3 Mg-2.1
CBC/COAG TREND
___ 08:45AM BLOOD WBC-12.7* RBC-3.89* Hgb-11.2* Hct-33.0*
MCV-85 MCH-28.8 MCHC-33.9 RDW-18.3* RDWSD-54.3* Plt ___
___ 06:09AM BLOOD WBC-7.4 RBC-3.96* Hgb-11.6* Hct-33.9*
MCV-86 MCH-29.3 MCHC-34.2 RDW-18.9* RDWSD-55.9* Plt ___
___ 06:20AM BLOOD WBC-8.8 RBC-3.95* Hgb-11.5* Hct-33.3*
MCV-84 MCH-29.1 MCHC-34.5 RDW-19.4* RDWSD-57.0* Plt ___
___ 08:54AM BLOOD ___ PTT-30.7 ___
___ 05:23PM BLOOD ___ PTT-23.6* ___
___ 06:09AM BLOOD ___ PTT-31.0 ___
___ 06:20AM BLOOD ___ PTT-31.4 ___
PERTINENT LABS
___ 05:23PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative IgM HAV-Negative
___ 05:23PM BLOOD HCV VL-6.3*
___ 05:23PM BLOOD ___ Titer-1:40
___ 05:23PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
___ 05:23PM BLOOD IgG-1192 IgA-274 IgM-301*
___ 05:23PM BLOOD HIV Ab-Negative
___ 05:23PM BLOOD HIV1 VL-NOT DETECT
HERPES SIMPLEX VIRUS 1 AND 2 (IGG)
Test Result Reference
Range/Units
HSV 1 IGG, TYPE SPECIFIC AB 1.52 H index
HSV 2 IGG, TYPE SPECIFIC AB <0.90 index
Index Interpretation
----- --------------
<0.90 Negative
0.90-1.09 Equivocal
>1.09 Positive
Brief Hospital Course:
Patient is a ___ man with IV heroin and cocaine use
disorder recently admitted for acute hepatitis (discharged ___
with ALT/AST > 1000, Tbili 7.3, and INR 1.4, found to be due to
acute hepatitis C, now presenting from ___ with worsening
jaundice.
#Hepatitis: Patient was recently admitted and found to have
acute hepatitis with positive HCV VL and antibody, with other
viral and toxin screens negative, concerning for HCV as the
underlying etiology. Given that both HCV VL and antibody were
positive on initial testing, it is somewhat difficult to
determine whether he has acute vs chronic HCV infection, as
patient reports he had not previously been tested for HCV or
liver enzymes and has at least a 6 month to over ___ year history
of IV drug use. We repeated a full workup for infectious,
autoimmune, and other causes that could explain his hepatitis in
addition to Hepatitis C infection. We found that the patient
still had a high hepatitis C viral load, and ruled out acute
HAV, HBV, HIV, EBV, CMV infection. HSV1 IgG was positive but no
other signs of HSV infection, IgM pending at discharge. We
carefully monitored vital signs, LFTs, AP, TBili, electrolytes,
and coags during his admission. Although LFTs and TBili
initially uptrended, he remained HD stable w/ no evidence of
hepatic synthetic dysfunction or encephalopathy.
On the day of discharge his LFTs had stabilized: ALT: 1751 AP:
219 Tbili: 18.4 AST: 1274 LDH: 354. We recommended that he stay
in the hospital for additional monitoring but after discussion
of risks of liver failure (bleeding, infection, confusion, and
death) he wanted to leave with outpatient lab monitoring.
Discharged with plan to recheck labs on ___ to be faxed
directly to Dr. ___ hepatologist.
#Opioid Use Disorder: On recent discharge, patient reported that
he was highly motivated to quit and was provided with outpatient
addiction service referrals, counseled on safe use and provided
with Narcan, and prescribed symptomatic treatments for
withdrawal. Given that he reports continued IV heroin use
through ___, we monitored him for signs of withdrawal and
provide symptomatic relief, as well as involved Social Work
during his admission.
#Hyponatremia: On admission, Na 130. Suspect hypovolemic
hyponatremia, and patient received 1L bolus in the ED and
another 1L bolus on floor, with improvement to Na 137.
#TOBACCO USE: Patient reports smoking ~1ppd of cigarettes since
discharge. We prescribed Nicotine patch 21mg TD daily.
TRANSITIONAL ISSUES
- Given first vaccine of Hep B series while inpatient. Needs Hep
A and B vaccinations.
- Consider discussing Hep C treatment options in the future if
indicated (generally wait at least 6 months to evaluate for
spontaneous clearance)
-Pending labs at discharge:
___ 17:23 HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
___ 17:23 ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY
-Patient very motivated to quit drug use. Please encourage
enrollment in structured program and continue counseling on harm
reduction. Provided with Narcan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO TID:PRN anxiety
2. HydrOXYzine 50 mg PO Q3H:PRN restlessness, insomnia, or
nausea
Discharge Medications:
1. Narcan (naloxone) 4 mg/actuation nasal 1X:ASDIR
RX *naloxone [Narcan] 4 mg/actuation asdir intranasal once Disp
#*1 Spray Refills:*0
2. CloNIDine 0.1 mg PO TID:PRN anxiety
3. HydrOXYzine 50 mg PO Q3H:PRN restlessness, insomnia, or
nausea
4.Outpatient Lab Work
ICD10 B17.1 acute hepatitis C. CBC, ALT, AST, Alk phos,
bilirubin, albumin, INR, ___, PTT. Na, K, Cl, HCO3, BUN,
Creatinine.
Fax attn. Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Hepatitis
Hepatits C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to worsening jaundice (yellowing
of the skin), and were found to have worsening of some of the
laboratory tests of your liver compared to when you were
discharged last week.
During your past admission, you were diagnosed with inflammation
of the liver ("hepatitis") and Hepatitis C. During this
admission, you were evaluated by our liver specialists and we
monitored your vital signs and blood tests. We checked many
laboratory tests to determine if there was any additional cause
for your liver injury. We found that your liver injry was most
likely due to hepatitis C.
We recommended that you stay in the hospital because your liver
tests were still not improving. We discussed with you risks of
leaving including bleeding, infection, confusion, and death if
your tests worsened and your liver stopped working normally.
However you did not wish to stay in the hospital so we decided
you could follow up with repeat labs to be checked on ___.
Please follow up with your primary care doctor within 1 week for
repeat liver tests with a prescription written for you to get
the labs done. Please also follow up with your liver specialist
(see below).
Keep up your efforts to quit using drugs. This is the most
important thing you can do to protect your health. We highly
recommend you seek help from an addiction specialist and enroll
yourself in a structured program like Narcotics Anonymous. If
you do use drugs, always use clean needles and use a fresh
needle each time. Have Narcan on hand in case you overdose.
Please get tested regularly for HIV and hepatitis.
You also have an active hepatitis C infection that you should
notify your partners or those you may have blood exposures with
like via sharing needles to be tested for hepatitis C. During
this admission, we vaccinated you against hepatitis B.
Do NOT take acetaminophen (Tylenol), ibuprofen (Advil, Motrin,
etc), or any over-the-counter medicines or supplements until you
discuss with your doctor ___ can worsen your liver injury).
We also gave you medications to help with your opioid
withdrawal.
It was a pleasure to take care of you!
Your ___ team
Followup Instructions:
___
|
10720174-DS-19
| 10,720,174 | 24,943,506 |
DS
| 19 |
2140-06-10 00:00:00
|
2140-06-10 17:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R face drooping, dysarthria, right hand clumsiness
Major Surgical or Invasive Procedure:
L ICA Stent via Vascular surgery
History of Present Illness:
HPI:
Mr. ___ is a ___ old man with a past medical history of
HTN, non-insulin dependent DM, CAD s/p MI who presents with
acute
onset right facial droop and dysarthria. Patient was last seen
well at 6:15am when he went to take a shower. After getting out
of the shower, his wife noticed a right facial droop. He was
taken to ___ where a telestroke was called. Exam at that
time was notable for dysarthria and right facial droop, but
normal strength. NIHSS 4. CT head showed evidence of old strokes
(per pt asymptomatic), but no acute hemorrhage. The decision was
made to proceed with tPA, which he received at 8:29am. Patient
was transferred to ___ for further management including
possible intervention. Patient takes ASA 81 for CVD and has not
missed any doses recently.
On neuro ROS, patient reports difficulty speaking and right hand
clumsiness.
Past Medical History:
CAD s/p MI x 2
Prostate cancer s/p radiation treatment, in remission
NIDDM
HTN
Hyperlipidemia
Social History:
___
Family History:
Family Hx: Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T: afebrile P: 76 R: 16 BP: 151/78 SaO2: 98% RA
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, dried blood in
oropharynx
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: soft, ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x to self, month, ___,
hospital. Language is fluent though slowed by dysarthria 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
moderately dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Right lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right pronation without
drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor. Moderate clumsiness of
finger
tap and wrist turn on the right. No dysmetria on FNF or HKS
bilaterally.
-Gait: Deferred
DISCHARGE PHYSICAL EXAMINATION:
VS - 98.7 68 120/71 18 97% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - nondistended, mild L groin swelling with surrounding
ecchymosis, no ttp
MSK & extremities/skin - no leg swelling observed b/l
Neuro - strength intact in all four extremities, CN grossly
intact w/ except of R sided facial droop exaggerated w/ smiling
Pertinent Results:
___ 10:25AM BLOOD Lipase-41
___ 10:25AM BLOOD ALT-21 AST-19 AlkPhos-71 TotBili-0.5
___ 06:50AM BLOOD %HbA1c-5.9 eAG-123
___ 06:50AM BLOOD Triglyc-102 HDL-45 CHOL/HD-3.1 LDLcalc-75
___ 06:50AM BLOOD TSH-2.0
___ 10:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:49AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 5.4 4.17* 13.1* 38.3* 92 31.4 34.2 12.3
40.9 168 Import Result
___ 6.4 4.29* 13.3* 39.0* 91 31.0 34.1 12.5
41.1 192 Import Result
___ 9.5 4.81 15.6 43.3 90 32.4* 36.0 12.4
40.5 215 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 79.5* 12.4* 6.6 0.9* 0.2 0.4 7.52*
1.18* 0.63 0.09 0.02 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 168 Import Result
___ 11.6 32.3 1.1 Import Result
___ 192 Import Result
___ 11.6 31.0 1.1 Import Result
___ 215 Import Result
___ 10.7 31.9 1.0 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 160* 14 0.8 141 3.9 ___ Import
Result
___ 135* 18 0.8 140 3.6 ___ Import
Result
___ 161* 22* 1.0 137 3.5 96 24 21* Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 21 19 71 0.5 Import Result
OTHER ENZYMES & BILIRUBINS Lipase
___ 41 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 8.3* 2.3* 2.0 Import Result
___ 8.5 2.1* 2.0 140 Import Result
___ 4.2 9.3 3.3 1.8 Import Result
DIABETES MONITORING %HbA1c eAG
___ 5.9 123 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 102 45 3.1 75 Import Result
PITUITARY TSH
___ 2.0 Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
___ NEG NEG NEG NEG NEG NEG Import Result
IMAGING:
Non-Contrast CT of Head ___ (OSH READ):
1. There is no evidence of a large acute territorial infarction,
an acute intracranial hemorrhage, or an intracranial mass.
2. Multiple old left hemispheric infarctions suggesting disease
of the left internal carotid artery and possibly posterior
circulation
reliance on a posterior communicating artery.
CXR ___:
1. There is no evidence of an acute cardiac or pulmonary
process.
2. Bilateral pleural calcifications.
CTA H and N ___:
1. Large hypodensity in the posterior left parietal, with a
relative paucity of branches of the left MCA is distribution, is
consistent with subacute infarct. No evidence of acute large
territorial infarct or intracranial hemorrhage.
2. Significant noncalcified atherosclerotic plaque in the left
internal
carotid artery with focal ulceration is at high risk for
rupture, and results in 51% stenosis of the left internal
carotid artery by NASCET criteria.
CT Head ___:
1. Acute infarction involving the left precentral gyrus. No
hemorrhage.
2. Otherwise stable intracranial findings, as above.
MR HEAD ___:
1. Acute/subacute infarct in the left frontoparietal lobes.
2. Chronic infarct in the posterior left parietal lobe.
3. A punctate focus of slow diffusion adjacent to the chronic
left parietal infarct may represent a small focus of
acute/subacute infarct.
4. Punctate focus of susceptibility artifact in the left
inferior parietal
lobe likely represents chronic hemosiderin deposition.
Carotid Series ___:
Brief Hospital Course:
Mr. ___ is a ___ old man with a past medical history of
HTN, non-insulin dependent DM, CAD s/p MI who presents with
acute onset right facial droop and dysarthria s/p tPA at 8:29am
on ___. His exam is notable for moderate dysarthria without
aphasia, right facial droop, right hand clumsiness but full
strength. Patient was admitted to ___ stroke service for
further work up.
The patient was admitted in the ___ s/p TPA. Patient noted to
have significant dysarthria more lingual and guttural, also
clumsy right hand. Otherwise full strength. Very emotional.
Passed swallow evaluation and started on a heart healthy diet.
Repeat head ct s/p 24 hours from TPA was negative for any bleed.
MRI showed L precentral gyrus ischemic stroke . CTA showed L ICA
occlusion 50-59% with soft plaque. Carotid duplex confirmed L
ICA plaque and showed that it was ulcerated. Vascular surgery
was consulted and it was decided to do a carotid stent. Patient
was started on aspirin and Plavix , atorvastatin was increased
to 80mg.
BP meds were held on admission for autoregulation of blood
pressure for 3 days s/p infarct however metoprolol was started
at half dose. After 3 days, patient then was started only on
nifedipine half dose. Lisinopril and HCTZ held as patient was
going to the OR for carotid stent.
Patient was maintained on telemetry which did not show any afib,
patient remained in sinus rhythm.
He underwent TCAR on ___. While in PACU, a hematoma
developed under his left groin puncture site, which improved
after pressure was held - some residual bruising and mild
swelling was noted on discharge. While on the floor he was also
noted to develop a neck hematoma under his incision, he had no
respiratory compromise or dysphagia, and his neuro exam remained
stable. His home antihypertensives were resumed, including his
HCTZ on POD1. His BP remained under good control (goal SBP was
between 90-160). He was discharged with Neurology follow up and
instructions to schedule an appointment with Vascular Surgery.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =70 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Transitions of Care Issues:
1. Patient to follow up with stroke Attending Physician ___
___
2. Patient to continue aspirin and plavix
3. Patient to follow up with PCP ___ 2 weeks post discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Lovastatin 40 mg oral DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. NIFEdipine 60 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke from atheroembolic source in L ICA.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right facial droop,
difficulty speaking clearly, and right hand clumsiness 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. Atherosclerosis
2. High blood pressure
We are changing your medications as follows:
1. Take aspirin 81 mg daily
2. Start to take Plavix 75mg daily
3. Increased dose of atorvastatin 80mg
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
You also underwent a stent in the left internal carotid artery
as it was blocked with plaque that likely traveled up into your
brain to cause stroke. This stent should stabilize the plaque
and prevent further strokes.
Followup Instructions:
___
|
10720286-DS-3
| 10,720,286 | 21,318,735 |
DS
| 3 |
2180-09-21 00:00:00
|
2180-09-22 08:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Tetanus / Demerol
Attending: ___.
Chief Complaint:
Hematemesis, shock
Major Surgical or Invasive Procedure:
___ EGD with variceal ligation
___ intubation for EGD s/p extubation ___
History of Present Illness:
___ is a ___ y/o woman with PMH of EtOH cirrhosis
c/b EV, PHG, GAVE who p/w hematemesis.
Yesterday afternoon, felt dizzy in the afternoon and nauseous
after dinner. Had episode of dark red emesis. Presented to
___ hypotensive with SBP 68, and had 2 large volume
episodes of coffee ground emesis. Hgb 7.1. Lactate 3.0. Received
2U pRBCs. Hgb up to 8.8. Received 1L NS. Started CTX and
octreotide gtt. Had a 20g L AC, 18g R FA PIV placed.
Last Hepatology visit ___ ___. Has been declining
relapse prevention. In ___ and ___ had
admissions for anemia, hematemesis, and melena with Hgb < 5.
Most
recent EGD ___ with GAVE, PHG, and 3 cords of medium size
varices w/o active bleeding. Hgb had been stable at 9.0.
She also recently had a car accident one month ago where she was
rear-ended. Hurt her shoulder, had hematuria, and had a
concussion.
In the ED,
Initial Vitals: T 97.7 HR 70 BP 107/70 RR 16 SaO2 94% RA
Exam:
Labs:
- Hgb 7.4
- CMP ___
- ALT 17 AST 41 AP 121 Tbili 1.7 Alb 3.4 lipase 70
Imaging:
Consults:
- Hepatology
Interventions:
- octreotide gtt
VS Prior to Transfer: HR 80 BP ___ RR 18 SaO2 95% RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
EtOH cirrhosis c/b EV, PHG, GAVE, ascites
EtOH hepatitis
anxiety
phobias - of choking, needs sedation with Propofol for EGD
depression
hypothyroidism
back pain
T12 compression fracture
scoliosis
Social History:
___
Family History:
Mother - migraines, COPD (died at ___)
Father - esophageal cancer (died at ___)
Son - ___ muscular dystrophy (died at ___)
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: AF HR 76 BP 85/38 (53) Sa97% 1LNC
GEN: alert, NAD
HEENT: sclera white
CV: RRR, normal S1/S2, no m/r/g
RESP: CTAB
GI: abd soft, NTND, normoactive BS
EXT: warm, well-perfused, trace ___ edema
NEURO: EOMI
DISCHARGE PHYSICAL EXAM:
========================
___ 2337 Temp: 99.0 PO BP: 125/80 HR: 89 RR: 18 O2 sat: 88%
O2 delivery: Ra
GENERAL: NAD. Comfortable
Eyes: Anicteric
ENT: MMM.
___: RRR, no m/r/g
LUNGS: CTAB, no w/r/c
ABDOMEN: soft, nontender, nondistended, normoactive bowel
sounds,
no rebound or guarding
SKIN: Warm. Dry.
EXT: well perfused, trace bilateral edema
NEURO: No asterixis.
Pertinent Results:
ADMISSION LABS
===============
___ 03:15AM BLOOD WBC-6.4 RBC-3.56* Hgb-7.4* Hct-26.3*
MCV-74* MCH-20.8* MCHC-28.1* RDW-22.5* RDWSD-59.2* Plt Ct-88*
___ 05:43AM BLOOD WBC-6.0 RBC-3.27* Hgb-6.8* Hct-23.7*
MCV-73* MCH-20.8* MCHC-28.7* RDW-22.1* RDWSD-58.0* Plt Ct-85*
___ 10:51AM BLOOD WBC-8.7 RBC-3.57* Hgb-7.6* Hct-25.9*
MCV-73* MCH-21.3* MCHC-29.3* RDW-22.1* RDWSD-57.2* Plt ___
___ 03:15AM BLOOD Neuts-62.8 ___ Monos-8.4 Eos-2.8
Baso-0.8 Im ___ AbsNeut-4.02 AbsLymp-1.58 AbsMono-0.54
AbsEos-0.18 AbsBaso-0.05
___ 03:15AM BLOOD Plt Smr-LOW* Plt Ct-88*
___ 05:43AM BLOOD ___ PTT-31.5 ___
___ 03:15AM BLOOD Glucose-150* UreaN-22* Creat-0.6 Na-130*
K-4.6 Cl-95* HCO3-19* AnGap-16
___ 03:15AM BLOOD ALT-17 AST-41* AlkPhos-121* TotBili-1.7*
___ 03:15AM BLOOD Lipase-70*
___ 03:15AM BLOOD Albumin-3.4* Calcium-7.9* Phos-2.8
Mg-1.4*
___ 05:43AM BLOOD ___
___ 05:39AM BLOOD Lactate-2.7*
___ 11:22AM BLOOD Lactate-2.0
DISCHARGE LABS:
===============
___ 05:20AM BLOOD WBC-4.8 RBC-3.26* Hgb-7.7* Hct-25.6*
MCV-79* MCH-23.6* MCHC-30.1* RDW-22.5* RDWSD-64.7* Plt Ct-73*
___ 05:20AM BLOOD ___ PTT-30.6 ___
___ 05:20AM BLOOD Glucose-188* UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-99 HCO3-28 AnGap-11
___ 05:20AM BLOOD ALT-15 AST-25 AlkPhos-102 TotBili-1.4
___ 05:20AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.6
MICROBIOLOGY:
=============
__________________________________________________________
___ 11:10 am BLOOD CULTURE Source: Venipuncture 1 OF
2.
Blood Culture, Routine (Pending): No growth to date.
IMAGING/STUDIES:
================
___ CXR PORTABLE
FINDINGS:
Endotracheal tube tip is approximately 1 cm above the carina.
The heart
remains enlarged. There is mild pulmonary vascular congestion.
No
pneumothorax. Bibasilar opacities which could represent
atelectasis.
PROCEDURES:
===========
___ EGD
-4 cords of grade II varices were seen in the distal esophagus.
One cord of varices below gastroesophageal junction most likely
represent GOV was oozing. Three bands were applied for
hemostasis successfully.
-Congestion, petechiae, and mosaic mucosal pattern in the
stomach fundus and stomach body compatible with portal
hypertensive gastropathy.
-Blood in the stomach.
-Normal mucosa in the whole examined duodenum.
Brief Hospital Course:
SUMMARY:
========
___ is a ___ with PMH of alcoholic liver
cirrhosis, PHT in the form of EV (on NSBB for primary
prophylaxis), PHG, ascites on diuretics (well controlled),
jaundice, overt obscure GI bleeding and chronic anemia (baseline
___, and ongoing alcohol use who presented with hematemesis
and hemorrhagic shock. She had an EGD ___ showing esophageal
varices and GOV (oozing) s/p banding after which her bleeding
and HgB stabilized, without recurrence of hematemesis or melena.
ACUTE ISSUES:
=============
#UGIB
#Hemorrhagic shock, improving
Ms. ___ initially presented with hematemesis and
hemorrhagic shock (hypotensive to SBP in the ___, lactate 3.0)
to ___. Her initial HgB there was noted to be 7.1
(from baseline ___. She required 2 U pRBCs and 1L IVF with
improvement in hemodynamics, and was started on octreotide gtt,
IV PPI, and IV CTX. She was subsequently transferred to ___
for further management. On arrival, she underwent EGD (___)
showing 4 cords of grade II varices in the distal esophagus, as
well as one cord of varices below the gastroesophageal junction
(most likely representing GOV) which was oozing. Three bands
were applied for hemostasis successfully. Since admission, she
has required an additional 3u pRBCs (last transfusion ___ for
resuscitation, after which her HgB has stabilized without
recurrent hematemesis/melena. She was continued on an octreotide
drip (___), then transitioned to home nadolol on day of
discharge. She finished a course of ceftriaxone for SBP
prophylaxis also on ___, and will continue on daily PPI and
sucralfate on discharge. Discharge HgB 7.7.
# EtOH cirrhosis:
Followed by Dr. ___. MELDNa 19. Decompensated this admission
by variceal bleed s/p banding as above. As of his
hospitalization, the patient was noted to be actively using
alcohol with positive alcohol level. She was seen by social work
and provided relapse prevention resources. She otherwise will
continue on home nadolol for bleeding prophylaxis. Home
diuretics were temporarily held given bleed, but restarted prior
to discharge. She will continue on furosemide
40mg/spironolactone 100mg. She has no history of SBP and
completed 5 day course of CTX for SBP prophylaxis given GIB. She
also has no history of hepatic encephalopathy and no evidence of
encephalopathy this admission. She will follow up with Dr. ___
in liver clinic ___ as scheduled.
# Alcohol use disorder
Serum EtOH 138 on admission. She was continued on thiamine,
folate, multivitamin. Social work was consulted for relapse
prevention, and patient accepted resources for this.
CHRONIC ISSUES
===============
#T2DM
Home metformin 500 BID was held in setting of acute illness.
Hyperglycemia managed with ISS while inpatient. Metformin
restarted on discharge.
#Pruritus
Continued home hydroxyzine 25 TID PRN.
#GERD
Will continue home omeprazole daily.
#Hypothyroidism
Continued home levothyroxine 175mcg daily.
#Depression
Continued home duloxetine 90 daily, home trazodone 150 QHS PRN
for sleep.
TRANSITIONAL ISSUES:
====================
- Discharge HgB: 7.7
- Discharge Plt: 73
- Discharge INR: 1.3
- Discharge ALT/AST: ___
- Discharge Tbili: 1.4
- Discharge BUN/Cr: ___
- Discharge weight: 173lbs
[] Please ensure liver clinic follow up ___
[] Please continue to encourage patient to abstain from all
alcohol use and participate in relapse prevention
[] Continue home nadolol for variceal bleed prophylaxis,
titrated to HR 55-60bpm
[] Continue sucralfate x 2 weeks post banding, then discontinue
(___)
[] Underwent banding of esophageal and gastric varices this
admission (___), will need follow up EGD in ___ weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. DULoxetine ___ 90 mg PO DAILY
3. TraZODone 150 mg PO QHS:PRN sleep
4. Omeprazole 40 mg PO DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Nadolol 40 mg PO DAILY
8. HydrOXYzine 25 mg PO Q8H:PRN itching
9. Spironolactone 100 mg PO DAILY
10. Thiamine Dose is Unknown PO DAILY
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Sucralfate 1 gm PO QID Duration: 2 Weeks
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*56 Tablet Refills:*0
2. Thiamine 200 mg PO DAILY
3. DULoxetine ___ 90 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. HydrOXYzine 25 mg PO Q8H:PRN itching
7. Levothyroxine Sodium 175 mcg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Nadolol 40 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Spironolactone 100 mg PO DAILY
12. TraZODone 150 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
#Acute decompensated alcohol cirrhosis
#Upper gastrointestinal bleeding
#Acute blood loss anemia
#Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because you were vomiting
blood.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You received blood transfusions for your bleeding
- You also underwent an endoscopy to identify the source of your
bleeding. You were noted to have dilated blood vessels in your
esophagus (called "varices") which were bleeding.
- These blood vessels can cause very serious bleeding that can
be life-threatening
- You underwent a procedure to stop this bleeding by putting a
band around these bleeding blood vessels
- After the procedure, we monitored your blood counts and you
did not have any repeat bleeding
- Overall you were improved and ready to leave the hospital..
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or your liver will fail and
you will die from this
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10720670-DS-15
| 10,720,670 | 28,037,938 |
DS
| 15 |
2174-06-10 00:00:00
|
2174-06-12 10:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ PMHx renal transplants x 2 in ___ and ___
(performed at ___, followed by Dr. ___ who p/w fever and
bladder discomfort/fullness x 24 hrs.
He was seen at a ___ clinic earlier yesterday
where he had a positive UA and was given ciprofloxacin. Upon
returning home, he had fever to 102.4 for which he took 1 gm
tylenol. Given his ongoing concern for his fever, he presented
to the ED. He reports that he continues to have fevers. He has
also had a sensation of bladder fullness with incomplete bladder
emptying. He denies any dysuria, hematuria, abdominal pain, n/v,
or diarrhea.
In the ED, initial vitals were 100.3 107 158/91 16 99% on RA
although patient became febrile to 102.9. Exam notable for
absence of CVAT and no TTP over renal transplant sites. Labs
notable for Na 133, Cr 2.3 (reported baseline of 1.6), WBC 23.4
(82% neuts, 4$ bands), lact 1.8. UA notable for large leuk, few
bacteria. CXR negative and renal US was wnl. Per the renal
transplant fellow, the patient received Zosyn prior to transfer
to the floor.
Upon arrival to the floor, initial VS 100.4, 153/69, 97, 16, 97%
on RA.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
Renal transplant x2 (developed ESRD in the setting of urologic
surgery for undescended testicles and hypospadias as an infant;
procedure complicated by HUS)
Hypertension
Social History:
___
Family History:
no history of renal disease
Physical Exam:
ADMISSION EXAM:
==============
Vitals: 100.4, 153/69, 97, 16, 97% on RA
General: Alert, oriented, no acute distress
HEENT: MMM, NCAT, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + physiologically split
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, NTND, well-healed surgical scars without any
tenderness over renal transplant sites, normoactive bowel
sounds, no CVAT
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: patient with stutter, otherwise grossly nonfocal
DISCHARGE EXAM:
==============
Vitals: Tm 99.3 T 98.9 130s-160s/70s-90s ___ 18 98%RA
General: Alert, oriented, no acute distress
HEENT: MMM, NCAT, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + physiologically split
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, NTND, well-healed surgical scars without any
tenderness over renal transplant sites, normoactive bowel
sounds, no CVAT
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: patient with stutter, otherwise grossly nonfocal.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:40AM PLT SMR-NORMAL PLT COUNT-275
___ 12:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 12:40AM NEUTS-82* BANDS-4 LYMPHS-2* MONOS-12 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-20.12* AbsLymp-0.47*
AbsMono-2.81* AbsEos-0.00* AbsBaso-0.00*
___ 12:40AM WBC-23.4* RBC-4.39* HGB-12.0* HCT-35.7*
MCV-81* MCH-27.3 MCHC-33.6 RDW-14.9 RDWSD-44.2
___ 12:40AM tacroFK-3.3*
___ 12:40AM estGFR-Using this
___ 12:40AM GLUCOSE-89 UREA N-24* CREAT-2.3* SODIUM-133
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-20* ANION GAP-23*
___ 12:48AM LACTATE-1.8
___ 01:05AM URINE RBC-3* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:05AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 01:05AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:05AM URINE GR HOLD-HOLD
___ 01:05AM URINE UHOLD-HOLD
___ 01:05AM URINE HOURS-RANDOM
___ 01:05AM URINE HOURS-RANDOM
___ 08:05AM PLT COUNT-236
___ 08:05AM WBC-18.6* RBC-4.29* HGB-11.5* HCT-35.2*
MCV-82 MCH-26.8 MCHC-32.7 RDW-15.2 RDWSD-45.2
___ 08:05AM CALCIUM-9.7 PHOSPHATE-4.4 MAGNESIUM-1.8
___ 08:05AM GLUCOSE-86 UREA N-24* CREAT-2.2* SODIUM-138
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
___ 11:11AM URINE HOURS-RANDOM UREA N-350 CREAT-67
SODIUM-45 POTASSIUM-21 CHLORIDE-34
___ 08:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:30PM BLOOD tacroFK-3.7*
___ 08:05AM BLOOD HCV Ab-NEGATIVE
MICRO:
=====
___ 12:40 am Blood (EBV)
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ 12:40 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
57 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ URINE:
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
================
+ ___ Imaging RENAL TRANSPLANT U.S.
IMPRESSION:
Normal renal transplant ultrasound.
+ ___ Imaging CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-13.9* RBC-4.15* Hgb-11.4* Hct-34.8*
MCV-84 MCH-27.5 MCHC-32.8 RDW-15.3 RDWSD-46.1 Plt ___
___ 07:35AM BLOOD Glucose-94 UreaN-22* Creat-1.9* Na-139
K-4.9 Cl-106 HCO3-23 AnGap-15
___ 07:35AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
Brief Hospital Course:
Pt is a ___ PMHx renal transplants x 2 in ___ and ___
(performed at ___, followed by Dr. ___ who p/w fever and
+U/A and Cr of 2.3 (baseline 1.5) concerning for acute allograft
dysfunction in the setting of acute pyelonephritis.
# Acute pyelonephritis: The patient presented with a positive
urinalysis and fevers, without stranding seen on renal
ultrasound but nonetheless consistent with acute pyelonephritis
given his immunocompromised state. He was started on Zosyn and
his fevers resolved. His WBC improved from 23 on admission to
13.9 on day of discharge. His urine culture here showed no
growth; however, the preliminary urine culture from ___
___ from ___ grew presumptive gram negative rods. (He had
taken one dose of cipro prior to presenting here). The patient
wished to go home, despite the fact that renal transplant and
transplant ID requested he stay until the return of urine
culture sensitivites. He was discharged on ciprofloxacin 500 mg
BID to complete a 14 day course of antibiotics. Of note, his
urine culture from ___ student health from ___ grew Enterobacter
cloacae, sensitive to ciprofloxacin (MIC <0.25) which was made
apparent by ___.
# Acute kidney injury/allograft dysfunction: On admission the
patient's creatinine was elevated to 2.3 (baseline 1.5 per
outpatient transplant nephrologist), likely prerenal in the
setting of sepsis. Renal ultrasound showed normal transplanted
kidney. He continued to make urine. With IVF his creatinine
improved to 1.9 by day of discharge.
# s/p renal transplants x2: The patient's home tacrolimus,
azathioprine and prednisone were initially held in the setting
of his acute infection. The patient's hepatitis serologies
(hepBsAg, sAb, cAb, and HepCab) were negative. CMV IgG was
positive, IgM negative. EBV VCA-IgG AB was positive, EBV EBNA
IgG AB was positive, EBV VCA-IgM AB was negative. Tacrolimus
level the next morning was low at 3.7. He was restarted on his
immunosuppressives. He should have tacrolimus checked ___.
# HTN: The patient's blood pressures were well-controlled;
continued home hydralazine and atenolol.
TRANSITIONAL ISSUES:
[] Patient needs to be seen ___. Please check an FK
(tacrolimus) level and a creatinine and fax results to Dr.
___ (transplant nephrologist) at ___.
Her office phone number is ___.
[] Please follow up BU urine culture results from ___ and
ensure sensitivity to ciprofloxacin.
[] Patient's WBC count was 14 day of discharge. Please check CBC
on follow up appointment.
[] Per transplant ID, the patient was asked to stop taking
prophylactic cephalexin while taking cipro. He should follow up
with transplant ID before restarting prophylaxis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prograf (tacrolimus) 3.5 MG oral BID
2. PredniSONE 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. HydrALAzine 25 mg PO BID
5. Tamsulosin 0.4 mg PO QHS
6. Keflex (cephALEXin) 250 mg oral BID
7. Azathioprine 75 mg PO DAILY
8. Ciprofloxacin HCl 250 mg PO Q12H
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Azathioprine 75 mg PO DAILY
3. HydrALAzine 25 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Prograf (tacrolimus) 3.5 MG oral BID
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*24 Tablet Refills:*0
8. Outpatient Lab Work
ICD-9: 584
Please draw FK level (tacrolimus), CBC and serum creatinine on
___ and fax results to: Dr. ___ (transplant
nephrologist) at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute pyelonephritis
Acute renal dysfunction
Secondary diagnoses:
S/p 2 renal transplants
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
because you had fever and symptoms of bladder fullness. You were
found to have a kidney infection and worsening of your kidney
function. You were given IV antibiotics and you felt better. You
were also given IV fluids and your kidney function got better,
however it was not back to normal. We advised that you stay
until your outside culture sensitivities returned, but you
requested to be discharged. You were discharged on
ciprofloxacin. Please take this NEW prescription and STOP taking
your old ciprofloxacin prescription that you got from ___.
You should stop taking your Keflex (cephalexin) while you are
taking your cipro. You should follow up with an infectious
disease doctor here at ___ within the next 2 weeks. The number
is provided below.
You wished to leave the hospital before your final urine culture
from BU returned. It is VERY important that you schedule an
appointment with BU student health on ___. At this
appointment you will need to have your creatinine checked and
your tacrolimus level checked, and these results will need to be
faxed to the renal transplant doctor at ___.
If you have worsening bladder discomfort or fevers, you need to
see student health right away.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10721478-DS-3
| 10,721,478 | 20,299,798 |
DS
| 3 |
2113-06-04 00:00:00
|
2113-06-12 13:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ Pain/Acute Cholecystitis
Major Surgical or Invasive Procedure:
___: Laparoscopic Cholecystectomy
History of Present Illness:
___ year old male who presents with abdominal pain nausea and
vomiting transferred from ___ with concern for
cholecystitis in setting of known ___ syndrome.
He reports onset of severe epigastric pain nausea and dry
heaving
on ___ and presented to ___ on ___ where he was
scanned which showed a large stone at the neck of the
gallbladder
and no intrahepatic or extra hepatic duct dilation despite a T
___ of 5 but with ___ of .3. This is increased form his
baseline 2 in ___. His WBC 14, He got unsasyn there and
received zosyn in the ed here.
Past Medical History:
Hypertension, Hyperlipidemia, Asthma
Social History:
___
Family History:
No significant family history
Physical Exam:
Admission Physical Exam:
Vitals: 97.9, 64, 159/70, 20, 100% RA
Gen: Well appearing, AAOx3, NAD
HEENT: No scleral icterus, midline trachea, neck supple
CV: RRR
Pulm: Breathing unlabored on room air
Abd: Soft, tender to palpation in RUQ, + ___, nondistended.
Ext: Warm and well perfused, no edema
Discharge Physical Exam:
Temp: 99.2 PO BP: 105/66 L Lying HR: 71 RR: 18 O2 sat: 95% O2
delivery: Ra
Gen: [x] NAD, [] AAOx3
CV: [] RRR, [] murmur
Resp: [x] breaths unlabored, no inc wob
Abdomen: [x] soft, [] distended, [x] appropriately tender around
incision site, [] rebound/guarding
Wound: [x] incisions clean, dry, intact
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 07:30AM BLOOD WBC-4.6 RBC-3.42* Hgb-10.7* Hct-31.1*
MCV-91 MCH-31.3 MCHC-34.4 RDW-11.8 RDWSD-38.8 Plt ___
___ 07:45AM BLOOD WBC-4.1 RBC-3.28* Hgb-10.4* Hct-30.0*
MCV-92 MCH-31.7 MCHC-34.7 RDW-11.4 RDWSD-38.1 Plt ___
___ 10:23AM BLOOD WBC-4.2 RBC-3.67* Hgb-11.7* Hct-33.7*
MCV-92 MCH-31.9 MCHC-34.7 RDW-11.4 RDWSD-38.5 Plt ___
___ 07:35AM BLOOD WBC-4.6 RBC-3.35* Hgb-10.8* Hct-32.0*
MCV-96 MCH-32.2* MCHC-33.8 RDW-11.3 RDWSD-39.2 Plt Ct-98*
___ 06:32AM BLOOD WBC-5.7 RBC-3.40* Hgb-10.9* Hct-33.7*
MCV-99* MCH-32.1* MCHC-32.3 RDW-11.9 RDWSD-43.0 Plt ___
___ 07:30AM BLOOD Glucose-88 UreaN-9 Creat-0.8 Na-140 K-3.5
Cl-102 HCO3-23 AnGap-15
___ 07:45AM BLOOD Glucose-90 UreaN-11 Creat-0.8 Na-137
K-3.9 Cl-102 HCO3-22 AnGap-13
___ 07:30AM BLOOD ALT-251* AST-230* AlkPhos-149*
TotBili-1.9* DirBili-0.5* IndBili-1.4
___ 07:45AM BLOOD ALT-202* AST-77* AlkPhos-132*
TotBili-1.7*
___ 08:34AM BLOOD ALT-336* AST-180* AlkPhos-125
TotBili-3.0* DirBili-0.8* IndBili-2.2
___ 07:35AM BLOOD ALT-372* AST-359* AlkPhos-89 TotBili-4.5*
DirBili-1.0* IndBili-3.5
___ 06:32AM BLOOD ALT-221* AST-245* AlkPhos-70 TotBili-5.8*
DirBili-0.9* IndBili-4.9
___ 08:30AM BLOOD ALT-14 AST-22 AlkPhos-74 TotBili-4.7*
DirBili-0.4* IndBili-4.3
___ 07:30AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
___ 07:45AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
___ 08:34AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9
Imaging:
RUQ
Gallstone in the gallbladder neck with distension of the lumen,
wall edema and pericholecystic fluid could reflect acute
cholecystitis in the proper clinical setting.
CT-
reviewed with rads here- large stone at neck without intra or
extra hepatic bile duct dilation
___ CT A/P:
1. Complex collection the gallbladder fossa status post
cholecystectomy could represent a hematoma vs bile leak. There
is associated inflammation of the adjacent duodenum. MRI with
Eovist can be performed to assess for bile leak.
2. Small bilateral pleural effusions with associated
atelectasis.
3. The spleen is borderline in size.
4. Prostatomegaly.
___ Gallbladder US:
Complex fluid collection within the gallbladder fossa after
cholecystectomy.
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Gallbladder, cholecystectomy:
- Acute and chronic cholecystitis and cholelithiasis.
Brief Hospital Course:
Mr. ___ is a ___ yo M with known history of Gilberts
syndrome, who presented to the emergency department with 48-hour
history of rigors, chills and right upper quadrant pain. He had
an ultrasound consistent with acute cholecystitis with a stone
impacted in the neck of the gallbladder. The common bile duct
was not dilated. He does have ___ disease and his liver
function tests were normal except for a bilirubin of 5.0. This
was fractionated and the direct component was only 0.3
consistent with his ___. White blood cell count was 14.
Informed consent was obtained and the patient was taken to the
operating and underwent laparoscopic cholecystectomy. Please see
operative report for details. The patient was hemodynamically
stable.
POD1-3, the patient was slow to progress due to poor appetite,
feeling weak, and low grade fevers. Tmax was 102. A repeat
gallbladder US and Abdominal CT was obtained on POD3. This
showed a small, complex fluid collection that could represent a
hematoma or biloma. However, by POD4, the patient had
defervesced and was feeling much better.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. triamcinolone acetonide 55 mcg nasal BID
3. Atorvastatin 20 mg PO QPM
4. Mometasone Nasal Spray (*NF*) 200 mcg Other TID
5. Naproxen 220 mg PO Q12H
6. Aspirin 81 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. albuterol sulfate 90 mcg/actuation inhalation PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 17 g by mouth once a day
Disp #*15 Packet Refills:*0
6. albuterol sulfate 90 mcg/actuation inhalation PRN
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. Lisinopril 5 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Mometasone Nasal Spray (*NF*) 200 mcg Other TID
12. Naproxen 220 mg PO Q12H
Take with food.
13. triamcinolone acetonide 55 mcg nasal BID
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute and chronic cholecystitis and cholelithiasis
Gilberts syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and found to have an infection in your
gallbladder. You underwent laparoscopic surgery to remove your
gallbladder. Your post operative course was complicated by
fevers and you were given antibiotics and watched closely. You
are now doing better, tolerating a regular diet, and pain is
improved. You are now ready to be discharged home to continue
your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10722545-DS-16
| 10,722,545 | 20,202,359 |
DS
| 16 |
2177-03-19 00:00:00
|
2177-03-19 19:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p 2 DES to the RCA
History of Present Illness:
___ male with a history of HTN, HLD and ___ Disease who
presented to ___ Urgent Care with intermittent chest
pain over the past ___ days. Patient states that he has been
having exertional chest pain for the last year. The pain was
mid-chest and felt dull; it did not radiate and was not
associated with shortness of breath or diaphoresis. The pain
resolved with rest. However, over the last ___ days, he has been
experiencing increasing nonexertional chest pain. His last
episode was this morning. He is now pain free. He has had
increased stress over the last ___ years with his wife's illness
and death one year ago.
At urgent care, he received full dose aspirin and was sent to
the ED. In the ED initial vitals were: T97.5, HR 64, BP 129/75,
RR 20, SpO2 95% RA. Found to have EKG with new STE in III (1mm)
and aVF (<1mm) and elevated troponin (0.81). Given aspirin and
loaded with ticagrelor. Chest pain-free on arrival.
Studies:
EKG: NSR 65, RBBB (old), STE in III (1mm) and aVF (<1mm)
CXR unremarkable
Labs/studies notable for: WBC 20.3, creatinine 0.9, troponins
0.81 and lactate 2.3.
Patient was loaded with ticagrelor and started on a heparin
drip.
Vitals on transfer: T 97.6 P 63 BP 119/80 R 20 99%RA
On the floor, VS T 98.4 BP 97 P 77 R 18 SpO2 98%RA. Patient
states he is comfortable without chest pain or shortness of
breath.
ROS:
+ chronic cough with clear phlegm production
+ recent increase in sinemet dosing
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, -
diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ___ Disease - followed by Dr. ___ in Cognitive
___
- Psoriasis
- Obesity
Social History:
___
Family History:
Father - CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=98.4 ___ RR=18 O2 sat= 98-99%RA
GENERAL: Siting up in bed in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL, EOMI. mmm
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: CTAB, Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Normoactive bowel sounds.
EXTREMITIES: warm, well perfused, no lower extremity edema, 2+
radial and 1+ ___ pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: baseline tremor
DISCHARGE PHYSICAL EXAM
VS: T=98.1 BP=80-118/53-61 ___ RR=20 O2 sat=97-98%RA
GENERAL: Sitting up in bed in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL, EOMI. mmm
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: CTAB, Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Normoactive bowel sounds.
EXTREMITIES: warm, well perfused, no lower extremity edema, 2+
radial and 1+ ___ pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: baseline tremor
Pertinent Results:
ADMISSION LABS
---------------
___ 10:37AM BLOOD WBC-20.3*# RBC-5.37 Hgb-16.5 Hct-48.5
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.4 RDWSD-44.8 Plt ___
___ 10:37AM BLOOD Neuts-83.9* Lymphs-9.4* Monos-6.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.02* AbsLymp-1.91
AbsMono-1.24* AbsEos-0.01* AbsBaso-0.04
___ 10:37AM BLOOD ___ PTT-31.4 ___
___ 10:37AM BLOOD Glucose-115* UreaN-14 Creat-0.9 Na-134
K-4.1 Cl-95* HCO3-25 AnGap-18
___ 10:37AM BLOOD cTropnT-0.81*
___ 04:08AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.0
___ 04:08AM BLOOD TSH-0.63
___ 12:34PM BLOOD Lactate-2.3*
TROPONIN TREND
----------------
___ 10:37AM BLOOD cTropnT-0.81*
___ 04:50PM BLOOD cTropnT-1.11*
___ 04:08AM BLOOD cTropnT-1.15*
___ 04:48PM BLOOD cTropnT-2.92*
___ 05:20AM BLOOD cTropnT-2.07*
DISCHARGE LABS
----------------
___ 05:20AM BLOOD WBC-16.2* RBC-4.85 Hgb-14.4 Hct-44.4
MCV-92 MCH-29.7 MCHC-32.4 RDW-13.5 RDWSD-45.5 Plt ___
___ 05:20AM BLOOD ___ PTT-29.0 ___
___ 05:20AM BLOOD Glucose-77 UreaN-19 Creat-0.9 Na-137
K-3.9 Cl-99 HCO3-24 AnGap-18
___ 05:20AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0
IMAGING
---------
___ CXR
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are
no focal consolidations, pleural effusion, or pulmonary edema.
There are no pneumothoraces. Bony structures are intact.
___
Left heart catheterization
Coronary anatomy
Dominance: right
LMCA without any flow-limiting stenosis
LAD has mid 40% stenosis
___ diagonal moderate size vessel without any significant
disease
Circumflex has mild luminal irregularities
___ marginal has mild luminal irregularities
RCA: 100% stenosis in proximal RCA before any substance marginal
branches. The lesion has a TIMI flow of 0 and has no noted
calcification. This lesion is further described as moderately
tortuous. An intervention was performed on the proximal and
mid-RCA with final stenosis of 0%. There were no lesion
complications.
TTE ___
IMPRESSION: Normal left ventricular chamber size with mild
regional systolic dysfunction (RCA territory). Mild to moderate
mitral regurgitation. Mildly dilated abdominal aorta. Mildly
dilated aortic sinus with mild functional aortic regurgitation.
MICROBIOLOGY
--------------
___ Urine culture: no growth
___ - BCx x2, NGTD
Brief Hospital Course:
___ male with a history of HTN, HLD and ___ Disease who
presented with a year of exertional chest pain and ___ days of
intermittent nonexertional chest pain, found to have a STEMI.
# STEMI
Exertional chest pain x ___ year with intermittent non-exertional
chest pain x ___. Increased stress over last ___ years, worse
since wife's passing ___ year ago. EKG with new STE in III (1mm)
and aVF (<1mm); troponin elevation to 0.81 on admit. Received
full dose aspirin and loaded with ticagrelor in ED, and put on
heparin drip continued overnight. He underwent cardiac
catheterization on ___ via the right radial artery which
showed a 100% occlusion of the RCA and 50% occlusion of the LAD.
Two ___ were placed to the RCA. Afterward, the patient
continued to be chest pain free. He was discharged on ticagrelor
(for at least one year), aspirin and high dose atorvastatin.
# LEUKOCYTOSIS: WBC 20 on admit with 84% PMNs. Lactate 2.3.
Chronic cough evaluated by CXR, but this was without focal
opacity or lesion. On history and exam, he had no other focal
signs/symptoms, so this was felt to be likely a stress reaction.
This was trended and decreased over time. Blood cultures were no
growth to date, but not finalized at discharge.
# HTN: He was initially continued on his home atenolol 50 daily
and nifedipine CR 30 daily; however, his BPs went down to the
high ___ with ambulation on ___. He was asymptomatic
with the low BPs, and heart rate did not change; we suspect that
this was possibly secondary to autonomic dysregulation from his
___ Disease. Patient was monitored and had improved BPs
later in the day, which did not decrease upon walking or
re-evaluation by Physical Therapy. Therefore, we stopped his
antihypertensives and told him to follow-up with his primary
care physician ___ cardiologists about the preferred blood
pressure regimen for him. We would suggest ___
metoprolol rather than previous regimen in order to optimize
cardiac function. He will also be seen by a visiting nurse who
will measure his blood pressure at home.
# HLD: patient had previously declined statin outpatient in
favor of lifestyle modifications. Started atorvastatin 80mg PO
daily while inpatient.
# PARKSINON'S DISEASE: continued home meds: sinemet,
trihexyphenidyl and pramipexole.
# ANXIETY: continue home Clonazepam 0.5mg PO BID.
TRANSITIONAL ISSUES:
[] Monitor blood pressure; we stopped his home atenolol and
nifedipine given relative hypotension while inpatient, as well
as concern for autonomic dysregulation due to ___
Disease. We recommend lower dose and possibly starting ___
or metoprolol over nifedipine or atenolol. He will be seen by a
___ who will monitor his BP at home.
[] Will need Ticagrelor for at least ___ year and
Aspirin/Atorvastatin indefinitely
[] recommend helping patient select a health care proxy
[] follow-up blood cultures pending at discharge
-Full code
-Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. ClonazePAM 0.5 mg PO BID
3. NIFEdipine CR 30 mg PO DAILY
4. Pramipexole 1 mg PO TID
5. Carbidopa-Levodopa (___) 2 TAB PO TID
6. Trihexyphenidyl 2 mg PO QAM:PRN tremor
Discharge Medications:
1. Carbidopa-Levodopa (___) 2 TAB PO TID
2. ClonazePAM 0.5 mg PO BID
3. Pramipexole 1 mg PO TID
4. Aspirin 81 mg PO DAILY
Take EVERY day to prevent heart disease
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Atorvastatin 80 mg PO QPM
Take every day to prevent heart disease
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. TiCAGRELOR 90 mg PO BID
Take TWICE DAILY day to prevent clotting of the stent in your
heart. Do NOT miss any doses.
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
7. Trihexyphenidyl 2 mg PO QAM:PRN tremor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
STEMI post 2 Drug Eluting Stents to the Right Coronary Artery
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into ___ because you
were having chest pain. At the hospital, you were found to be
having a heart attack. This occurs when one or more of the
vessels providing blood to your heart muscle is clogged. You
underwent a cardiac catheterization (a procedure where they look
at the heart vessels with dye). During the catheterization, they
placed two stents to prop open the vessel that was clogged. We
also added several new medications to your regimen. It will be
important to take these medications EVERY DAY. Do NOT miss ___
dose of the Ticagrelor or the Aspirin as the stents could clot
up again! We also stopped your blood pressure medications
because your blood pressure was low while in the hospital. You
should discuss whether you should restart these medications with
your cardiologist. You can find a full list of your medications
below. Please go over this list carefully and bring a copy with
you to your next doctor's appointment.
It was a pleasure caring for you at ___.
We are glad that you are feeling better!
Take Care,
Your ___ Cardiology Team
Followup Instructions:
___
|
10722837-DS-7
| 10,722,837 | 20,334,674 |
DS
| 7 |
2187-08-07 00:00:00
|
2187-08-07 15:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / ceftriaxone
Attending: ___
Chief Complaint:
symptomatic bradycardia
Major Surgical or Invasive Procedure:
___: dual chamb ___ ppm placement
History of Present Illness:
___ year old male with recent Group B Strep bacteremia
complicated by acute kidney injury who presents with near
syncope. He is noted to have a baseline LBBB. The patient was
hospitalized at ___ from ___ to ___ for the above mentioned
bacteremia and discharged to rehab.
The patient was reportedly doing well at rehab. While watching
football had the sudden onset of feeling dizzy and lightheaded.
He also admitted to feeling nauseated. Though he was lying in
bed, he felt as though he was falling backwards. Denied loss of
consciousness. Called nurse who reported low blood pressure and
EMS was contacted. When EMS arrived BP 86/44 and intimal ECG
with sinus rhythm with 1:1 conduction at HR 58 bpm.
EMS reported that his heart rate slowed to as low as 20 bpm. At
that time an IV placed and urgently brought into ER. Per the ED
the patient had a HR in ___ and was talking, though dizzy. Later
his HR slowed to ___ and he started mumbling, though no clear
loss of consciousness. He was given atropine with improvement in
his HR. Per EP heart rate improved to the ___ with 1:1
conduction.
In the ED intial vitals were: not recorded on Dash, per report
HR ___, SBP 100s
Patient was given: atropine,aspirin, normal saline
On the floor the patient was hemodynamically stable. He had no
acute complaints other than feeling fatigue. Overall improved
from prior.
Past Medical History:
- Recent Strep B bacteremia as above. Now off antibiotics.
- DVT
- Hypertension
- Spinal stenosis (s/p L1-L2 laminectomy; right L2-L3
hemilaminectomy ___
- Umbilical hernia
- Prostate cancer (s/p 45 radiation therapy that was completed
in ___, now receiving leuprolide injections q3 months,
followed by Dr. ___
- h/o Diverticulitis
- ___ edema
- Osteoarthritis
Social History:
___
Family History:
Mother - colon cancer
Sister - jaw cancer
Physical Exam:
Admission:
VS: T= 98 BP= 165/69 HR= 50 RR= 14 O2 sat= 97%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Fatigued.
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. RR, normal S1, S2. ___ systolic murmur at ___. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: full in all extremities
Discharge:
98.2 136/72-166/66 60-67 20 95% RA
W: 107.5 kg
GEN: NAD, A&Ox3
HEENT: conjunctiva pink, sclera anicteric
NECK: supple, FROM, no LAD
CV: RRR, no m/r/g
LUNG: CTAP b/l
ABD: soft, ntnd
EXT: wwp, no c/c/e, PPM site c/d/i
NEURO: grossly intact
Pertinent Results:
Admission:
___ 10:34PM BLOOD WBC-5.9 RBC-3.39* Hgb-10.2* Hct-31.1*
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.4 Plt ___
___ 10:34PM BLOOD ___ PTT-32.8 ___
___ 10:34PM BLOOD Glucose-162* UreaN-28* Creat-2.0* Na-138
K-3.9 Cl-103 HCO3-23 AnGap-16
___ 10:34PM BLOOD ALT-10 AST-16 AlkPhos-51 TotBili-0.3
___ 10:34PM BLOOD cTropnT-0.04*
DISCHARGE:
___ 07:25AM BLOOD WBC-5.5 RBC-3.43* Hgb-10.3* Hct-30.9*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.3 Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-30.0 ___
___ 07:25AM BLOOD Glucose-107* UreaN-22* Creat-1.6* Na-141
K-3.8 Cl-102 HCO3-27 AnGap-16
___ 07:25AM BLOOD ALT-12 AST-15 AlkPhos-47 TotBili-0.4
___ 07:25AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
CXR ___:
As compared to the previous image, the patient has received a
left pectoral pacemaker. The pacemaker leads project over the
right atrium and right ventricle, respectively. There is no
evidence of pneumothorax. Normal size of the cardiac silhouette.
No pulmonary edema.
Brief Hospital Course:
___ w/ h/o recent DVT on warfarin, recent group B strep
bacteremia c/b osteomyelitis, discitis, and ___ s/p 8 weeks
treatment with clindamycin, now admitted for new onset
symptomatic bradycardia and hypotension.
# Heart block: Patient presented with presyncopal episode, found
to be in 3rd degree AV block with ventricular escape in the
___ in the ED. Given atropine with improvement. He
underwent placement of dual chamber ___ pacemaker through
left cephalic on ___. Given vancomycin post-procedurally while
in house and transitioned to clindamycin post-discharge to
complete 48 hours.
# Recent GBS bacteremia: s/p 8 weeks of antibiotics, no active
signs or symptoms of infection. Per ID, no contraindication to
pacer placement.
# RLE DVT: patient on warfarin on admission. Transitioned to
rivaroxaban at discharge per previous plans.
# CKD: stable. Cr 1.6 on day of discharge.
# Constipation: continued aggressive bowel regimen in setting on
ongoing opiate use.
#Peripheral neuropathy: Per prior discharge summary the patient
has reduced sensation in the plantar aspects of both feet
bilaterally. HgA1c 5.7 and B12 normal at 505. This neuropathy is
possibly related to prior right ankle surgery, but deficit seems
to be equally present bilaterally.
#Anemia: Stable to improved from discharge. Normal MCV. Likely
due to chronic disease.
#Prostate cancer: Recommend follow up with Dr. ___
discharge. Patient will likely need to resume Lupron.
# Hypertension: Continued home amlodipine. Labetalol initially
held, restarted following PPM placement.
Transitional issues:
- follow up with device clinic in 1 week
- rivaroxaban 15mg BID x 3 weeks, then 20mg daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H
2. Vitamin D 1000 UNIT PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
gas pain
5. Labetalol 400 mg PO TID
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN constipation
9. Warfarin 5 mg PO DAILY16
10. Docusate Sodium 200 mg PO DAILY constipation
11. Bisacodyl ___AILY:PRN constipation
12. Furosemide 20 mg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Omeprazole 20 mg PO DAILY
15. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
16. Calcium Carbonate 500 mg PO QID:PRN heartburn
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
gas pain
3. Amlodipine 5 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 200 mg PO DAILY constipation
6. Furosemide 20 mg PO DAILY
7. Labetalol 400 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 hr Disp #*30 Tablet
Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. Rivaroxaban 15 mg PO BID Duration: 3 Weeks
then switch to 20mg daily
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*50 Tablet Refills:*0
16. Milk of Magnesia 30 mL PO Q6H:PRN constipation
17. Calcium Carbonate 500 mg PO QID:PRN heartburn
18. Clindamycin 300 mg PO Q8H Duration: 1 Day
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth three times a
day Disp #*5 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: symptomatic bradycardia, paroxysmal complete
heart block
Secondary diagnosis: DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted to the hospital because of an
episode of dizziness and nausea caused by a slow heart rate. You
underwent pacemaker placement which you tolerated well. You
should not lift above your shoulder for 6 weeks and or lift >10
lbs. Your blood thinner has been changed from warfarin to
rivaroxaban.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
10723022-DS-6
| 10,723,022 | 23,223,199 |
DS
| 6 |
2140-10-16 00:00:00
|
2140-10-17 15:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided numbness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ is a ___ year-old right-handed woman who presents
with left abdominal numbness and pressure sensation. Per the
patientis report, her symptoms began approximately ___,
at which time the patient noted after some light running the
sensation of sciatic distribution pain and odd sensation which
was transient. Approximately two weeks later, on ___, she
noted some sensation of intraabdominal distress similar to a GI
illness as well as some significant tension-type headache
(non-throbbing, holocephalic, without photophobia/phonophobia)
which lasted for some of the evening. However, the patient did
not note any nausea, vomiting, diarrhea, or progression of
symptoms to worsening pain. On the next day, ___, Ms.
___
noted a constant numbness sensation ranging from the sternum to
the umbilicus and encompassing the whole left-side or her torso
to the midline in her back. Since that time, the numbness has
been constant without any pain or radiation. On ___, the
patient
had presented to her PCP for workup of these odd subjective
sensations at which time she underwent an MRI Head w/wo contrast
which although remaining in "Unread" status at this time, was
unremarkable on this examiners read for any pathologic lesions
including slow diffusion, hemorrhage, mass lesion, or evidence
of
demyelination (only some periventricular white matter disease).
The patient on ___ went to bed that evening without any notable
issues after an uneventful day. She awoke early this morning
around 0230hrs at which time she noted a downward sensation of
sub-sternal pressure with some radiation to the shoulder and
left
jaw. For this she tried to go to the kitchen to have a cup of
tea and see if the symptoms resolved; however, she noted that
she
had the sense that this was not a normal and transient
sensation.
She contacted a friend of hers as her husband is out of town on
travel who transported her to ___ ED for further evaluation.
She has already undergone cardiac workup which has been
unremarkable. Initial EKG showed a normal RSR variant sinus
rhythm without ST changes and initial troponins <0.01. She was
given a full dose ASA 325mg.
She notes the sensation of downward pressure in the left torso
persists although is not as profound as prior. She denies any
recent exposures, no recent travel except to ___ and
___, ___, both of which were confined to urban areas. She
notes no recent illness, no sick contacts, and no changes to
diet
or behaviour with the exception of some recent light running.
On neuro ROS, the pt denies recent headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
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:
MVA in ___
left tibial and femoral fracture
3 IVF cycles in ___
Past Surgical Hx:
Internal fixation for fracture in ___
D&C in ___
Social History:
___
Family History:
Family Hx:
Mother - alive , HTN, asthma, carpel tunnel syndrome
Father - alive, arthritis
Siblings - 1 brother
Children - 1 daughter ___ years old
No family h/o Breast ca ovarian ca or colon ca. No family
history
of hypercoagulability
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.1 71 135/80 14 100%
General: Awake, cooperative, NAD. Physically fit woman at
stated
age. Pleasant.
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, on telemetry
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent ___ is second language,
___ first) 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 had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, with V2 demonstrating
80% on left of 100% on right to pinprick (which was unable to be
redemonstrated in retesting). Masseter contracted normally.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ 5- 5 4+ 4 4+ 5 4+ 4+ 5 4+ 4+
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory:
On pinprick testing, there was no report of the patient having
any lateralizing deficit, nor was there any reported decrease in
sensation between the body and face. On temperature, also no
report of lateralizing deficit was reported. Touch and
vibration
intact without any lateralizing deficit. The patient
demonstrated no sensory change to stimulation in the left torso
where she had been describing the "half-corset" loss of
sensation.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor in the right and extensor on the
left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAM:
Full strength. "Different" sensation to light touch on left
hemibody
Pertinent Results:
___ 04:38AM GLUCOSE-86 UREA N-17 CREAT-0.8 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10
___ 04:38AM estGFR-Using this
___ 04:38AM cTropnT-<0.01
___ 04:38AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 04:38AM URINE HOURS-RANDOM
___ 04:38AM URINE HOURS-RANDOM
___ 04:38AM URINE UHOLD-HOLD
___ 04:38AM URINE GR HOLD-HOLD
___ 04:38AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:38AM WBC-5.3 RBC-4.51 HGB-12.9 HCT-38.8 MCV-86
MCH-28.6 MCHC-33.2 RDW-12.7
___ 04:38AM NEUTS-40.8* LYMPHS-49.9* MONOS-5.2 EOS-3.5
BASOS-0.6
___ 04:38AM PLT COUNT-190
___ 04:38AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
MRI cervical spine: There are 2 T2 bright, nonenhancing lesions
in the
cervical spinal cord, posterior to the C2-3 and C3-4 disk
spaces. Vertebral body heights and signal intensities are
maintained. There is no abnormal signal in the prevertebral soft
tissues. No abnormal focus of enhancement is seen in the
cervical spine. No significant neural foraminal narrowing or
central canal narrowing.
MRI thoracic spine: Posterior to the T4 vertebral body, there is
a T2 bright, nonenhancing focus in the spinal cord. There is no
area of abnormal enhancement within the thoracic spine.
Vertebral body heights and signal intensities are maintained. No
abnormal signal in the prevertebral soft tissues is thoracic
spine. Significant neural foraminal or central canal narrowing.
IMPRESSION:
Three foci in the cervical and thoracic spinal cord that are T2
bright and nonenhancing. These lesions are consistent with a
demyelinating process, with no evidence of active inflammation.
No significant neural foraminal or spinal canal narrowing.
Brief Hospital Course:
Ms. ___ was admitted to the general neurology service for
further workup after presenting with left-sided numbness been
found to have several lesions in the brain concerning for MS.
___ underwent MRI of her spine showing non-enhancing lesions
C2-3, C3-4 and T4 concerning for multiple sclerosis. LP was
done, routine studies were normal. ___ were sent and were
pending at time of discharge. After discussion with MS
specialist, she was started on a three day course of IV
methylprednisolone, 1g daily. She received two doses in house,
and ___ was set up so that she could receive the third dose at
home. Vitamin D level checked, which was low at 29, and she was
started on Vitamin D 4000U daily.
She was scheduled for follow up with Dr. ___ in ___ clinic.
OUTSTANDING ISSUES
[ ] F/U MS panel (___)
[ ] Has ___ clinic follow up
[ ] Will need repeat vitamin D in future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Multiple
Sclerosis Duration: 3 Days
RX *methylprednisolone sodium succ [Solu-Medrol] 1,000 mg 1 g
daily Disp #*1 Vial Refills:*0
2. Vitamin D 4000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 2 tablet(s) by mouth
DAILY Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multiple Sclerosis (likely)
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 at ___ for sensory
changes on the left side of your body. We found several lesions
in your spine and in your brain which are concerning for a
disease called multiple sclerosis, or MS. ___ gave you your first
dose of steoroids here. We plan for a three day course and you
will get the last dose at home. We did a lumbar puncture, and
the routine studies from this were normal. We are still waiting
on a test (oligoclonal bands) which will help to confirm the
diagnosis. We spoke with Dr. ___ of our MS specialists.
He will be following you in clinic. ___ is the earliest
date available, but you are on a wait list and will be
re-scheduled if there is a cancellation. You can also call the
clinic to reschedule, since you have a vacation planned.
Your vitamin D level was low (29) so we are starting you on
supplementation.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
10723086-DS-23
| 10,723,086 | 24,547,115 |
DS
| 23 |
2189-02-20 00:00:00
|
2189-02-22 10:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin
Attending: ___.
Chief Complaint:
fever and chills, cellulitis, hypoxia
Major Surgical or Invasive Procedure:
Arterial line ___
PICC placement ___
TEE ___
History of Present Illness:
___ y/o female with multiple medical problems, including morbid
obesity, lymphedema, and recurrent cellulitis ___ left lower
extremity (followed closely by infectious disease), who p/w
fever to 101.2 and chills for the past few days.
.
Of note, she had recent hospitalization from ___ for left
lower extremity cellulitis, for which she was treated with IV
vancomycin and miconazole cream. No specific pathogen was found,
but she did clinically improve. She subsequently completed
moxifloxacin therapy and then resumed BID Clindamycin for
suppressive therapy. She started to go to a ___ clinic at
the ___, but has lately stopped going. She has a 10+ year
history of worsening lymphedema peppered with multiple episodes
of cellulitis, typically responsive to vancomycin. She is on
chronic suppressive therapy with clindamycin which she attests
to taking regularly, and will undergo about a week of
moxifloxacin therapy when she feels typical cellulitic symptoms
like worsening lower extremity pain, swelling, fevers, chills,
and fatigue.
.
Of late, she reports "raging fever and chills" despite taking 3
rounds of her avelox and has not been feeling better. Reports
her thighs and knees are red and swollen. She has had continued
and issues with cellulitis of her chronic lymphedema. She states
this feels like when she has problems eating. She feels short of
breath which she says happens when she has fevers related to her
cellulitis. Requested a "visitng nurse to just come ___ and give
a dose of vancomycin."
.
ROS also notable for increased SOB and SOB with exertion. C/O
weakness and lethargy.
.
___ the ED, initial vs were: 99.8, 114, 135/62, 16, 99%. Pt was
tachypneic, hypoxic with a RA SAO2 of 85% and diaphoretic. With
neb tx pt's breathing became more comfortable but she remained
hypoxic on RA and required NRB to maintain a Sat of >92%.
Labs notable for WBC 23.1 with left shift, Hct 32.6, Cr 1.1,
lactate 1.1, U/A wnl. CXR difficult to see lung bases given body
habitus could be pleural effusion vs penetration issues from
size. Patient was given albuterol, ipratropium, vancomycin,
levofloxacin. Vitals on transfer - 97% nrb, 129/80
access - 20G
.
On the unit, her initial VS were 161/59, 116, 100% NRB. Her
sats oscillate between 80-100% on room air, as she falls asleep
mid sentence. She is fully aware, appropriate, and answers
questions when awake. She has felt poorly for about 4 days with
what she suspects to be cellulitis. Her breathing has been
difficult for about 4 weeks, dominated by chest tightness,
cough, and occasional wheeze. Effective treatment with
bronchodilation.
Past Medical History:
1. Morbid obesity
2. Asthma (since childhood)
3. HTN
4. Recurrent cellulitis ___ left lower extremity
5. Osteoarthritis
6. Recurrent otitis media
7. Lymphedema
8. Obstructive sleep apnea (on home CPAP)
9. hiatal hernia
10. Ventral hernia repair ___
11. Exploratory laparotomy and salpingo-oophorectomy for ectopic
pregnancy ___
Social History:
___
Family History:
1. Mother, ___, with lymphedema and cellulitis and is morbidly
obese
2. Father passed away at ___ due to HTN, OSA, and MI
3. Brother, ___, who is morbidly obese and has lymphedema
Physical Exam:
ADMISSION EXAM
Vitals: 161/59, 116, 100% NRB
General: fatigued, morbidly obese, falling asleep between
questions.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: difficult to assess due to habitus
Lungs: very quiet breath sounds on limited anterior examination,
no overt wheezes can be appreciated.
CV: quiet heart sounds but no MRG appreciated.
Abdomen: obese, nontender, soft bowel sounds
Ext: Marked left lower extremity edema with intertriginous areas
of erythema, pain, and warmth. Right lower extremity likewise
edematous without pain. Warm and well perfused otherwise.
Neuro: A&Ox3, sensation and strength grossly intact ___ all
extremities
DISCHARGE EXAM
VS: Tc 96.7, 162/80, 89, 26, 92-93%RA
General: morbidly obese, awake, alert pleasant, appropriate
HEENT: MMM, oropharynx clear
Neck: difficult to assess due to habitus
Lungs: difficult to assess but CTAB, no wheezes, rhonchi, or
rales appreciated
CV: quiet heart sounds but RRR, no MRG appreciated
Abdomen: morbidly obese, nontender, soft, bowel sounds. Mesh
palpated ___ pannus over left lower abdomen.
Ext: Marked left lower extremity edema with intertriginous areas
of erythema, pain, and minimal warmth posteriorly (unchanged)
and fungal skin irritation ___ creases. Right lower extremity
edematous without pain. Warm and well perfused otherwise. Unable
to palpate pulses ___ feet, but toes are warm and well perfused.
Neuro: A&Ox3, sensation to light touch and strength grossly
intact ___ all extremities
Pertinent Results:
Admission labs:
___ 12:30AM BLOOD WBC-23.1*# RBC-4.75 Hgb-10.9* Hct-32.6*
MCV-69* MCH-22.9* MCHC-33.4 RDW-19.2* Plt ___
___ 12:30AM BLOOD Neuts-79* Bands-12* Lymphs-3* Monos-2
Eos-4 Baso-0 ___ Myelos-0
___ 12:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-OCCASIONAL
Ovalocy-OCCASIONAL Target-3+ Tear Dr-OCCASIONAL
___ 06:01AM BLOOD ___
___ 12:30AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-133
K-6.0* Cl-97 HCO3-28 AnGap-14
___ 12:30AM BLOOD ALT-19 AST-48* LD(LDH)-678* AlkPhos-78
TotBili-0.3
___ 12:30AM BLOOD proBNP-1311*
___ 12:30AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.6 Mg-1.8
Iron-22*
___ 12:30AM BLOOD calTIBC-273 Ferritn-144 TRF-210
___ 01:43AM BLOOD ___ pO2-104 pCO2-58* pH-7.35
calTCO2-33* Base XS-3 Comment-GREEN TOP
___ 12:38AM BLOOD Lactate-1.1
Other labs:
DFA antigen negative
Vanc troughs 21.0,19.4
ESR: 107, CRP 283
c. diff: negative
Urine culture negative
Urine Legionella Ag negative
Blood culture negative
Sputum: GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ABGs:
___ 01:43AM BLOOD ___ pO2-104 pCO2-58* pH-7.35
calTCO2-33* Base XS-3 Comment-GREEN TOP
___ 08:45AM BLOOD Type-ART pO2-162* pCO2-89* pH-7.21*
calTCO2-38* Base XS-4
___ 10:20AM BLOOD Type-ART pO2-85 pCO2-90* pH-7.23*
calTCO2-40* Base XS-6
___ 12:40PM BLOOD Type-ART pO2-95 pCO2-86* pH-7.22*
calTCO2-37* Base XS-4
___ 05:16PM BLOOD Type-ART Temp-38.6 Rates-/25 O2 Flow-8
pO2-91 pCO2-93* pH-7.20* calTCO2-38* Base XS-4 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-99.4F AXIL
___ 11:27PM BLOOD Type-ART pO2-85 pCO2-87* pH-7.23*
calTCO2-38* Base XS-5
___ 06:14AM BLOOD Type-ART pO2-90 pCO2-80* pH-7.27*
calTCO2-38* Base XS-6
___ 03:06PM BLOOD Type-ART pO2-106* pCO2-81* pH-7.28*
calTCO2-40* Base XS-8
___ 04:51PM BLOOD Type-ART pO2-51* pCO2-67* pH-7.36
calTCO2-39* Base XS-8
LFTS:
___ 05:51AM BLOOD ALT-11 AST-17 LD(LDH)-308* AlkPhos-73
TotBili-0.3
___ 12:30AM BLOOD ALT-19 AST-48* LD(LDH)-678* AlkPhos-78
TotBili-0.3
Discharge labs:
___ 05:40AM BLOOD WBC-21.3* RBC-4.54 Hgb-10.0* Hct-30.9*
MCV-68* MCH-21.9* MCHC-32.3 RDW-19.2* Plt ___
___ 05:40AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-135
K-4.8 Cl-93* HCO3-37* AnGap-10
___ 05:40AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.9
Imaging:
ECHO ___ Poor image quality.The left atrium is mildly
dilated. The estimated right atrial pressure is at least 15
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. The left ventricular
cavity is moderately dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CXR ___ The radiograph is suboptimal due to patient body
habitus. Within this limitation, unclear if there is layering
pleural effusion bilaterally with adjacent opacification or
whether this represents underpenetration. Recommend a repeat
chest radiograph.
CXR ___ Cardiac silhouette remains enlarged and is
accompanied by pulmonary vascular congestion. Apparent area of
homogeneous opacity has developed at the right lung base,
partially obscuring the right hemidiaphragm. This could
represent a right pleural effusion with or without adjacent
atelectasis or consolidation. When the patient's condition
permits, standard PA and lateral radiographs may be helpful to
more fully evaluate this region.
___ ___: Limited study, with nonvisualization of the left
peroneal and posterior tibial calf veins. Otherwise, no DVT
identified within the left lower extremity.
___ CXR: The right PICC line tip is at the level of
cavoatrial junction. Cardiomediastinal silhouette is unchanged.
Pulmonary edema is
re-demonstrated, slightly progressed since the prior study. Left
basal
opacity might represent prior pulmonary edema but infectious
process cannot be excluded ___ this area.
___ TEE: No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal ___ diameter and free of
atherosclerotic plaque to 35 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild to moderate (___) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion. IMPRESSION: No
echocardiographic evidence of endocardits. Mild right
ventricular dilation with global right ventricular hypokinesis.
Mild to moderate mitral regurgitation.
Brief Hospital Course:
___ y/o female with multiple medical problems, including morbid
obesity, lymphedema, and cellulitis ___ left lower extremity, who
p/w fever, hypoxia, erythema, and concern for recurrent left
lower extremity cellulitis and possible community acquired
pneumonia.
Active Issues:
# LLE CELLULITIS: This is a chronic problem due to her body
habitus. She has been on numerous antibiotic treatments ___ the
past (clindamycin prophylaxis and avelox as needed). Presented
febrile with leukocytosis (23.1) and bandemia (12%) and admitted
to the ICU for hypoxia. Started on vancomycin IV while ___ the
ICU as well as miconazole cream. Transferred to the floor on
___ stable. Patient was continued on IV vancomycin.
Outpatient ID physician ___ (Dr. ___ and inhouse
ID consult recommended 14days of IV vancomycin. Patient's WBC
trended down and patient was feeling better. PICC line was
placed. WBC increased from 16->24 shortly after discontinuation
of levaquin for presumed PNA. ___ of LLE negative for DVT,
though study was suboptimal ___ body habitus. Patient was
discharged with IV vancomycin and instructions for follow up
with Dr. ___ on ___. Given her high CRP (283.2)
and ESR (107), ID recommended checking weekly labs as an
outpatient.
.
# LEUKOCYTOSIS: Leukocytosis decreased with vancomycin and
levaquin. Upon discontinuation of levaquin patient had low grade
fevers/chills with a WBC increase from 16->17->24. Levaquin was
restarted for a 7 day course (cont as outpatient) and WBC
trended down to 21 and then 19. Repeat CXR on ___ showed
possible RLL consolidation. C. diff negative, Urine legionella
negative, Urine culture from ___ pending on discharge (UA
showed WBC 22, RBC 25, epi 3, moderate bacteria, negative
nitrate, small leuk est). TEE showed no echocardiographic
evidence of endocardits, mild right ventricular dilation with
global right ventricular hypokinesis, mild to moderate mitral
regurgitation. Patient will have weekly labs (including CBC) and
has close follow up with PCP and ID.
.
# HYPERCARBIA: Initially admitted to the MICU for hypercarbia
(pCO2 90) and hypoxemia. She became anxious with respiratory
rates ___ the ___ to ___ and was started on BiPAP. Shortly after
receiving steroids, she became extremely agitated, yelling and
swing her arms violently. She was sedated with haldol 10mg IV.
Steroids were stopped. She tolerated BiPAP overnight and was
weaned to nasal cannula. Hypercarbia thought to be due to acute
asthma vs. obesity hypoventilation. She was given albuterol and
ipratropium nebs and continued on her flutisacone. On transfer
to the floor, ABG still showed a pCO2 of 67, but she was
mentating well. On the floor she maintainted an O2sat of 94% on
2L NC, 92-93% on RA. She refused CPAP at night.
# HYPOXEMIA: On admission to MICU, patient was desatting to
mid-80s. Concern was for pneumonia given her bandemia, but the
CXR was difficult to read due to body habitus. Also possible it
was due to her asthma. She was started on levaquin and treated
briefly for an asthma exacerbation, but could not tolerate the
steroids. She was given prn nebs for intermittent wheezing.
Given IV lasix with net negative ~1.5L daily. Improved
overnight. Remained 97% on nasal cannula ___ ICU. Flu swab
negative. She was stable on transfer to the floor after 1 day.
ID was consulted and recommended discontinuing ___ the
levofloxacin, as they didn't feel treatment for CAP was
indicated. However, WBC bumped after discontinuation, and
patient was restarted on levaquin with improved symptoms.
Patient continued to receive albuterol and ipratropium nebs prn
and was satting 94% on 2L, 92-93% on RA. Lasix was decreased on
teh floor gradually to home dose of 40mg PO daily.
Chronic Issues:
# ANEMIA: Chronic, at basline. No evidence of bleeding. Iron low
at 22 with an MCV 69, ferritin and TIBC WNL. Hct trended and
stable. Started on iron supplementation.
# HTN: Continued metoprolol and diltiazem.
# OSA: refused CPAP.
Transitional Issues:
Patient will have follow up with Dr. ___ week,
___. She will need weekly blood work (CBC, CHEM7, ESR, CRP)
to ensure her infection is improving.
Episodes of recurrent cellulitis may not represent antibiotic
failure as much as mechanical/anatomical issues and chronic
lymphedema. It has been previously discussed with ID that the
ultimate solution may be weight loss options and possible
bariatric surgery. Per ID, concern would be continued episodes
of cellulitis ___ the future if her lymphedema and obesity are
not addressed. This may unfortunately be complicated by
infections with bacteria that are resistant to broad spectrum
oral antibiotics, like moxifloxacin. Patient has gone to many
meetings regarding gastric bypass surgery over the last ___
years, but has had trouble with mobilizing to have the procedure
done.
Medications on Admission:
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2 (Two) puffs inhaled every six (6) hours - No Substitution
CLINDAMYCIN HCL - 150 mg Capsule - 1 Capsule by mouth twice a
day as needed for cellulitis
CLOTRIMAZOLE - 1 % Cream - 1 Cream(s) twice a day
DICLOFENAC SODIUM - 100 mg Tablet Extended Release 24 hr - 1
(One) Tablet by mouth once a day as needed for pain
DILTIAZEM HCL - 240 mg Capsule, Ext Release 24 hr - 1 (One)
Capsule by mouth once a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet by mouth once a day as
needed for lower extremity edema
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet by mouth once a day
MOXIFLOXACIN [AVELOX] - 400 mg Tablet - 1 Tablet by mouth daily
(Please take one tablet a day for ___ days when you start to
experience cellulitis)
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 1 Tab by
mouth daily
OXYCODONE - 5 mg Tablet - ___ Tablets by mouth every four to six
(6) hours as needed for leg pain
IRON - Dosage uncertain (patient states that she does not take
this)
Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*51 Recon Soln(s)* Refills:*0*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day.
3. Clotrim Antifungal 1 % Cream Sig: One (1) application Topical
twice a day.
4. diclofenac sodium 100 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day as needed
for pain.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
6. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day.
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
11. Outpatient Lab Work
Please get weekly (___) lab work drawn:
CBC, Chem7, ESR, CRP. Please have labs drawn at ___
___, so that the results are available for
Dr. ___.
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Left Leg cellulitis
Secondary Diagnosis:
- Morbid obesity
- Lymphedema
- Recurrent cellulitis ___ left lower extremity
- Asthma (since childhood)
- HTN
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 at ___
___. You were admitted to the hospital for cellulitis
(infection) of your left leg. You spent a day ___ the Intensive
Care Unit because you had an increased oxygen requirement
(meaning you were not breathing as well as you should), which
was likely related to your asthma as well as the effects of the
infection on your body. Your cellulitis was treated with
Vancomycin, which you will require as an outpatient for a total
of 14days. Your asthma was treated with nebulized medication
and you are also being given Levaquin to treat a possible
infection ___ your lungs.
The following medication changes have been made:
STOP taking Diltiazem 240mg daily
START taking lisinopril 10mg by mouth Daily.
START taking Vancomycin 1500mg IV twice daily for 7 days (please
see Dr. ___ ___ ___ clinic before stopping)
START taking Levaquin 750mg by mouth daily for 3 days (last dose
on ___
START taking senna and docusate sodium as needed for
constipation.
CONTINUE taking iron supplements twice daily. This can
constipate you, so you are being discharge on a bowel regimen
(senna and docusate sodium, above), which you should take as
needed.
STOP taking your home clindamycin and avelox. Follow up with Dr.
___ (Infectious Disease) concerning restarting
these medications.
You will need weekly lab work to ensure your infection is
improving.
Please continue your other home medications as prescribed. No
changes have been made.
Followup Instructions:
___
|
10723086-DS-24
| 10,723,086 | 27,055,936 |
DS
| 24 |
2189-04-17 00:00:00
|
2189-04-17 13:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo F with a history of morbid obesity,
obesity hypoventilation, venous insufficiency with chronic
lymphedema, recurrent cellulitis, and asthma who presents with
apneic episodes and mouth pain. She is primarily concerned about
tongue lesions and pain on eating from nightly teeth grinding.
She admits that she needs to see a dentist. When she became
somnolent at the kitchen table today and startled awake in front
of her family, she decided to present to the ED for both
problems.
.
She has not felt well since being discharged from the hospital
two months ago. She remains tired, and admits that she only
comes downstairs every ___ days. She has been falling asleep
during the daytime, often waking with confusion with choking
sounds characteristic of her apnea. She has known OSA with
historically very poor compliance with CPAP- she can sleep with
it in place though can tolerate the mask for no more than 2
hours. She also mentions some dyspnea on exertion or with
bathing. She has some orthopnea, though has "been able to lay
much flatter recently than normal." She thinks her lower
extremity swelling is worse bilaterally as well, though this is
a subacute process over the course of the year. There has been
no fevers or chills. She has had a nonproductive cough for the
past year.
.
She complains of progressive shortness of breath over past few
weeks, assuming a orthopneic nature as she she struggles to lay
flat and sleep. . She awoke confused and short of breath with
EMS sats of 84% RA.
.
In the ED, initial VS: 98 87 173/108 24 100% 15L. A CXR was
difficult to interpret. She was treated with albuterol and
ipratropium nebs (partially due to patient preference) with sats
rebounding to the low-mid ___ on 2LNC. Nasal c02 capnography
placed pC02 in the mid___ per report. BNP was roughly at
previous level, around 1500.
.
She was admitted in ___, initially to the MICU, for an
episode of cellulitis accompanied by hypoxia/hypercarbia with
sats in the ___ on RA and a PC02 in the mid-upper ___. She
became acutely agitated when this author prescribed steroids for
potential asthma exacerbation, but finished a course of levaquin
for ?CAP prompted mostly by a poorly explained leukocytosis and
a poorly-interpretable CXR due to habitus.
On arrival to the floor, her VS were 96.1 176/103, 87, 24,
96/3L. She desats to 85 on room air though her sats rebound with
deep breathing. She thinks her breathing is "about normal" right
now and denies overt shortness of breath. She otherwise has no
complaints.
.
REVIEW OF SYSTEMS:
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:
1. Morbid obesity
2. Asthma (since childhood)
3. HTN
4. Recurrent cellulitis in left lower extremity
5. Osteoarthritis
6. Recurrent otitis media
7. Lymphedema
8. Obstructive sleep apnea (on home CPAP)
9. hiatal hernia
10. Ventral hernia repair ___
11. Exploratory laparotomy and salpingo-oophorectomy for ectopic
pregnancy ___
Social History:
___
Family History:
1. Mother, ___, with lymphedema and cellulitis and is morbidly
obese
2. Father passed away at ___ due to HTN, OSA, and MI
3. Brother, ___, who is morbidly obese and has lymphedema
Physical Exam:
ADMISSION EXAM:
VS - 96.1 176/103, 87, 24, 96/3L
GENERAL - morbidly obese but NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
lateral ulcerations on the tongue bilaterally.
NECK - obese, cannot appreciate JVP
LUNGS - limited exam due to habitus, scant exp wheeze in
anterior fields
HEART - quiet heart sounds, but normal rhythm and no murmurs
ABDOMEN - Obese, NABS, soft/NT/ND
EXTREMITIES - massive bilateral lower extremity edema, no
intertriginous erythema or warmth
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
.
DISCHARGE EXAM:
VS - 97.8, 144/74, 67, 18, 99% on BiPAP, 95 RA
Incontinent no output recorded
GENERAL - morbidly obese but NAD laying in bed
LUNGS - limited exam due to habitus, scant exp wheeze in
anterior fields
HEART - quiet heart sounds, but normal rhythm and no murmurs
ABDOMEN - Obese, with dependent edema/errythema in lower panus,
no pain with palpation.
EXTREMITIES - massive bilateral lower extremity edema with many
redundant skin folds
SKIN - no rashes or lesions appreciated on exposed surfaces
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
Pertinent Results:
ADMISSION LABS:
___ 07:05PM BLOOD WBC-8.3 RBC-4.88 Hgb-10.5* Hct-33.9*
MCV-69* MCH-21.4* MCHC-30.9* RDW-19.8* Plt ___
___ 07:05PM BLOOD Neuts-66.8 ___ Monos-6.0 Eos-4.1*
Baso-0.9
___ 07:05PM BLOOD ___ PTT-31.8 ___
___ 07:05PM BLOOD Glucose-116* UreaN-11 Creat-0.9 Na-137
K-4.2 Cl-97 HCO3-36* AnGap-8
___ 07:05PM BLOOD proBNP-1527*
___ 06:05AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9
___ 07:12PM BLOOD Glucose-109* Lactate-1.0 Na-141 K-4.2
Cl-92* calHCO3-40*
ABGs:
___ 10:31PM BLOOD Type-ART pO2-41* pCO2-96* pH-7.24*
calTCO2-43* Base XS-9
___ 01:57PM BLOOD Type-ART pO2-76* pCO2-104* pH-7.23*
calTCO2-46* Base XS-11
___ 02:17AM BLOOD Type-ART pO2-66* pCO2-72* pH-7.38
calTCO2-44* Base XS-13 Comment-BIPAP
___ 08:01AM BLOOD Type-ART pO2-68* pCO2-82* pH-7.35
calTCO2-47* Base XS-15
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-5.3 RBC-5.00 Hgb-10.6* Hct-34.1*
MCV-68* MCH-21.2* MCHC-31.1 RDW-20.3* Plt ___
___ 07:00AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-139
K-3.8 Cl-94* HCO3-40* AnGap-9
IMAGING:
CXR: AP semi-upright portable view of the chest was provided.
Evaluation is limited given the large body habitus and
underpenetrated
technique. Allowing for this, the right lung appears clear. The
left lung
base cannot be assessed. The left upper lung appears well
aerated. The heart size appears enlarged, though this could be
related to technique. Mediastinal contour is normal. Bony
structures appear intact
EKG: Sinus rhythm. Left atrial abnormality. Prior inferior
myocardial infarction. Delayed precordial R wave transition.
Diffuse non-specific ST-T wave flattening. Compared to the
previous tracing of ___ ventricular ectopy is now absent.
Otherwise, no diagnostic interim change.
PULMONARY CONSULTATION:
A/P: ___ morbidly obese female with prior history of OSA
non-compliant with CPAP, obesity hypoventilation (PCO2> 48 since
___, also w/DOE), ?asthma and diastolic heart failure in the
setting of her persistent and poorly controlled hypertension in
addition to severe chronic lyphedema with recurrent cellulitis
who presents with increasing fatigue and SOB since ___.
Many
of these issues are chronic, however the patient likely has had
an acute decompensation on top of her chronic hypoxemic
hypercarbic respiratory failure and the etiology of this is less
clear (although it likley does not take much of a metabolic or
physiologic disturbance to cause an acute decompensation in this
patient). The decompensation could have been due to diastolic
CHF exacerbation in the setting of hypertension, increased
___ swelling causing worsening restriction (on top of
restriction caused by her obesity), an exacerbation of a
ventilatory deficit such as asthma (not seen on sprio but she
does have some relief with nebulizers) and possibly occult
infection (such as a cellulitis, there is no obvious pulmonary
infection).
.
#obesity hypoventilation/OSA - I had a long discussion with the
patient today regarding the importance of using her BiPAP at
night to treat her chronic respiratory failure and its symptoms;
she needs an outpatient BiPAP titration study to improve
compliance
-would get ABG on BiPAP tonight and in the morning 1 hour after
BiPAP is off to ensure utility of current settings
-we spoke about the importance of weight loss as well
-BiPAP at night
-minimize sedating medications and rule out occult infection as
able
-patient may also have pulmonary hypertension from precapillary
(chronic OSA) and postcapillary (CHF) causes which could be
contributing to her dyspnea
.
#?asthma - not confirmed with spirometry but she does get relief
with nebulizers
-start flovent 220mcg BID (with spacer if needed)
-duonebs Q4-6 hours standing and PRN
-needs PFTs as outpt (inpatient if easier for patient) with
sprio, lung volumes, DLCO, bronchodilator challenge
.
#HTN/diastolic CHF - needs diuresis (using diamox is OK if
bicarbonate is getting high to prevent further CO2 retention)
and
strict BP control
.
#restrictive ventilatory deficit - seen on prior spirometry,
likely due to obesity and now likely increased abd edema/fluid
is
contributing, unable to get imaging due to body habitus
Addendum by ___, ___ on ___ at 6:56 pm:
On this day I was present for the key portion of the service
provided and reviewed today's note of Dr. ___. I agree with
the findings and plan of care.
Thanks for asking us to see Ms. ___ in consultation for her
hypoxemia. She has obesity hypoventilation and morbid obesity.
She has a history of asthma which is stable.
She has been non-compliant with her BiPAP, and her PCO2 is
greater than 100 on admission. Her repeat gases have been
consistent with chronic respiratory acidosis. She has signs of
cor pulmonale on exam. Echocardiogram is insufficient to
exclude
elevated right sided pressures in this morbidly obese patient.
We would recommend that you continue to gently remove volume
with
diuresis and that she absolutely needs to maintain adequate
oxygenation and nocturnal BiPAP.
Brief Hospital Course:
ASSESSMENT AND PLAN: Ms. ___ is a ___ F here with
shortness of breath and hypoxia that was felt to be from BiPAP
non-compliance at home. Patient had BiPAP and agressive
diuresis while inpatient with improvement in her symptoms. She
was discharged to rehab for further recovery prior to discharge
home.
.
# OSA/Hypercarbia: Patient presented with hypnogogic
hallucinations and day time somulnece after an extended period
of non-compliance with her BiPAP machine. the patient was seen
by our pulmonologists and found to have a pCO2 of 108 when not
using BiPAP that improved to the ___ while on BiPAP. In
addition to BiPAP use while sleeping the patinet was
aggressively diursed (negative ___ L a day) in order to decrease
and chest wall restriction and component of pulmonary edema that
may have been adding to her work of breathing. Patient was
discharged to rehab to have continued bipap administration and
physical therapy and had a follow up in sleep clinic scheduled
for after discharge from rehab. Settings on BiPAP were IPAP 19,
EPAP 15.
.
# HYPOXIA: patient was noted to be hypoxic on room air with O2
saturations as low as 85% the patient required several liters of
oxygen by nasal canula to maintain saturations in the high ___
while at rest. These symptoms were felt to be the result of
obesity hypoventilation syndrome rather than another process.
The patient was discharged to rehab with the plan that lower
than normal oxygen saturations ie titrating nasal O2 to 85-92%
rather than high ___ in order to avoid pulmonary toxicity from
oxygen. Active diuresis should be continued with goal negative
___ L daily until creatinine rises.
.
# NOROVIRUS: patient developed high output stool that was c
diff toxin negative and resolved after 48 hours while inpatinet
felt to be related to viral enteritis.
.
# UTI: Patient had a Urine Cx from admission growing
cipro/bactrim/ceftriaxone resistant E coli that was treated with
nitrofurontin for a 3 day course.
.
# Lymphemdema: Patient has extreme lower extremity lymphedema
and certianly part of her compromised respiratory status oculd
be from pulmonary edema though exam is very limited. Anti-fungal
cream per home regimen.
.
# MOUTH SORES: Evidence of tongue trauma on exam along the
lateral tongue surface abutting bite surface. ___ be result of
angioedema from lisinopril as patient gives temporally related
history of worsening tounge edmea after starting this medication
versus generalized edema. Patinet was started on losartan with
discontinuation of ace inhibitor and treated with viscous
lidocaine for symptom control.
.
# HYPERTENSION: Patient was switched to losartan 25 mg with
adequate blood pressure control.
.
# ASTHMA: bronchospastic process was felt to contribute to
hypoxia and patient was given nebulizers.
.
# OA: Stable on home diclofenac and oxycodone prn
.
# MORBID OBESITY: encouraged weight loss and discuss bariatric
surgery
.
# MICROCYTIC ANEMIA: Iron deficient according to ___ iron
panel continued supplemental iron
.
TRANSITIONAL ISSUES:
-Patient is a full code
-Patient should be on BiPAP whenever sleeping
-Please continue aggressive diuresis until creatinine rises.
Medications on Admission:
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
(Two) puffs inhaled every six (6) hours - No Substitution
BARIATRIC DROP-ARM COMMODE - - USE AS DIRECTED. LIFETIME NEED.
DX:PERIPHERAL NEUROPATHY, MORBID OBESITY. WT. 565 LBS.
CLOTRIMAZOLE - (Prescribed by Other Provider) - 1 % Cream - 1
Cream(s) twice a day
DICLOFENAC SODIUM - 100 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day as needed for pain
DILTIAZEM HCL - 240 mg Capsule, Ext Release 24 hr - 1 (One)
Capsule(s) by mouth once a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for lower extremity edema
___ - ___ HG - WEAR STOCKINGS EVERY DAY
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
MOTORIZED SCOOTER - - use as directed dx: limited mobility,
morbid obesity, and lymphedema
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 1 Tab(s)
by mouth daily
OXYCODONE - 5 mg Tablet - ___ Tablet(s) by mouth every four to
six (6) hours as needed for leg pain
IRON - (Prescribed by Other Provider) - Dosage uncertain
MICONAZOLE NITRATE [LOTRIMIN AF POWDER] - 2 % Aerosol Powder -
Apply to toes twice a day
Discharge Medications:
1. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
2. diclofenac sodium 25 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as
needed for joint pain.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lidocaine Viscous 2 % Solution Sig: One (1) Mucous membrane
four times a day as needed for pain.
12. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Obesity Hypoventilation Syndrome
-Obstructive Sleep Apnea
-Hypoxia
-Hypercarbia
-Urinary Tract Infection
-Viral Gastroenteritis
SECONDARY:
- Asthma
- HTN
- Recurrent cellulitis in left lower extremity
- Osteoarthritis
- Lymphedema
- hiatal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital you were admitted for evaluation of your sleepiness and
hallucinations. Both of these symptoms were felt to be related
to retaining carbon dioxide in your lungs. This difficulty
breathing is related to your weight as well as fluid in your
lungs. You were put on your BiPAP machine and your breathing
improved. It is extremely important that you continue to use
your machine WHENEVER you are sleeping. Not doing so can be
very dangerous and may shorten your life dramatically. Part of
your problems with breathing come from being overweight and you
should try dieting to help improve your breathing. We also gave
you medications to help you remove fluids from your lungs.
During your hospitalization you developed an a viral diarrheal
illness that improved by the time of your discharge. You will
need to follow up with your primary care doctor regarding the
potential for bariatric surgery in the near future as well as
your sleep doctors to have your BiPAP adjusted.
The Following Changes were Made to Your Medications:
-STOP Lisinopril
-START Losartan 25 mg daily
-START Lasix 80 mg Twice daily
-START Lidocaine Mouth wash 4 times a day as needed for mouth
pain
-START Albuterol and Ipratropium nebulizers every 6 hours
Followup Instructions:
___
|
10723086-DS-25
| 10,723,086 | 24,538,677 |
DS
| 25 |
2189-05-22 00:00:00
|
2189-05-22 17:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___.
Chief Complaint:
SOB and fever
Major Surgical or Invasive Procedure:
___ Right PICC placement
History of Present Illness:
___ yo F with morbid obesity, asthma, OSA on CPAP and recent
admission for hypoxia (___) thought to be ___ OSA/obesity
hypoventilation presents today with shortness of breath, fever,
and chest tightness.
.
Of note, after last admission, patient was discharge to rehab
for about 2 weeks, during which she was weaned off oxygen. She
was then discharged home by the beginning of ___, feeling
better overall, able to ambulate with walker at home although
sleeping on the first floor because she wasn't able to climb up
the stairs yet due to SOB. Since last week, she noticed more
swelling and pain in her LLE which is normally larger than the
RLE. She decided to self-medicate with Avelox. She then had
fever up to 102 for about 2 days after starting Avelox. Fever
than subsided, but she continued to have pain in her LLE that is
worse than baseline. On the day prior to admission on ___, she
felt more fatigued and lost her appetite. In addition, she had 2
episodes of loose BM without blood. By 6PM prior to admission,
she developed chill, rigor, and body ache. She felt out of
breath and sweaty. Denies vomiting or abdominal pain but does
have mild nausea. She also thinks that her BP is lower than
baseline, which is usually in the 140s systolically. Because of
how ill she felt, she came to the ED.
.
In the ED, initial VS: ___ 108 130/p 34 100%. Labs are
significant for WBC 30.8, 94.2% neutrophils, Hct 34.7, MCV 67,
INR 1.3, proBNP 531, Cl 95, Crt 0.9, VBG 7.38/56/41/34, lactate
2.0, UA negative. CXR showed possible RLL pneumonia. She
received 750 mg IV levofloxacin and 1L NS. She also got
albuterol and ipraropium nebs, tylenol and ibuprofen. Foley was
placed due to incontinence. VS upon transfer T 102.7, HR 95, BP
112/49, RR 28, O2Sat 95% 4L NC.
.
Currently, feels slightly better than last evening.
Past Medical History:
1. Morbid obesity
2. Asthma (since childhood)
3. HTN
4. Recurrent cellulitis in left lower extremity
5. Osteoarthritis
6. Recurrent otitis media
7. Lymphedema
8. Obstructive sleep apnea (on home CPAP)
9. hiatal hernia
10. Ventral hernia repair ___
11. Exploratory laparotomy and salpingo-oophorectomy for ectopic
pregnancy ___
Social History:
___
Family History:
1. Mother, ___, with lymphedema and cellulitis and is morbidly
obese
2. Father passed away at ___ due to HTN, OSA, and MI
3. Brother, ___, who is morbidly obese and has lymphedema
Physical Exam:
admission exam
VS - 98.2F, 89/48 on repeat 113/56, hr 87, RR 28, O2Sat 98% 4L
GENERAL - Alert, interactive, uncomfortable appearing with
movements
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, diminished breath sound in the RLL
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, + non-pitting lymphedema, L > R in size, L
leg/posterior thigh warmer to touch and firmer, 2+ peripheral
pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
.
Pertinent Results:
LABS:
Admission Labs:
___ 01:00AM BLOOD WBC-30.8*# RBC-5.23 Hgb-11.5* Hct-34.7*
MCV-67* MCH-21.9* MCHC-33.0 RDW-20.6* Plt ___
___ 01:00AM BLOOD Neuts-94.2* Lymphs-3.9* Monos-0.9*
Eos-0.7 Baso-0.3
___ 01:00AM BLOOD ___ PTT-29.7 ___
___ 01:00AM BLOOD Glucose-98 UreaN-11 Creat-0.9 Na-135
K-3.9 Cl-95* HCO3-31 AnGap-13
___ 08:05AM BLOOD ALT-10 AST-16 AlkPhos-64 TotBili-0.5
___ 08:05AM BLOOD Calcium-8.6 Phos-4.8* Mg-1.7
___ 01:09AM BLOOD ___ pO2-41* pCO2-56* pH-7.38
calTCO2-34* Base XS-5 Comment-GREEN TOP
___ 01:09AM BLOOD Lactate-2.0
.
URINE
___ 01:15AM URINE Color-Straw Appear-Clear Sp ___
___ 01:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:15AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:15AM URINE Mucous-RARE
___ 01:15AM URINE UCG-NEGATIVE
.
MICRO:
blood culture ___
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP G.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ AT 3:55PM ON
___.
urine culture ___ - no growth
legionella urinary antigen - negative
Cdiff negative
.
STUDIES:
admission ECG:
Baseline artifact. Sinus tachycardia. Leftward axis. Consider
inferior
myocardial infarction, age undetermined. ST-T wave
abnormalities. Borderline low precordial voltage. Since the
previous tracing of ___ the rate is faster. ST-T wave
abnormalities are more prominent. Voltage is now more prominent.
.
CXR:
Recurrent heart failure. Basal pneumonia and pleural effusions,
even moderate in volume are open questions due to limitations of
conventional radiography with a patient of this size.
.
Pelvic ultrasound
Limited examination, however, IUD appears in satisfactory
position.
LLE ultrasound
IMPRESSION: No focal lesion identified. Diffuse subcutaneous
edema with no
focal fluid collection.
.
RLE ultrasound
No evidence of abscess. Marked subcutaneous edema overlying the
calf.
.
TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The estimated cardiac index is
normal (>=2.5L/min/m2). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No valvular pathology or
pathologic flow identified. Right ventricular cavity enlargement
with free wall hypokinesis. Mild symmetric left ventricular
hypertrophy with mild cavity dilation and preserved global
systolic function. Pulmonary artery hypertension. Biatrial
enlargement.
Compared with the prior study (images reviewed) of ___,
right ventricular cavity dilation and free wall hypokinesis are
more apparent. Is there a history to suggest an acute pulmonary
event (e.g., pulmonary embolism, bronchospasm, etc.). The
current study is of superior image quality.
Brief Hospital Course:
___ yo morbidly obese female with h/o OSA on CPAP, obesity
hypoventilation syndrome, chronic lymphedema, HTN, who presents
with fever, chills, SOB found to have cellulitis and group G
strep bacteremia.
.
ACTIVE ISSUES BY PROBLEM:
# Cellulitis and Bacteremia - Patient presented with fever of
104, tachycardia, relatively low BPs, and WBC count of 48K.
Blood cultures on admission positive for BETA STREPTOCOCCUS
GROUP G, likely from impressive RLE cellulitis. Urine culture
negative, CXR with no infiltrate. LLE and RLE ultrasound
negative for focal fluid collection. Started on penicillin and
clindamycin IV, however clinda was stopped after 2 days.
Infectious disease was consulted, who recommended TTE to eval
for endocarditis. TTE did not show vegetations, however it was a
limited study, so TEE was recommended but patient refused.
Given the inability to rule out endocarditis, she will need to
undergo 4 weeks IV PCN therapy as empiric treatment, with
possible continued PO abx after that. Subsequent blood cultures
from ___ bottle), ___ all with no growth on
discharge. Fevers abated, WBC count came down (15K at
discharge), and ___ was placed on ___ for continued IV abx.
She will need weekly safety labs at rehab and will follow with
the ___ clinic. Decision on need for PO penicillin as
suppressive antibiotic therapy will be left to her ID team in
outpatient follow-up.
# Shortness of breath - Patient reports on day prior to
presentation was increasingly short of breath and required use
of her nebulizers. She was initially satting well on 4L of o2
which was eventually tapered to room air. She did
intermittently have wheezes on exam, so may have had component
of bronchospasm and asthma flare. She was diuresed for 2 days
with improved symptoms. Continued home flovent with albuterol
and ipratropium scheduled nebs.
# HTN: BP meds initially held on admission given SIRS. Once
clinically stable, restarted home doses of losartan, diltiazem,
metoprolol and lasix. Lasix was then decreased from 80mg BID to
80 mg daily due to incontinence issues, which is how she's been
taking at home.
# OSA/obesity hypoventilation state: continued nighttime BiPAP.
# Arthritis: continued diclofenac, tylenol, and oxycodone.
TRANSITION OF CARE ISSUES:
- Bactermia/Cellulitis: will complete 4 weeks IV PCN therapy,
needs weekly OPAT labs sent to ID nurse. Information sent to
rehab facility in discharge paperwork
- Patient remained FULL CODE
Medications on Admission:
1. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
2. diclofenac sodium 25 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as
needed for joint pain.--> usually takes 25 mg tab once a day
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain. --> usually BID prn
10. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. -->
Has only been taking 80 mg daily for the last week because the
BID dosing made her very thirsty.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Discharge Medications:
1. clotrimazole 1 % Cream Sig: One (1) application Topical twice
a day.
2. diclofenac sodium 25 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as
needed for joint pain.
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
9. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation every six (6)
hours.
13. penicillin G potassium 20 million unit Recon Soln Sig: Four
(4) million units Injection Q4H (every 4 hours) for 23 days:
Continue through ___ .
14. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
15. Outpatient Lab Work
Please draw WEEKLY: CBC w/diff, BUN/Cr, LFTs
All laboratory results should be faxed to Infectious disease
R.Ns. at ___
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ___
or to on call MD in when clinic is closed
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cellulitis
Bacteremia
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 for shortness of breath and
fevers, and you were found to have a significant leg infection
that had caused bacteria to enter your blood stream. You were
started on intravenous antibiotics, which helped to treat this
infection. You will need to stay on these antibiotics for at
least one month. While on these antibiotics, you will need labs
drawn weekly for monitoring.
Changes to your medications:
START penicillin G Potassium 4 Million Units IV every 4 hours
(until ___
INCREASE oxycodone to 10 mg every 4 hours as needed for leg pain
It was a pleasure to take care of you at ___!
Followup Instructions:
___
|
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DS
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2189-10-17 00:00:00
|
2189-10-17 21:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with h/o lymphedema, morbid obesity, multiple
cellulitis, presenting with pain in ___ and concern for
cellulitis. She reports that she had a fever to 101 at home. She
called her ID doctor, ___, on ___, who
prescribed avelox, as this is her typical regimen. Despite
taking this medication, she still developed pain and fever,
similar . She denies chest pain, SOB. She denies dysuria but
describes urinary frequency. She notes pain which occassional
radiates from her foot to her knee, and states that these are
like her prior incidences of cellulitis. She has no c/abd pain,
n, v, or change in bowel habits.
In the ED, initial vitals: 99.2 100 160/90 19 96%.
Exam notable for Ext- WWP, notable for white exudate in left
ankle skin fold with superficial excoriation, no surrounding
edema or warmth. Labs notable for WBC 19.8 (N:89.7 L:6.9 M:1.5
E:1.7 Bas:0.2)
The pt underwent a CXR
He received Vancomycin 1gm IV, Tylenol ___ PO x1, and
oxycodone 5mg PO x1. Vitals prior to transfer: Temp: 100.7 °F
(38.2 °C), Pulse: 113, RR: 28, BP: 198/91, O2Sat: 91%, O2Flow:
(Room Air), Pain: 5., Comment: 3L NC on, O2 sat up to 95%. Blood
Cx x2 drawn.
Currently, she states that she is feeling better. Her ros is
otherwise negative.
Past Medical History:
1. Morbid obesity
2. Asthma (since childhood)
3. HTN
4. Recurrent cellulitis in left lower extremity
5. Osteoarthritis
6. Recurrent otitis media
7. Lymphedema
8. Obstructive sleep apnea (on home CPAP)
9. hiatal hernia
10. Ventral hernia repair ___
11. Exploratory laparotomy and salpingo-oophorectomy for ectopic
pregnancy ___
Social History:
___
Family History:
1. Mother, ___, with lymphedema and cellulitis and is morbidly
obese
2. Father passed away at ___ due to HTN, OSA, and MI
3. Brother, ___, who is morbidly obese and has lymphedema
Physical Exam:
ADMISSION
99.7 148/66 103 20 97% 3L
GENERAL - well-appearing woman in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD,
LUNGS - CTA bilat, with occasional expiratory wheeze, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, mildy tachycardia with RR, no MRG, nl
S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - chronic lymphedema b/l, milky white exudate
present in distal skin fold of LLE, no apparent additional
erythema or redness
LYMPH - no ___
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE
afebrile normotensive not tachycardic
GENERAL - well-appearing woman in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD,
LUNGS - CTA bilat, with occasional expiratory wheeze, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, mildy tachycardia with RR, no MRG, nl
S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - chronic lymphedema b/l, skin breakdown in distal
skin fold of LLE, no apparent additional erythema or redness, no
exudate
LYMPH - no ___
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION
___ 12:20PM BLOOD WBC-19.8* RBC-5.63*# Hgb-13.0# Hct-40.0#
MCV-71* MCH-23.1* MCHC-32.5 RDW-19.3* Plt ___
___ 12:20PM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-138
K-5.0 Cl-99 HCO3-31 AnGap-13
___ 06:30AM BLOOD Calcium-8.4 Phos-5.6* Mg-1.9
___ 12:30PM BLOOD Lactate-1.1
DISCHARGE
___ 06:10AM BLOOD WBC-9.5 RBC-4.41 Hgb-10.2* Hct-31.8*
MCV-72* MCH-23.2* MCHC-32.2 RDW-18.9* Plt ___
___ 06:10AM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-139
K-4.5 Cl-100 HCO3-35* AnGap-9
___ 06:10AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
Micro: All blood cultures negative to date
CXR
FINDINGS:
Underpenetration limits evaluation. Cardiomegaly stable. No
definite signs
of pneumonia or overt CHF. No large pleural effusions are seen.
Bony
structures are intact. Mediastinal contour is normal.
IMPRESSION:
Cardiomegaly, stable. No acute findings in the chest.
Brief Hospital Course:
Ms ___ is a ___ yo female with a hx of chronic LLE
cellulitis presenting with recent LLE fevers and leg pain
concerning for cellulitis despite course of moxifloxacin.
ACUTE
# LLE Cellulitis - Pt with longstanding hx of chronic LLE
cellulitis. Febrile to 101 at home despite moxifloxacin called
in by Dr. ___. LLE with milky exudate in skin fold. Pt states
that erythmea is usually a late development for her and that her
white count may often climb to 40 and her fever to 104 during
these episodes. She feels that she has caught this episode
early. This may in fact represent a fungal infection in the skin
fold with secondary bacterial infection. No other evidence of
UTI or PNA to explain fever or leukocytosis. Patient started on
IV vanc. Improvement in pain was noted. Leukocytosis resolved.
No fevers were noted. Blood cultures were negative to date on
discharge. Was planning to send out patient on IV vanc but
unable to place PICC line. Opted instead to send out on
linezolid for 7 more days and a total course of 10 days of
antibiotics. She will have quick follow-up with Dr. ___.
CHRONIC
# Chronic lymphedema: pt was continued on lasix 40 daily.
# OSA: BiPAP with supplemental O2 was continued per recent
sleep study recommendations.
# HTN; Pt was continued on home dilt and labetalol
# Osteoarthritis: Pt was continued long acting oxycontin with
prn oxycodone
TRANSITIONAL
# patient to follow-up with Dr. ___
___ on Admission:
Dilt 240 mg qday
labetalol 200 PO BID
furosemide 40mg qd
senna 8.6 mg tab BID
colace 100mg qd PRN constipation
Dulcolax 10mg qd PRN constipation
oxycodon 5mg PO q4 PRN severe pain
oxycontin 20mg q12
ipratropium bromide 0.5mg and albut 3mg NEB q4
lidocaine swab of mouth
Neurontin 200mg qhs
** moxifloxacin started ___
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath,
wheezing, coughing
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Furosemide 40 mg PO DAILY
6. Gabapentin 200 mg PO HS
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dypsnea
8. Labetalol 200 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
11. Senna 1 TAB PO BID
12. Linezolid ___ mg PO Q12H Duration: 7 Days
RX *Zyvox 600 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Cellulitis
Secondary: Lymphedema, Obstructive Sleep Apnea, Hypertension,
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ was a pleasure taking care of you during your most recent
admission to ___. You were admitted because of a cellulitis
and elevated white count. You were started on IV vancomycin.
You remained afebrile while admitted and your white count
trended down. Additionally, your pain in your left leg
improved. You will be sent out on zyvox for 7 more days for
management of your infection, and you should followup with Dr.
___.
Followup Instructions:
___
|
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2189-12-13 00:00:00
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2189-12-15 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___
Chief Complaint:
Fevers, leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ C/o fever, myalgias for the last 2 days. Also with
bilateral, left more than right, lower extremity pain. She has a
history of morbid obesity and chronic lymphedema of the lower
extremities with recurrent cellulitis. Last course of IV
antibiotics was ___. Denies abdominal pain, chest pain,
shortness of breath, nausea, vomiting,
Recently admitted to ___ from ___ for MRSA cellulitis and
completed IV Vancomycin at home on ___ with post-discharge and
OPAT follow up. Had been doing well at home until last night-
states that she has had increased pain on her left inner thigh
and feels her LL has "hardened" and become more painful- this is
similar to the pain she felt when she recently had cellulitis.
She also has had increased itching and pain under one of her
skin folds where there's an evident rash that has been more
painful. Additionally, she has also been urinating more, but
says that she accidentally took 2 extra lasix tablets as she
thought they were oxycodone. No dysuria, hematuria.
Additionally, during these episodes she describes a profound
fatigue when she is moving about the house that is new- this
happened during her multiple drips to the bathroom. She also
says her knee pain has been worse bilaterally.
In the ED, initial vs were 102.4 ___ 18 100%
Non-Rebreather. Labs were significant for WBC 15.4 with 88%
Neutrophils
On arrival to the floor, patient reports syptoms as described
above. Says she feels
REVIEW OF SYSTEMS:
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.
All other 10-system review negative in detail.
Past Medical History:
MEDICAL HISTORY:
-HTN
-Asthma (since childhood)
-lymphedema
-recurrent cellulitis in lower extremities
-morbid obesity
-peripheral neuropathy
-OSA (on home BiPAP)
-OA
-recurrent otitis media
-hiatal hernia
PSH: ventral hernia repair ___, exploratory laparotomy and
salpingo-oophorectomy for ectopic pregnancy in ___
Social History:
___
Family History:
1. Mother, ___, with lymphedema and cellulitis and is morbidly
obese
2. Father passed away at ___ due to HTN, OSA, and MI
3. Brother, ___, who is morbidly obese and has lymphedema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.5 95 148/80 17 97%
GEN Alert, oriented, no acute distress, morbidly obese
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM decreased breath sounds bilaterally
CV RRR normal S1/S2, no mrg
ABD obese, soft NT ND normoactive bowel sounds, no r/g
EXT: Massive lymphedema in LLE- skin somewhat hardened and
tender to palpation on inner thigh. Under distal skin fold there
is pinkish excoriation without erythema or purulence about 80%
the circumference of her leg. Slightly warm to touch. Severe
edema of RLE as well without evidence of infection
NEURO CNs2-12 intact, motor function grossly normal
Discharge PE
S - 98.5 180/100 88 20 94% RA
GEN Alert, oriented, no acute distress, morbidly obese
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM decreased breath sounds bilaterally
CV RRR normal S1/S2, no mrg
ABD obese, soft NT ND normoactive bowel sounds, no r/g
EXT: Massive lymphedema in LLE- skin somewhat hardened and
tender to palpation on inner thigh. Under distal skin fold there
is pinkish excoriation without erythema or purulence about 80%
the circumference of her leg. Slightly warm to touch. Severe
edema of RLE as well without evidence of infection
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 12:35PM WBC-15.4*# RBC-4.83 HGB-11.8* HCT-34.7*
MCV-72* MCH-24.4* MCHC-33.9 RDW-18.5*
___ 12:35PM NEUTS-88* BANDS-5 LYMPHS-2* MONOS-3 EOS-2
BASOS-0 ___ MYELOS-0
___ 12:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL
___ 12:35PM PLT SMR-NORMAL PLT COUNT-225
___ 12:35PM GLUCOSE-103* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12
___ 12:54PM LACTATE-1.3
___ 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 01:50PM URINE RBC-4* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
Discharge Labs
___ 08:00AM BLOOD WBC-12.6* RBC-4.15* Hgb-10.0* Hct-29.9*
MCV-72* MCH-24.2* MCHC-33.5 RDW-18.3* Plt ___
___ 08:00AM BLOOD Glucose-93 UreaN-6 Creat-0.6 Na-137 K-3.8
Cl-98 HCO3-33* AnGap-10
___ 10:44AM URINE Color-ORANGE Appear-Hazy Sp ___
___ 10:44AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 10:44AM URINE RBC->182* WBC-9* Bacteri-NONE Yeast-NONE
Epi-2
Ultrasound LLE
IMPRESSION:
1. No drainable fluid collection.
2. Evidence of cellulitis, edema, and inflammatory changes of
the
subcutaneous fat are seen in the area of pain.
Brief Hospital Course:
This is a ___ y/o F with PMHx of chronic lymphedema and recurrent
cellulitis presents with fevers to 102 and tenderness of LLE
#Gram negative septicemia/LLE Cellulitis: Patient presented with
similar symptoms of her past episodes of cellulitis so she was
empirically started on Vancomycin. An ultrasound of her LLE was
obtained which showed cellulitic changes but no drainable
pocket. She continued to spike through the vancomycin; her
blood cultures came back positive for GNR so cefepime was added.
We repeated a U/A which was initially negative as she was
experiencing polyruria, but the repeat was again negative. She
continued to have fevers so flagyl was added on. An ID consult
was placed who recommended tailoring her therapy down to oral
ciprofloxacin given the sensitivities of the bug. Her fevers did
not continue and she was discharged on a 14 day course of oral
cipro. Additionally, we started daily chlorhexadine baths on
the day prior to admission as she had multiple points of skin
break down in between skin folds on her legs. She was given a
Rx for this as an outpatient; nystatin powder was applied as an
inpatient. In regards to her symptomatology, she had pain in
her LLE upon presentation and was a distinct firmness on her
medial aspect. Over the subsequent days of treatment she stated
that her leg felt "fiery" and more firm and that this
presentation was normal for her when she was treated with
cellulitis. This should be noted for future admissions
#Chronic Lymphedema and Pre-renal Azotemia
-Patient had mild pre-renal azotemia on initial presentation so
her lasix was held and she received fluids overnight. When her
creatinine came down we restarted her lasix at 20 mg daily and
then increased it to her home dose of 40 mg daily upon
discharge. We recommended that she follow-up in a ___
clinic, and she expressed interest in the program at either
___ or ___.
#HTN
-Continue home labetolol 200 mg BID with one time dose 200 mg on
initial presentation. The patient was also on home diltiazem ER
which was continued. We had a lot of trouble maintaining BPs
below 180 systolic so Amlodipine 5 mg daily was added and
hydralazine TID was used as a bridge (10 mg IV and then 25 mg
PO). This brought her pressures down to the 150s-160s. The day
of discharge she continued to be hypertensive so we increased
her labetolol to 300 mg in the morning and 200 in the evening
(from 200 BID)
Transitional Issues:
-Her HTN regimen should be adjusted by her PCP as she appears to
be hypertensive on labetolol and diltiazem, although this was in
the setting of infection.
-She was given a Rx for chlorhexadine solution so she could
apply this to her wounds at home- her PCP should make sure she
understands how to apply or bathe in this solution as an
outpatient, and to ensure she has enough solution
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Furosemide 40 mg PO DAILY
4. Gabapentin 200 mg PO HS
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Labetalol 200 mg PO BID
7. Nystatin Cream 1 Appl TP BID
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Furosemide 40 mg PO DAILY
4. Gabapentin 200 mg PO HS
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Labetalol 200 mg PO HS
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin [Cipro] 750 mg 1 tablet(s) by mouth q12 hrs
Disp #*23 Tablet Refills:*0
10. Nystatin Cream 1 Appl TP BID
11. chlorhexidine (bulk) *NF* Miscellaneous daily
Have nurses bathe you once a day.
RX *chlorhexidine (bulk) Bath in chlohexadine once a day daily
Disp #*7 Bottle Refills:*3
12. Labetalol 300 mg PO BREAKFAST
RX *labetalol 300 mg 1 tablet(s) by mouth BREAKFAST Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gram negative septicemia
LLE cellulitis
Secondary diagnoses:
chronic lymphedema
uncontrolled HTN
morbid obesity
OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
You were admitted to ___ for
recurrence of cellulitis and gram negative bacteria infection in
your blood. We started you on Vancomycin, but you continued to
have fevers so we ended up adding cefepime and flagyl. We
consulted the infectious disease doctors who recommended that we
change your regimen to oral cipro which you will be discharged
out on. We had some issues with your hypertension so amlodipine
5 mg daily was added onto your hypertension medication regimen.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You will be STARTING these medications:
Ciprofloxacin
Amlodipine
Labetolol 300 mg in the morning, and 200 mg at night. This is
changed from 200 mg BID
It was a pleasure taking care of you while at ___
Followup Instructions:
___
|
10723086-DS-31
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2190-03-06 00:00:00
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2190-03-13 17:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___.
Chief Complaint:
Fever, leg pain, myalgia, and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of morbid obesity, OSA on biPAP, chronic
lymphedema, and recurrent cellulitis with past complications of
bacteremia presenting to the emergency room with fever x 1 day.
Pt reports diffuse myalgia beginning at 8PM last night. She also
developed fever (101 at home), and LLE tightness, warmth and
pain. Pt tried to take avalox for fever but awoke with
persistent chills and L thigh pain. Pt also reports a mild
temporal/occipital headache and neck pain but denies neck
stiffness. Pt also reports a mild cough productive for yellow
sputum and a sore throat within the past 24hrs.
She denies any chest pain, shortness of breath, abdominal pain,
nausea vomiting, dysuria or hematuria, sick contacts, rashes,
diarrhea, recent travel, dental work or hiking.
Pt has had 5 admissions for cellulitis this year and several
admissions for hypoxemia in the past. She has been
intermittently on suppressive therapy with clindamycin and prn
avalox. Most recently, pt was admitted ___ - ___ sp 14d course
for cellulitis (cipro + vanc --> levofloxacin). Previously, pt
was admitted in ___ for cellulitis and acinetobacter bacteremia
(sp cipro x 14d). Pt also has a hx of GBS bacteremia (___) sp
4wk course of IV PCN --> vanc. In addition, pt has previously
had MRSA in throat cx and foot wound cx, VRE in urine in ___,
E. coli UTI in ___ and ___, ESBL Klebsiella UTI in ___.
In the ED, initial VS were: Pain ___, Temp 103.8, HR 116, BP
176/86, RR 24, Sat 98% RA. Appears ill. Skin warm and dry. LLE
appears swollen very warm to touch. Labs sig for WBC of 38 (96%
neuts), HCT of 25 (MCV 72), Na 131. ABG ___, lactate
1.7.
UA showed no UTI with 1 WBC.
Pt received Vanco 1.5g x 1 and cipro 400mg IV (for cellulitis
and emperic coverage of ? UTI). Pt also received tylenol with
improvement of appearance. Pt was admitted to MICU for concern
of potential for worsening. Transfer VS: HR 101 BP 134/56 RR 20
96% on RA last temp 101.8.
On arrival to the MICU: T 102, P ___, BP 130/68, R 20, 100% on
4LNC
Past Medical History:
Morbid obesity
Lymphedema
Recurrent ___ cellulitis
h/o MRSA
Acinetobacter bacteremia (see HPI)
OSA on BiPAP
Asthma
HTN
Peripheral neuropathy
OA
Hiatal hernia
Recurrent otitis media
s/p ventral hernia repair ___
s/p ex lap and salpingo-oophorectomy ___ (ectopic pregnancy)
Social History:
___
Family History:
Mother with morbid obesity, lymphedema and cellulitis and is
morbidly
Father died at age ___ due to HTN, OSA, and MI
Brother with morbid obesity and lymphedema
Physical Exam:
Admission PE:
Vitals: T 102.1, P ___, R 20, BP 130/68, O2 100% on 4LNC
General: Morbidly obsese, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, unable to assess JVP, no tenderness on flexion or
point spinal tenderness
CV: Tachycardic; HSM at RUSB and LUSB
Lungs: Clear to auscultation bilaterally; mild ee wheezing
Abdomen: Obese, non-tender, non-distended, no organomegaly
Ext: Marked lymphedema L>>R; L upper/inner thigh warm and tight.
Mildly tender and hyperpigmented.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Discharge PHYSICAL EXAM:
Vitals: Tm 100.0 Tc98.5 HR 77-82, BP ___ RR 18 SaO2
93-97%RA
General: Morbidly obsese, NAD, pleasant, cooperative,
appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, unable to assess JVP, no tenderness on flexion or
point spinal tenderness
CV: regular rate and rhythm, faint systolic murmur at RUSB and
LUSB; exam significantly limited by body habitus
Lungs: Clear to auscultation bilaterally anteriorly and
posteriorly but exam limited by body habitus, no cough or use of
accessory muscles
Abdomen: Obese, non-tender, non-distended, no organomegaly
Ext: Marked lymphedema L>>R; L upper/inner thigh and LLE warm
and tight. nontender, hyperpigmented. unchanged from prior exam
Neuro: CNII-XII intact, MAE, ___ UE, grossly normal sensation
Pertinent Results:
Admission Labs:
___ 06:30PM BLOOD WBC-38.2*# RBC-4.95 Hgb-12.5 Hct-35.5*
MCV-72* MCH-25.2* MCHC-35.2* RDW-17.1* Plt ___
___ 06:30PM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-131*
K-3.7 Cl-95* HCO3-23 AnGap-17
___ 06:30PM BLOOD ALT-12 AST-20 LD(LDH)-214 AlkPhos-65
TotBili-0.5
___ 07:00PM BLOOD Type-ART Temp-39.4 pO2-75* pCO2-40
pH-7.47* calTCO2-30 Base XS-4 Intubat-NOT INTUBA
___ 07:00PM BLOOD Lactate-1.7
___ 08:53PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 08:53PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 08:53PM URINE Color-Yellow Appear-Clear Sp ___
PAST Microbiology Results:
___ BCX
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.12 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BCx
BETA STREPTOCOCCUS GROUP G.
___ UCX
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ UCX
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
___ UCX
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
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---- =>16 R
___ UCX
ENTEROBACTER CLOACAE
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S R
CEFTAZIDIME----------- 8 S =>64 R
CEFTRIAXONE----------- 32 I R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 256 R 128 R
PIPERACILLIN/TAZO----- 32 I =>128 R
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
___ L foot swab
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ Throat Cx
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
DISCHARGE LABS:
___ 06:53AM BLOOD ___-12.6* RBC-3.95* Hgb-9.8* Hct-28.7*
MCV-72* MCH-24.7* MCHC-34.1 RDW-18.0* Plt ___
___ 05:00PM BLOOD Na-131* K-9.4* Cl-95*
___ 03:16PM BLOOD Vanco-15.3
___ 11:54AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:54AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 11:54AM URINE RBC-96* WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE (Final ___: NO GROWTH.
___ CXR line placement: Left PICC line is difficult to
visualize, likely ending in the region of the
cavoatrial junction. Recommend pulling back by 3.5 cm to be in
the mid to
lower SVC. The moderate cardiomegaly and mild pulmonary
vascular congestion
are unchanged. No pneumothorax.
NOTIFICATION: Telephone notification to ___, IV nurse, ___.
___ at
12:00 on ___.
Brief Hospital Course:
___ with history of morbid obesity, OSA on biPAP, chronic
lymphedema, and recurrent cellulitis with past complications of
bacteremia p/w fever x1day admitted to the MICU for close
monitoring, now stable for transfer to the floor.
.
#) Sepsis: (Fever/Leukocytosis) Likely cellulitis given
recurrent bacterial infections ___ lymphedema. In the past, pt
has presented with WBC elvation to >30. She had previously been
on prophylactic clinda but is no longer on ppx. Given Vanc,
cipro for cellulitis and discharged with PICC to complete course
of antibiotics at home.
.
#) Hyponatremia: Resolved with return to euvolemia.
.
#) Tachycardia: Resolved with resolution of fevers, resolving
infection.
.
#) OSA: Continued BiPAP at home parameters.
.
#) HTN: Continued BB, dilt and amlodipine
.
.
.
Transitional Issues:
- f/u with ___ clinic crucial in prevention of further
recurrent cellulitis. PCP contacted for assistance with
insurance/referral to clinic
- f/u with PCP for resolution of infection
- home with ___, PICC to be pulled after last dose of
antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 7.5 mg PO DAILY
2. Diltiazem 240 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Labetalol 300 mg PO BID
Hold for SBP <120 and P <70
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gabapentin 200 mg PO HS
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Diclofenac Sodium ___ 50 mg PO BID
11. Nystatin Ointment 1 Appl TP BID:PRN pruritis
12. Oxybutynin 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 7.5 mg PO DAILY
3. Diclofenac Sodium ___ 50 mg PO BID
4. Gabapentin 200 mg PO HS
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
6. Labetalol 300 mg PO BID
Hold for SBP <120 and P <70
7. Nystatin Ointment 1 Appl TP BID:PRN pruritis
8. Oxybutynin 10 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Ciprofloxacin HCl 750 mg PO Q12H Duration: 13 Doses
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every 12 hours
Disp #*13 Tablet Refills:*0
11. Diltiazem 240 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Furosemide 20 mg PO DAILY
14. Vancomycin 1000 mg IV Q 8H
RX *vancomycin 1 gram 1,000mg IV every 8 hours Disp #*19 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: cellulitis, lymphedema
Secondary diagnosis: morbid obesity, OSA on biPAP
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 in the hospital. You were
admitted to treat cellulitis in your leg, probably due to the
lymphedema. You were initially admitted to the ICU and then
transferred to the floor. You were given IV and oral antibiotics
which you will continue at home for another 6 days.
Please make sure you follow up with Dr. ___. Included below
is the number for a ___ clinic at ___. It
is very important that you keep this appointment to prevent
future infections.
Please see the attached sheet for an updated medication list.
The following changes were made:
Please START vancomycin 1,000mg IV every 8 hours for 6 days,
last day ___.
Please START cipro 750mg every 12 hours for 6 days, last day
___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10723086-DS-33
| 10,723,086 | 27,602,635 |
DS
| 33 |
2191-08-31 00:00:00
|
2191-09-02 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Nafcillin / prednisone
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ w/ PMH morbid obesity, OSA, asthma, hypertension, chronic
lymphedema, and chronic cellulitis of lower extremities, now
presenting with fever and weakness. Pt reports that she was
feeling weak over the last two days. She measured a temperature
of ___ last night and ___ this morning. She came to the ED for
evaluation.
In the ED initial vitals were: 103.1 121 230/91 34 91% Nasal
Cannula.
- Labs were significant for Leukocytosis to 19. UA was notable
for neg leuks, neg nitrites, with many bacteria, WBC 16, Epi 2.
CXR was notable for low lung volumes, no focal consolidation
however difficult to interpret given body habitus.
- Patient was given Tylenol, vancomycin, cefepime, 2L NS and
admitted to medicine for further management.
On the floor, Pt states that she has been taking her furosemide
more regularly over the last two weeks. She has been urinating
more than usual due to this medication, but states that her
lower extremity swelling has been improved. She also had a mild
dry cough for the last few weeks, but attributes this to
allergies. She felt weak over the last few days and measured her
temperature, initially at ___ yesterday and ___ this morning.
She denies any dysuria or back pain. She has not had any shaking
chills. She thinks she may have some skin breakdown in her skin
folds on her L leg. She denies any nausea, vomiting, or
diarrhea. Of note, Pt has been admitted multiple times
previously with recurrent cellulitis of her left lower
extremity, most recently in ___, which was treated with
vancomycin.
Review of Systems:
(+) per HPI
(-) chills, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Morbid obesity
-Lymphedema
-Recurrent ___ cellulitis
-h/o MRSA
-Acinetobacter bacteremia
-OSA on BiPAP
-Asthma
-HTN
-Peripheral neuropathy
-OA
-Hiatal hernia
-Recurrent otitis media
-s/p ventral hernia repair ___
-s/p ex lap and salpingo-oophorectomy ___ (ectopic pregnancy)
Social History:
___
Family History:
Mother with morbid obesity, lymphedema and cellulitis
Father died at age ___ due to HTN, OSA, and MI
Brother with morbid obesity and lymphedema
Physical Exam:
Admission Physical Exam:
Vitals - 99.6F, 94, 161/87, 20, 96% 4L nc
GENERAL: morbidly obese woman in bed in no acute distress
HEENT: PERRL, EOMI, moist mucous membranes
CARDIAC: distant heart sounds, RRR, S1/S2, no murmurs, gallops,
or rubs
LUNG: difficult to assess but seems clear anteriorly
ABDOMEN: morbidly obese, soft and non-tender to palpation, 1+
pitting edema in dependent areas
EXTREMITIES: morbidly obese, numerous excess skin folds, 1+
pitting edema in R leg, L leg with 2+ pitting edema in ankle and
calf, erythema and warmth, non-tender to palpation, ankle skin
fold with foul smelling material, large skin fold behind L knee
with significant area of superficial breakdown, mild bleeding,
erythema and edema.
NEURO: A&O x 3, grossly normal sensation and motor function
Discharge Physical Exam:
Vitals-Tm 98.6 189/81 83 18 94% 2L, desats to 84% at rest on RA
GENERAL: morbidly obese woman in no acute distress
HEENT: PERRL, EOMI, moist mucous membranes, oropharynx is clear,
mildly erythematous.
CARDIAC: distant heart sounds, RRR, S1/S2, no murmurs, gallops,
or rubs
LUNG: CTAB anteriorly without wheezes or audible crackles
although limited by body habitus
ABDOMEN: morbidly obese, soft and non-tender to palpation, 1+
pitting edema in dependent areas
GU: Foley with dark yellow urine. No suprapubic or CVA
tenderness.
SKIN: morbidly obese, numerous excess skin folds, 1+ pitting
edema in R leg, L leg with 2+ pitting edema in ankle and calf,
erythema and warmth, non-tender to palpation, ankle skin fold
with powder, large skin fold behind L knee now with a mepilex
and powder. L upper thigh fold is slightly wamer than R. Left
arm PICC site c/d/i no erythema. New ___ edema at feet, more than
prior day.
NEURO: A&O x 3, grossly normal sensation and motor function,
limited by body habitus
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD WBC-19.2* RBC-4.82 Hgb-10.0* Hct-32.3*
MCV-67* MCH-20.7* MCHC-30.9* RDW-19.5* Plt ___
___ 05:20PM BLOOD Neuts-88.9* Lymphs-5.9* Monos-3.7 Eos-0.9
Baso-0.5
___ 05:20PM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-133
K-4.0 Cl-95* HCO3-29 AnGap-13
___ 05:20PM BLOOD Calcium-9.4 Phos-3.3 Mg-1.8
___ 05:36PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 06:04AM BLOOD WBC-12.9* RBC-3.87* Hgb-7.8* Hct-26.2*
MCV-68* MCH-20.2* MCHC-29.9* RDW-19.7* Plt ___
___ 06:04AM BLOOD Glucose-101* UreaN-8 Creat-0.7 Na-140
K-4.1 Cl-98 HCO3-38* AnGap-8
___ 06:04AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
PERTINENT LABS:
___ 05:36PM BLOOD Lactate-1.1
___ 07:00AM BLOOD calTIBC-291 Ferritn-97 TRF-224
___ 07:00AM BLOOD proBNP-245*
URINE:
___ 06:40PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:40PM URINE Blood-MOD Nitrite-NEG Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:40PM URINE RBC-1 WBC-17* Bacteri-MANY Yeast-NONE
Epi-2
MICROBIOLOGY:
___________________________________________________
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:10 pm BLOOD CULTURE Source: Line-L PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:51 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:52 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
TTE ___
Conclusions
The left atrium is moderately dilated. 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 cavity is dilated with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. No aortic regurgitation is
seen. Trivial mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality (even with Optison
contrast). Preserved overall left ventricular systolic function.
Dilated and hypokinetic right ventricle with moderate pulmonary
artery systolic hypertension.
___ CXR
IMPRESSION:
Moderate to severe cardiomegaly and pulmonary vascular
engorgement have both progressed since ___ common indication
of cardiac decompensation. Since ___ mild pulmonary edema is
unchanged. Contribution of right pleural effusion and additional
consolidation to the greater opacification of the right lower
lobe might be clarified with a lateral view, certainly with
chest CT scanning.
No pneumothorax.
___ CXR
IMPRESSION:
Extensive opacification, diffuse in the right lung, is probable
pneumonia. Given the size of this patient CT scanning is
vasculature visible in the left lung is still engorged, but I
doubt there is left-sided pulmonary edema, indicated to
precisely characterize and localize the abnormality. The severe
enlargement of cardiac silhouette may have progressed the volume
of presumed right pleural effusion is impossible to assess on a
single frontal view. Left pleural effusion is small if any. Left
basal atelectasis is substantial, and unchanged recently.
LLE ULTRASOUND ___
IMPRESSION:
No fluid collections identified. Extensive soft tissue edema
throughout the left lower extremity.
Brief Hospital Course:
___ y/o female with a history of morbid obesity, OSA, HTN,
chronic lymphedema, and recurrent cellulitis who presents with
fever, leukocytosis due to cellulitis and pneumonia.
# Sepsis, L leg cellulitis: On arrival to the ED, patient met
sepsis criteria with fever and leukocytosis. She had history of
recurrent LLE cellulitis, most recently in ___ which
was treated with IV vancomycin for 10 days. She had erythema,
redness and pain in the folds of her LLE. She was started on
vancomycin with improvement in her pain and erythema, and seen
by wound care. She also had a negative LLE ultrasound to rule
out underlying fluid collection as she continued to spike temps
and had leukocytosis, which was secondary to pneumonia as below.
She had a PICC line placed to complete her 10-day antibiotic
course and is to have appointment set up with outpatient
___ clinic.
# R lung bacterial pneumonia: Patient presented with cough and
shortness of breath which was initially thought secondary to
asthma exacerbation and volume overload seen on CXR. Initially
there was no definitive evidence of pneumonia on CXR which was a
severely limited film due to body habitus. Heart failure was
considered but BNP was 245 and echo and EKG were unchanged from
prior. As she continued to have dyspnea and new O2 requirement
___ for desat to 84% on RA despite diuresis, and she continued
to spike temp on vancomycin, a repeat CXR was performed which
showed R lung pneumonia. She was started on cefepime for a
7-day course through ___ line.
CHRONIC ISSUES:
# chronic lower extremity edema: Pt had been noncompliant with
furosemide until few days prior to her admission. She was given
IV Lasix for diuresis PO Lasix increased from 20mg to 40mg for
five days at discharge. Patient to resume normal 20mg daily dose
on ___. She is to get f/u with ___ clinic for further
management.
# HTN: She was hypertensive in ED and intermittently throughout
her hospital course and was started on lisinopril in addition to
home labetalol.
# Asthma: Continued home fluticasone and albuterol/ipratropium
neb prn.
# OSA: Continued BiPAP at nights.
# leg pain: Continued home diclofenac and oxycodone prn.
# chronic urinary frequency: home oxybutynin
TRANSITIONAL ISSUES:
-Continue vancomycin with PICC for 10-day course through ___,
cefepime for 7-day course through ___.
-PO Lasix increased from 20mg to 40mg for five days. Patient to
resume normal 20mg daily dose on ___.
-Please ensure patient is able to follow up in ___
clinic.
-Started lisinopril for better blood pressure control and iron
supplements for iron-deficiency anemia.
-Patient discharged on home ___ for O2 sats to 84% on RA due
to resolving pneumonia.
-CODE STATUS: full
-Emergency contact: ___ Husband:
___ Cell phone: ___
# Dispo: patient declined evaluation for discharge to rehab so
was sent home with services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diclofenac Sodium ___ 50 mg PO BID:PRN pain
2. Furosemide 20 mg PO DAILY
3. Labetalol 200 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN leg pain
5. Albuterol Inhaler 2 PUFF IH BID
6. Nystatin 100,000 unit/gram TOPICAL BID
7. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 2
puffs twice daily
8. Ditropan XL (oxybutynin chloride) 10 mg oral daily
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
Discharge Medications:
1. Vancomycin 1500 mg IV Q 8H
RX *vancomycin 750 mg 2 vials IV q8 Disp #*10 Vial Refills:*0
2. Diclofenac Sodium ___ 50 mg PO BID:PRN pain
3. Labetalol 200 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN leg pain
5. Albuterol Inhaler 2 PUFF IH BID
6. Ditropan XL (oxybutynin chloride) 10 mg oral daily
7. Flovent HFA (fluticasone) 220 mcg/actuation INHALATION 2
PUFFS TWICE DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
9. Nystatin 100,000 unit/gram TOPICAL BID
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % ___ ml IV daily Disp #*5 Vial
Refills:*0
11. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 1 each IV every eight (8) hours
Disp #*13 Vial Refills:*0
12. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
15. Furosemide 40 mg PO DAILY
Take 40 mg for the next 5 days, resume taking 20 mg on ___.
RX *furosemide 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
16. Continuous Oxygen
2 liters per minute via nasal canula.
ICD-9: 486 (Pneumonia, organism unspecified)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
left lower extemity cellulitis
asthma ___
hospital-acquired pneumonia
hypertension, essential
SECONDARY DIAGNOSIS:
Obstructive sleep apnea
lymphedema
iron-deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound and able to get to bedside commode.
Discharge Instructions:
You were admitted with fever due to left lower leg cellulitis.
You were treated with IV vancomycin, which you will continue
through the ___ line. You were also found to have a pneumonia
which is being treated with IV cefepime. You also had an asthma
exacerbation, which was treated with nebulizer treatments with
improvement. You required oxygen supplementation which was
thought to be due to your resolving pneumonia and some fluid in
your lungs. Please increase your lasix dose to 40 mg for the
next 5 days.
You were started on lisinopril for better blood pressure control
as well as iron supplements for low iron levels. Please have
your PCP help you make a follow up appointment with ___
clinic.
Followup Instructions:
___
|
10723263-DS-12
| 10,723,263 | 24,568,459 |
DS
| 12 |
2130-04-20 00:00:00
|
2130-04-20 12:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
mango / Compazine / pravastatin / Sulfa (Sulfonamide
Antibiotics) / Iodinated Contrast Media - Oral and IV Dye /
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ - 1. Aortic valve replacement with a 21 ___
___ Ease tissue valve. 2. Coronary artery bypass graft x3,
left internal mammary artery to left anterior descending artery,
and saphenous vein grafts to the distal right coronary artery
and obtuse marginal artery.
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of diabetes
mellitus type II, hyperlipidemia, hypertension, and lupus. She
also has known cholelithiasis due to have removal of gallbladder
next week. She presented to presented to an
outside hospital with severe right upper abdominal pain and
shortness of breath, also noted pain under right breast which
the pain has been occurring since ___ and comes/goes. Her
shortness of breath she felt was due to her anxiety. She was
noted at OSH for metabolic acidosis and lactate 4.5 treated with
IV fluids which was stopped after CXR obtained that demonstrated
pulmonary edema. She developed wheezing, was placed on bipap and
given Lasix for diuresis - after diuresis she was weaned off
bipap. Her second troponin was 0.49 and ruled in for non-ST
elevation myocardial infarction. She was transferred to ___
for further cardiac management. A cardiac catheterization
revealed aortic stenosis and multivessel coronary artery
disease.
Past Medical History:
Coronary Artery Disease
Anxiety
Chronic Back Pain
Diabetes Mellitus Type II
Gastritis
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Hypothyroid
Irritable Bowel Syndrome
Lumbar Radiculopathy
Lupus
Social History:
___
Family History:
Significant family history of early MI, including MGM dying of
MI at ___, and multiple uncles dying in ___ of MI.
No hx of arrhythmia, cardiomyopathies.
Physical Exam:
ADMISSION:
VS: 98.2 169/89 99 16 95% on 2L NC
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP at clavicle at 40 degrees HOB.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. III/VI systolic
murmur best heard at RUSB, II/VI apical murmur
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION:
___ 05:07AM BLOOD WBC-7.9 RBC-2.71* Hgb-7.3* Hct-23.2*
MCV-86 MCH-26.9 MCHC-31.5* RDW-13.8 RDWSD-42.5 Plt ___
___ 04:46AM BLOOD WBC-8.8# RBC-3.12* Hgb-8.7* Hct-26.6*
MCV-85 MCH-27.9 MCHC-32.7 RDW-13.5 RDWSD-41.4 Plt ___
___ 05:22AM BLOOD WBC-4.6 RBC-2.58* Hgb-7.1* Hct-22.2*
MCV-86 MCH-27.5 MCHC-32.0 RDW-13.6 RDWSD-42.5 Plt ___
___ 05:36AM BLOOD WBC-6.7 RBC-2.78* Hgb-7.6* Hct-23.9*
MCV-86 MCH-27.3 MCHC-31.8* RDW-14.1 RDWSD-44.3 Plt ___
___ 12:04PM BLOOD Hct-26.8*
___ 04:46AM BLOOD ___
___ 02:18AM BLOOD ___ PTT-27.1 ___
___ 02:29AM BLOOD ___ PTT-26.8 ___
___ 05:07AM BLOOD Glucose-161* UreaN-26* Creat-1.1 Na-137
K-4.1 Cl-98 HCO3-27 AnGap-16
___ 04:46AM BLOOD Glucose-204* UreaN-29* Creat-1.1 Na-136
K-4.7 Cl-96 HCO3-28 AnGap-17
___ 05:22AM BLOOD Glucose-147* UreaN-28* Creat-0.9 Na-137
K-4.1 Cl-98 HCO3-28 AnGap-15
___ 05:36AM BLOOD Glucose-150* UreaN-27* Creat-0.9 Na-135
K-3.8 Cl-95* HCO3-30 AnGap-14
___ 02:18AM BLOOD Glucose-150* UreaN-20 Creat-0.9 Na-134
K-3.7 Cl-96 HCO3-25 AnGap-17
___ 06:22PM BLOOD UreaN-20 Creat-0.9 Na-136 K-4.6
___ 07:05AM BLOOD WBC-7.3 RBC-4.66 Hgb-13.6 Hct-38.4 MCV-82
MCH-29.2 MCHC-35.4 RDW-12.8 RDWSD-38.4 Plt ___
___ 07:05AM BLOOD Neuts-73.2* Lymphs-15.6* Monos-8.1
Eos-1.7 Baso-0.6 Im ___ AbsNeut-5.32 AbsLymp-1.13*
AbsMono-0.59 AbsEos-0.12 AbsBaso-0.04
___ 07:05AM BLOOD ___ PTT-32.2 ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-244* UreaN-20 Creat-0.9 Na-138
K-4.5 Cl-105 HCO3-23 AnGap-15
___ 07:05AM BLOOD CK(CPK)-351*
___ 04:40AM BLOOD ALT-13 AST-36 AlkPhos-90 TotBili-0.3
___ 07:05AM BLOOD CK-MB-44* MB Indx-12.5*
___ 07:05AM BLOOD cTropnT-0.63*
IMAGING:
Cardiac Catheterization ___
left main: sepoarate Ostia
LAD: 90% mid
LCX: 70% proximal
RCA: 70% distal
LVEDP 40 mmHg
severe AS
IABP inserted due to refractory heart failure
Carotid study ___
Duplex was performed of bilateral carotid arteries. There is
heterogeneous plaque in the proximal ICA bilaterally. Right:
Peak velocities are 148, 135 and 104 cm/sec in the ICA, CCA and
ECA respectively. The ICA end-diastolic velocity is 36. The
ICA CCA ratio is
1.2. This is consistent with 40-59% right ICA stenosis. Left:
Peak velocities are 151, 119 and 167 cm/sec in the ICA, CCA and
ECA respectively. The ICA end-diastolic velocity is 39. The
ICA CCA ratio is
1.2. This is consistent with 60-69% left ICA stenosis.
Vertebral flow is antegrade bilaterally.
Transesophageal Echocardiogram ___
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast is seen
in the left atrial appendage. No atrial septal defect or PFO is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis
(estimated LVEF 40-45 %). Doppler parameters are most consistent
with Grade I (mild) left ventricular diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened with more
significant calcification of the right coronary cusp.
Significant aortic stenosis is present however measurements
quantifying severity are discordant. Aortic valve area by
continuity equation (average of three beats) is 0.9 cm2 using
VTI and 1.1 cm2 using Vmax. Dimensionless index is 0.27 (LVOT
VTI 17 cm, AoV VTI 62.3 cm). Aortic valve area by 3D planimetry
is 1.3-1.5 cm2 (two measurements taken). Gradients are
consistent with mild aortic stenosis, however they likely
underestimate the severity due to a low flow state. Overall the
findings are consistent with moderate-to-severe aortic stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen. An
intraaortic ballon pump is visualized in the descending aorta
with the tip appoximately 4 cm distal to left subclavian artery.
POST-BYPASS:
The patient is in sinus rhythm and receiving phenylephrine and
low dose epinephrine (0.01-0.03 mcg/kg/min) infusions. Left
ventricular function is improved (estimated EF 50%) on noted
infusions. Right ventricular function remains preserved. A
bioprosthetic valve (21 mm ___ Ease) is visualized in the
aortic position. The valve is well-seated with normal trileaflet
motion. There is no regurgitation. Peak gradient across the
valve is 23 mmHg, mean gradient is 8 mmHg at a cardiac index of
2.3 L/min. Remaining valvular function is unchanged. There are
expected post-surgical changes of the aortic root. The tip of
the IABP remains approximately 4 cm distal to the left
subclavian artery. The aorta is intact following decannulation.
MR ___ W/O Contrast + MRA ___ & Neck ___:
1. Presumed late acute to subacute infarcts of the left caudate
___, left inferior cerebellar hemisphere and tonsil, as well as
left lateral aspect of the medulla. No hemorrhagic
transformation.
2. Occlusion of the left V3 and V4 segments is identified,
chronicity uncertain. Multifocal mild to severe narrowing of
the
intracranial circulation as described above, likely representing
atherosclerotic disease. Apparent occlusion of the left A2
segment with reconstitution at the A3 segment is noted.
3. Sulci, ventricles and cisterns are within expected limits for
the patient's age. No evidence of prominent encephalomalacia.
Lack of flow related signal of the visualized left V3 and V4
segments is identified, compatible with occlusion with
short-segment reconstitution of flow along the mid aspects of
the
left V4. There is asymmetrically decreased flow related signal
involving the right posterior cerebral artery (series 102, image
11), which may be secondary to atherosclerotic disease.
Short-segment stenosis of the left P1 segment (series 12, image
83) is noted. There is moderate narrowing of the left internal
carotid artery just prior to the petrous segment (series 103,
image 7) as well as multifocal narrowing of the bilateral A1 and
M1 segments, potentially secondary to atherosclerotic disease.
Multifocal narrowing of the distal bilateral M2 branches are
noted. There is lack of flow related signal of the left A2
segment (series 103, image 10) with distal reconstitution at the
A3 segment. No aneurysms are noted.
CT ___ W/O Contrast ___:
No acute intracranial abnormality. Please note that MR is more
sensitive in the detection of acute infarct.
MICRO:
Staph aureus Screen (Final ___: STAPH AUREUS COAG +.
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000
CFU/mL.
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
She was admitted to ___ on ___. An echocardiogram on
___ demonstrated an estimated ejection fraction of 33% and
cath revealed LVEDP of 40 mmHg. She was admitted with an acute
systolic heart failure exacerbation and severe aortic stenosis.
She developed acute kidney injury with peak creatinine of 1.9
likely related to diuresis and decreased cardiac output. She
remained hemodynamically stable on IABP and was taken to the
operating room on ___. She underwent coronary artery bypass
grafting and replacement of her aortic valve. Please see
operative note for details. She arrived out of OR in Epi/Neo
gtts and IABP. She was slow to wake, initial reassuring nonfocal
neuro examination. Narcotics held due to ongoing somnolence.
Remained intubated ___ to fluid overload and hypoxia. IABP and
pressors weaned off by POD 1 transitioned to nicardipine to
hypertension and aggressively diuresed. Post-op delirium then
cleared but following commands inconsistently. Extubated POD 2.
Post op Urine grew klebsiella started Cipro, completed ___nemia and thrombocytopenic slowly improving, transfused
1PRBC on POD3 for hct 21. Transferred to floor POD3. Mental
status slow to clear, noted to have left arm weakness on POD4.
Neuro was consulted, ___ CT negative for acute process, MRI/MRA
revealed presumed late acute to subacute infarcts of the left
caudate ___, left inferior cerebellar hemisphere and tonsil, as
well as left lateral aspect of the medulla. Occlusion of the
left V3 and V4 segments is identified, chronicity uncertain.
Multifocal mild to severe narrowing of the intracranial
circulation as described above, likely representing
atherosclerotic disease. Apparent occlusion of the left A2
segment with reconstitution at the A3
segment is noted. Per neurology, brain MRI confirmed a subacute
left inferior cerebellar, left lateral pontine and small
bihemispheric infarcts. She had minimal deficits from these
lesions and they expected a good recovery going forward with
aggressive ___. Patient is to have 30 consecutive days of
Holter monitoring to rule out paroxysmal atrial fibrillation.
___ of hears monitor was placed ___. See full instructions.
Neurology follow up was arranged. She was seen by speech and
swallow passed for regular diet with thin liquids. Working with
___ requiring walker. She is to be discharged to ___ in
___ on ___ with ___ of hearts placed on day of
discharge. All follow up appointments were arranged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. DICYCLOMine 10 mg PO BID
6. glimepiride 2 mg oral DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO EVERY OTHER DAY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
2. Artificial Tears ___ DROP BOTH EYES PRN dry eye
3. Docusate Sodium 100 mg PO BID
4. Ezetimibe 10 mg PO DAILY
5. Furosemide 60 mg PO DAILY Duration: 7 Days
Take this medication daily for 7 days, then stop.
6. Lactulose 30 mL PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Tartrate 75 mg PO Q8H
10. Milk of Magnesia 30 mL PO DAILY
11. ___ ___ UNIT PO QID
12. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
13. Polyethylene Glycol 17 g PO DAILY
14. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K > 4.5
15. Pravastatin 40 mg PO QPM
16. Simethicone 80 mg PO QID:PRN gas/heartburn
17. Lisinopril 10 mg PO DAILY
18. Aspirin 81 mg PO DAILY
19. glimepiride 2 mg oral DAILY
20. Hydroxychloroquine Sulfate 200 mg PO EVERY OTHER DAY
21. Levothyroxine Sodium 88 mcg PO DAILY
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. Pantoprazole 40 mg PO Q24H
24. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease
Acute Blood Loss Anemia
Acute Kidney Injury
Acute Systolic Congestive Heart Failure
Aortic Stenosis
Cerebrovascular Accident
Coronary Artery Disease
Non-ST Elevation Myocardial Infarction
Thrombocytopenia
Urinary Tract Infection
Anxiety
Chronic Back Pain
Diabetes Mellitus Type II
Gastritis
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Hypothyroid
Irritable Bowel Syndrome
Lumbar Radiculopathy
Lupus
Discharge Condition:
Alert and oriented x3 nonfocal: weepy and emotional at times
Ambulating with walker and assist
Incisional pain managed with Toradol, Tylenol
Incisions: Prevena removed ___
Sternal - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
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2122-01-02 14:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old with a history of CHF, type 2 DM, and HTN on
lisinopril presenting from OSH with submental edema and found to
have supraglottic edema on fiberoptic exam. Pt reports
developing subjective fevers and chills begining on ___ and
extending through the weekend. She then developed nausea and
vomiting yesterday with reported bright red blood at 2Pm after
eating a few bites of a fish sandwich from ___. Pt's
nausea and vomiting resolved, however after eating ___ food
yesterday evening at 6PM she subsequently noticed new submental
edema that was progressive. She reports symptoms of mild
difficulty breathing, changes in her voice, and a sense of
anxiety. After noticing the new edema, she then developed
watery diarrhea. Pt subsequently presented to ___ for
evaluation. At ___, labs were notable for a leukocytosis to
12.3. CT scan was ordered showing submandibular stranding
concerning for infectious process as well as soft tissue
thickening in the region of the aryepiglottic folds extending to
the false vocal cords with some narrowing of airway. She was
started on Clindamycin and transferred to ___ for further
evaluation.
In the ___ ___, initial VS were 98.3 95 123/95 18 98% RA. Exam
was notable for pt being in no apparent distress with submental
edema. Labs were notable for BMP within normal limits, WBC 9.5,
H/H 12.5/38.2, plts 155. ENT was consulted in the ___, and
fiberoptic exam was performed demonstrating watery edema and
fullness of the epiglottis, AE folds, arytenoid complex, and
FVC. Given acute onset, ENT believed presentation to be most
consistent with angioedema/allergic reaction. Pt was started on
Dexamethasone 10mg IV Q8hrs, Diphenhydramine 25mg IV Q6hrs, and
Famotidine 40mg BID. In addition, pt was continued on
Clindamycin to cover for potential infectious etiology.
Pt was transferred to the ___ for airway monitoring, and
initial VS on arrival were 97.7 106 141/96 25 98% on RA. Pt
reports that she feels much better overall, and noticed
significant improvement after receiving antibiotics at ___.
Past Medical History:
Congestive heart failure
Type 2 DM
Hypertension
Hyperlipidemia
Social History:
___
Family History:
No family history of angioedema, mother and multiple siblings
with hypertension and CHF
Physical Exam:
ON ADMISSION:
Vitals- 106 141/96 25 98% on RA
General: Alert, oriented, no acute distress
HEENT: Submental edema, no associated LAD, large tonsils
bilaterally with white exudate
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes
CV: S1 + S2, tachycardic, no murmurs, rubs, gallops
Abdomen: Obese, 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
ON DISCHARGE:
Vitals- 98.6, 120s-130s/60s-80s, 90s-100s, 16, 98%RA
General: Alert, oriented, no acute distress
Eyes: EOMI, PERRLA
HENT: OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes
CV: S1 + S2, tachycardic, no murmurs, rubs, gallops
Abdomen: Obese, 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
Pertinent Results:
___ 11:58AM C3-157 C4-46*
___ 06:09AM GLUCOSE-92 UREA N-16 CREAT-0.8 SODIUM-139
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
___ 06:09AM WBC-9.5 RBC-4.21 HGB-12.5 HCT-38.2 MCV-91
MCH-29.7 MCHC-32.7 RDW-12.9
___ 06:09AM NEUTS-62.3 ___ MONOS-6.2 EOS-1.8
BASOS-0.5
___ 06:09AM PLT COUNT-155
ESOPHAGRAM
IMPRESSION:
1. No extravasation of contrast to suggest esophageal
perforation.
2. Small amount of gastroesophageal reflux.
3. Small hiatal hernia.
Brief Hospital Course:
___ year old female with CHF, HTN and DM presenting to the FICU
with submental and supraglottic edema for airway monitoring.
Subsequently transferred to the general medical ward, from which
she is being discharged.
# Submental and supraglottic edema: DDx allergic reaction to
food vs drug allergy vs infectious etiology. History of long
standing lisinopril use suggestive of angioedema. Pt endorses
fevers, leukocytosis in OSH concerning for infection. CT from
OSH and ENT fiberoptic exam significant for diffuse submental
edema with one mildly enlarged level IA node. Treated with IV
benadryl 25mg q6h, IV decadrom 10mg q8h, famotidine 40mg BID,
unasyn 3g IV q6h. Home Victoz and lisinopril held. ENT performed
repeat fiberoptic exams with improvement. Overall, they felt
presentation was most consistent with angioedema. Barium swallow
did not show evidence of esophageal rupture. Her diet was
advanced and antihistamines, steroids were discontinued. She is
being discharged with 5 day course of Augmentin per ENT
recommendations.
- Complete course of Augmentin
- Lisinopril added to allergy list
- Followup with ENT scheduled for ___ weeks from discharge, as
below
# Diarrhea: Pt reported multiple episodes of watery diarrhea
coinciding with onset of edema. ___ represent infectious
gastroenteritis, however may represent bowel manifestation of
angioedema. Resolved while inpatient.
# Hypertension: Discontinued lisinopril. HTN treated with HCTZ
25mg daily, Lasix 20mg daily, Metoprolol XL 25mg daily
- Scheduled ___ with PCP for ___ BPs and adjustment to
medication regimen
# sCHF: Discontinued lisinopril. HTN treated with HCTZ 25mg
daily, Lasix 20mg daily, Metoprolol XL 25mg daily.
- Scheduled outpatient ___ with cardiologist so she can be
re-assessed for ___ therapy in the future
# Type 2 DM: Held home oral agents in house, covered with SSI.
Resumed home regimen at discharge.
# Hyperlipidemia: Continued home simvastatin
# Chronic back pain: Continued tramadol PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Januvia (sitaGLIPtin) 50 mg oral DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Zestoretic (lisinopril-hydrochlorothiazide) ___ mg oral
DAILY
6. Furosemide 20 mg PO DAILY
7. GlipiZIDE XL 10 mg PO BID
8. Simvastatin 10 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN Back pain
10. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN Back pain
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*10 Tablet Refills:*0
8. GlipiZIDE XL 10 mg PO BID
9. Januvia (sitaGLIPtin) 50 mg oral DAILY
10. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ACE inhibitor angioedema
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 face and neck swelling.
After a thorough evaluation, it was felt that you may have had
an allergic reaction, an infection, or possibly angioedema
(perhaps the most likely). You were treated with steroids,
antibiotics, and antihistamines and you got better. Because
angioedema may have been caused by Lisinopril, so your
lisinopril was stopped permanently and added to your allergy
list.
Followup Instructions:
___
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10723529-DS-8
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2125-03-09 00:00:00
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2125-03-09 20:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
___ female with history of asthma, COPD (not on home
O2), severe OSA, T2DM, HTN, and ___ (EF 20% ___ who presents
for shortness of breath. History is provided by EMS report.
Apparently patient was in a car with her friend and became
acutely short of breath. The patient was breathing at
respiratory rate 40. When EMS arrived, they were concerned
about her tiring out; they perform rapid sequence intubation.
She received IM epinephrine and multiple nebulizers. Also
received magnesium IV 2 mg, nebs, and solumedrol. and Versed 5
mg IV and 75 mcg of fentanyl per EMS.
Per husband ___, prior to this episode patient was in her USOH
until the time of initial SOB. Denies dietary indiscretion,
denies med non-compliance. Does not weigh herself every day. Has
not been febrile, no cough, no sick contacts, no SOB prior to
initial episode
In ED initial VS: T 100.6 heart rate 100s-120s BPs 100s to
146/57 and 100s RR 28 100% on ___ 100% fiO2, weaned to 80%
FiO2
Exam: Fevers, wheeze per EMS notes
Labs significant for: 6.93/141/45, lactate 5.3, creatinine 1.2,
K +5.9, ALT/AST ___, serum tox screen negative, WBC 17.1,
flu negative
Patient was given: Ketamine, ceftriaxone, methylprednisolone 25
IV, fentanyl, propofol, azithro, ceftriaxone, vecuronium
Imaging notable for: ETT, opacity projects over the right
hemithorax which may be due to asymmetric right-sided pulmonary
edema or infection. The left costophrenic angle is obscured,
possibly due to overlying soft tissue, but a small pleural
effusion is not excluded. No large pleural effusion is seen.
There is no evidence of pneumothorax. The cardiac silhouette is
mildly enlarged. Mediastinal contours are grossly unremarkable.
Consults: none
VS prior to transfer: 97.8 105 112/69 24
On arrival to the MICU, patient intubated, sedated. Notably, a
joint found in her pocket
REVIEW OF SYSTEMS: Unable to obtain
Past Medical History:
- Hypertension
- Hyperlipidemia
- systolic CHF EF 27% on nuclear stress, ___ on TTE ___
- Clean cardiac cath ___
- mild mitral valve regurgitation
- DM II
- Severe OSA
- COPD (previously intubated)
- Angioedema (secondary to lisinopril)
Social History:
___
Family History:
notable for HF
no malignancy or CAD
No family history of angioedema, mother and multiple siblings
with hypertension and CHF.
Physical Exam:
=======================
EXAM ON ADMISSION
=======================
VITALS: Tm 100.7 HR 88 BP 104/75
GENERAL: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: rhonchorous bilaterally in anterior-lateral lung fields,
no wheeze or rales
CV: tachycardic, regular, no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm, no rash
NEURO: 2+ reflexes
=======================
EXAM ON DISCHARGE
=======================
VS: T 98.2, HR 68, BP 113/72, RR 18, 97% Ra
GENERAL: No acute distress.
PSYCH: awake, alert, oriented x3
LUNGS: clear to auscultation, no wheeze or rales
CV: tachycardic, regular, no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness
EXT: Warm, well perfused, 2+ pulses, trace edema
Pertinent Results:
=============================
LABS ON ADMISSION
=============================
___ 08:56PM BLOOD WBC-17.1* RBC-4.77 Hgb-13.6 Hct-46.2*
MCV-97 MCH-28.5 MCHC-29.4* RDW-14.4 RDWSD-52.0* Plt ___
___ 08:56PM BLOOD Neuts-32* Bands-0 Lymphs-54* Monos-12
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-5.47 AbsLymp-9.23*
AbsMono-2.05* AbsEos-0.34 AbsBaso-0.00*
___ 08:56PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Pencil-OCCASIONAL
___ 08:56PM BLOOD Glucose-370* UreaN-14 Creat-1.2* Na-138
K-5.9* Cl-99 HCO3-26 AnGap-13
___ 08:56PM BLOOD ALT-43* AST-59* AlkPhos-114* TotBili-0.3
___ 08:56PM BLOOD Lipase-172*
___ 08:00AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.6
___ 11:44PM BLOOD proBNP-516*
___ 08:56PM BLOOD cTropnT-0.02*
___ 08:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
=============================
INTERVAL PERTINENT LABS
=============================
___ 08:36AM BLOOD %HbA1c-8.3* eAG-192*
=============================
LABS ON DISCHARGE
=============================
___ 08:00AM BLOOD WBC-10.7* RBC-4.58 Hgb-13.2 Hct-41.7
MCV-91 MCH-28.8 MCHC-31.7* RDW-15.1 RDWSD-48.1* Plt ___
___ 03:15AM BLOOD ___ PTT-27.7 ___
___ 08:00AM BLOOD Glucose-355* UreaN-10 Creat-0.9 Na-136
K-3.9 Cl-94* HCO3-22 AnGap-20*
___ 08:00AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.6
=============================
MICROBIOLOGY
=============================
=============================
IMAGING
=============================
##CTA chest: ___
IMPRESSION:
1. Exam is slightly limited by respiratory motion. No evidence
of pulmonary embolism or aortic abnormality within these
limitations.
2. Extensive atelectasis of bilateral lower lobes.
3. Subcutaneous edema along the left upper chest wall.
Correlate with physical exam and history of prior trauma or
manipulation.
##TTE ___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated with severe global hypokinesis (LVEF = 25 %). Systolic
function of apical segments is relatively preserved. 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 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 pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mildly dilated left ventricular cavity with severe
global hypokinesis in a pattern most suggestive of a
non-ischemic cardiomyopathy. Mildly dilated thoracic aorta. No
valvular pathology or pathologic flow identified. Increased
PCWP.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
___ CXR:
IMPRESSION:
Compared to chest radiographs since ___ most recently
___.
Mild pulmonary edema has redistributed but not resolved.
Cardiomegaly is still severe and pulmonary vasculature is
engorged. Previous right basal atelectasis has improved, left
lower lobe consolidation, probably atelectasis, has worsened
accompanied by increasing moderate left pleural effusion. No
pneumothorax.
ET tube and nasogastric drainage tubes are in standard
placements.
Brief Hospital Course:
Ms. ___ is a ___ yo female with severe OSA, COPD, sCHF with
EF 20%, DM, HTN who presents for hypoxemic hypercarbic
respiratory failure requiring intubation and ICU admission.
#Acute Hypercarbic hypoxemic respiratory failure:
#COPD:
#Severe OSA:
Patient was acutely hypercarbic and hyoxemic requiring
intubation by EMS in the field. Cause of acute decompensation
was not entirely clear but suspected to be asthma vs COPD given
wheeze. She was admitted to the ICU, where she was started on a
steroid ___. She was also treated for community acquired
pneumonia with ceftriaxone/azithromycin x5 days. Some element of
HF was suspected given known CHF with EF 20%, and she was
diuresed with IV Lasix. CTA was negative for PE. She was placed
on advair, duonebs, and standing albuterol. The majority of her
ICU stay, however, was marked by management of agitation with
lightening sedation, which limited the timing of her extubation.
She ultimately required precedex along with several boluses of
haldol and IV ativan as well as standing seroquel at increasing
doses prior to extubation. Ultimately she was extubated and
transferred to the medicine floor, where her mental status
improved markedly. Antipsychotics were stopped prior to
discharge.
#Acute on chronic systolic heart failure: (EF 20%) on last TTE
___, felt to be nonischemic given negative LHC in ___. She was
diuresed as above and her home torsemide, spironolactone, and
carvedilol were initially held given soft BP and intermittent
bradycardia with sedating meds as described above. These were
restarted prior to discharge.
#Acute kidney injury: Cr 1.2-1.3 on admission from baseline Cr
0.9 ___ be due to congestion iso volume overload.
Normalized over hospitalization.
#Transaminitis: Mildly elevated transaminases in ___ may be due
to congestion in setting of HF. may alternatively be due to med
effect with DM meds and statin. AST/ALTs in ___ were around
___. LFTs normalized over hospital course.
#NIDDM: Hgb 8.7 in ___. SSI while inpatient; held home
metformin, invokana, glipizide, and Januvia. She was discharged
on her home regimen
#Hypertension: Initially held carvedilol while with soft BPs on
sedating meds, but was able to restart prior to discharge.
#CAD primary prevention: continued pravastatin 40 mg daily
====================================
TRANSITIONAL ISSUES
====================================
[] Patient discharged on her home medications
[] Discharged with follow up with cardiology, pulmonology, and
primary care.
[] HgA1c found to be 8.3%, and often with high blood sugars
while on ISS. She was discharged on her home regimen, and should
have close follow up for diabetes.
[] Would recommend ___ (allergy to lisinopril) given EF of 20%.
Not started in house given relatively low blood pressures in
house.
[] Should have repeat lytes and CBC at next appointment
# Code - Full
# Communication: HCP: ___ husband ___ son
___ is HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Spironolactone 25 mg PO DAILY
4. Torsemide 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. sitaGLIPtin 100 mg oral DAILY
7. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous ONCE
10. Pravastatin 40 mg PO QPM
11. Invokana (canagliflozin) 300 mg oral DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
4. Aspirin 81 mg PO DAILY
5. Invokana (canagliflozin) 300 mg oral DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Pravastatin 40 mg PO QPM
8. sitaGLIPtin 100 mg oral DAILY
9. Spironolactone 25 mg PO DAILY
10. Torsemide 40 mg PO DAILY
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous ONCE
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
# Acute hypoxemic respiratory failure
Secondary Diagnoses:
# Acute on chronic systolic heart failure
# COPD
# OSA
# community acquired pneumonia
# acute metabolic encephalopathy
# Acute kidney injury
# Diabetes
# Hypertension
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 trouble breathing, and we
had to use a breathing tube and machine to help you breath. We
treated you with antibiotics, and also worked to get some of the
fluid off of your lungs. You were breathing better, but stayed
pretty confused for a while, which can happen when people get
really sick. Luckily this got better, and you were able to be
discharged home.
Please weigh yourself every day, and call your doctor if you
gain or lose more than 3 pounds.
Please see below for your follow up appointments and
medications.
Again, it was very nice to meet you, and we wish you all the
best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10723820-DS-4
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DS
| 4 |
2184-10-21 00:00:00
|
2184-10-21 20:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral wrist injuries
Major Surgical or Invasive Procedure:
___
Bilateral complex tendon, nerve, and arterial repair
History of Present Illness:
HPI: EU Critical ___ is a ___ year old male with no significant
PMH who was cutting wood with his uncle tonight at about 8:30 ___
with a machete and states that he wasn't paying attention and
somehow was accidentally struck on his volar wrists, leading to
deep wrist lacerations bilaterally. Reports he had 2 beers and
marijuana earlier in the day, no other substances. He was
brought
to ___ where he was noted to have
significant bleeding and tourniquets were placed bilaterally. He
now has been transferred by helicopter here for further
management. Tourniquets were reportedly on for < 90 minutes and
reportedly controlled the left sided bleeding but did not fully
control the right. He reports bilateral pain, reports some
numbness of ulnar digits on the right, no numbness on the left.
Reports some lightheadedness and thirst.
Past Medical History:
Healthy
Social History:
___
Family History:
NC
Physical Exam:
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
All digits good cap refill, WWP
Firing EPL/FPL on both hands, flexing all digits (not able to
assess FDS vs FDP due to splint)
B/l dorsal blocking splints
SILT all exposed digits
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have bilateral complex wrist injuries and was admitted to the
hand surgery service. The patient was taken to the operating
room on ___ for bilateral tendon repair, nerve repair,
arterial repair, 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 ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the bilateral upper extremity, and will be
discharged on aspirin 325 mg for 1 month for DVT prophylaxis.
The patient will follow up with Dr. ___. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin EC 325 mg PO DAILY
Take for 1 month (until ___
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*31
Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 3 hours as needed
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral wrist complex injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand 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 both upper extremities, activities of daily
living as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 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.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, 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 < DAYS OF REHAB
FOLLOW UP:
Please follow up with your Hand Surgeon, Dr. ___ 1
week. Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Followup Instructions:
___
|
10724174-DS-18
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2154-08-07 11:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Left frontal acute intracranial hemorrhage
Major Surgical or Invasive Procedure:
___ Trach and PEG placement
History of Present Illness:
___ y/o male found down at train station earlier today after
falling. He was noted to have a cut on the right side of his
forehead and blood dripping from his nose. He was transported
via
EMS to ___ ED for further evaluation.
Past Medical History:
HTN
s/p R craniotomy
s/p b/l cataract surgery
Lumbar Fusion
ACL repair
ORIF L ankle
EtOH abuse
Chronic Back Pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission exam:
T: 98.7 BP: 122/75 HR: 92 RR: 10 O2Sats 99% RA
Gen: Lying in bed with hard cervical collar in place. Difficult
to wake. Drowsy but awakes to loud voice and sternal rub.
HEENT: Pupils 3-2mm bilaterally.
Neuro:
Mental status: Drowsy but awakes to loud voice and sternal rub.
Orientation: Oriented to self only.
Language: Speech garbled and unintelligible.
Motor: Lifts arms and wiggles toes to command bilaterally.
Toes downgoing bilaterally.
Discharge exam:
A&Ox3
PERRL
EOMs intact
Face symmetrical
No pronator drift
Motor: ___ throughout
trach site: c/d/i healing appropriately
Pertinent Results:
___ 01:40PM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-139
K-4.5 Cl-103 HCO3-27 AnGap-14
___ 04:05AM BLOOD Glucose-83 UreaN-17 Creat-0.6 Na-135
K-4.1 Cl-103 HCO3-20* AnGap-16
___ 01:40PM BLOOD WBC-11.7*# RBC-3.89* Hgb-9.1* Hct-29.9*
MCV-77*# MCH-23.5* MCHC-30.6* RDW-18.1* Plt ___
___ 01:40PM BLOOD Neuts-85.0* Lymphs-4.6* Monos-8.2 Eos-1.7
Baso-0.4
___ 04:05AM BLOOD WBC-7.9 RBC-3.84* Hgb-9.1* Hct-29.3*
MCV-76* MCH-23.8* MCHC-31.1 RDW-18.6* Plt ___
___ 03:10PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD W/O CONTRAST Study Date of ___ 2:07 ___
IMPRESSION:
Small acute left frontal extra-axial hemorrhage without skull
fracture.
Nondisplaced left nasal bone fracture, new from ___.
CT C-SPINE W/O CONTRAST Study Date of ___ 2:07 ___
IMPRESSION:
No evidence of acute cervical spine fracture or subluxation.
ANKLE (AP, MORTISE & LAT) RIGHT Study Date of ___ 2:29 ___
IMPRESSION:
Marked degenerative changes within the ankle joint with probable
remote
posttraumatic deformity. No acute fracture or dislocation.
Diffuse soft tissue
swelling.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 8:20 ___
IMPRESSION:
Right middle lobe peripheral opacity may represent pulmonary
contusion. No overlying acute fracture seen. No intra-abdominal
injury. No acute fractures identified. Dilated common bile duct
and pancreatic duct, no pancreatic head mass identified, this
may be due to history stenosis. Nonurgent MRCP is suggested for
further evaluation. Renal hypodensities, some of which are
greater density than would be expected for simple cyst, not
completely characterized, can be further assessed by
ultrasound or at time of MRCP. Right hilar and lower lobe
opacities may represent pneumonia or aspiration.
CT CHEST W/CONTRAST Study Date of ___ 8:20 ___
Right middle lobe peripheral opacity may represent pulmonary
contusion. No overlying acute fracture seen. No intra-abdominal
injury. No acute fractures identified.
Dilated common bile duct and pancreatic duct, no pancreatic head
mass
identified, this may be due to history stenosis. Nonurgent MRCP
is suggested
for further evaluation.
Renal hypodensities, some of which are greater density than
would be expected for simple cyst, not completely characterized,
can be further assessed by ultrasound or at time of MRCP.
Right hilar and lower lobe opacities may represent pneumonia or
aspiration.
CT HEAD W/O CONTRAST Study Date of ___ 4:48 AM
Stable small acute left frontal extra-axial hemorrhage without
mass effect.
Head CT without Contrast: ___
Stable left frontal hemorrhage and right frontal/parietal
subdural hematoma without mass effect. No new hemorrhagic
lesions.
EEG ___:
This six hour recording captured primarily a sleeping background
with a focal area of sharp theta frequency slowing seen in the
right central region, suggesting the presence of a subcortical
lesion in this area. No seizures were seen.
EEG ___:
This 24 hour EEG telemetry is notable for brief and more
prolonged runs of rhythmic epileptiform activity involving the
right
centroparietal region without obvious clinical correlate.
Background activity is consistent with a mild to moderate
encephalopathy of toxic, metabolic, or anoxic etiology.
CT Head ___:
Resolution of left extra-axial hematoma. No evidence for acute
intracranial abnormalities
EEG ___:
This continuous EEG recording captured interictal discharges
seen in the right centroparietal region, consistent with an area
of focal
cortical irritability; additionally, focal slowing was also
evident in this area, suggesting the presence of a subcortical
lesion in this region. Background activity was slower than
normal suggesting the concomitant existence of a mild to
moderate encephalopathy. No ongoing seizure activity was
detected.
EEG ___:
This continuous EEG recording captured interictal discharges
seen
in the right centroparietal region, consistent with an area of
focal cortical irritability; additionally, focal slowing was
also evident in this area, suggesting the presence of a
subcortical lesion in this region. These discharges, however,
improved in the latter half of the recording. Background
activity was slower than normal suggesting a concurrent mild to
moderate encephalopathy. No ongoing seizure activity was
detected.
ECHO ___:
Normal biventricular cavity sizes with preserved regional and
global biventricular systolic function. No valvular pathology or
pathologic flow identified.
ECG ___:
Sinus rhythm with bigeminal ventricular premature beats. Left
axis deviation. Possible left anterior fascicular block.
Compared to the previous tracing of ___ sinus tachycardia
is absent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 118 92 442/470 85 -29 55
ECG ___:
Significant baseline artifact. Sinus tachycardia with premature
atrial
contractions. Suggestion of an incomplete right bundle-branch
block with left axis deviation. Left anterior fascicular block.
Non-specific ST segment flattening in the lateral leads.
Compared to the previous tracing of ___ the rate is faster
and now tachycardic. Bigeminal ventricular ectopy has resolved.
Suggestion of incomplete right bundle-branch block morphology in
lead V2 is new and may be secondary to incorrect electrode
placement. Repeat tracing and clinical correlation are
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 112 98 368/448 84 -45 63
___ CXR:
Tracheostomy is in place replacing previously demonstrated ET
tube. Central venous line tip is at the level of lower SVC.
There is interval development of bibasal, right more than left
can consolidations associated most likely with pleural effusion.
Upper lungs are overall clear and there is no pneumothorax.
The findings might reflect aspiration, aspiration pneumonia or
infectious
pneumonia.
___ CXR:
Compared to ___, lung volumes have improved
substantially and any
prior pleural effusions nearly resolved, however there is
appreciable
consolidation in both lower lobes, right greater than left
concerning for
pneumonia. Heart size is normal. Catheter of a right-sided
central infusion port ends in the mid to low SVC. No
pneumothorax.
There is the suggestion of soft tissue fullness in the
mediastinum separating the catheter in the right internal
jugular vein from the trachea displaced leftward. This feature
has probably been present on chest radiographs as since
___. No goiter or other soft tissue mass was seen on a
chest CT ___. It is probably a slowly resolving
hematoma, not an acute abnormality.
Brief Hospital Course:
___: The patient was found down, transported to ___ ED. Head
CT showed tiny L frontal acute bleed, new facial fractures. No
other acute injury found. Urine toxicology screen was positive
for benzodiazepines and opioids.
___: A repeat CT head showed a stable, small hemorrhage. As his
level of alertness improved, he was transferred to the floor -
step down unit.
___: pt began to score on the CIWA. Zyprexa was started for
considerable agitation.
___: ongoing agitiation- pt remained step down level of care.
___: ___, Social work, and speech and swallow consults were
placed. Pt underwent a stat NCHCT due to ongoing agitation and
inability to follow commands. The scan was stable from prior.
swallow eval revealed aspiration and the patient remained NPO.
___: The patient was started on PPN, and nutrition consult was
placed. Magnesium and potassium repleated, continues with NPO,
valium dose decreased
___: Valium orders discontinued, patient started on zyprexa.
The patients cervical spine was cleared and the C-Collar was
discontinued per Dr. ___. The patient continues to recieve PPN,
patients brother was at bedside discussing option of peg tube
and guardianship and states he will contact social work tomorrow
___. Patient was placed on hydralazine for blood pressure
control.
On ___, the patient's neurologic examination remained stable.
He underwent a placement of a PEG tube.
On ___ patient was found to be developing tachycardia overnight
and mid-day also looked to have increased work of breahing. He
was hemodynamically ___, with his heart rate in the 1110-120
range with a oxygen saturation of 83% on a non rebreather. On
the floor, he underwent a chest xray and recieved a nebulizer
treatment withought effect. He was then transferred to the
intensive care unit in respiratory distress. Upon arrival, his
ABG result showed marked hypoxemia with a PAo2 of 45. Patient
was intubated urgently.
On ___, Patient developed a fever of 102.3 in AM and
started on vanc/zosyn for presumed PNA. A CT of the head was
performed that was stable. Patient remained intubated in the ICU
with sedation given persistant aggitation, he required pressers
on/off for blood pressure support.
On ___, a family meeting was held with patient's daughter and
sister along with the ICU team. Family was updated about
patient's status and updated on likely need for a Trach and Peg
in the near future. Patient's daughter would like to proceed
with Trach and Peg. He remained on precedex for agitation
through the day.
On the morning of ___ his sedation was lightened and he was
able to briskly follow commands with all 4 extremities. He also
worked with ___ and OT. He continued to await trach and PEG
placement.
On ___ he was neurologically stable following commands with all
4 extremities. He underwent trach and PEG placement with the
ACS service and was transported back to the ICU
post-operatively. He was on the ventilator via the trach and was
able to be weaned to trach mask in the evening. He also was
requiring sedation with precedex and prn Haldol secondary to
agitation.
On ___ he remained stable following commands x all 4
extremities, he was on trach mask, attempting to mouth words,
and his precedex was being weaned.
On ___. The patient's precedex was discontinued. The patient
was trasnferred to the Step Down Unit.
On ___, The patients potassium was repleated.
On ___, The patient's serum potassium was low and was
repleated. Speech & Swallow was consulted for a Passey Muir
Valve. The ACS service evaluated the patient and found a soft,
nontender and reducible right inguinal hernia. There were no
acute surgical Indications and it was determined that the
patient may follow-up as an out patient for elective repair.
Overnight into ___ he had increased agitation and he was given
an extra 25mg of seroquel with good effect.
On ___ he was evaluated by speech and swallow and passed for a
regular diet with thin liquids, he also was found to tolerate a
PMV. His diet was as such advanced. Overnight the patient became
agitated and required redirection.
On ___ the patient was attempting to leave the floor and a code
purple was called twice. Seroquel was continued and Haldol was
given IM x1. He again had a code purple and was wandering the
halls and being uncooperaitve. He was given anohter dose of IM
haldol and he was placed in restraints. A psychiatry consult was
also called for assistance with agitation management and
competency determination. On ___, the patient was more relaxed
and less agitated. ACS was called to help determine whether his
trach could be discontinued and the decision was made to d/c
trach. Respiratory discontinued the trach.
On ___, the patient required no restraints the prior
evening/night. During the day, he had one episode of agitation,
but was verbally de-escalated. Occupational Therapy worked with
the patient on this day. Case management continued to work on
disposition planning.
On ___, the patient was neurologically stable. His agitation
was well controlled on new regimen and he was no longer
restrained.
On ___, he remained stable. His trach site was evaluated and
determined that he was healing well.
On ___, he was stable and discharged to a shelter for homeless
individuals.
Medications on Admission:
Seroquel 100mg PO QPM
Nystatin oral suspension
Terbinafine-Hydroxypropyl to toes BID
Paroxetine 20mg PO daily
Quetiapine 25mg PO BID prn
Lisinopril 5mg PO daily
Folic Acid 1mg PO daily
Keppra 500mg PO BID
Multivitamin PO daily
Tylenol ___ 2 tabs PO daily PRN
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN headache
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
2. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch Daily Disp #*1 Box Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*1
4. Docusate Sodium 100 mg NG BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*90 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawl
Altered mental status
Subarrachnoid hemorrhage
Respiratory failure
Hypoxemia
Protien/calorie malnutrition
Aggitation/Delerium
Hypokalemia
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:
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this when cleared by neurosurgery.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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:
___
|
10724174-DS-19
| 10,724,174 | 25,825,034 |
DS
| 19 |
2154-09-01 00:00:00
|
2154-09-04 23:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with history of ICH one month ago presents with altered
mental status and intoxicated. Patient was found wandering
outside of shelter; initially reported that he had drank EtOH,
but currently denies. History of trauma unclear as patient could
not answer simple questions in ED.
Of note, patient has a recent Admission to ___ ___ for
___ frontal acute intracranial hemorrhage after being found
down at a train station. Course was complicated by AMS and
inability to tolerate PO prompting placement of PEG tube and
trach. Trach decannulated ___. In addition, he developed
agitation prompting a Code Purple at one point. He was
discharged to ___ ___.
In the ED initial vitals were: 97.6 86 92/58 16 95% RA
- Labs were significant for potassium 5.5, creatinine 1.5.
Alcohol level negative. Mildly positive UA (see below)
-CT head/neck - no acute findings. no cspine fracture but showed
prevertebral mass at level of cricoid cartilage. seen on prior
but enlarged.
-CT abdomen - distended bladder, right inguinal hernia which is
nonobstructed; stable CBD dilatation and renal hypodensities
recommend nonurgent MRCP and renal US
- Patient was given 1L NS and ceftriaxone.
Vitals prior to transfer were: 97.6 79 113/69 14 96% RA
On the floor, patient reports he has no pain, but when asked if
he has neck pain he says "do whatvever you need to do, doc."
Says he cannot remember the last time he had a drink.
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:
HTN
s/p R craniotomy
s/p b/l cataract surgery
Lumbar Fusion
ACL repair
ORIF L ankle
EtOH abuse
Chronic Back Pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:98 BP:136/76 HR:86 RR:20 02 sat: 100RA
GENERAL: NAD, C collar on, oriented to name, month, and ___
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: C collar on, will not answer directly if has c spine
tenderness, scar from prior trach appreciated, also evidence of
tunneled port on R side
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: PEG in place with mild surroinding erythema,
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: R ankle with marked swelling (chronic per patient)
and L first toe with bunion
PULSES: 2+ DP pulses bilaterally
NEURO: CN III-XII intact, moving all 4 extremities, would not
comply with sensory exam, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - T:98 BP:135/68 HR:72 RR:20 02 sat: 97RA
GENERAL: NAD, C collar, oriented to name, month, and ___
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: C collar on, patient denied point tenderness over
C-spine; had normal range of motion without tenderness or pain;
also evidence of tunneled port on R side
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: PEG in place with mild surroinding erythema,
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: R ankle with marked swelling (chronic per patient
and by chart review) and L first toe with bunion
PULSES: 2+ DP pulses bilaterally
NEURO: CN III-XII intact, moving all 4 extremities, would not
comply with sensory exam, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 11:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 11:00PM URINE RBC-1 WBC-16* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 11:00PM URINE HYALINE-9*
___ 08:45PM GLUCOSE-85 UREA N-40* CREAT-1.5* SODIUM-139
POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
___ 11:00PM URINE MUCOUS-RARE
___ 08:45PM estGFR-Using this
___ 08:45PM ALT(SGPT)-40 AST(SGOT)-38 ALK PHOS-76 TOT
BILI-0.3
___ 08:45PM LIPASE-55
___ 08:45PM ALBUMIN-4.8 CALCIUM-9.5 PHOSPHATE-5.6*#
MAGNESIUM-2.4
___ 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:45PM WBC-7.0 RBC-3.66* HGB-8.8* HCT-29.5* MCV-81*
MCH-24.0* MCHC-29.7* RDW-15.7*
___ 08:45PM NEUTS-78.4* LYMPHS-9.5* MONOS-9.6 EOS-2.0
BASOS-0.5
___ 08:45PM PLT COUNT-323
___ 08:45PM ___ PTT-21.1* ___
DISCHARGE LAB
___ 07:15AM BLOOD WBC-3.4* RBC-3.28* Hgb-8.1* Hct-26.3*
MCV-80* MCH-24.5* MCHC-30.6* RDW-15.8* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-89 UreaN-13 Creat-0.7 Na-140
K-3.9 Cl-109* HCO3-21* AnGap-14
___ 07:15AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
___ 07:40AM BLOOD calTIBC-361 Ferritn-11* TRF-278
STUDIES
Cardiovascular ReportECGStudy Date of ___ 10:40:20 ___
Sinus rhythm. ___ anterior fascicular block. Early precordial R
wave
transition. Compared to the previous tracing of ___ the rate
has slowed.
The tracing is of improved technical quality without diagnostic
interim change.
Read ___
___
___
CT Abdomen ___
1. Right inguinal small bowel containing hernia without evidence
of
obstruction. No associated fluid collection suggestive of
ischemia.
2. Status post percutaneous gastric tube, unremarkable and
appears in
appropriate position within the gastric lumen.
3. Markedly distended bladder.
4. Persistently dilated common bile duct as well as prominent
pancreatic duct
without definite obstructing mass seen. Nonurgent MRCP can be
performed for
further evaluation as well as correlation with labs.
4. Bilateral renal cortical hypodensities, incompletely
characterized on
current examination and which can be further characterized by
ultrasound or at
the time of MRCP.
5. Status post spinal hardware spanning T12 -L2, its appearance
unchanged
compared to prior examinations. Multiple posterior chronic rib
fractures.
6. Bibasilar atelectasis. No acute intrathoracic abnormality.
CT C Spine ___
1. No cervical spine fracture or malalignment
2. Mild increase in prominence of the prevertebral soft tissues
with a 0.8 x2.5 cm soft tissue prominence at the level of the
cricoid cartilage is nonspecific and may represent tumor or less
likely secretions. Patent but narrowed airway at this level.
Consider direct inspection and if not visualized neck MR.
3. ___ maxillary sinus disease with air-fluid levels suggests
acute
inflammatory component.
CT Head ___
No acute findings.
CXR ___
IMPRESSION:
Top-normal heart size. Mild bibasilar atelectasis.
EKG: normal sinus rhythm, ___ axis deviation, normal intervals,
no acute STT changes, unchanged from prior
Brief Hospital Course:
___ with history of ICH one month ago presents with altered
mental status and thought to be intoxicated. Patient had
negative alc/tox screen in ED. Positive UA and U culture
pending. Given ceftriaxone x1 and transitioned to ciprofloxacin.
Patient found to be anemic ___ to iron deficiency and given unit
of blood and started on iron/folic acid/thiamine oral
supplements. Plan was for patient to be transferred to ___
___ for ongoing care after hospital, but patient
decided to leave against medical advice. Patient understood the
risks of leaving the hospital AMA, said if he felt unwell he
would return to the emergency room. He will complete a course of
ciprofloxacin and be started on iron/thiamine and folate. He
says he will go to ___ for tonight and go to their
clinic today. Patient ___ the hospital without his discharge
instructions. He said he could not wait another minute and ___.
ACUTE ISSUES:
#Encephalopathy
CT Head/Abdomen done on admission to the ED showed no acute
change from prior imaging. The differential initially was
___ and UTI. The patient had a negative alcohol
level when he arrived at the ED. He had a mildly positive UA but
patient denies symptoms and he is afebrile. Unclear if his
current mental status is at baseline or acutely changed. Patient
was seen by Psychiatry last admission who felt behavior was
cause of delirium on top of cognitive impairtment. Given the
history of ICH and alcoholism the patient may have poor
neurological reserve complicated by wernikes encephalopathy or
an infection. Patient's mental status improved over hospital
stay. He was treated for UTI with ciprofloxacin and will
complete the course as an outpatient. He ___ against medical
advice. Plan was to have pt return to ___ ___ but
he did not want to go back. He said that he wanted to leave the
hospital. He did not wait for his discharge instructions. He
took his prescriptions and ___ the floor.
#Iron supplementation for microcyctic anemia. We increased iron
to 3x perday and folic acid daily. He had no active bleeding on
CT. He will need follow up colonoscopy. Pt ___ before we could
schedule a PCP visit for him as an outpatient. He said he would
take care of the PCP visit after he ___.
#Acute Kidney Injury
Creatinine was 0.7 on discharge earlier this month. Now 1.5
which is likely pre-renal from poor intake. Cr resolved to 0.8
on the floor after hydration. Continued to trend due to contrast
load given in ED. Patient at baseline at discharge.
#Microcytic anemia
Pt hgb 6.7 x2. Was transfused 1 unit of blood. Patient type +
screened and consented. CT body showed no active bleeding.
Patient started on iron supplementation. Will need colonoscopy
as outpatient. Will also need close PCP follow ___ AMA
prior to being set up for apt.
#Hyperkalemia
Likely from ___ above. No concerning findings on ECG. Resolved
with IVF. Pt will need follow up Chem 7.
#C-Collar
Patient was sent up from ED with C Collar. Unclear from ED
signout or patient whether this was placed in ED or prior. No
concerning findings on CT. However, patient not a great
historian and will not answer definitively initially if he had
cervical spinal tenderness. After the interview and physical he
was cleared by nexus criteria and by CT scan.
#G Tube Placement
Patient had G tube placed during last admission. Appears as if
he is able to swallow and has been eating since discharge.
Patient will need follow up with his Heme/Onc team at ___ and
with his ACS team at ___.
#Urine Retention in ED s/p Foley Placement. Patient given
tamsulosin on floor. Foley was pulled and pt able to void on his
own.
CHRONIC ISSUES
#Recent Intracranial Hemorrhage
Appears stable based on CT Head. Continued Keppra for seizure
ppx.
#Inguinal Hernia
No evidence of associated bowel obstruction or ischemia.
#Soft Tissue Prominence at Cricoid Cartilage
Noticed Incidentally on imaging. Unclear the clinical
significance though does have a history of tonsillar cancer.
Consider MRI outpatient to further characterize. Patient
followed with ___ heme/onc, but unable to contact them prior
to pt leaving AMA.
TRANSITIONAL ISSUES
-Pt started on Ciprofloxacin 500mg BID PO x8days for UTI
-will need continuous thiamine/folate/iron supplementation
-pt received prescription for his keppra medication
-pt does not want to wait for Wall___'s to deliver the
medications and said he will have them filled after he leaves
the hospital.
-pt needs to have Colonoscopy scheduled as outpt
-discuss G-tube removal as outpatient
-pt needs to find new PCP ___ 1 week of discharge; he reports
that ___ will help find him a PCP
-___ will need to follow up with HEME/ONC and ACS as outpatient.
-Patient ___ against medical advice; understands the risks;
understands to come back to the hospital if he feels unwell
-Pt will need follow up for his Hepatitis C
OF NOTE: PATIENT ___ WITHOUT DISCHARGE INSTRUCTIONS AGAINST
MEDICAL ADVICE
HE DID TAKE HIS PRESCRIPTIONS AND SAID HE WOULD FOLLOW UP WITH
PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN headache
2. Nicotine Patch 14 mg TD DAILY
3. LeVETiracetam 500 mg PO BID
4. Docusate Sodium 100 mg NG BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO TID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Docusate Sodium 100 mg NG BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
6. Nicotine Patch 14 mg TD DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN headache
8. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Delirium, Iron Deficiency Anemia, Urinary Tract
Infection
Secondary: S/P ICH, S/P b/l cataract surgery, lumbar fusion,
Alcoholism, Substance abuse, Throat Cancer, Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take part in your care during your stay
here at ___. You were brought into the hospital when you were
found wandering outside. When you were brought into the ED you
told the Emergency Room that your had been robbed with your
wallet and sweatshirt stolen. You had a CT scan in the ED
showing no dangerous injuries or bleeding. Your tests in the ED
showed you to have an infection of your bladder (urinary tract
infection). You were brought the medicine floor.
You were continued on antibiotics for treatment of your urinary
tract infection. Your blood levels were low because of low iron
levels. You were given blood and started on iron pills. You will
continue to take these medications as an outpatient. We
recommended that you be transferred back to ___
House. You wanted to leave the hospital on ___ against
medical advice. You understood the risks of leaving the hospital
at time of discharge. You will follow up with Acute Care
Surgery for removal of your G-Tube and your PCP. You should also
make an apt with your hematology/oncology physicians after
discharge.
Thank you for allowing us to participate in your care during
your stay here at ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10724271-DS-21
| 10,724,271 | 29,437,324 |
DS
| 21 |
2132-12-15 00:00:00
|
2132-12-19 07:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
- ___ guided drainage of paraspinal muscle abscess on ___
- ___ guided drainage and drain placement of paraspinal muscle
abscess on ___
attach
Pertinent Results:
DISCHARGE LABS
==============
___ 06:37AM BLOOD WBC-6.9 RBC-4.71 Hgb-14.2 Hct-41.9 MCV-89
MCH-30.1 MCHC-33.9 RDW-12.7 RDWSD-41.2 Plt ___
___ 06:37AM BLOOD Plt ___
___ 06:37AM BLOOD ___ PTT-31.8 ___
___ 06:37AM BLOOD Glucose-199* UreaN-12 Creat-0.6 Na-137
K-4.7 Cl-98 HCO3-28 AnGap-11
___ 06:37AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.3
ADMISSION LABS
==============
___ 02:00AM BLOOD WBC-14.3* RBC-4.27* Hgb-12.9* Hct-38.5*
MCV-90 MCH-30.2 MCHC-33.5 RDW-12.5 RDWSD-41.3 Plt ___
___ 02:00AM BLOOD Neuts-74.2* Lymphs-13.8* Monos-10.0
Eos-0.4* Baso-0.6 Im ___ AbsNeut-10.59* AbsLymp-1.98
AbsMono-1.43* AbsEos-0.06 AbsBaso-0.09*
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-34.0 ___
___ 02:00AM BLOOD Glucose-279* UreaN-6 Creat-0.6 Na-134*
K-4.0 Cl-95* HCO3-27 AnGap-12
___ 02:00AM BLOOD ALT-39 AST-17 AlkPhos-96 TotBili-0.6
___ 02:00AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.7 Mg-1.9
Cholest-180
___ 06:10AM BLOOD %HbA1c-10.1* eAG-243*
___ 02:00AM BLOOD Triglyc-155* HDL-23* CHOL/HD-7.8
LDLcalc-126
___ 10:15AM BLOOD Vanco-9.7*
___ 02:23AM BLOOD ___ pO2-57* pCO2-44 pH-7.41
calTCO2-29 Base XS-2
___ 02:23AM BLOOD Lactate-1.0
CT ABDOMEN/PELVIS ___
=========================
1. Smaller extensively loculated left paraspinal intramuscular
abscess with
largest component measuring 4.1 x 3.5 x 10.7 cm. Likely
communication with a
stable 2.2 cm loculated component within the left pleural space.
Small volume
superolateral pleural fluid appears separate from this
collection.
2. The spinal canal is not well assessed on CT and comparison
with prior MRI
findings is difficult given differences in technique.
3. Focal area of hypoenhancement in the left kidney raises the
possibility
pyelonephritis in the setting of known UTI. No intrarenal
abscess or
hydronephrosis.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Outpatient cardiology clinic follow up will need to be
arranged by PCP-- ___ insurance required PCP referral for
specialist appointments
[ ] Needs outpatient TEE-- arranged as above for ___
[ ] Needs outpatient pMIBI-- will need to be arranged by PCP
[ ] Follow up with infectious diseases in ___ clinic-- ID to
arrange
[ ] Trend CRP/ESR weekly-- Initial ESR 97, initial CRP >300
[ ] Plan for presumed 6 week course of Cefazolin (ID to
determine final duration)-- day 1= ___
[ ] IP will arrange follow up in their clinic in ___ weeks (will
also arrange repeat chest CT for pleural effusion)
[ ] Outpatient fibro scan given fatty liver disease
[ ] Consider starting high intensity statin given DM and lipid
panel
[ ] Consider ___ follow up for DM-- got DM education and
started on insulin as inpatient
[ ] Follow up blood sugars and adjust insulin PRN
[ ] Consider starting Metformin and/or SGLT-II inhibitor as
outpatient for T2DM
SUMMARY
=======
Mr. ___ is a ___ male with history of obesity, found
to have type II diabetes on admission without prior diagnosis,
who presented with 10 days of back pain, found to have GPC
bacteremia, a large paraspinal abscess, and a staph aureus
urinary tract infection.
ACUTE ISSUES
============
# Staph Aureus Bacteremia (MSSA)
# Paraspinal Muscle & Pararenal Abscesses
# Concern for Spinal Osteomyelitis
The patient presented to ___ with back pain and was
found to have blood cultures positive for GPCs which ultimately
speciated out to oxacillin sensitive staph aureus. Initial ESR
97, initial CRP >300. He was initially started on Vancomycin and
Cefazolin, but ultimately narrowed to Cefazolin. On MRI of his
back on ___ he was noted to have a multi-loculated left T11-L3
paraspinal muscle abscess with abscess also medial of left crus
of diaphragm with extension into epidural space through left
T11-12 neural foramen spanning from mid T11-L1 with possible
left transverse process T12 OM, secondary myositis of his left
psoas muscle and a left pleural effusion. He then underwent ___
guided aspiration/drainage of the paraspinal collection on ___
with drainage of 110cc of purulent fluid. The patient did have a
urine culture at ___ growing staph with the same
sensitivities as his blood cultures, which makes this suspicious
at the source of his infection. However, given the ___ new
diagnosis of diabetes and no history of IVDU, it is also
possible that the patient had staph colonization and
defect/injury to skin may have resulted in occult bacteremia.
The patient also has a small loculated pleural effusion on CT
scan which could be the source of his infection-- however, he
has no respiratory symptoms. IP was consulted and felt this was
too small to drain and felt this was unlikely to be the source
of his infection. Given staph bacteremia, the patient had an
initial TTE which was negative. An inpatient TEE was deferred
given he would be on antibiotics for 6 weeks regardless given
his back infection. He was scheduled for an outpatient TEE to
occur on ___. The patient underwent repeat
imaging on ___/P which continued to show large
paraspinal muscle abscess with loculations and potential
communication with the pleural space. Given these findings, ___
was re-consulted and he ___ subsequently placed an ___ Fr drain
under US/CT guidance on ___ 60 cc blood tinged orange pus
removed. He was discharged with this drain and plans to follow
up in ___ clinic. The patient was ultimately discharged on IV
cefazolin 2g every 8 hours [day 1: ___ through a double lumen
PICC (placed on ___.
# Arrhythmia
Patient was noted to have tele findings concerning for
non-sustained ventricular tachycardia and consequently consulted
cardiology. Patient was asymptomatic at the time and lying on
his side. Cardiology was consulted and recommended TEE and pMIBI
which could be done as an outpatient. Patient will bed
discharged with Holter zio patch on discharge.
# Staph Aureus UTI
# Pyelonephritis on CT A/P
Urine culture obtained on ___ at ___ grew MSSA. No
urinary symptoms. Likely secondary to high grade bacteremia -
Antibiotic management as noted above with Cefazolin.
# Small Loculated L pleural effusion
CT Chest on ___ shoed small loculated L pleural effusion,
likely secondary to high grade bacteremia. No evidence of septic
pulmonary emboli and no respiratory symptoms. ___ was consulted
and felt this was too small to drain and felt this was unlikely
to be the source of his infection. The recommended
antibiotic/medical management as noted above. He will have
repeat CT imaging in 4 weeks and follow up in ___ clinic which ___
will arrange.
# Type II diabetes
New diagnosis this admission based on HbA1C of 10.1. ___ was
consulted and he will be discharged on Lantus to 20 units QPM
and 5U of Humalog with meals per ___ recommendations.
Consider starting Metformin and SGLT-II inhibitor as outpatient.
Consider ___ follow up as outpatient. Received diabetes
education while inpatient.
# HTN
New diagnosis this admission-- BPs in 160-180s intermittently.
Usually in 140s. Also new diagnosis of T2DM, so will benefit
from ___. -Started Lisinopril 5mg PO QD with improvement in
his BPs.
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g three times
a day Disp #*126 Intravenous Bag Refills:*0
2. Glargine 20 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 5 mg PO DAILY
4. OneTouch Delica Lancets (lancets) 30 gauge lancets 4x/day to
test blood suagr
RX *lancets [OneTouch Delica Lancets] 30 gauge four times a day
Disp #*100 Each Refills:*0
5. OneTouch Ultra Blue Test Strip (blood sugar diagnostic)
strips 4x/day
Use 4x/day to test blood sugar
RX *blood sugar diagnostic [OneTouch Ultra Blue Test Strip]
four times a day Disp #*100 Strip Refills:*0
6. OneTouch Verio IQ Meter (blood-glucose meter) 1 Meter
Machine Blood Sugar Monitoring 4x/day
RX *blood-glucose meter four times a day Disp #*1 Kit
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA Bacteremia
Paraspinal Muscle Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
================================
- You were admitted to the hospital because you were having back
pain and were found to have a severe back pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
=======================================
- You were diagnosed with an infection in your blood and in your
back.
- You were given IV antibiotics to treat the infection.
- You had 2 procedures done with the interventional radiologists
to drain the collections of fluid from your back.
- You were given medications to control your pain.
- You were seen by the infectious disease doctors who
recommended further studies and recommended specific
antibiotics.
- You were seen by the cardiologists (heart doctors) who
recommended that you get an outpatient heart ultrasound and
outpatient stress test.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
================================================
- Continue to take all your medicines and keep your
appointments.
- You will need to continue to take IV antibiotics until seen by
infectious diseases and directed otherwise
- You will need an outpatient echocardiogram (heart ultrasound)
- You will need an outpatient stress test
___ Drain Care:
==============
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc for 2 days in a row,
please have the ___ call Interventional Radiology at ___ at
___ and page ___. This is the Radiology fellow on
call
who can assist you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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10724345-DS-13
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2153-01-31 00:00:00
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2153-01-31 17:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Lisinopril / Insulins /
Toprol XL / Glyburide / Prasugrel / Isosorbide / metformin /
Brilinta
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o PVD, CAD, cardiomyopathy, and multiple ___
revascularization procedures most recently a Left fem-AT bypass
of ___. The patient was discharged on POD 5 (___). Since
discharge, she has not taken lasix and noted SOB in the morning
on ___ and eventually went to an OSH who transferred her to
___ for evaluation given her recent vascular surgery.
Past Medical History:
- CAD s/p STEMI in ___ treated with BMS 2.5 x 28mm Minivision
stent of the D1; s/p ___ successful PTCA/stenting of the mid
LAD with a Promus OTW 2.5x12 mm ___ to 2.75 mm and
then the proximal LAD with a Promus OTW 3.0x12 mm ___
___ to 3.25 mm
- Cardiomyopathy ___ per Dr. ___ ___
- PVD
- Diabetes mellitus
- Hypertension
- Hyperlipidemia
- Hyperkalemia
- Tobacco abuse
- Right carotid bruit
- Cataract surgery in right eye, cataract left eye; poor vision
- Skin CA ___ cell-under left eye excision ___ years ago)
- Anxiety/depression
- NSVT on Holter monitor (refusing ICD per documentation)
___ -
___: stent to the L common and external iliac
___: PTA of R SFA with three self-expanding stents. Direct
stenting of the R ostialiliac artery.
___: s/p b/l ___ angiogram: PTA and stenting of the L SFA
with a 6.0x80mm Zilver self-expanding stent.
___ bilateral ___ angiogram: angioplasty 80% discrete
in-stent restenosis in distal left SFA, dilation x 3 proximal AT
___ right SFA and femoral and pop angioplasty, distal SFA
with dissection (drug elutingstent was deployed)
___ PTA and stenting of the left SFA with DES
___ staged rotational atherectomy, PTA and stenting of the
right occluded SFA with overlapping self-expanding stents, small
stable right CFA dissection
Social History:
___
Family History:
Father died of an MI at age ___ and mother died of ___
disease. No siblings.
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 144/70 HR 98 RR 20, 97% on room air
Carotids: 2+, no bruits or JVD
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral palp , DP dop ,___ dop graft
pulse palp
Right Femoral palp , DP dop ,___ dop
Feet warm, well perfused. No open areas
Incision clean dry and intact, wound edges well approximated.
Leg is soft with no edema.
Pertinent Results:
___ 05:30AM BLOOD WBC-7.3 RBC-3.08* Hgb-9.2* Hct-27.0*
MCV-88 MCH-29.7 MCHC-33.9 RDW-16.1* Plt ___
___ 04:06AM BLOOD ___ PTT-25.3 ___
___ 05:30AM BLOOD Glucose-132* UreaN-30* Creat-1.3* Na-138
K-4.8 Cl-93* HCO3-32 AnGap-18
___ 04:06AM BLOOD CK-MB-2 cTropnT-0.08* proBNP-3481*
___ 05:30AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.3
TTE: ___
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is severe regional left
ventricular systolic dysfunction with akinesis of the mid- and
distal anterior and septal segments as well as basal inferior
wall (multivessel CAD). The remaining segments contract normally
(LVEF = 25%). Right ventricular chamber size and free wall
motion are normal. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild aortic regurgitation.
Moderate mitral regurgitation.
CTA Chest: ___
1. No pulmonary embolism.
2. Ground-glass opacities predominantly in the bilateral lower
lobes could be
inflammatory versus infectious.
3. Bilateral pulmonary nodules measuring up to 6 mm. Recommend
chest CT in ___ months to assess stability.
4. Prominent in number mediastinal lymph nodes may be reactive
in nature.
Brief Hospital Course:
___ yo F with PAD, CAD with presumed infarct-related CM with EF
of ___, presents POD 7 from left Fem-AT bypass with shortness
of breath. She was discharged 2 days
ago with reports of episodes of dyspnea while in the hospital
which improved with Lasix. Her husband reports progressively
worsening SOB until to the point where she could barely walk
across the room. She went to an OSH and were transferred here
for further care given her recent vascualr surgery.
BNP on admission was 3481. Cardiology was consulted given her
underlying systolic dysfunction and agreed with diuresis and
nebs for her hypoxia and tachypnea although there was no overt
evidence of CHF. CTA was done that showed no PE. She had no
tempature, elevated wbc or radiographic evidence of pneumonia
althoug she was treated emperically with levoquin while in the
hospital.
TTE showed severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild aortic regurgitation.
Moderate mitral regurgitation. EF is 25%. We have arranged
followup with her cardiologist for further evaluation.
She did have given increased Cr and HCO3 secondary to the
aggressive diuresis so we have instructed the patient to hold
the lasix (20 mg po) for 2 days and restart on ___. At that
time we have arranged for the ___ to draw BUN/Cr anf
electrolytes with results to Dr. ___.
She was unable to void for over 18 hours after her foley
catheter had been removed. She was therefore sent home with a
foley in place and will follow up with urology in clinic to have
the foley removed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Gabapentin 600 mg PO BID
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Nortriptyline 10 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Acetaminophen 1000 mg PO Q8H:PRN discomfort
8. Furosemide 20 mg PO DAILY:PRN lower extremity swelling,
shortness of breath
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
10. Levemir FlexTouch (insulin detemir) 20 units subcutaneous
BID
11. Codeine Sulfate 90 mg PO Q4H:PRN pain
12. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Codeine Sulfate 90 mg PO Q4H:PRN pain
4. Gabapentin 600 mg PO BID
5. Nortriptyline 10 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Vitamin D 5000 UNIT PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Furosemide 20 mg PO DAILY
RESTART THIS MEDICATION ___. Monitor and record weights
every morning.
10. Acetaminophen 1000 mg PO Q8H:PRN discomfort
11. Levemir FlexTouch (insulin detemir) 20 units subcutaneous
BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Congestive Heart Failure
Peripheral Arterial Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to the hospital
after experiencing severe shortness of breath at home. We
consulted the cardiology team and our workup showed that your
shortness of breath was secondary to congestive heart failure.
You were given IV lasix and your shortness of breath improved.
There was no evidence of pneumonia or pulmonary embolism.
-To manage your CHF:
Weigh yourself every morning, call Dr. ___ weight goes
up more than 3 lbs or the shortness of breath returns. Please
take your lasix daily starting on ___ until your
follow up with Dr. ___.
As you also recently had bypass surgery to improve the blood
flow to your leg. Please adhere to the following:
Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
You will be on ASPIRIN AND PLAVIX for life.
Follow your discharge medication instructions including daily
lasix.
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Followup Instructions:
___
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10724345-DS-15
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2153-09-10 00:00:00
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2153-09-19 08:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Lisinopril / Insulins /
Toprol XL / Glyburide / Prasugrel / Isosorbide / metformin /
Brilinta / acetaminophen / Plavix
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this patient is a ___ yoF with history of tobacco use,
PAD s/p multiple revascularizations, CAD s/p STEMI w/ BMSx1 and
DESx2, ischemic cardiomyopathy (EF 25%) refused AICD, IDDM, HTN,
and NSVT p/w SOB presenting with 3 episodes of hemoptysis in the
past 10 days. She states the first episode was 7 days ago, and
the last was three days ago. She reports coughing up large
volumes of bright red blood, about half a cup full. She endorses
shortness of breath for the past month, which has become more
progressive. She also reports weight loss of 10 lbs over the
past
few months. She states that she has recently been diagnosed with
a thickened gallbladder and had planned to have it removed.
After
discussing her symptoms with her PCP/cardiologist Dr.
___ was referred to ___ to further management.
Past Medical History:
CARDIAC HISTORY:
- CAD s/p STEMI in ___ treated with BMS 2.5 x 28mm Minivision
stent of the D1; s/p ___ successful PTCA/stenting of the mid
LAD with a Promus 2.5x12 mm ___ to 2.75 mm and then
the proximal LAD with a Promus 3.0x12 mm ___ to
3.25 mm
- LVEF 25% on echo ___
- NSVT on Holter monitor (refusing ICD per documentation)
OTHER PAST MEDICAL HISTORY:
- PAD
- Hyperkalemia
- Tobacco abuse
- Right carotid bruit
- Cataract surgery in right eye, cataract left eye; poor vision
- Skin Ca ___ cell-under left eye excision ___ years ago)
- Anxiety/depression
PAST VASCULAR/SURGICAL HISTORY
___: stent to the L common and external iliac
___: PTA of R SFA with three self-expanding stents. Direct
stenting of the R ostial iliac artery.
___: s/p b/l ___ angiogram: PTA and stenting of the L SFA
with a 6.0x80mm Zilver self-expanding stent.
___ bilateral ___ angiogram: angioplasty 80% discrete
in-stent restenosis in distal left SFA, dilation x 3 proximal AT
___ right SFA and femoral and pop angioplasty, distal SFA
with dissection (drug eluting stent was deployed)
___ PTA and stenting of the left SFA with DES
___ staged rotational atherectomy, PTA and stenting of the
right occluded SFA with overlapping self-expanding stents, small
stable right CFA dissection
___ s/p left common CFA to AT bypass graft with in situ
saphenous vein complicated by incisional dehiscence and
incisional infection
Social History:
___
Family History:
Father died of an MI at age ___ and mother died of ___
disease. No siblings.
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals: 97.6 91 141/66 22 97% on RA
General: Alert, oriented, yet appears overall fatigued and
exhausted; appears older than stated age.
HEENT: Sclera anicteric, MMM, PERRL
Neck: Supple, JVP not elevated sitting upright
CV: Regular rate and rhythm, S4, distant hearts sounds,
difficult
to palpate PMI, right carotid bruit
Lungs: Basilar rales on the right side; clear throughout apices
and left
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding; negative ___ sign.
GU: No foley
Ext: 2+ edema in ___ bilaterally
Neuro: Non-focal.
ON DISCHARGE:
Vitals: 97.8 128/78 78 18 97RA
General: alert, oriented, seated over bed. Not SOB, but appears
overall tired and fatigued.
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally today, minimal wheezing
throughout, but no 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 12:20AM BLOOD WBC-9.7 RBC-5.25* Hgb-13.2 Hct-41.6
MCV-79* MCH-25.1* MCHC-31.7* RDW-19.9* RDWSD-54.7* Plt ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-110* UreaN-31* Creat-1.0 Na-133
K-5.0 Cl-99 HCO3-25 AnGap-14
___ 08:45AM BLOOD ALT-39 AST-43* LD(LDH)-517* AlkPhos-152*
TotBili-0.6
___ 08:45AM GLUCOSE-311* UREA N-27* CREAT-1.1 SODIUM-137
POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-19* ANION GAP-20
___ 08:45AM ALT(SGPT)-39 AST(SGOT)-43* LD(LDH)-517* ALK
PHOS-152* TOT BILI-0.6
___ 08:45AM proBNP-8940*
___ 08:45AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 08:45AM HCT-UNABLE TO
___ 08:45AM ___ TO PTT-UNABLE TO ___
TO
___ 12:20AM GLUCOSE-409* UREA N-28* CREAT-1.0 SODIUM-131*
POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-22 ANION GAP-19
___ 12:20AM estGFR-Using this
___ 12:20AM WBC-9.7 RBC-5.25* HGB-13.2 HCT-41.6 MCV-79*
MCH-25.1* MCHC-31.7* RDW-19.9* RDWSD-54.7*
___ 12:20AM NEUTS-58.8 ___ MONOS-8.7 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-5.67 AbsLymp-2.96 AbsMono-0.84*
AbsEos-0.09 AbsBaso-0.05
___ 12:20AM PLT COUNT-239
___ 06:00AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0
___ 08:45AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
___ 12:20AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
___ 06:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
___ 08:45AM BLOOD B-GLUCAN-Test
IMAGING:
___ CXR
1. Right upper lobe consolidation is new since ___ and
could represent hemorrhage, aspiration or infection. Follow-up
to resolution is recommended. If the consolidation does not
resolve on chest radiograph after treatment, chest CT is
recommended.
2. Mild interstitial pulmonary edema has worsened since ___.
___ CT Chest
IMPRESSION:
New large region of mixed ground-glass and nodular opacities in
an area of preexisting severe emphysema in the right upper
lobe. Given the history of hemoptysis, much of the abnormality
is probably pulmonary hemorrhage. Any of the several soft tissue
elements within it could be mycetoma responsible for the
bleeding, but these are indistinguishable from small clots.
Several pulmonary nodules measuring 6 mm or less are stable
since ___. Recommend Follow up in ___ year.
Increased, mild pulmonary edema is responsible for s mall
bilateral pleural effusions and enlargement of edematous lymph
nodes.
Brief Hospital Course:
Mrs. ___ is a ___ yoF w/ significant hx of left ventricular
systolic
dysfunction, bilateral ___ DES, multivessel CAD, MR ___/ EF 25%
presenting with 3 episodes of hemoptysis, found on Chest CT to
have new large region suspicious for mycetoma vs aspergilloma vs
hemorrhage into an area of emphysema
#Hemoptysis: CT scan was concerning for aspergilloma vs
pulmonary hemorrhage into pre-existing area of emphysema vs
malignancy. On chest xray showed mild pulmonary edema,
consistent with LV failure and low EF, though volume overload
was not considered the primary source of hemoptysis. Low
suspicion for TB per pulmonology. She was tested for
b-glucan/galactomannan for possible pulmonary aspergillosis,
received Lasix, and seen by interventional pulmonology who had
scheduled her for an outpatient bronchoscopy for further workup.
B-glucan returned positive with galactomannan negative,
supporting the dx of fungal infection. The patient was called
to relay this information and to follow-up with IP for
definitive diagnosis.
# Thickened gallbladder wall: Pt reports recent RUQ U/S with
thickened gallbladder. She did not have tenderness on exam and
had a negative ___ sign to suggest acute cholecystitis.
Workup was deferred to outpatient.
# CAD, PAD: She is s/p multiple peripheral vascular stents and
revascularizations. Per records, was plavix restarted during
last admission, though she experiences nausea with this and does
not want to take this medication. We deferred this to her
outpatient cardiologist and continued her metoprolol during her
stay.
# Type 2 DM: The patient was placed on sliding scale and her
home dose of Levemir was witheld. Her FSB was well controlled.
Transitional Issues
--------------------
-Interventional pulmonology to call patient and schedule
outpatient bronchoscopy and PET CT to workup new lesions found
on Chest CT
- Patient to initiate discussion with cardiologist regarding
anti-coagulation with plavix, Xarelto, or ticlopidine. Patient
will contact cardiologist for appointment.
- Ongoing management of post-menopausal vaginal dryness.
Consider estrace cream
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Codeine Sulfate 120 mg PO TID-QID
2. Metoprolol Succinate XL 12.5 mg PO BID
3. Vitamin D 5000 UNIT PO 2X/WEEK (MO,TH)
4. Furosemide 80 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Levemir 20 Units Breakfast
Levemir 20 Units Dinner
7. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
Start: ___, First Dose: Next Routine Administration Time
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
9. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Codeine Sulfate 120 mg PO TID-QID
3. Levemir 20 Units Breakfast
Levemir 20 Units Dinner
4. Metoprolol Succinate XL 12.5 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN Nausea
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
7. Albuterol Inhaler 2 PUFF IH Q4H
RX *albuterol sulfate 90 mcg ___ puff IH Q4-6 hours Disp #*1
Inhaler Refills:*0
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff IH twice a day Disp #*1 Disk Refills:*0
9. Vitamin D 5000 UNIT PO 2X/WEEK (MO,TH)
10. Furosemide ___ mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis, new mass on Chest CT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure having you on our service.
You were brought in from the emergency room after having several
episodes of coughing up blood. You had a CT scan of the chest
which showed a new finding in the upper part of your right lung.
Interventional pulmonology will follow up with you for
scheduling an outpatient bronchoscopy and discuss the results
with you as an outpatient. Please follow up with your
appointments below.
Thank you for letting us serve you.
Followup Instructions:
___
|
10724406-DS-7
| 10,724,406 | 28,536,479 |
DS
| 7 |
2146-07-26 00:00:00
|
2146-07-26 13:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
incidentally found head bleed
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
HPI: Mr. ___ is a ___ with h/o diabetes, hypertension (high
blood pressure), renal disease, gout, acoustic neuroma s/p
cyberknife and parkinsons's who was sent in for subacute
subdural
hematoma. Patient was getting an head MRI at ___ in
___. The MRI showed subacute blood in a chronic subdural
fluid collection. Patient reports he has no numbness, weakness,
headache. Denies any recent falls or trauma. Denies any double
vision. Denies fever, chills, chest pain, cough. Reports he went
in for his yearly MRI for his prior acoustic neuroma. Reports he
was very surprised at this phone call. His son corroborates that
he has been at his baseline to improved with increased mobility.
Reports he does have some left leg weakness at baseline though
no
acute changes. Reports he has been on Coumadin for about a year
due to a DVT in his left leg but has not had a recent ultrasound
to see if the DVT is still there.
He and his son deny any history of trauma, falls, trips, head
strike or other accidents. He does not report any headaches or
visual changes.
In ER: (Triage Vitals:0| 98.4|53 |162/67 |18 |100% RA )
INR = ___
Meds Given: None
Fluids given: None
Radiology Studies:
B/L E US:
IMPRESSION:
1. Occlusive thrombus of the left superficial femoral and a left
peroneal vein.
2. No right lower extremity deep venous thrombosis
.
consults called: Neurosurgery:
Patient evaluated and imaging reviewed. Routine outpatient MRI
from today shows small R subacute on chronic SDH with no mass
effect or MLS. Patient is completely asymptomatic with no
neurologic deficits. Recommend reversal of INR with 1 ___
in
the ER. After FFP administered patient may discharge home. Hold
Coumadin until follow up. Patient should follow up in 4 week
with
Dr. ___ with repeat ___ at that time. Please call
___ to schedule this appointment.
Plan determined by attending Dr. ___
___ Medical History:
PMH:
His neurological history started with
dizziness and imbalance in ___, which was followed locally.
Incidental right vestibular schwannoma was picked up on a head
MRI. This was then followed by Dr. ___ with serial MRIs. In
___, MRI showed increase in size of schwannoma and he was
referred to radiation oncology. He completed Cyberknife SRS on
___ to 2500cGy.
.
Past Medical History: Prostate cancer treated with radiation.
Skin cancer resected from right ear ___ and left ear ___.
Melanoma resected from his back over ___ years ago. Hypertension,
Vitamin B12 deficiency dx ___. Left lower DVT & PE in ___ on
Eliquis- then switched to Coumadin
Hypothyroidism.
Social History:
___
Family History:
Mother deceased after complications of cardiac surgery at ___
which was a stroke.
Father deceased at ___,
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: LLE edema and weakness
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Right neck IVC filter placed, covered with gauze, CDI
Pertinent Results:
___ 07:40AM BLOOD WBC-8.0 RBC-4.90 Hgb-15.1 Hct-42.3 MCV-86
MCH-30.8 MCHC-35.7 RDW-12.6 RDWSD-39.6 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-35.4 ___
___ 07:44AM BLOOD Glucose-97 UreaN-24* Creat-1.4* Na-144
K-3.8 Cl-102 HCO3-29 AnGap-13
___ 07:40AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-144
K-3.8 Cl-103 HCO3-27 AnGap-14
___ 07:40AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
Final Report
INDICATION: ___ year old man with ___ DVT and acute on chronic
bleeding to
___// please place a removable IVC filter into patient as he has
DVT and SHD
with acute on chronic bleeding
COMPARISON: ___ CT abdomen pelvis from outside
institution.
TECHNIQUE: OPERATORS: Dr. ___
___ and
Dr. ___ radiologist performed the procedure.
Dr. ___
___ supervised the trainee during the key components of
the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Sedation was provided by administrating divided
doses of 75 mcg of
fentanyl while the patient's hemodynamic parameters were
continuously
monitored by an independent trained radiology nurse. 1%
lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
.
MEDICATIONS: None.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.2 min, 18 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal retrievable IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the
healthcare proxy. The patient was then brought to the
angiography suite and
placed supine on the exam table. A pre-procedure time-out was
performed per
___ protocol. The right neck was prepped and draped in the
usual sterile
fashion.
Under ultrasound and fluoroscopic guidance, the patent and
compressible right
internal jugular vein was punctured using a 21G micropuncture
needle.
Ultrasound images of the access was stored on PACS. A ___
wire was
advanced through the micropuncture sheath into the inferior vena
cava. Using
a 5 ___ x 65 cm Kumpe catheter, the ___ wire was advanced
into the left
iliac vein.
The micropuncture sheath was exchanged for the sheath including
the inner
dilator of an internal jugular vein approach Denali IVC filter.
The
sheath/dilator was advanced into the left iliac vein. The wire
was removed.
The inner dilator was flushed. Gentle contrast injection
confirmed
positioning within the left iliac vein.
A left common iliac and inferior vena cava venogram was
performed. Based on
the results of the venogram, detailed below, a decision was made
to place a
retrievable infrarenal filter. The inner dilator of the sheath
was removed.
The sheath was flushed with saline. A vena cava filter was
advanced through
the sheath until the cranial tip was at the level of the
inferior margin of
the lower renal vein. The sheath was then withdrawn until the
filter was
deployed. The wire and loading device were then removed through
the sheath and
a repeat contrast injection was performed, confirming
appropriate filter
positioning. The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes, at
which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no
immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal retrievable IVC
filter.
IMPRESSION:
Successful deployment of infrarenal, retrievable IVC filter.
RECOMMENDATION(S): If the filter is no longer medically
indicated, it may be
removed by our service at any time. Our service can be
contacted for a clinic
appointment at ___. Alternatively, the filter is
approved for
permanent usage if the patient requires it to remain permanently
in place.
1. Occlusive thrombus of the left superficial femoral and a left
peroneal
vein.
2. No right lower extremity deep venous thrombosis.
Brief Hospital Course:
___ year old male with h/o an acoustic neuroma s/p cyberknife,
LLE
DVT, PE, ___ Disease on sinemet who presents after
an incidental finding of subacute on chronic SDH on routine MRI.
#subacute on chronic SDH on routine MRI.
-patient s/p IVC filter, he is comfortable
- no midline shift or mass effect on imaging per neurosurgery's
read, pending radiology read of MRI
- Follow up in 4 weeks with Dr. ___ with repeat ___
at that time. Call ___ to schedule this appointment.
DVT/PE hx; last PE approx. ___ ago
- pt was on Coumadin, US demonstrates residual thrombous of LLE
- heme and neuro-onc were consulted, recommended IVC filter
- Stopped Coumadin
- Held amlodipine given LLE swelling
HTN:
- continued lisinopril and beta blocker
.
___ DISEASE
- continued sinemet
- continued donepezil for presumed PD- associated dementia vs
___ body dementia
HYPOTHYROIDISM
- continue synthyroid
Chronic LLE edema
-Patient is likely on Lasix for this and HTN, continued
Diet
Regular
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. amLODIPine 5 mg PO DAILY
5. Carbidopa-Levodopa (___) ODT 1 TAB PO TID
6. Furosemide 40 mg PO DAILY
7. Donepezil 10 mg PO QHS
8. Potassium Chloride 10 mEq PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) ODT 1 TAB PO TID
2. Cyanocobalamin 1000 mcg PO DAILY
3. Donepezil 10 mg PO QHS
4. Furosemide 40 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Potassium Chloride 10 mEq PO DAILY
Hold for K > 5.5
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until PCP follow up
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute on chronic subdural hematoma
Occlusive thrombus of the left superficial femoral and a left
peroneal vein
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted with evidence of subacute on chronic
intracranial bleeding. Your Coumadin was stopped. Your INR
become subtherapeutic. ___ were seen by neurosurgery and
interventional radiology while ___ were here. ___ were also
seen be hematology/oncology while ___ were here. Because ___
still have lower extremity deep vein thrombosis, an inferior
vena cava filter (IVC filter), was placed.
Please follow up with your primary care physician ___ ___ weeks
Please keep your IVC filter site clean and dry, do not soak it
If ___ have any issues with your IVC filter placement site
please call Inteventional Radiology at ___
Followup Instructions:
___
|
10724467-DS-5
| 10,724,467 | 20,908,635 |
DS
| 5 |
2189-11-27 00:00:00
|
2189-11-28 22:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
L pilon fx
Major Surgical or Invasive Procedure:
L ankle ex fix (___)
ORIF L pilon fx (___)
History of Present Illness:
___ old healthy F w/ PMHx sig for HTN who stepped onto a
jetty, falling through with her left leg lodged between two
rocks. No headstrike. Friends called for ambulance, went to ___
where XR showed comminuted, angulated, mildly displaced complex
fx of distal tib w/ c/f pilon fx. Ortho splinted, reduced,
transferred here.
She has mild pain at the left ankle. No numbness, weakness, or
tingling. No presyncopal component or lightheadedness to the
fall. No chest pain, shortness of breath, abd pain, naus, fever,
chills, vomiting.
Past Medical History:
nc
Social History:
___
Family History:
nc
Physical Exam:
Gen - NAD, AxO x3
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Splint c/d/i
- Minimal edema to the ankle
- No erythema or induration
- Soft, non-tender thigh and leg
- Painful flexion and eversion of the ankle, however, with full
range of motion
- Full, painless AROM/PROM of hip, and knee
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
___ 04:30PM URINE MUCOUS-RARE
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
___ 04:10PM estGFR-Using this
___ 04:10PM estGFR-Using this
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L pilon fx and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___ for
L pilon ORIF, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours as needed for pain Disp #*120
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Alophen] 5 mg 2 tablet(s) by mouth once a day as
needed for constipation Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day as needed for constipation Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 0.4 ml subcutaneous once a day at
bedtime Disp #*14 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 3 hours
as needed for pain Disp #*120 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day as needed for constipation Disp #*60 Tablet
Refills:*0
7. amLODIPine 5 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
L pilon 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:
Ms. ___,
- 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:
- Nonweightbearing in the left lower extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40 mg at bedtime daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
10724737-DS-14
| 10,724,737 | 22,183,932 |
DS
| 14 |
2155-08-08 00:00:00
|
2155-08-08 18:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with past
history of a white matter disease of unclear etiology (the
patient refers to it as leukodystrophy) complicated by residual
weakness, pain in lower extremities (right more than left) with
ambulation, as well as multiple episodes of transient right
sided weakness who presents this morning after sudden onset of
slowly progressive tingling/numbness and subsequent weakness in
the right hemibody, dysarthria and right facial droop.
Per the patient and her daughter, she was noted to be in her
usual state of health at 1100hrs on ___ at which time she
began experiencing tingling in her right upper extremity which
evolved to numbness and heaviness in both her arm and leg over
minutes (slowly progressive). She called to her daughter
___ who responded with observation that the patient seemed
to have a right facial droop and some dysarthria (noting
her mother is normally quite articulate). EMS was activated and
the patient was brought to ___ ED where a code stroke was
called. Her initial NIHSS was 4 (for right hemibody weakness),
but on repeat assessment, I rated it as a 1 for dysarthria.
After ___ and CTA were without acute abnormality, it was noted
that the patient's lower extremity weakness had improved, yet
her
right arm remained feeling heavy.
Past Medical History:
- White matter disease of unclear etiology (patient calls it
leukodystrophy) diagnosed in ___ she had various tests done,
but we do not have any of these records; noted to have previous
episode in ___ in ___ with similar symptoms resolving
over
1 week.
- Tubal Ligation
- Multiple Knee Operations bilaterally
Social History:
___
Family History:
- Mother - ___
- Father family - ___ CA, CAD
Physical Exam:
ADMISSION EXAM:
BP=118/68-135/78, HR=78, RR=18, SaO2=100% RA
General: Awake, cooperative, concerned appearing.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension although slower to respond. Normal prosody,
but slightly hypophonic. 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 on
"___" or "sunny day in ___. Able to follow both
midline and appendicular commands. Attentive, with good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: Mild right NLF flattening with decreased excursion of the
right lips on smile, facial musculature otherwise symmetric and
___ strength, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ 4+ 5- 4+ 4+ ___ 4+ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, some dysdiadochokinesia and
dysmetria noted with rapid alternating movements noted in the
right hand.
-Gait: Good initiation. Wider-based, with some hesitance and
limit in arm swing. Romberg absent.
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-6.2 RBC-4.47 Hgb-14.5 Hct-41.3 MCV-92
MCH-32.3* MCHC-35.0 RDW-12.3 Plt ___
___ 12:20PM BLOOD ___ PTT-36.4 ___
___ 12:20PM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-142
K-4.2 Cl-102 HCO3-30 AnGap-14
___ 12:26PM BLOOD Glucose-95 Na-142 K-4.3 Cl-98 calHCO3-31*
IMAGING:
NECT: No acute intracranial process. No hemorrhage.
CTA: No thrombosis, dissection or aneurysm greater than 3 mm.
Bovine aortic arch. Patent dural venous sinuses. Anterior
fusion hardware C5-7. Recons pending.
HEAD MRI:
IMPRESSION:
No infarct or hemorrhage. Nonspecific scattered T2/FLAIR
hyperintensities in the periventricular and subcortical white
matter
Brief Hospital Course:
55 RHF with past history of white matter disease (etiology
unclear) with prior multiple episodes of transient right sided
weakness who presented after sudden onset, but slowly
progressive tingling/numbness/weakness of the right hemibody,
dysarthria and right facial droop. Stroke risk factors were
checked (lipid panel and HbA1C), patient started on 81mg
aspirin. - f/u lipid panel and HbA1c. Patient's home gabapentin
was increased from 300mg po TID to ___ po TID, propranolol was
discontinued, and Amitryptiline was continued. On discharge,
patient was instructed to stop her propranolol for 2 days and to
start verapamil 120mg po qHS for migraine prophylaxis. Verapamil
can both be an antihypertensive and migraine prophylaxis
(anti-vasospasm). Patient was monitored on telemetry, her LFTs
and Utox were normal. Patient refused SC heparin and pneumoboots
while hospitalize.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO HS
2. Zolpidem Tartrate 10 mg PO HS
3. TraMADOL (Ultram) 50 mg PO PRN pain
4. Propranolol 80 mg PO QHS
5. Gabapentin 300 mg PO TID
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Zolpidem Tartrate 10 mg PO HS
3. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*60 Tablet Refills:*0
4. Verapamil 120 mg PO QHS
RX *verapamil 120 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
5. Gabapentin 400 mg PO Q8H
RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day
Disp #*120 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Complex migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right-sided weakness
likely resulting from complex migraines.
We are changing your medications as follows:
STOPPING propranolol
STOPPING TRAMADOL
INCREASING gabapentin dose
STARTING verapamil (please start on ___
STARTING aspirin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
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10724828-DS-14
| 10,724,828 | 22,486,652 |
DS
| 14 |
2113-01-16 00:00:00
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2113-01-16 19:25:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain/ abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ y/o F presenting with sudden onset of headache around 4am
this morning. She then developed abdominal pain, nausea,
vomiting. A few hours later, she developed sharp central chest
pain.
Her headache is occipital, typical of her usual migraines,
negative for photophobia, positive for phonophobia, and has been
constant and worsening since onset. Her chest pain has also been
constant, described as both "burning" and "pressure" ___ this
morning, now ___, not helped by nitro and ASA, associated w/
sob, but no diaphoresis. Her usual angina comes on after about
30 stairs, but also at rest in times of emotional stress.
One loose stool, non-bloody emesis x4, last episode bilious.
Denies sick contacts. Patient was scheduled for stress ECHO this
week after she was unable to complete her exercise stress test 2
days due to left hip pain from a fall several days ago.
In the ED, initial vitals were 97.7 87 138/74 18 100%RA.
On arrival to the floor, she complains of ___ headache,
palpitations, and ___ chest pain. Denies SOB.
Review of sytems:
(+) Per HPI. Also chronic dry cough, weakness/numbness in R hand
x 3 months, bilateral facial swelling x 1 month.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
1. Likely CAD with stable angina
2. Paroxysmal Afib, s/p 7 DCCV in ___. Unconfirmed.
3. Dyslipidemia
4. HTN
5. Varicose veins s/p stripping many years ago (no symptoms, and
does not want further interventions)
6. Breast CA s/p R mastectomy, chemorad
7. Depression/anxiety
8. CCY
9. Migraines
Social History:
___
Family History:
Father died of an MI at age ___. No history of strokes, PAD, CHF
in the family.
Physical Exam:
ADMISSION EXAM:
================
VS: 97.9 140/72 80 20 100%RA
General: lying flat in bed w/ wet rag on forehead, in NAD
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, non-distened, mild tenderness in epigastric area,
no rebound or guarding.
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE EXAM:
================
VS: 98.1 100s-140s/50s-80s ___ 20 98%RA
General: lying in bed, in NAD
Neck: supple, no JVD
CV: regular rhythm, II/VI SEM at RUSB
Lungs: CTAB, no w/r/r
Abdomen: soft, non-distended, non-tender, no rebound or
guarding.
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
================
___ 08:00AM BLOOD WBC-12.6*# RBC-4.38 Hgb-12.1 Hct-37.5
MCV-86 MCH-27.5 MCHC-32.2 RDW-13.6 Plt ___
___ 08:00AM BLOOD Neuts-84.1* Lymphs-11.5* Monos-3.3
Eos-0.6 Baso-0.5
___ 08:00AM BLOOD ___ PTT-23.6* ___
___ 08:00AM BLOOD Glucose-137* UreaN-21* Creat-0.6 Na-142
K-3.8 Cl-105 HCO3-25 AnGap-16
___ 08:00AM BLOOD ALT-20 AST-19 AlkPhos-83 TotBili-0.4
___ 08:00AM BLOOD cTropnT-<0.01
___ 10:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:00AM BLOOD Albumin-3.9
___ 08:10AM BLOOD Lactate-1.7
___ 08:00AM BLOOD Lipase-23
DISCHARGE LABS:
=================
___ 06:50AM BLOOD WBC-8.8 RBC-4.19* Hgb-11.6* Hct-35.4*
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.6 Plt ___
___ 06:50AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-141 K-3.3
Cl-102 HCO3-30 AnGap-12
___ 06:50AM BLOOD Mg-2.1
STUDIES:
====================
___ Nuclear stress test:
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
INTERPRETATION:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 74%.
IMPRESSION: Normal myocardial perfusion.
Brief Hospital Course:
___ y/o F w/ HTN, HLD who presents with chest pain, abdominal
pain, nausea and vomiting x 1 day.
# Chest pain: EKG normal, and trop negative x 2. Pharmacologic
nuclear stress test was normal. Continued sublingual nitro prn,
atorva 80, ASA 81, imdur 30.
# N/V/Abdominal pain: Pt was treated with iv fluids and
anti-emetics and symptoms resolved as rapidly as they began. Her
presentation was most consistent with a viral gastroenteritis.
# HTN: continued dilt, imdur.
# Depression: continued home citalopram.
# ?Afib: Per outpt cards note, unconfirmed history from ___.
Currently in NSR, not on anticoagulation.
# CODE: Full
# EMERGENCY CONTACT: ___ (daughter/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Nitroglycerin SL 0.4 mg SL PRN chest pain
4. Pravastatin 20 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. potassium gluconate 550 mg (90 mg) oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Vitamin D ___ UNIT PO DAILY
7. potassium gluconate 550 mg (90 mg) oral daily
8. Pravastatin 20 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain Duration: 5 Days
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for chest pain with abdominal pain, nausea and
vomiting. You were treated with intravenous fluids and
anti-emetics. You underwent a stress test, which revealed no
abnormalities in the vessels around your heart.
This is most likely from a virus, you should continue to feel
better. If you are continuing to have symptoms that concern,
please contact you primary care doctor.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
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