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10724828-DS-16
| 10,724,828 | 27,970,601 |
DS
| 16 |
2117-08-14 00:00:00
|
2117-08-14 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / morphine
Attending: ___.
Chief Complaint:
Right knee swelling
Major Surgical or Invasive Procedure:
Right knee arthrocentesis on ___
History of Present Illness:
___ woman with hx breast cancer s/p mastectomy and
chemoradiation (___), osteoporosis, recent fall with R wrist
fracture, presenting with acute onset knee pain and swelling
while working with ___.
Patient has had home ___ after her recent fall resulting in
distal
R radius fracture and R hip insufficiency fracture. The
therapist
was flexing and massaging her right knee when she suddenly felt
a
pop sensation in the back of her knee and developed significant
swelling. She denies fever/chills, n/v/d, cough, dysuria,
abdominal pain.
Of note, when she was here after her fall, she was noted to have
mild R patellar pain and plain film showed a high riding
patella.
As her knee function was intact, this was felt to likely
represent a remote injury, and ortho did not recommend any
intervention.
In the ED, initial VS were:
98.1
95
129/58
18
95% RA
Exam notable for: large R knee effusion.
Labs showed: Hb 10.7 (at baseline), chemistry unremarkable.
Knee x-ray showed: Very large right knee joint effusion, new
since the prior study of ___. No acute fracture or
dislocation seen.
She subsequently developed a fever to 101, prompting admission
to
medicine.
Patient received: Tylenol 1g, gabapentin 100mg, pravastatin 20mg
Transfer VS were:
99.1
96
133/66
18
97% RA
On arrival to the floor, patient reports ongoing ___ R knee
pain. She denies fever/chills, vomiting/diarrhea, dysuria,
abdominal pain. She has been feeling well aside from her knee
pain, and hip pain from her past fall.
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
10. Cognitive impairment, likely Alzheimer's
11. GERD
12. Osteoporosis
13. Iron deficiency anemia (___)
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: reviewed in eflowsheets
GENERAL: Lying in bed, mild distress
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
KNEE: R knee with large effusion with lateral deviation of
patella. No visible ecchymosis. AROM and PROM significantly
limited by pain.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
==============
24 HR Data (last updated ___ @ 709)
Temp: 98.2 (Tm 99.1), BP: 119/78 (88-129/51-78), HR: 92
(71-94), RR: 16 (___), O2 sat: 99% (94-99), O2 delivery: Ra
GENERAL: Lying in bed
PULM: No increased work of breathing
GI: Abdomen non-distended
KNEE: R knee with large effusion, esp. superior and lateral. No
visible skin changes.
EXTREMITIES: No cyanosis, clubbing, or edema
DERM: Warm and well perfused, no excoriations or lesions
Pertinent Results:
ADMISSION LABS
==============
___ 07:43PM BLOOD WBC-8.1 RBC-4.33 Hgb-10.7* Hct-35.0
MCV-81* MCH-24.7* MCHC-30.6* RDW-14.6 RDWSD-43.0 Plt ___
___ 07:43PM BLOOD Neuts-73.7* Lymphs-13.3* Monos-12.0
Eos-0.2* Baso-0.4 Im ___ AbsNeut-5.98 AbsLymp-1.08*
AbsMono-0.97* AbsEos-0.02* AbsBaso-0.03
___ 07:43PM BLOOD Plt ___
___ 08:14PM BLOOD ___ PTT-26.4 ___
___ 07:43PM BLOOD Glucose-107* UreaN-13 Creat-0.5 Na-137
K-4.2 Cl-99 HCO3-24 AnGap-14
___ 07:43PM BLOOD ALT-11 AST-17 AlkPhos-144* TotBili-0.6
___ 07:43PM BLOOD Calcium-10.2 Phos-2.4* Mg-1.5*
NOTABLE LABS
============
___ 09:15AM BLOOD CRP-165.0*
___ 09:00PM BLOOD CRP-176.4*
___ 09:14PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-INTRAC Birefri-NEG Comment-c/w monoso
___ 09:14PM JOINT FLUID TNC-___* RBC-2 Polys-76* Lymphs-2
___ Macro-22
DISCHARGE LABS
==============
___ 09:00PM BLOOD WBC-6.4 RBC-4.00 Hgb-10.2* Hct-31.4*
MCV-79* MCH-25.5* MCHC-32.5 RDW-14.8 RDWSD-42.5 Plt ___
___ 09:00PM BLOOD Glucose-121* UreaN-14 Creat-0.5 Na-138
K-3.8 Cl-101 HCO3-26 AnGap-11
___ 09:00PM BLOOD Albumin-3.9 Calcium-9.8 Phos-1.7* Mg-2.1
UricAcd-PND Iron-15*
___ 09:15AM BLOOD Albumin-4.3 Calcium-10.2 Phos-3.1 Mg-2.9*
Iron-38
___ 09:00PM BLOOD calTIBC-367 Ferritn-104 TRF-282
___ 09:15AM BLOOD calTIBC-441 Ferritn-112 TRF-339
___ 09:00PM BLOOD 25VitD-37
___ 09:15AM BLOOD 25VitD-43
NOTABLE IMAGING
===============
___ R KNEE XR
IMPRESSION:
Very large right knee joint effusion, new since the prior study
of ___. No acute fracture or dislocation seen.
___ R KNEE MRI
IMPRESSION:
1. Large joint effusion, without definite evidence of
lipohemarthrosis or
hemarthrosis.
2. Complex degenerative tear of the lateral meniscus as
described above.
3. There is moderate-grade posterior-lateral corner injury,
involving the
popliteus, fibular collateral ligament and lateral
gastrocnemius.
4. Radial tear of the midbody of the medial meniscus, with
meniscal capsular strain and partial separation around the
posterior horn.
5. Moderate to high-grade tricompartmental cartilage loss, most
severe in the patellofemoral compartment.
Brief Hospital Course:
HOSPTAL COURSE
==============
___ woman with hx breast cancer s/p mastectomy and
chemoradiation (___), osteoporosis, recent fall with
polytrauma, presenting with acute onset knee pain and swelling
while working with ___, underwent arthrocentesis with findings
concerning for gout.
ACUTE ISSUES
============
# Complex lateral meniscus tear
# Knee effusion
# Gout: Initial concern was for recurrent hemarthrosis given
patient history. However, orthopedics performed arthrocentesis
on ___ with fluid showing minimal blood, significant WBCs, and
monosodium urate crystals consistent with gout. Patient likely
with underlying predisposition for gout triggered by trauma
during ___. Started colchicine ___, and will start allopurinol
once acute flare resolves. She had good initial response to
colchicine alone, and allowed us to avoid NSAIDs (concern for
risk of bleeding w/ CAA) as well as systemic steroids (concern
for risk of exacerbating her cognitive dysfunction).
MRI obtained ___ showing complex degenerative tear of the
lateral meniscus along with significant ligamentous injury.
These were likely sustained during recent fall and exacerbated
by ___. Per orthopedics, no inpatient management needed but will
follow up in clinic to consider arthroscopy or knee replacement.
# Acute toxic metabolic encephalopathy: likely due to gout flare
and severe pain on top of chronic cognitive impairment/dementia.
Improved with pain control and treatment of gout. Back to
baseline mental status per family at time of discharge.
# Acute urinary retention: likely medication(opioid)- or
pain-induced; required straight cath PRN initially, but this
ultimately resolved with improved R knee pain and decreased PO
oxycodone.
CHRONIC ISSUES/RESOVLED ISSUES
==============================
# Fever (resolved): Isolated fever to 101 in ED without
preceding infectious symptoms. No localizing symptoms. CXR and
UA no evidence of infection. No leukocytosis. Suspect reactive
fever i/s/o gout flare. Afebrile while inpatient.
# Microcytic anemia: 4% iron saturation indicating iron
deficiency, ferritin normal but likely falsely elevated in
setting of gout flair. Continued PO vs. IV repletion as
outpatient once infection completely excluded.
# GERD: Continued home protonix BID.
# HLD: Continued home pravastatin.
# Pain: Continued home gabapentin.
# HTN, ?AF: Per PCP note, AF is questionable diagnosis. Neuro
recommended against anticoagulation (and aspirin) given cerebral
angiopathy. Continued home dilt 120.
# Osteoporosis: Continued home calcium/vit D.
# Depression: Continued home citalopram.
TRANSITIONAL ISSUES
===================
[] Please ensure transportation to upcoming Rheumatology
appointment on ___
[] If patient develops diarrhea or abdominal cramping, would
consider colchicine as cause and either decrease dose or stop
medication
[] Iron deficient, consider PO vs. ___ repletion as an outpatient
on acute illness has resolved
# CONTACT: ___ (son)
.
.
.
.
Time in care: greater than 30 minutes in discharge-related
activities today.
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Gabapentin 100 mg PO QHS
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
7. Pravastatin 20 mg PO QPM
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. diclofenac sodium 1 % topical QID
10. Pantoprazole 40 mg PO Q12H
11. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500-200-40
mg-unit-mcg oral DAILY
12. Sumatriptan Succinate 25 mg PO ONCE MR1 migraine
13. Citalopram 10 mg PO DAILY
14. Cyanocobalamin 250 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Colchicine 0.6 mg PO DAILY
3. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500-200-40
mg-unit-mcg oral DAILY
4. Citalopram 10 mg PO DAILY
5. Cyanocobalamin 250 mcg PO DAILY
6. diclofenac sodium 1 % topical QID
7. Diltiazem Extended-Release 120 mg PO DAILY
8. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
9. Gabapentin 100 mg PO QHS
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Pravastatin 20 mg PO QPM
16. Sumatriptan Succinate 25 mg PO ONCE MR1 migraine Duration:
1 Dose
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right knee meniscal tear
Right knee gout
Acute toxic-metabolic encephalopathy
Acute urinary retention
Anemia (microcytic)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you developed swelling
in your right knee. We performed an MRI which showed significant
damage to the internal parts of the knee joint, which likely
occurred after you fell. You will see the orthopedic surgeons as
an outpatient to determine if surgery is needed.
We also saw crystals in the fluid which indicate a medical
condition called gout. We started a medication called colchicine
to treat this.
You will go to rehab to work on your strength and coordination.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10725020-DS-10
| 10,725,020 | 26,885,436 |
DS
| 10 |
2184-08-20 00:00:00
|
2184-08-20 16:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
ORIF - R ankle fracture
History of Present Illness:
___ assaulted overnight, with R ankle injury. C/o pain R
ankle and R small finger pain. denies headstrike or LOC. Denies
ever injuring RLE before.
Past Medical History:
Denies
Social History:
___
Family History:
NC
Physical Exam:
PE: 98.2 90 123/77 18 96%
NAD
A&Ox3
RLE: skin intact, skin wrinkleable at ankle
edema and mild ecchymoses ankle
TTP about ankle. No TTP knee.
thigh and leg compartments soft
___, FHL
SILT s/s/spn/dpn/pn's
+dp pulse
Pertinent Results:
LABS: none
IMAGING: R ankle xrays showing weber c distal fibula ankle fx,
syndesmoses widening and medial joint space widening.
R hand xrays - no fx or dislocation
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with R ankle fracture. Patient was taken to the
operating room and underwent ORIF R ankle fracture. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to NWB RLE, to be in splint at all times.
Throughout the hospitalization, patient worked with physical
therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT was stable throughout her
hospitalization and she did not require any transfusion/blood
products.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #1, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with crutches, voiding without
assistance, and pain was well controlled. The incision was
clean, dry, and intact without evidence of erythema or drainage;
the extremity was NVI distally throughout. The patient was
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient will be
continued on chemical DVT prophylaxis for 2 weeks
post-operatively. All questions were answered prior to
discharge and the patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN CONSTIPATION
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL Inject one 40 mg syringe
subcutaneously once a day Disp #*14 Syringe Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*75 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
- Please keep your splint clean, dry and intact until your
follow up appointment. Any stitches or staples that need to be
removed will be taken out at your 2-week follow up appointment.
******WEIGHT-BEARING*******
Non weight bearing, right lower extremity - to be in splint at
all times
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
Take Lovenox for DVT prophylaxis for 2 weeks post-operatively
Physical Therapy:
NWB, LLE - to be in splint at all times.
Patient will need ___ for home ___ safety evaluation as well.
Treatments Frequency:
Home ___
Followup Instructions:
___
|
10725972-DS-3
| 10,725,972 | 26,353,279 |
DS
| 3 |
2130-04-02 00:00:00
|
2130-04-02 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subacute subdural hematoma, agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year-old man with a history of
hypertension, hypothyroidism, osteoporosis, and prostate cancer
status post seed radiation, who initially presented to an
outside hospital for agitation and was transferred to the ___
for evaluation of a subdural hematoma.
On ___, he had a fall about which he cannot
remember any details. His first memory after the fall was
waking up at ___. Per ___ records, he
had a drink, lost his balance while walking and fell, and had a
sternal fracture and gluteal hematoma. He was discharged from
___ to rehab on ___. Of note, during his
time at ___, his wife passed away of a cardiac arrest.
Per ___ records, his family feels that he has not been
quite the same since his ___ hospitalization and rehab stay.
Upon discharge from rehab, he went to live with his
___. Per ___, his PCP started him on
sertraline four days prior to presentation (___). Three
days prior to presentation, he became agitated, making
statements about how he didn't know if life was worth living.
He also developed decreased appetite, with significant diarrhea
two days prior to presentation and milder diarrhea the night
prior to presentation.
Per ___ records, the night prior to presentation, he
also made a statement that he wanted to take his medications to
die, his granddaughter was holding them trying to keep him away
from them, and he grabbed onto her wrist. The patient was
brought to ___ for evaluation. ___ records
further state that Mr. ___ said that this was just a
misunderstanding, and adamantly denied suicidal or homicidal
ideation.
At ___, a head CT scan was done there, showing a 7 mm,
right subacute subdural hematoma with 5 mm of midline shift. He
was transferred to the ___ for neurosurgical evaluation.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, pain, headache, visual
change, dizziness, shortness of breath, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, and
changes in urination. Endorses feeling down, but denies
suicidal or homicidal ideation.
Past Medical History:
Hypertension
Hyperlipidemia
Hypothyroidism
Osteoporosis
Prostate cancer status post seed radiation
Known left cystic hygroma
Social History:
___
Family History:
No family psychiatric history
Physical Exam:
ADMISSION EXAM:
VS 97.4 68 124/60 16 97% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, Anisocoria (left pupil 1 mm, right 4 mm),
anicteric sclerae, pink conjunctivae, patent nares, MMM,
nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Distant breath sounds, CTAB, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AAOx3, Spells WORLD forward, but
difficulty backward. Counts ___ forward/backward. ___ immediate
recall, ___ delayed recall. ___ strength in upper and lower
extremities bilaterally. Downward babinski bilaterally. Pt able
to ambulate without assistance or difficulties. Finger to nose
and heel to shin intact bilaterally.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS 99.0 58 18 142/55 96ra
GENERAL: NAD
HEENT: AT/NC, EOMI, Anisocoria (left pupil 1 mm, right 4 mm),
anicteric sclerae, pink conjunctivae, patent nares, MMM,
nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Distant breath sounds, CTAB, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AAOx3, spells days of week and months
of year forward and backward.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 04:11AM BLOOD WBC-11.5* RBC-4.49* Hgb-14.1 Hct-41.6
MCV-93 MCH-31.5 MCHC-34.0 RDW-12.3 Plt ___
___ 04:11AM BLOOD Neuts-84.4* Lymphs-7.9* Monos-6.7 Eos-0.9
Baso-0.1
___ 04:11AM BLOOD ___ PTT-27.9 ___
___ 04:11AM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-138
K-4.0 Cl-97 HCO3-27 AnGap-18
___:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
___ 04:11AM BLOOD Vit___*
___ 04:11AM BLOOD TSH-0.55
DISCHARGE LABS
___ 01:25PM BLOOD Hgb-12.2* Hct-36.0*
___ 07:40AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-136
K-3.7 Cl-100 HCO3-27 AnGap-13
___ 07:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
IMAGING AND STUDIES
___ CHEST X-RAY (PA & LAT)
IMPRESSION: No acute cardiopulmonary process.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Left subdural hygroma or chronic hematoma resulting in 6 mm
rightward midline shift.
2. Mildly hyperdense subdural collection over the right cerebral
convexity suggesting subacute subdural hemorrhage.
3. The above findings are on a background of generalized
cerebral atrophy with enlargement of the ventricles and
subarachnoid spaces.
Brief Hospital Course:
Mr. ___ is an ___ year-old man with a history of
hypertension, hypothyroidism, osteoporosis, and prostate cancer
status post seed radiation who initially presented to an outside
hospital for agitation and was transferred to the ___ for
evaluation of a subdural hematoma.
# Subdural hematoma: Patient presented with a right possible
subacute subdural hemorrhage, left subdural hygroma or chronic
hematoma resulting in 6 mm rightward midline shift, generalized
cerebral atrophy, and baseline anisocoria on physical exam. He
was seen by neurosurgery, who felt that no surgical intervention
was necessary at this time, but recommended outpatient
neurosurgical follow-up. Neurological exams were conducted
every four hours initially. Aspirin was held until his follow-up
appointment with neurosurgery.
# Agitation: Patient presented with a few days of agitation and
suicidal ideation. This occurred in the context of stressors,
such as death of loved ones and recent hospitalization, as well
as the recent outpatient initiation (exact timing unknown) of
sertraline. Ultimately, these factors seemed to be the primary
etiology of his agitation. Though altered mental status can
result from subdural hematoma, this would be more likely to have
an insidious onset with cognitive impairment and somnolence, in
contrast to Mr. ___ history of agitation and questioning
of whether life is worth living. Delirium could also have
contributed to his agitation, though the patient remained
oriented x3 and with intact to mildly impaired attention during
his stay (able to state days of the week backwards, and
intermittently able to state months of the year backward).
Work-up for altered mental status (CBC, chem-7, TSH, B12,
urinalysis, chest x-ray, head CT scan) was largely unrevealing,
except for a history of a few days of diarrhea and mildly
elevated WBC with left shift on presentation. Though the patient
did not report a history of alcoholism, but does have relatively
heavy reported alcohol use. However, he did not have
ophthalmoplegia, truncal ataxia, or apparent confabulation
suggestive of We___-___ syndrome. Delirium precautions
were implemented, home multivitamin continued, and thiamine and
folic acid supplement started. He was seen by psychiatry, who
felt that his presentation was consistent with normal
bereavement, and that akathisia from his recent initiation of
sertraline may have contributed to his agitation. They
recommended against psychiatric treatment and antidepressant use
at this time. These psychiatric factors seemed to be the primary
explanation for his recent behavioral change. Sertraline was
discontinued.
# Falls: Though Mr. ___ has a history of recent fall, his
lack of orthostatic hypotension and benign cardiovascular exam
and ECG make cardiovascular etioloy of his falls (e.g.,
myocardial infarcion, valvular lesion, arrhythmia) less likely.
Furthermore, per report from ___, it seems as though his
fall in ___, was likely in the context of alcohol use.
Fall precautions were implemented, and he was counseled how
alcohol use can contribute to falls.
# Pain: Though Mr. ___ had a sternal fracture status post
___ in ___, he reported no pain during this admission,
and did not seem entirely clear on why he is still on methadone.
Methadone was tapered and discontinued.
# Diarrhea: Mr. ___ had a few days of diarrhea in the
context of recent hospital exposure. Though he had not had
diarrhea since ___, he began to have diarrhea the night of
___. C. difficile DNA amplification assay was negative.
# Weight Loss: Mr. ___ was seen by nutrition on ___ for
12 lbs of unintentional weight loss, likely linked to decreased
appetite with depressed mood. Patient was started on Ensure
supplements TID.
# Thrombocytosis: Mr. ___ platelet count was mildly
elevated at 488 on presentation. The most likely caue of this
was reactive thrombocytosis in the context of recent trauma
(e.g., sternal fracture) from a fall in ___.
# Anemia: Though hemoglobin and hematocrit were within normal
limits on presentation, they dropped to anemic range during this
admission. MCV was normal. Though this could represent a
transient drop, other possible etiologies include anemia of
chronic inflammation.
# Elevated B12: Mr. ___ B12 is slightly elevated at 964
pg/mL. On presentation, he was taking cyanocobalamin 1000 mcg
IM/SC MONTHLY. Cyanobalamin was discontinued.
# Chronic:
Hypertension: Continued home atenolol, amlodipine, and
lisinopril as an inpatient. Blood pressures remained within
normal range during this admission.
Hyperlipidemia: Continue home simvastatin
Hypothyroidism: Continue home levothyroxine
Osteoporosis: Continued home alendronate
TRANSITIONAL ISSUES:
====================
Subdural hematoma: Non-contrast head CT and follow up
appointment at ___ clinic on ___. Aspirin
and other NSAIDs should be held until this appointment.
- Agitation: Discontinuation of sertraline was advised by
psychiatry; please monitor to ensure that no depressive disorder
emerges.
- Pain: Patient's methadone was discontinued on discharge after
a 3- day taper.
- Diarrhea: Please monitor for resolution on an outpatient
basis.
- Weight loss: Further work-up is advised as indicated at the
discretion of his primary care physician.
- Thrombocytosis and anemia: Further work-up is advised as
indicated at the discretion of his primary care physician.
- Elevated vitamin B12 level: B12 supplementation was
discontinued on discharge and may be resumed as an outpatient as
needed.
- EtOH abuse: Patient given prescription for thiamine and folate
given history of chronic EtOH abuse.
- Contact: Daughter ___ ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
3. Methadone 5 mg PO BID
4. Lisinopril 5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO QAM
6. Simvastatin 10 mg PO QPM
7. Amlodipine 10 mg PO QAM
8. Atenolol 50 mg PO DAILY
9. Sertraline 25 mg PO DAILY
10. Alendronate Sodium 70 mg PO QTUES
11. Fish Oil (Omega 3) Dose is Unknown PO DAILY
12. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
13. Multivitamins 1 TAB PO DAILY
14. Aspirin 81 mg PO DAILY
15. Docusate Sodium 100 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QTUES
2. Amlodipine 10 mg PO QAM
3. Atenolol 50 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO QAM
5. Lisinopril 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 10 mg PO QPM
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Subacute subdural hematoma
Agitation
Bereavment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You initially came to ___
___ for agitation and were transferred to the ___
for evaluation of bleeding in your head that was seen on a CT
scan. Our neurosurgery doctors ___ and did not
recommend surgery at this time, but rather outpatient follow-up,
with repeat CT scan at that time. Please do not take aspirin or
other NSAIDs (such as ibuprofen/Motrin) until you see them.
Our medical doctors ___ and did not find a source of
infection or other clear medical cause of agitation. Our
psychiatrists also evaluated you and felt that you were feeling
sad from the death of your wife, but that you no longer needed
an antidepressant medication (sertraline). In addition, your
pain medications (methadone, Percocet, and tramadol) were
lowered and then stopped since you were not reporting pain, and
pain medications may contribute to confusion and agitation.
Please keep any outpatient follow-up appointments for which you
are scheduled and take all of your medications as prescribed
according to the attached sheet. Please seek medical attention
if you have mental changes that are concerning to you or your
loved ones (e.g., confusion, agitation, feelings of hurting or
killing yourself or others), headache, visual change, numbness,
tingling, difficulty talking or walking, falls, diarrhea, blood
in your stool, black stool, dehydration, fevers, chills, or any
other symptoms that concern you.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10726367-DS-17
| 10,726,367 | 20,238,938 |
DS
| 17 |
2152-05-31 00:00:00
|
2152-05-31 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:
Epidural abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of IVDU, last used 5 days ago, reported saddle
anesthesia and back pain with urinary incontinence and decreased
strength for 9 days. Patient initially presented to outside
hospital with leukocytosis and MRI showing epidural abscess and
as transferred to ___. Patient received ceftriaxone and
vancomycin that were infusing on arrival.
Exam:
___ strength in bilateral lower extremities. Intact gross
sensation. Downgoing toes bilaterally. Saddle anesthesia.
Refused rectal exam.
In the ED, initial vitals were:
Temp. 99.1, HR 59, BP 134/70, RR 16, 96% RA
- Exam notable for: ___ strength in bilateral lower
extremities. Intact gross sensation. Downgoing toes bilaterally.
Saddle anesthesia. Refused rectal exam.
- Labs notable for:
CBC 10.7, Hg 11.2, platelets 424. Normal chemistry. Tox screen
negative.
- Imaging was notable for (patient had L spine MRI at OSH, C/T
spine here):
There is no cord signal abnormality. No abnormal fluid
collections are seen within the spinal canal. There is moderate
disc bulge at C4-5 and C6-7 without effacement of the spinal
cord.
- Spine was consulted: Felt MRI at OSH shows small enhancing
collection posterior to the L3 and L4 vertebral bodies without
compression, No surgical indication at this time. Would
recommend medicine service for infectious work up. Felt urinary
incontinence from earlier was related to back pain and inability
to get to the restroom quick enough. No saddle anesthesia and
intact rectal tone. No hoffmans, No clonus. Felt patient reports
constipation is a chronic issue
- Patient was given: ongoing infusion vanc, ceftriaxone
- Vitals prior to transfer: 98.7 64 109/69 16 96% RA
Upon arrival to the floor, patient reports worsening back pain
over 9 days. Reported some fvers, chills. He had a BM yesterday.
He reports that he has been bedridden so unable to get up to
bathroom, but otherwise feels sensation and urge to defecate or
urinate otherwise. He reprots he has never gotten an abscess of
infection from his drug use before, save for "a lung infection"
back when he inhaled heroin
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Back pain
IVDU
Social History:
___
Family History:
Father with cardiac disease
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, in ___ pain, severe back pain,
slightly cachetic
HEENT: Sclerae anicteric, dry mucous membranes, oropharynx
clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Back: severe tenderness over midline spine over lumbar area.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No evidence of skin popping. IV track marks over medial
lateral aspect of elbow and antecubital fossa.
Neuro: CNII-XII intact, diminished dorsiflexion/plantar flexion
B/L ___, L > R, though largely diminished ___ pain. Intact
sensation in saddle area for myself. Refused rectal ___ pain.
DISCHARGE EXAM:
Vitals: 98.4 121 / 77 42-60 18 94 Ra
General: Alert, interactive, NAD
CV: RRR, no m/r/g
Pulm: CTAB without wheezes or rales
Abd: Soft, voluntary guarding, NTTP
Ext: Point tenderness at L3/L4 spinal region; No ___ edema
Neuro: ___ strength b/l hip flexion/extension, dorsi-,
plantarflexion; sensation grossly intact
Pertinent Results:
========================
ADMISSION LABS
========================
___ 07:43PM BLOOD WBC-10.7* RBC-4.01* Hgb-11.2* Hct-36.1*
MCV-90 MCH-27.9 MCHC-31.0* RDW-12.3 RDWSD-40.1 Plt ___
___ 07:43PM BLOOD Neuts-78.5* Lymphs-10.1* Monos-8.9
Eos-1.3 Baso-0.5 Im ___ AbsNeut-8.40* AbsLymp-1.08*
AbsMono-0.95* AbsEos-0.14 AbsBaso-0.05
___ 07:43PM BLOOD Plt ___
___ 07:43PM BLOOD Glucose-99 UreaN-19 Creat-0.9 Na-139
K-4.1 Cl-94* HCO3-32 AnGap-17
___ 07:55AM BLOOD ALT-12 AST-11 LD(LDH)-98 CK(CPK)-64
AlkPhos-74 TotBili-0.4
___ 07:55AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.9 Mg-2.1
___ 07:55AM BLOOD CRP-125.5*
___ 07:50AM BLOOD Vanco-11.6
___ 07:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:41AM BLOOD Lactate-1.3
___ 02:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:38PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 02:38PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
=================
KEY INTERIM LABS
=================
___ 05:41AM BLOOD CRP-94.7*
___ 07:55AM BLOOD CRP-125.5*
___ 10:59PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:34PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:01AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 07:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:00AM BLOOD HCV Ab-Negative
=========================
DISCHARGE LABS
=========================
___ 06:20AM BLOOD WBC-5.9 RBC-3.19* Hgb-8.7* Hct-28.5*
MCV-89 MCH-27.3 MCHC-30.5* RDW-12.9 RDWSD-42.3 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-92 UreaN-16 Creat-1.4* Na-144
K-3.9 Cl-105 HCO3-28 AnGap-15
___ 06:30AM BLOOD ALT-15 AST-9 AlkPhos-105 TotBili-0.2
___ 06:20AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.0
___ 05:41AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.0
======================
IMAGING
======================
Transthoracic Echo ___:
IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
KUB ___:
Severe stool burden from the ascending colon to the rectum.
MRI C/T-Spine ___: 1. No evidence of infection within the
cervical or thoracic spine. No
concerning enhancing lesions are seen.
2. No cord signal abnormalities identified.
3. Mild-to-moderate cervical spondylosis, most pronounced at
C4-C5 with
moderate spinal canal narrowing secondary to disc bulge and a
focal central disc protrusion. Severe left and moderate right
neural foraminal narrowing is seen at this level.
MRI L-spine ___: 1. Worsened L3-L4 intervertebral disc
height and endplate irregularity is presumably the sequela of
discitis osteomyelitis. No definite intervertebral disc
enhancement. Enhancing soft tissue posterior to the L3 and L4
vertebral bodies is compatible with epidural phlegmon or
granulation tissue as the
sequela of recent treated infection. No discrete abscess
formation.
2. There is enhancing STIR hyperintense signal of the medial
bilateral psoas muscles at the L4-L5 level, compatible with
infectious myositis. This appears to be minimally more
prominent when compared to examination ___.
3. Otherwise, relatively mild multilevel lumbar spondylosis as
described in the findings.
4. Additional findings as described above.
CXR ___: Left PICC tip is in themid SVC. Cardiac size is
normal. Retrocardiac
opacities have improved. There is no pneumothorax or pleural
effusion.
=========================
MICROBIOLOGY
=========================
No growth on any blood cultures at ___
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
Brief Hospital Course:
___ M with hx IVDU (fentanyl) who presented with lumbar epidural
abscess.
ACTIVE ISSUES:
# Epidural abscess: Patient with active IVDU presenting with
lumbar epidural abscess. No evidence clinically or on imaging of
cord compression. Imaging was reviewed by Interventional
Radiology team who felt that there was no drainable collection.
Initially treated with vanc/cefepime. A TTE was performed and
showed no abnormalities; TEE deferred as unlikely to change
management. Neurosurgery consulted and recommended nonoperative
management; infectious disease team was consulted and followed
patient. Cultures speciated to ___ and patient was narrowed to
nafcillin for planned 6-week course (for MSSA epidural abscess
with
concern for underlying osteo). A repeat MRI L-spine and CRP were
performed due to fever on ___ these showed no clinically
significant change from prior and patient had no further fevers.
He was discharged with PICC in place to ___ to complete his
IV antibiotic course.
# Back pain: Likely in the setting of epidural disease, myositis
in the lumbar spine region. His pain was controlled with: APAP
1000mg q8h, gabapentin (uptitrated over time to 800mg TID),
oxycodone 15mg q4h:prn, tizanadine 4mg TID, lidocaine patch, hot
packs.
# ___: Patient presented at baseline creatinine which then
increased and peaked at 1.6. This was thought to be
multifactorial, with volume depletion, supratherapeutic
vancomycin, and toradol all playing a role. Downtrending at time
of discharge (Creatinine 1.4).
# First-degree / Mobitz I AV block:
# Bradycardia:
Patient with bradycardia on ECG with PR interval ~280.
Intermittently in ___. Prior EKGs from ___ were
reviewed and AV block appears to be baseline for him, likely in
the setting of nodal blockade with high methadone dose. As above
TTE showed no valvular abnormalities.
# IVDU: At baseline patient on methadone 105mg daily, ___
clinic ___ ___. Patient with ongoing active
IVDU (using fentanyl on top of his methadone), patient states
would like to quit using but that his living situation with
people around him using is a major impediment to cessation.
# Diarrhea/Constipation: Patient had severe constipation on
presentation with ongoing constipation in the setting of opioid
usage. Was given regimen of standing senna/Colace/miralax with
magnesium citrate PRN.
TRANSITIONAL ISSUES:
- Will complete 6-week course of IV nafcillin 2gm q4h (last day
___
- Discharge pain regimen: acetaminophen 1000mg Q8H, lidocaine
patch and hot packs, tizanadine, oxycodone 15mg q4h:prn,
gabapentin 800mg TID
- ___ start topical diclofenac gel if needed for better pain
control
- When back pain improves, please wean off oxycodone and change
tizanadine to PRN.
- Omeprazole 20mg daily started for GERD. If symptoms resolve
please discontinue PPI.
- Discharge Cr: 1.4. Please re-check 1 week after discharge and
ensure continued downtrend.
- Please provide narcan script and resources for opioid
cessation on discharge
- Please ensure discharge with a bowel regimen of senna,
docusate, and miralax to prevent constipation as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Methadone (Concentrated Oral Solution) 10 mg/1 mL 105 mg PO
DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Cyclobenzaprine 5 mg PO TID spasm
3. Docusate Sodium 200 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Nafcillin 2 g IV Q4H
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 17.2 mg PO BID constipation
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
12. Methadone (Concentrated Oral Solution) 10 mg/1 mL 105 mg PO
DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Epidural abscess
First-degree heart block
Constipation
SECONDARY DIAGNOSIS:
Opioid use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to a collection of infected fluid
in your back. You were evaluated by our infectious disease
doctors and we treated you with IV antibiotics. You were
discharged to ___ for continued treatment with antibiotics.
Please work with the doctors at ___ to continue your care.
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
10726413-DS-9
| 10,726,413 | 27,476,782 |
DS
| 9 |
2191-11-25 00:00:00
|
2191-11-25 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ativan
Attending: ___.
Chief Complaint:
headache, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
Ms. ___ is a ___ year-old right-handed woman with PMH
significant for right posterior parietal lobe hemorrhage
(believed to be due to amyloid during admission in ___ given
scattered foci of microbleeds on MRI), CAD s/p 2 stents,
bilateral carotid stenosis, HTN, and HLD who presented to OSH
with dizziness and headache and who was transferred to ___
after small SAH noted on NCHCT. She was not clear as to exactly
why she went to the hospital, but according to transfer records,
she was dizzy (described as a room spinning sensation) worse
with
positional changes and movement of her head. She says she
vomited
yesterday and felt nauseated this morning as well as a had a
frontal headache. In addition, she says she is having visual
hallucinations frequently for the past 3 weeks. It is unclear if
she was having any hallucinations prior to this. She has been
seeing children in ballet outfits as well as women in dresses
and
big hats, in addition to others. She says she knows these are
not
real and while the images are not scary, she notes they do
bother
her. The ED staff spoke with nursing in her PCP office, who
noted
that she was recently d/c from rehab back to her retirement home
(___). She is reportedly easily confused and has mild
dementia. They note she has been refusing to take her
medications. She was noted to have fallen recently with fracutre
of her right hip (according to transfer records, she had right
hip replacement in ___.
Neuro ROS: Positive for headache, vertigo, and visual
hallucinations. No loss of vision, blurred vision, diplopia,
dysarthria, dysphagia. She notes hearing difficulty in her right
ear but no tinnitus. No difficulties producing or comprehending
speech. No focal weakness, numbness, parasthesiae. No bowel or
bladder incontinence or retention.
She is able to ambulate with a walker at her retirement house.
General ROS: Positive for vomiting yesterday and persistent
nausea. No fever or chills. No cough, shortness of breath, chest
pain or tightness, palpitations. No diarrhea, constipation or
abdominal pain. No dysuria. No rash.
Past Medical History:
-right posterior parietal hemorrhage
-amyloid angiopathy
-CAD s/p 2 stents
-carotid stenosis bilaterally
-HTN
-HLD
-hypothyroidism
-s/p appendectomy
-s/p cholecystectomy
-s/p right hip replacement (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam:
Vitals: T: 97.5 P: 54 R: 14 BP: 130/73 SaO2: 96%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Skin: no rashes or lesions noted.
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Difficulty providing HPI. Attentive, able to name ___ backward
without difficulty. Able to follow both midline and appendicular
commands. No right-left confusion. Able to register 3 objects
and
recall ___ at 5 minutes. No evidence of apraxia or neglect.
Unable to learn Luria sequence. Notes she is having active
visual
hallucinations.
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
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.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Decreased hearing to finger rub on right.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk. Increased tone in ___ b/l. Both arms drift
slightly (R>L), no pronation noted. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- ___ ___ 5 5- 5 5
R 5- 5- 5- 5- ___ 5 4+ 5- 5
Sensory: No deficits to light touch. There is mild decreased
pinprick in L5 distrubtion on left. Decreased proprioception at
great toe b/l.
DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 0
R 3 2 3 2 0
No clonus. Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF. RAMs intact b/l.
Gait: deferred.
**********
Laboratory Data:
WBC 7.2 Hb 12.5 Hct 37.0 Plt 680
Na 141 K 4.6 Cl 104 CO2 28 BUN 18 Cr 0.6 Glu 110
___ 11.0 PTT 30.2 INR 1.0
UA: 6 WBC, trace ___, few bacteria
EKG: NSR @ 55, t wave inversion V1-V2.
Radiologic Data:
NCHCT: small focus SAH in left frontal sulcus
Pertinent Results:
___ 10:45AM ___ PTT-30.2 ___
___ 10:45AM PLT COUNT-680*#
___ 10:45AM NEUTS-77.1* LYMPHS-16.2* MONOS-5.2 EOS-0.6
BASOS-0.8
___ 10:45AM WBC-7.2 RBC-4.31 HGB-12.5 HCT-37.0 MCV-86
MCH-29.1 MCHC-33.9 RDW-12.4
CTA:
. Small focus of subarachnoid hemorrhage in the left frontal
lobe as
described above, which appears unchanged from that seen on the
outside
hospital CT. Review of previous MRI images from ___ reveals
multiple
microhemorrhages and lobar hemorrhage. Given the pattern of
hemorrhage,
amyloid angiopathy with leptomeningeal involvement appears to be
the most
likely etiology of subarachnoid hemorrhage.
2. Atherosclerotic changes in bilateral internal carotid
arteries, otherwise unremarkable CTA of the head.
3. Confluent bilateral periventricular white matter
hypodensities likely
represent small vessel ischemic disease.
MR: ___ of microhemorrahges, no obvious venous sinus
thrombosis
___ 04:50AM BLOOD WBC-7.8 RBC-3.95* Hgb-11.4* Hct-33.5*
MCV-85 MCH-28.9 MCHC-34.2 RDW-12.6 Plt ___
___ 10:40AM BLOOD WBC-9.8 RBC-4.46 Hgb-12.8 Hct-37.8 MCV-85
MCH-28.7 MCHC-33.9 RDW-12.3 Plt ___
___ 04:50AM BLOOD Glucose-108* UreaN-24* Creat-0.7 Na-141
K-4.0 Cl-110* HCO3-25 AnGap-10
___ 10:40AM BLOOD Glucose-129* UreaN-20 Creat-0.7 Na-136
K-3.8 Cl-100 HCO3-26 AnGap-14
___ 05:25AM BLOOD ALT-19 AST-28 TotBili-0.6
Brief Hospital Course:
The patient was admitted with with nausea and vomiting over the
last ___ days. She was initially sent to an OSH where on a
routine CT scan of the brain she was found to have a small
subarachnoid hemmorhage on the left frontal convexity. There
was no history of trauma (although she did fall a few months ago
resulting in a hip fracture). As there was no clear trauma a
CTA was obtained to rule out any anuerysm - which was normal.
She had evidence of amyloid angiopathy on an MRI scan in ___
and it is thought that this could be the source of the bleed (As
it was likely the cause of her right occipital hemorrage in
___. She had a repeat MRI and MRV which did not show evidence
of cortical vein thrombosis, but did show a worsening of her
microbleeds, likely a result of her amylodosis.
She was also noted to sundown and have episodes of confusion.
It seems that this has been an issue for some time. We had ___
evalaute her safety to return home and they found that she
should not return to her assisted living, and would be safer in
a skilled nursing facility. This was arranged by her family.
She was confused and we decided to hold her evening temaezpam.
She had one night were she became confused and required a small
dose of ativan, but otherwise has not needed any benzos. Should
she have anxiety this can be readdressed at the SNF, although a
non-benzodiazapine medication for sleep would be preferred.
She also had a borderline postive UA, that given her confusion
we decided to treat. She was started on Bactrim, but a repeat
UA in two days was still positive and she was switched to
ceftriaxone. Her urine culture was negative so her ceftriaxone
was stopped. Her white count and platelets rose while she was an
inpatient, which we think is like a result of the subarachnoid
blood, and they began to trend down on their own.
We recommend that she not be started on any antiplatelet agents
given her bleeding history.
Medications on Admission:
-Xanax 0.25 mg bid
-Vit C 500 mg daily
-Vit B12 50 mcg daily
-Vit D 1000 units daily
-Temazepam 15 mg qhs
-Atenolol 50 mg daily
-Levothyroxine 50 mcg daily
-Simvastatin 20 mg daily
-donepezil 10mg qhs
Discharge Medications:
1. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
7. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation.
9. temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
sub arachnoid hemorrhage
amyloid angiopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
She is usually attentive although at night can become confused.
Often thinks she is in her own house. CN: intact, motor:
intact: gait: walks slightly hunched with walker
Discharge Instructions:
You were admitted with nausea and vomiting over the last ___
days. You were found on a routine head CT, to have a small
bleed on the surface of your brain. This is called a
subarachnoid hemmorhage. It is very small and likely not
causing you any disability. These bleeds are usually do to head
trauma, but we have no history of you having any trauma. These
bleeds are also associated with a condition called amyloid
angiopathy, which results in a number of very small bleeds
within the brain. It appears based on the MRI that you have
this condition. This condition is also assoiciated with
dementia of which you also seem to have. There is no particular
treatment for this condition, we will just follow you in clinic.
You also had a urine analysis that indicated that you may have
a small urinary tract infection. We started you on a medication
called Bactrim, but switched to an IV medication called
ceftriaxone. We Your cultures were negative so there is no need
for further antibiotics.
We made no changes to your medication, although held your
benzodiazepines while you were in the hospital. You did not
show any signs of withdrawal.
You may resume your home medications of xanax and temazepam.
Please use these medications with caution as they can cause
confusion.
We recommend that you not be put on any antiplatelet agents,
such as aspirin given your history of bleeding
Please keep all follow up appointments. Take your medication as
perscribed. If you have any of the warning signs listed below,
please call your doctor or return to the nearest ED.
Followup Instructions:
___
|
10726562-DS-17
| 10,726,562 | 22,056,507 |
DS
| 17 |
2143-07-10 00:00:00
|
2143-07-10 18:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
grass pollen
Attending: ___.
Chief Complaint:
Bilateral hip pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of right acetabular fracture,
examination under anesthesia of left
History of Present Illness:
___ in high speed head-on collision going down ___
in the wrong direction, EtOH+, car totaled. 6min extrication. On
arrival awake and following commands but intoxicated.
Complaining
of R-sided low back pain and right hip pain. +palpable pulses
and
good sensation as far as could be ascertained by ED but exam
unreliable as was agitated. No other injuries aside from hand
abrasion.
Past Medical History:
asthma
Social History:
___
Family History:
NC
Physical Exam:
NAD
Breathing comfortably
RRR as assessed peripherally
Right lower extremity:
Dressings intact
Not firing ___ fires ___
Palp DP pulse
SILT DPN/SPN
Left lower extremity:
Dressings intact
Fires ___
Palp DP pulse
SILT DPN/SPN
Pertinent Results:
___ 04:20AM URINE HOURS-RANDOM
___ 04:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:20AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 04:20AM URINE MUCOUS-RARE
___ 03:35AM PO2-50* PCO2-45 PH-7.31* TOTAL CO2-24 BASE
XS--3
___ 03:20AM UREA N-17 CREAT-1.2
___ 03:20AM estGFR-Using this
___ 03:20AM LIPASE-75*
___ 03:20AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:20AM WBC-10.6* RBC-4.98 HGB-15.4 HCT-46.1 MCV-93
MCH-30.9 MCHC-33.4 RDW-12.9 RDWSD-42.9
___ 03:20AM PLT COUNT-296
___ 03:20AM ___ PTT-21.8* ___
___ 03:20AM ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right posterior hip dislocation acetabular fracture and
left acetabular fracture. His hip was closed reduction and ___
was placed into skeletal traction and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of right acetabular fracture and examination under anesthesia,
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 ___ 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
WBAT in the left lower extremity, TDWB in right 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:
Albuterol prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*80 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral acetabular fractures, right hip dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
Weight bearing as tolerated on the left lower extremity, touch
down weight bearing of right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox for 4 weeks to prevent blood clots.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please change your dressing only as needed for drainage.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Weight bearing as tolerated on left leg; touch down weight
bearing of right leg; ROMAT at all joints; encourage PROM and
right foot exercises for foot drop
Treatments Frequency:
Dressing changes as needed for soiled dressing
Followup Instructions:
___
|
10726620-DS-21
| 10,726,620 | 23,442,663 |
DS
| 21 |
2186-12-22 00:00:00
|
2186-12-22 15:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ - sigmoidoscopy
___ - EGD/colonoscopy
History of Present Illness:
Ms. ___ is a ___ female with a PMHX of Crohn's
disease, previously on adalimumab, hx of diverticulitis who
presents with abdominal pain.
Patient reports severe ___ sharp abdominal pain starting just
below the umbilicus radiating to the RUQ, associated with nausea
and vomiting that started last night. Reports it has
progressively gotten worse.
Patient with hx of Crohn's Disease. She previously received care
from ___ doctor in ___, but moved to ___ a month ago and
has not established medical care. Last flare was a year ago. She
previously was on humira and omeprazole, but has not taken it in
the past 8 months as she did not follow up with her doctor. She
states this pain feels just like her previous Crohn's flare in
which she often was admitted for a week. She denies any fevers,
chills. Has vomited multiple times, denies any hematemesis.
Unable to tolerate PO. Denies chest pain, dyspnea. Reports
diarrhea mixed with blood, has had 2 episodes today. Denies
dysuria. Not taking any NSAIDs.
In the ED, initial VS: 96.5 74 ___ 100% RA
Exam notable for uncomfortable patient, writhing in pain. Abd is
soft with diffuse tenderness in LLQ.
Labs notable for WBC 13.1, hgb 11.6, plt 153. Chem panel was Cr
0.7. Bicarb of 14. Lactate was 2.9 -> 6.0 -> 3.8.
CT A/P
Mild hyperemia and bowel wall thickening involving the region of
the
descending colon, cecum, and the terminal ileum, which can be
seen in the setting of inflammatory bowel disease.
GI was consulted: recommended NPO/bowel rest, CTX/flagyl, quant
gold, hep B serologies, c. diff/stool cultures. If c. diff
negative, can start IV methylpred 20mg q8h.
Patient given morphine 4mg IV x1, IV dilaudid 1mg x6, Zofran 4mg
x2, 4L IVF, CTX/flagyl
Upon arrival to the floor, she reports hx as above. She
continues
to have severe pain, stating that the IV dilaudid took the edge
off of her pain. She is not sure if she can have another BM as
she has not eaten anything.
Past Medical History:
Crohn's disease
History of appendectomy
Hx of tubal ligation
Hx of hernia repair
C- section x 2
Social History:
___
Family History:
Father and brother with Crohn's Disease
Physical Exam:
ADMISSION EXAM:
VITALS: 98.1 112/59 69 18 98% RA
GENERAL: Moving around persistently ___ pain
EYES: Anicteric, PERRL
ENT: Ears and nose unremarkable. MMM
CV: RRR. S1, S2. No mrg
RESP: Unlabored breathing. CTA b/l
GI: +BS. Soft, tender diffusely. No rebound, guarding, or
rigidity
GU: foley not present
MSK: WWP. No ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric. Speech fluent, moves all
limbs.
DISCHARGE EXAM:
GENERAL: Sitting in bed, holding abdomen
EYES: Anicteric, PERRL
ENT: Ears and nose unremarkable. MMM
CV: RRR, S1, S2. No r/m/g
RESP: CTAB
GI: Diffuse mild abdominal tenderness, most notable in bilateral
lower quadrants. Abd soft, no rebound/guarding.
MSK: WWP. No ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric. Speech fluent, moves all
limbs.
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-13.1* RBC-3.97 Hgb-11.6 Hct-35.1
MCV-88 MCH-29.2 MCHC-33.0 RDW-12.6 RDWSD-40.5 Plt ___
___ 09:22AM BLOOD Glucose-158* UreaN-15 Creat-0.8 Na-139
K-5.5* Cl-107 HCO3-12* AnGap-20*
___ 07:25AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
___ 11:12AM BLOOD Lactate-2.9*
___ 02:54PM BLOOD Lactate-6.9*
RELEVANT IMAGING:
___ CT A/P w/contrast:
IMPRESSION:
Equivocal mild wall thickening and stranding at the terminal
ileum, which
could represent very mild active IBD. No focal fluid collection
or fistula.
No obstruction.
___ CT A/P w/contrast:
IMPRESSION:
1. Mild active inflammatory changes of a short segment of the
proximal
ascending colon, which can be seen in the setting of
inflammatory bowel
disease. No evidence of stricture, upstream dilatation, or
penetrating
disease.
2. Mild degenerative changes along the inferolateral aspect of
the left
sacroiliac joint are nonspecific. Clinical correlation
recommended.
3. New small right and trace left pleural effusions.
EGD ___
Normal mucosa in the whole esophagus.
Erythema, congestion, and friability in the stomach body and
fundus compatible with gastritis
Normal mucosa in the whole examined duodenum
Congestion and erythema in the duodenal bulb compatible with
duodenitis
Colonoscopy ___
One erosion in terminial ileum and 2 erosions each at 40 cm and
20 cm in the colon
PATHOLOGY
Path:
1. Distal esophagus:
-Squamous epithelium within normal limits.
2. Stomach fundus:
-Fundic mucosa within normal limits.
3. Duodenal bulb:
-Duodenal mucosa with focal surface foveolar metaplasia,
suggestive of peptic injury. No active
inflammation identified
4. Duodenum:
-Duodenal mucosa within normal limits.
5. Terminal ileum:
-Small intestinal mucosa within normal limits.
6. Cecum:
-Colonic mucosa within normal limits.
7. Ascending colon:
-Colonic mucosa within normal limits
8. Transverse colon:
-Colonic mucosa within normal limits.
9. Descending colon:
-Colonic mucosa within normal limits.
10. Sigmoid colon at 40 cm:
-Colonic mucosa within normal limits.
11. Sigmoid colon erosion at 40 cm:
-Colonic mucosa within normal limits.
12. Colon at 20 cm:
-Colonic mucosa with crypt regeneration, consistent with mucosa
adjacent to an erosion. No
significant active inflammation.
13. Rectum:
-Colonic mucosa within normal limits. See note.
Note: No granulomata or dysplasia identified in any of the
biopsies.
LAB RESULTS ON DISCHARGE:
___ 06:20AM BLOOD WBC-8.3 RBC-4.04 Hgb-11.6 Hct-35.1 MCV-87
MCH-28.7 MCHC-33.0 RDW-13.2 RDWSD-41.5 Plt ___
___ 06:20AM BLOOD Glucose-103* UreaN-6 Creat-0.5 Na-145
K-3.6 Cl-105 HCO3-25 AnGap-15
___ 06:20AM BLOOD ALT-17 AST-14 AlkPhos-50 TotBili-0.3
___ 06:20AM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.9 Mg-1.9
___ 10:00AM BLOOD CRP-2.6
___ 11:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:55AM BLOOD Lactate-1.0
___ 07:25AM BLOOD QUANTIFERON-TB GOLD-Test
Brief Hospital Course:
___ female with a reported PMHX of Crohn's disease
(unknown phenotype and extent, previously on adalimumab),
multiple abdominal surgeries, and hx of diverticulitis who
presented with severe abdominal pain, vomiting and diarrhea,
with work up only notable for gastritis, duodenitis, and
colonic/ileal erosions thought inactive Crohn's.
# Abdominal pain
# Reported history of Crohn's disease
Patient with reported history of Crohn's disease (unknown
phenotype and extent, previously on adalimumab, stopped 8 months
ago due to concern for side effects).
___ presented with ___ sharp abdominal pain associated with
nausea and vomiting.
Lactate of 6 on admission, downtrended to normal with IVF. She
underwent sigmoidoscopy on ___ with question of mild colitis
(possible mild architectural distortion and loss of vascularity
in the sigmoid colon), and was initially on a dilaudid PCA. GI
was consulted.
Initially clinically improving, then had recurrence of severe
pain associated with vomiting and diarrhea. CT enterography
revealed evidence of mild colitis in a short segment of the
proximal ascending colon; no evidence of stricture, upstream
dilatation, or penetrating disease. CRP only 2.6, infectious
studies (stool cultures and C. diff) were negative. She
underwent EGD and colonoscopy which showed gastritis,
duodenitis, and colonic and ileal erosions. In discussion with
GI, her pain cannot be explained by these findings --they may
represent inactive Crohn's. They recommend pantoprazole 40 mg
BID x ___ weeks. She did not receive steroids this stay
(although as previously had some question of Crohn's, sent quant
gold- negative, hepatitis B non immune).
In discussion with GI, there is no indication for further
imaging or procedures, but would establish care with outpatient
gastroenterology given history of Crohn's disease; no obvious
organic cause.
We considered other items such as intermittent bowel obstruction
given intermittent nature, given multiple abdominal surgeries
including tubal ligation, cholecystectomy, hernia repair,
C-section x 2, as well as appendectomy. However, she continued
to pass/BM and previously findings of bowel obstruction on
imaging.
Report of worsening pain after eating also makes one consider
etiologies such as ischemia, although she is young and has no
particular risk factors and imaging not suggestive.
Considered possible gynecological cause, but patient is s/p
tubal ligation, hcg negative, diffuse pain, no vaginal
discharge, making this less likely.
Hence, she was treated symptomatically. Her pain improved and
she was able to be weaned off hydromorphone PCA, and actually
reported more relief with simethicone for bloating. Course was
complicated by opioid induced constipation, but she was able to
have BM prior to discharge; no further episodes of nausea,
vomiting, or diarrhea. She tolerated regular diet and was
ambulating the halls without difficulty. She is discharged OFF
opioids.
# E coli UTI: She was found to have an E. coli UTI and received
IV ceftriaxone x 3 doses. No urinary symptoms at time of
discharge.
# Concern for administration of ?outside substances
On morning of day of discharge, RN witnessed patient go into
public floor bathroom
with significant other and stay for several minutes. Afterwards
appeared very unsteady and drowsy, with report of pinpoint
pupils in slurred speech.
We asked patient and spouse whether they had taken any
medications/substances in the bathroom, which both vehemently
denied. Husband endorsed exhaustion from working so much and
proceeded to empty his bag. Bathroom was searched, no drug
paraphernalia found. Upon my evaluation several minutes
afterwards, patient was at baseline mental status and denied any
symptoms- reported that she went to the bathroom and strained to
have BM and husband had to help her. Both patient and husband
were quite upset at interaction. Husband stated that he works in
recovery and was visibly offended. We explained that this was
done to ensure safety for both patient and spouse given mental
status change.
Note that patient was discharged off opioid medication, as no
indication for these medications, concern that it would worsen
abdominal pain by contributing to slow transit.
TRANSITIONAL ISSUES:
====================
[] Started pantoprazole 40 mg BID x 10 weeks for
gastritis/duodenitis, also continued sucralfate 1 g QID
[] Simethicone PRN for bloating, calcium carbonate 500 mg QID
for reflux and abdominal distension, miralax daily PRN for
constipation
[] Patient given script for ondansetron 4 mg q8H PRN although
did not require for 48 hours prior to D/C, QTc was 412
[] Follow up with gastroenterology pending at discharge
[] Please note patient is hepatitis B non-immune, consider
vaccination
[] Yersinia enterocolitica antibodies pending at discharge
[] Incidental finding: Mild degenerative changes along the
inferolateral aspect of the left sacroiliac joint are
nonspecific. At this time patient denied back pain to me, but
please note that in setting of ?history of Crohn's disease could
consider IBD associated arthritis
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Calcium Carbonate 500 mg PO QID:PRN reflux, abd discomfort
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: PO dose; IV only if unable
to tolerate PO
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*120 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Refills:*0
6. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg 80 mg by mouth four times a day Disp #*80
Tablet Refills:*0
7. Sucralfate 1 gm PO QIDACHS
RX *sucralfate 1 gram 1 tablet(s) by mouth With meals and at
night Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
History of Crohn's disease
Opioid induced constipation
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 came here initially due to sharp abdominal pain, loose
stools, and inability to eat. While you were here, you were seen
by our gastroenterologists, and we performed multiple studies
including CT scan, EGD, and a colonoscopy. Initially we were
wondering if it could be related to your history of Crohn's
disease given some mild inflammatory changes on your CT scan,
however, the EGD and colonoscopy only revealed some gastritis
and duodenitis (irritation of your stomach lining and part of
your small intestine), as well as some erosions. Your
inflammatory markers were negative, and stool cultures were also
negative. In discussion with our gastroenterologists, they did
not think that these findings explained your abdominal pain, and
it was also not thought that there is any evidence of active
Crohn's disease.
We managed your symptoms with medications, and started you on
anti-reflux medications to treat the gastritis and duodenitis.
At time of discharge you were able to tolerate an oral diet,
abdominal pain had improved, and you had no further episodes of
diarrhea.
You will need to follow up with your primary care doctor ___
arranged for a new one given that you just moved here from ___
___), as well as the gastroenterologists.
Please take care, we wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10726697-DS-17
| 10,726,697 | 29,454,014 |
DS
| 17 |
2149-05-12 00:00:00
|
2149-05-12 10:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
___ ERCP with sphincterotomy and stent placement
attach
Pertinent Results:
ADMISSION LABS
___ 02:32PM RET AUT-1.2 ABS RET-0.05
___ 02:32PM PLT SMR-LOW* PLT COUNT-66*
___ 02:32PM ANISOCYT-1+* POIKILOCY-1+* ECHINO-1+*
ACANTHOCY-1+*
___ 02:32PM NEUTS-73* BANDS-13* LYMPHS-5* MONOS-7 EOS-0*
___ METAS-2* AbsNeut-7.74* AbsLymp-0.45* AbsMono-0.63
AbsEos-0.00* AbsBaso-0.00*
___ 02:32PM WBC-9.0 RBC-4.03* HGB-12.0* HCT-37.6* MCV-93
MCH-29.8 MCHC-31.9* RDW-15.9* RDWSD-55.0*
___ 02:32PM ALBUMIN-3.1*
___ 02:32PM cTropnT-0.06*
___ 02:32PM LIPASE-15
___ 02:32PM ALT(SGPT)-203* AST(SGOT)-155* ALK PHOS-172*
TOT BILI-6.8* DIR BILI-3.4* INDIR BIL-3.4
___ 02:32PM estGFR-Using this
___ 02:32PM GLUCOSE-96 UREA N-45* CREAT-2.9* SODIUM-141
POTASSIUM-5.2 CHLORIDE-109* TOTAL CO2-19* ANION GAP-13
___ 02:39PM ___
___ 02:42PM LACTATE-1.7
___ 02:42PM COMMENTS-GREEN TOP
___ 09:27PM calTIBC-217* FERRITIN-404* TRF-167*
___ 09:27PM PHOSPHATE-2.8 MAGNESIUM-1.6 IRON-16*
___ 09:27PM cTropnT-0.07*
___ 09:27PM LIPASE-45 GGT-301*
___ 09:27PM ALT(SGPT)-183* AST(SGOT)-136* LD(LDH)-170 ALK
PHOS-174* TOT BILI-7.2*
___ 09:27PM GLUCOSE-76 UREA N-45* CREAT-2.9* SODIUM-143
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
IMAGING
___ CXR -- IMPRESSION: Small bilateral pleural effusions
and minimal atelectasis in the lung bases. No focal
consolidation to suggest pneumonia.
___ Abdominal U/S -- IMPRESSION: Biliary dilatation
concerning for a distal obstructing process. Mid to distal
extrahepatic biliary ducts and pancreatic head region are not
well visualized with this modality, however. If needed
clinically, MRCP may be very helpful to evaluate the findings
further, which may imply either distal ductal stones or
obstructing malignancy. Poor visualization of the gallbladder,
which probably corresponds to a shadowing structure implying
porcelain gallbladder. Mildly enlarged spleen of uncertain
significance.
___ MRCP -- IMPRESSION: Choledocholithiasis with marked
biliary dilatation. Subtotal cholecystectomy versus very small
gallbladder containing a stone.
___ DUPLEX LIVER -- IMPRESSION: 1. Limited examination of
the hepatic parenchyma due to pneumobilia and biliary ductal
dilatation. Within these limitations, there is normal hepatic
blood flow. 2. Marked short-term decrease in dilatation of the
biliary system following interval ERCP. 3. Redemonstrated
splenomegaly, measuring up to 14.2 cm. 4. Mildly echogenic
liver suggesting a parenchymal abnormality.
___ CTA PANCREAS -- IMPRESSION: 1. Common bile duct stent
with extensive left-sided pneumobilia, suggestive of stent
patency. 2. Subtotal cholecystectomy versus very small
gallbladder, without evidence of stones identified. Correlation
with surgical history is recommended.
3. Minimal intrahepatic biliary dilatation, substantially
improved from prior studies. 4. Mild circumferential bladder
wall thickening. Correlation with urinalysis is recommended.
5. Small bilateral pleural effusions with adjacent compressive
atelectasis. 6. Mild splenomegaly measuring up to 14.0 cm.
7. Mild prostatomegaly.
___ TTE -- IMPRESSION: 1) Grade III LV diastolic
dysfunction wtih elevated LVEDP as well as possible RA pressure
overload suggests biventricular congestive heart failure in
setting of normal radial and low normal longitudinal global LV
systolic function. 2) Mild concentric left ventricular
hypertrophy. 3) Longitudinal myocardial strain reduced in LCX
territory together with > 20% post-systolic shortening
suggestive of CAD in the LCX territory.
PROCEDURE
___ -- Mucosa suggestive of ___ esophagus.
Successful ERCP with sphincterotomy, extraction of sludge and
plastic biliary stent insertion as described above. No distinct
stones extracted. Differential diagnosis for clinical
presentation includes passed stones, missed stones or ampullary
lesion less likely. Recommendations: Return to inpatient ward
for ongoing care. N.p.o. overnight with IV hydration using LR,
if no abdominal pain in the morning advance diet to clear
liquids and then advance as tolerated. Recommend surgical
evaluation for possible cholecystectomy of complete gallbladder
in situ. Trend LFTs. Repeat ERCP plus minus EUS pending MRCP
final read in ___ weeks for stent removal and reevaluation.
PATHOLOGY
___ Tissue: GASTROINTESTINAL MUCOSAL BIOPSY -- PENDING
MICROBIOLOGY
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
DISCHARGE LABS
Brief Hospital Course:
___ man w/PMHx 3V CABG ___ ___, HTN, possible
CKD, rectal mass s/p XRT, colectomy and consolidative
chemotherapy ___ (which may have turned out to have been a
benign rather than malignant tumor, was treated at ___,
admitted for 3 days of sharp constant upper abdominal pain with
radiation to the back, now intermittent, with obstructive LFTs
and imaging evidence of biliary dilation. Now s/p ERCP which
showed no stones.
He underwent further evaluation by Cardiology and the Acute Care
Surgery consult teams. Ultimately, it was decided that he could
leave the hospital and follow-up in clinic for the results of
his tests and next steps in his care plan.
Discharge day exam:
AVSS
Older man lying in bed, awake, alert, cooperative, NAD.
Slightly
icteric, MMM.
Equal chest rise, CTAB, no work of breathing or cough.
Heart regular.
Abdomen soft, nontender to palpation, extremities warm and
well-perfused.
DETAILS BY PROBLEMS
#Suspected biliary obstruction/choledocholithiasis
#MRCP: "Choledocholithiasis with marked biliary dilatation.
Subtotal cholecystectomy versus very small gallbladder
containing a stone."
#ERCP without stones, sphincterotomy done, stent placed
-He was able to advance his diet without difficulty after the
ERCP
-He will need to f/u w/ERCP in ___ weeks for stent pull and
perhaps EUS
-CTA pancreas added no new information beyond what the MRCP had
shown
Tumor marker testing revealed an elevated ___, but a normal
CEA
-The pathology from the ERCP was still pending at time of
discharge and will be discussed with patient in ___ clinic
appt.
___ on suspected CKD, improving
#Non-gap metabolic acidosis consistent with kidney disease
Although imaging showed slight prostatomegaly, he had no signs
of hydronephrosis
-UA with only small amt of hematuria (for which a UA should be
repeated as an outpatient, with referral to Urology if the
hematuria persists), no WBCs, small amt of protein, and urine
electrolytes show FeNa 0.5%, UNa 38, so a mixed picture
-SPEP showed hypogammaglobulinemia, UPEP was never sent and can
be followed up in clinic if indicated.
#Moderately severe thrombocytopenia, stable
#Mild normocytic anemia, hypoproliferative
#Mild leukopenia
#Mildly enlarged spleen of uncertain significance
#Mild coagulopathy
-Labs were inconsistent with hemolysis, no schistocytes were
seen on lab-read smear, and no signs of DIC (fibrinogen normal)
-Hep B serologies all negative (not hep B immune), hep C
negative, HIV negative
-gave some vitamin K with normalization of INR
-suspect he may have some underlying liver disease from remote
heavy EtoH use, and his splenomegaly would be consistent with
this
-Right upper quadrant ultrasound with Doppler showed mildly
echogenic liver suggesting a parenchymal abnormality,
splenomegaly, and normal hepatic blood flow
-Ultimately, it was decided that pt could follow up in
___ clinic for further workup, including a Fibroscan to
examine for cirrhosis.
#Rectal mass s/p XRT, colectomy and consolidative chemotherapy
___ (which may have turned out to have been a benign rather
than malignant tumor, was treated at ___
#Chronic fecal incontinence, related to the above resection
-tried to obtain outside records from ___, but was
unsuccessful
#Non-MI troponin elevation
#3v CABG -- per ___ operative note, LIMA to LAD, SV to diag,
SV to obtuse marginal
#Hypertension
-Cardiology consulted
-ECGs only showed lateral T wave inversions, perhaps slight ST
depressions
-TTE was consistent with likely LCx disease
-Continued aspirin, metoprolol (fractionated), atorvastatin
-Held amlodipine, lisinopril given above noted process, which
can be restarted by outpatient doctors if ___
#Intermittent hypoglycemia
-suspect this was related to his intermittent NPO status
-his fingerstick blood glucoses were monitored and the
hypoglycemia resolved
#Scrotal Rash
-suspect this was related to his chronic fecal incontinence
(which is from the surgery noted above)
-suspected was due to ___, was given miconazole powder
#Microscopic hematuria
-recommend repeat UA as outpatient
#GERD
-continued home pantoprazole
[X] The patient is safe to discharge today, and I spent []
<30min; [X] >30min in discharge day management services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Pantoprazole 40 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
Hold for K >
8. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until your doctor tells you to.
9. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until your doctor tells you to.
Discharge Disposition:
Home
Discharge Diagnosis:
#Biliary obstruction
#Acute renal failure from dehydration
#Thrombocytopenia
#Non-MI troponin elevation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with obstruction of your bile ducts. You
underwent a procedure (ERCP), and a stent was placed to relieve
the obstruction and help your liver drain. You were also found
to have significant acute renal failure, likely related to
dehydration. With IV fluids and time, you improved. You were
also evaluated by the surgeons and Cardiology. Ultimately it
was decided that you could leave the hospital and follow-up in
clinic to determine the next steps for your care.
It will be important to follow-up as noted below. Please stay
hydrated.
Followup Instructions:
___
|
10726866-DS-5
| 10,726,866 | 20,979,482 |
DS
| 5 |
2193-01-03 00:00:00
|
2193-01-03 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ P / Penicillins
Attending: ___.
Chief Complaint:
dyspnea, wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMH significant for asthma, HTN, HLD,
glaucoma, s/p thyroidectomy, and OSA on home BiPap who presented
with increased difficulty breathing, wheezing, and dry cough
concerning for an acute asthma exacerbation. The patient was see
in the ED one week prior, and given a short 5-day burst of
prednisone 50 mg daily, which she completed. Her symptoms had
not completely resolved, and continued having dyspnea, wheezing,
and dry cough, and her PCP then prescribed ___ second burst of
prednisone 10 mg for antoher 5 days in addition to newly
prescribed montelukast. She was walking to the pharmacy when she
became acutely dyspneic, and she was then taken to ___ ED. She
endorses nasal congestion and wheezing for the past week, and
denies fevers, chills, myalgias, sore throat, nausea, vomiting,
dysuria, or chest pain/pressure. Of note, the patient's peak
flows are normally in the 400 range.
In the ED, the patient was having increased difficulty
breathing, but did not require intubation (she has never been
intubated).
The flow prior to arrival was 250 her peak flows normally in the
400.
In the ED, initial vital signs were: 98.1 87 119/64 18 99% neb
- Exam notable for: diffuse wheezes, poor air movement
- Labs were notable for slightly elevated Ca and phos, normal
creatinine, slightly elevated blood glucose. U/A concerning for
infection (small leuk, WBC 9). Patient declined flu shot.
- CXR: low lung volumes and bibasilar atelectasis.
- Patient was given duonebs, solumedrol 125 mg IV x 1, magnesium
2mg IV x1, 1L NS, and home meds.
Peak flow improved to 330 after nebulization treatment. Patient
remained with poor air movement and decision made to admit to
medicine.
- Vitals on transfer: 97.8 72 133/60 18 95% RA
Past Medical History:
Airway: Mallampati Class III-->h/o difficult intubation
Asthma
Obstructive sleep apnea (being setup with BiPAP)
allergic rhinitis
arthritis (neck and low back)
s/p left tibial plateau fracture
Papillary thyroid cancer ___
Graves Disease ___
s/p subtotal thyroidectomy
hypercalcemia
GERD, PUD
hx of mild elevated LFTs
glaucoma
Bilateral reduction mammoplasty ___
Social History:
___
Family History:
brother - asthma
Physical ___:
Physical Exam on Admission:
Vitals- T 97.8 HR 69 BP 149/80 RR 19 SaO2 96%/RA
General: pleasant, sitting in bed in NAD
HEENT: PERLA, EOM intact, dry mucosa, clear oropharynx (not
fully visualized due to anatomy)
Neck: supple, no LAD, JVD not visualized
CV: RR, no murmurs, rubs, gallops
Lungs: mild expiratory wheezes bilaterally, moderate air
movement
Abdomen: soft, obese, non-tender to palpation, no guarding,
normal bowel sounds
GU: deferred; no foley
Ext: no cyanosis or edema
Neuro: grossly intact motor strength
PHYSICAL EXAM on DISCHARGE:
Vitals: 98.5 ___ 61-64 18 96-98/RA
General: NAD, speaking in full sentences, no increased WOB
HEENT: anicteric sclera, clear oropharynx, moist mucosa
Neck: supple, flat JVD
Lungs: CTAB, only wheezing when coughs
CV: RR, no murmurs, rubs, gallops
Abdomen: soft, non-distended, non-tender to palpation,
normoactive bowel sounds, no guarding
Ext: no edema or cyanosis
Pertinent Results:
LABS on ADMISSION:
___ 03:57PM BLOOD WBC-9.2# RBC-4.67 Hgb-15.1 Hct-43.4
MCV-93 MCH-32.3* MCHC-34.8 RDW-13.0 RDWSD-43.5 Plt ___
___ 03:57PM BLOOD Neuts-67.3 ___ Monos-7.6 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-6.19*# AbsLymp-2.11 AbsMono-0.70
AbsEos-0.08 AbsBaso-0.04
___ 03:57PM BLOOD ___ PTT-27.8 ___
___ 03:57PM BLOOD Plt ___
___ 03:57PM BLOOD Glucose-130* UreaN-16 Creat-0.8 Na-142
K-4.3 Cl-102 HCO3-24 AnGap-20
___ 03:57PM BLOOD Calcium-10.7* Phos-5.3*# Mg-2.1
LABS on DISCHARGE:
___ 07:52AM BLOOD WBC-8.9 RBC-4.19 Hgb-13.7 Hct-40.3 MCV-96
MCH-32.7* MCHC-34.0 RDW-12.9 RDWSD-45.2 Plt ___
___ 07:52AM BLOOD Plt ___
___ 07:52AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-139
K-3.6 Cl-102 HCO3-28 AnGap-13
___ 07:52AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.3
PERTINENT STUDIES:
- CXR (___):
Low lung volumes and bibasilar atelectasis
Brief Hospital Course:
Ms. ___ has a history of asthma, HTN, HLD, glaucoma, s/p
thyroidectomy, and OSA on home BiPap who presented with
increased difficulty breathing, wheezing, and dry cough
consistent with an acute asthma exacerbation.
ACUTE ISSUES:
# Asthma exacerbation: Patient had recently presented to the ED
about one week prior, and sent home with a 5-day course of
prednisone 5 mg for asthma exacerbation. She completed that
course on ___. Her symptoms had not improved, so her PCP
prescribed ___ second steroid burst and montelukast. Given
solumedrol in ED on ___. She will follow a 14-day tapered
course of prednisone 60 mg (start ___, end ___, continued
Ipratropium-Albuterol Neb 1 NEB NEB Q6H, Albuterol 0.083% Neb
Soln 1 NEB IH Q2H:PRN, montelukast 10 mg daily. Peak flow on
discharge was 320. Ambulatory O2 sat was 93%/RA.
# UTI: Patient has UA mildly concerning for UTI, although has no
dysuria. Will monitor. Follow up urine cx.
CHRONIC ISSUES:
# Hypothyrodism s/p thyroidectomy: Continued home synthroid ___
mcg daily.
# HLD: Continued home pravastatin 40 mg QHS.
# HTN: Patient's sbp on admission to floor was 149, although
normotensive in ED, and sbp 120s-130s while on floor. Patient is
not on anti-hypertensive agents at home. Will monitor blood
pressure.
# OSA: Patient has OSA and uses BiPap at home. Recommended CPAP
while inpatient.
TRANSITIONAL ISSUES:
- Please follow up with PCP regarding your recovery form asthma
exacerbation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. dorzolamide-timolol 22.3-6.8 mg/mL ophthalmic BID
6. Vitamin D 1000 UNIT PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
8. Multivitamins 1 TAB PO DAILY
9. biotin 10 mg oral DAILY
10. fluticasone-salmeterol 115-21 mcg/actuation inhalation BID
11. PredniSONE 40 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Montelukast 10 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
7. biotin 10 mg oral DAILY
8. dorzolamide-timolol 22.3-6.8 mg/mL OPHTHALMIC BID
9. fluticasone-salmeterol 115-21 mcg/actuation INHALATION BID
10. Multivitamins 1 TAB PO DAILY
11. Pravastatin 40 mg PO QPM
RX *pravastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
12. PredniSONE 60 mg PO DAILY Duration: 1 Dose
Take on ___
This is dose # 1 of 6 tapered doses
RX *prednisone 10 mg 6 tablet(s) by mouth DAILY Disp #*6 Tablet
Refills:*0
13. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Take on ___ and ___
This is dose # 4 of 6 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth DAILY Disp #*6 Tablet
Refills:*0
14. PredniSONE 50 mg PO DAILY Duration: 2 Doses
Take on ___ and ___
This is dose # 2 of 6 tapered doses
RX *prednisone 10 mg 5 tablet(s) by mouth DAILY Disp #*10 Tablet
Refills:*0
15. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Take on ___ and ___
This is dose # 5 of 6 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth DAILY Disp #*4 Tablet
Refills:*0
16. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Take on ___ and ___
This is dose # 6 of 6 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth DAILY Disp #*2 Tablet
Refills:*0
17. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Take on on ___ and ___
RX *prednisone 10 mg 4 tablet(s) by mouth DAILY Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Asthma exacerbation
Secondary:
Obstructive sleep apnea
Hyperlipidemia
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had worsening shortness of breath and wheezing, due
to an asthma exacerbation. We started you on a new medication,
montelukast 10 mg daily. We also started a course of steroids
and continued your home nebulizers. You will need to take
prednisone on a taper:
- ___: take 60 mg
- ___: take 50 mg
- ___: take 50 mg
- ___: take 40 mg
- ___: take 40 mg
- ___: take 30 mg
- ___: take 30 mg
- ___: take 20 mg
- ___: take 20 mg
- ___: take 10 mg
- ___: take 10 mg (last dose)
If you should have another episode of sudden onset shortness of
breath and wheezing that is getting worse, please call ___ and
see a doctor.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10726866-DS-6
| 10,726,866 | 28,720,032 |
DS
| 6 |
2193-01-13 00:00:00
|
2193-01-17 23:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Alphagan P / Penicillins
Attending: ___.
Chief Complaint:
asthma exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of asthma, OSA on home bipap, Graves (s/p
thyroidectomy), and glaucoma, who presents with worsening
dyspnea. Of note, patient had been evaluated x2 for dyspnea
previously this month, with one resulting in ED observation, and
the most recent presentation necessitating admission
___, discharged on prednisone taper from 60mg daily).
Patient currently reports taking 40mg PO prednisone daily. She
was seen by PCP today, with dyspnea, received Duo-Neb in office,
and was brought to ___ ED for further evaluation. Of note,
peak flow was 250 in PCP office today and was 320 on last
discharge. States that her baseline is around 400.
In the ED, initial vitals were:
98.4, 107, 160/82, 20, 94% on 2L NC
Pt dyspneic, with audible wheeze, nonproductive cough
Limited air entry bilaterally, inspiratory/expiratory wheezing
throughout all lung fields bilaterally
- Labs were significant for WBC 14.4, otherwise unremarkable
- CXR showed no acute process.
- The patient was given:
albuterol neb x2, ipratropium neb, and 60mg prednisone
After neb treatment in ED, peak flow was about 300-320/
Upon arrival to the floor, patient states that she is feeling a
lot better at time of last discharge. She was doing nebs at
home, but not as continuously as she was in the hospital. Since
discharge she was noticing worsening DOE. She presented to her
PCP today for routine post-DC follow up and was sent to the ED.
She doesn't feel as bad as last time she was hospitalized on
___. At that time she was barely able to talk. After nebs in
the ED and HCA, patient states that her breathing is already
improved. She has noticed significant improvement in wheezing.
She thinks that her recent exacerbations have been due to
exposure to cats a few weeks ago. Since then she hasn't returned
to baseline. She was also exposed to a dog yesterday. No recent
illness or cold symptoms. earlier this year she was also
switched from symbicort to adviar due to insurance reasons and
she thinks that her symptoms have also worsened since this
switch. She has never been intubated for asthma.She took 40mg
prednisone today and got another 60 in the ED.
Past Medical History:
Airway: Mallampati Class III-->h/o difficult intubation
Asthma
Obstructive sleep apnea (being setup with BiPAP)
allergic rhinitis
arthritis (neck and low back)
s/p left tibial plateau fracture
Papillary thyroid cancer ___
___ Disease ___
s/p subtotal thyroidectomy
hypercalcemia
GERD, PUD
hx of mild elevated LFTs
glaucoma
Bilateral reduction mammoplasty ___
Social History:
___
Family History:
brother - asthma
Physical ___:
ADMISSION
Vitals: 97.2, 149/75, 77, 18, 93/RA
General: Alert, oriented, no acute distress. able to speak in
half to full senstences but diminished voice.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased air movement throughout.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, AOx3
DISCHARGE
Vitals: Tmax 99.0, 110/63 (110-146/63-89), HR 63-88, RR 18, O2
96% RA
General: Alert, oriented, no acute distress. Able to speak in
full sentences w/high pitched voice.
HEENT: Sclera anicteric, conjunctivae noninjected, MMM,
oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, (+) S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds throughout. No wheezes, crackles,
rhonchi.
Abdomen: Soft, NT/ND, bowel sounds present, no rebound or
guarding
Ext: Warm, well perfused, no edema
Neuro: AOx3, gait normal, MAE
Pertinent Results:
ADMISSION
___ 07:30PM PLT COUNT-231
___ 07:30PM WBC-14.4*# RBC-4.61 HGB-14.5 HCT-44.0 MCV-95
MCH-31.5 MCHC-33.0 RDW-12.9 RDWSD-45.1
___ 07:30PM CALCIUM-10.1 PHOSPHATE-4.0 MAGNESIUM-2.3
___ 07:30PM GLUCOSE-131* UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18
STUDIES
-CXR (___): IMPRESSION: No acute cardiopulmonary process.
-CT Chest (___): IMPRESSION: Please note that the study is
somewhat degraded by respiratory motion artifact.
1. No evidence of pneumonia, diffuse lung disease, or
hypersensitivity
pneumonitis.
2. Left basilar atelectasis versus scarring is slightly more
prominent as
compared to ___.
3. Moderate hepatic steatosis. Steatohepatitis cannot be
excluded based on imaging.
4. Partially calcified splenic artery aneurysm, unchanged from
___ allowing for differences in technique.
-TTE (___): The left atrium and right atrium are normal in
cavity 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. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal study. Normal
estimated PA systolic pressure. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. No structural heart disease or pathologic flow
identified.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
-CT TRACHEA W/O C W/3D RENDStudy Date of ___
Dynamic collapse of the tracheobronchial tree with measurements
provided above, most pronounced in the distal trachea and
proximal bronchial tree.
DISCHARGE
___ 05:40AM BLOOD WBC-10.0 RBC-4.05 Hgb-13.2 Hct-39.6
MCV-98 MCH-32.6* MCHC-33.3 RDW-12.8 RDWSD-45.7 Plt ___
___ 05:40AM BLOOD Glucose-82 UreaN-22* Creat-0.7 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 05:40AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.2
___ 07:09AM BLOOD ANCA-NEGATIVE B
Brief Hospital Course:
___ F PMHx asthma w/recent d/c for asthma exacerbation ___,
___ presenting from PCP office ___ flow = 250, wheezing
c/f asthma exacerbation. She was treated with nebulizer
treatment, continued on steroids. She was eval by Pulmonology
team who recommended increasing her Advair, adding Spiriva, and
continuing her montelukast. A Ct chest was performed which was
negative for infxn, CT trachea showed dynamic airway collapse,
but it was felt to be unlikely that Sx due to
tracheobronchomalacia. IgE; Aspergillus Antibody; Pneumonitis
Hypersensitivity Profile were checked for contributing causes
for her exacerbations; these tests were also negative. She was
d/c'd w/ plan to do a long taper of prednisone, starting at 60mg
daily and going down in dose by 10mg per week.
# Asthma exacerbation: Patient has required x2 admissions in
last month (d/c ___. She was recently discharged
(___) on 14d prednisone taper, starting at 60mg and she
presented with symptoms while on 40mg daily. Baseline peak flow
is about 400, dropped to 250 now ___. Concern for exacerbations
___ multiple environmental triggers (cat and dog exposures) vs
possible role of medication change as patient reports she was
recently changed to Advair from Symbicort due to insurance
reasons. On admission patient was able to speak in full
sentences, but became tachycardic and unable to speak in full
sentences with ambulation. CXR was unrevealing for acute
processes. She was started on duonebs and albuterol nebs and
continued on her home advair and montelukast. The steroids were
continued at 60mg daily. Pulmonology was consulted given
multiple recent hospitalizations; per their recommendations she
was started on Spiriva and her Advair dose was increased to
500/50 (from 100/50). The decision was made to continue patient
on extended-term steroids, so Bactrim was started for
prophylaxis, as well as a PPI. Given concern for etiology other
than asthma. PFTs were obtained which revealed no evidence of
obstruction. IgE, ANCA, aspergillus, pulmonary hypersensitivity
profile, strongyloides were obtained and were negative. Due to
dysphonia and concern for possible paroxysmal vocal dysfunction,
ENT was consulted who felt patient's picture was not consistent
with upper respiratory problem and would plan for outpatient
laryngoscopy. A dynamic CT Trachea was done which showed TBM,
though Pulmonary thought this was most likely not clinically
significant. Pulmonary will refer to IP for possible Tx of TBM
pending Pulm outpatient f/u. Plan is for steroids to taper 10mg
qweekly.
# Leukocytosis: On admission the patient was noted to have a
leukocytosis to 14.4. Given no localizing symptoms c/f infection
and clear CXR, thought to be most likely due to steroids, given
patient had been on steroids for a number of days and received
an additional dose of 60mg (total of 100mg prednisone on day of
admission). Her WBC was trended and returned to normal.
# OSA: Pt was continued on home CPAP.
CHRONIC ISSUES:
# Hypothyrodism s/p thyroidectomy: Continued home synthroid ___
mcg daily.
# Glaucoma: Continued home dorzolamide-timolol
# HLD: Continued home pravastatin 40 mg QHS.
***Transitional Issues***
- started on Bactrim PCP prophylaxis and pantoprazole 40mg ___ GI
ppx given prolonged steroid course
- started on Prednisone 60mg ___ continue for one week at
each dose and will taper 10mg weekly
- started on Spiriva ___ for asthma exacerbation
- increased dose of Advair
- outpatient ENT appt made to be evaluated for paradoxical vocal
cord dysfunction
- may need IP f/u for TBM depending on Pulm f/u appointment
- will need repeat IgE levels as were low on this admission but
this was c/b being on prednisone
# CODE STATUS: full
# CONTACT: ___, ___ (sister)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Montelukast 10 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
7. biotin 10 mg oral DAILY
8. dorzolamide-timolol 22.3-6.8 mg/mL OPHTHALMIC BID
9. fluticasone-salmeterol 115-21 mcg/actuation INHALATION BID
10. Multivitamins 1 TAB PO DAILY
11. Pravastatin 40 mg PO QPM
12. PredniSONE 40 mg PO DAILY
This is dose # 1 of 6 tapered doses
Tapered dose - DOWN
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. dorzolamide-timolol 22.3-6.8 mg/mL OPHTHALMIC BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Montelukast 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pravastatin 40 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH
daily Disp #*30 Capsule Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. biotin 10 mg oral DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
13. Tretinoin 0.025% Cream 1 Appl TP QHS
RX *tretinoin 0.025 % apply to affected area at bedtime
Refills:*0
14. fluticasone-salmeterol 230-21 mcg/actuation INHALATION BID
2 puffs twice a day
RX *fluticasone-salmeterol [Advair HFA] 230 mcg-21 mcg/actuation
2 puffs IH twice a day Disp #*1 Inhaler Refills:*0
15. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
16. PredniSONE 40 mg PO DAILY Duration: 7 Days
This is dose # 1 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
17. PredniSONE 60 mg PO DAILY Duration: 7 Doses
This is dose # 1 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
18. PredniSONE 50 mg PO DAILY Duration: 7 Doses
This is dose # 2 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 50 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
19. PredniSONE 30 mg PO DAILY Duration: 7 Doses
This is dose # 4 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
20. PredniSONE 20 mg PO DAILY Duration: 7 Doses
This is dose # 5 of 6 tapered doses
Tapered dose - DOWN
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
21. PredniSONE 10 mg PO DAILY Duration: 7 Doses
This is dose # 6 of 6 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Asthma exacerbation
SECONDARY DIAGNOSES:
Airway: Mallampati Class III-->h/o difficult intubation
Obstructive sleep apnea (on BiPAP)
Allergic rhinitis
Arthritis (neck and low back)
Papillary thyroid cancer ___
___ Disease ___ s/p subtotal thyroidectomy
GERD, PUD
Hx of mild elevated LFTs
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital due to an asthma exacerbation.
You received treatment with steroids and nebulizers. A number of
tests were performed to ensure you were not having an infection
triggering your recent asthma exacerbations. You were evaluated
by the Pulmonology team who recommended increasing the dose of
your Advair; you should take 2 puffs twice per day. You should
also start taking Spiriva; 1 cap inhaled daily. You should
continue taking montelukast 10mg daily. In addition, you were
continued on prednisone; you should taper this medication as
described below.
***TAPER INFO***
- Please continuing taking 60mg prednisone daily from ___ -
___
- ___: take 50 mg daily
- ___: take 40 mg daily
- ___: take 30 mg daily
- ___: take 20 mg daily
- ___: take 10 mg daily
You should use your rescue inhaler and nebulizer treatments as
needed. Please follow-up with your primary care doctor on . In
addition, you will be called by the ___ office with an
appointment within this week.
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
|
10726866-DS-9
| 10,726,866 | 27,814,015 |
DS
| 9 |
2196-04-29 00:00:00
|
2196-04-29 22:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ P / Penicillins / dust mites, mold, cats/ dogs /
oysters / pravastatin / Simbrinza
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ and
lifelong non-smoker with a PMH pertinent for asthma,
hypertension, hypothyroidism, and glaucoma who presented ___
with shortness of breath consistent with prior asthma
exacerbations.
Since last week she's been feeling more tired and short of
breath
than usual. She worries that construction being done at the ___
school may have triggered her symptoms. By the morning of ___
her sister told her she "sounded terrible" and the patient went
to urgent care due to shortness of breath, chest tightness,
fatigue, and a nonproductive cough. Denies fevers/chills,
productive cough, chest pain, nausea/vomiting, diarrhea,
abdominal pain. She was evaluated at ___ urgent care
___ where she was found to be tachycardic to 130 bpm, lungs
tight on exam, intermittently mildly hypoxic, and was given neb
treatments and 60mg of prednisone and transferred to ___ ED
for
further management.
ED course:
T 98.0, HR 84, BP 132/80, 96% 4L NC
___ VBG 7.35/50
Albuterol nebs, Mag, azithromycin 500, IVF
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
P
Past Medical History:
- Airway: Mallampati Class III-->h/o difficult intubation
- Obstructive sleep apnea, on BiPAP
- Grave's disease status-post subtotal thyroidectomy
- Glaucoma
- Peptic ulcer disease
- Asthma
- Dyslipidemia
- Status-post breast reduction surgery
- S/p L4/L5 back surgery
Social History:
___
Family History:
Father and mother deceased.
PMR in mother. Father with prostate cancer.
Other family members with ___ disease, psorisasis, glaucoma,
Hasthimoto's thyroiditis, Celiac disease, ocular ___
___ and rheumatoid arthritis.
Brother and nephew with asthma/allergies.
Physical Exam:
discharge:
97.5 PO BP: 136/76 HR: 101 RR: 20 O2 sat: 96%
O2 delivery: RA
GENERAL: Alert, coughing intermittently but otherwise NAD.
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 and tachycardic, no murmur, no S3, no S4. No
JVD.
RESP: Breathing comfortably on room air without accessory muscle
use. Lungs sound tight with scattered wheezes, poor air movement
throughout, no crackles. Coughing fits following trying to
inspire deeply.
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:
Admission:
___ 05:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:00PM URINE HOURS-RANDOM
___ 03:00PM URINE UHOLD-HOLD
___ 03:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:06PM ___ PO2-29* PCO2-50* PH-7.35 TOTAL
CO2-29 BASE XS-0
___ 01:06PM O2 SAT-50
___ 12:56PM GLUCOSE-126* UREA N-10 CREAT-0.7 SODIUM-143
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
___ 12:56PM cTropnT-<0.01
___ 12:56PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 12:56PM WBC-8.6 RBC-4.69 HGB-15.0 HCT-45.1* MCV-96
MCH-32.0 MCHC-33.3 RDW-13.1 RDWSD-46.5*
___ 12:56PM NEUTS-81.9* LYMPHS-12.2* MONOS-4.6* EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-7.05* AbsLymp-1.05* AbsMono-0.40
AbsEos-0.03* AbsBaso-0.02
___ 12:56PM ___ PTT-28.8 ___
___ 12:56PM PLT COUNT-206
___ 12:56PM D-DIMER-249
___ 11:08AM GLUCOSE-134* UREA N-11 CREAT-0.8 SODIUM-141
POTASSIUM-6.1* CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
___ 11:08AM estGFR-Using this
___ 11:08AM estGFR-Using this
___ 11:08AM WBC-7.0 RBC-4.76 HGB-15.6 HCT-45.6* MCV-96
MCH-32.8* MCHC-34.2 RDW-13.1 RDWSD-45.5
___ 11:08AM NEUTS-62.6 ___ MONOS-8.7 EOS-1.1
BASOS-0.6 IM ___ AbsNeut-4.37 AbsLymp-1.84 AbsMono-0.61
AbsEos-0.08 AbsBaso-0.04
___ 11:08AM PLT COUNT-231
Imaging:
CXR ___: FINDINGS:
PA and lateral views of the chest provided. Lungs are clear.
There is no
focal consolidation, effusion, or pneumothorax. There are no
signs of
congestion or edema. The cardiomediastinal silhouette is
normal. Imaged
osseous structures are intact. No free air below the right
hemidiaphragm is
seen.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
Ms. ___ is a ___ ___ and lifelong
non-smoker with a PMH pertinent for asthma, hypertension,
hypothyroidism, and glaucoma who is admitted with an asthma
exacerbation.
# Asthma exacerbation: She presented to urgent care with dyspnea
consistent with prior asthma exacerbations. She received duonebs
and steroids but given her hypoxia was to the ED. Her D-dimer
was negative so PE unlikely, and her exam and CXR without
concern for pneumonia. She was continued on steroids,
nebulizers, and her home inhalers. She slowly improved over
several days. Patient discharged on prednisone taper and home
asthma regimen, including home nebulizer therapy. She should
eventually follow up with her Pulmonologist, Dr. ___.
# Hypertension: continued home nifedipine
# Hypothyroidism: continued home levothyroxine
# Glaucoma: continued home dorzolamide eye drops. Latanoprost
was recently removed due to concern that it was promoting
bronchospasm.
Transitional Issues:
[] Close pulmonary follow up
> 3O mins spent on dc planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___)
5. Montelukast 10 mg PO DAILY
6. Tretinoin 0.025% Cream 1 Appl TP QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
11. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
scaly ear
12. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
13. Calcium Carbonate 500 mg PO QID:PRN heartburn
14. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN coughing
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 1 tbsp by mouth q___
prn Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 3 Doses
Start: ___, First Dose: Next Routine Administration Time
This is dose # 1 of 4 tapered doses
RX *prednisone 10 mg ___ as dr ___ by mouth daily Disp
#*18 Tablet Refills:*0
4. PredniSONE 30 mg PO DAILY Duration: 3 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 4 tapered doses
5. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 3 of 4 tapered doses
6. PredniSONE 10 mg PO DAILY Duration: 3 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 4 of 4 tapered doses
7. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 vial IH q6h prn
Disp #*30 Vial Refills:*0
9. Calcium Carbonate 500 mg PO QID:PRN heartburn
10. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
11. Cetirizine 10 mg PO DAILY
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
13. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
scaly ear
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___)
16. Montelukast 10 mg PO DAILY
17. NIFEdipine (Extended Release) 30 mg PO DAILY
18. Tretinoin 0.025% Cream 1 Appl TP QHS
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Asthma exacerbation
Secondary: Hypertension, Hypothyroidism, Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to ___ with an asthma
exacerbation. This improved with nebulizer treaments and
steroids. It is now safe to be discharge. You should follow up
with Dr. ___ ongoing care. We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10726867-DS-9
| 10,726,867 | 21,075,028 |
DS
| 9 |
2125-03-23 00:00:00
|
2125-03-23 16:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ with PMH of post-operative AF, CAD s/p
CABG who presents with chest pain. Patient reports 1 day of left
sided chest pain. He noted the pain while walking today, but it
is not reliably associated with activity. He describes the pain
as pleuritic, noted with deep inspiration and also worse with
movement. The pain is located on his left anterior chest around
the nipple. He denies associated dyspnea, nausea, vomiting,
diarphoresis. He called his PCP, ___ was referred to
the ED for further evaluation.
Past Medical History:
1. CAD s/p CABG in ___ (left internal mammary artery to left
anterior descending and saphenous vein graft to posterior
descending artery)
2. Hyperlipidemia
3. History of postoperative atrial fibrillation.
4. History of chronic obstructive pulmonary disease.
5. History of cellulitis of the saphenous vein harvest site
in ___.
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Admission PE:
VS: 98.3 152/89 97 17 94 Ra
GENERAL: NAD
HEENT: MMM
NECK: no JVD
HEART: RRR, nl S1 S2, no murmurs, reproducible tenderness to
palpation around L chest
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: WWP, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no rashes
Discharge PE:
VS:97.8, 118-152/74-89, P 78-97, RR 16, 93-96%RA
Weight: 176.15 lbs
Tele: SR/ST 80-105
EKG: NSR with PVC, normal axis and intervals, q waves II, III,
AVF
GENERAL: NAD
HEENT: MMM
NECK: no JVD
HEART: RRR, nl S1 S2, no murmurs, reproducible tenderness to
palpation around L chest
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: WWP, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no rashes
Pertinent Results:
___ 08:10AM BLOOD WBC-6.0 RBC-4.93 Hgb-15.1 Hct-46.2 MCV-94
MCH-30.6 MCHC-32.7 RDW-14.1 RDWSD-48.1* Plt ___
___ 04:58PM BLOOD WBC-6.1 RBC-4.80 Hgb-14.6 Hct-45.6 MCV-95
MCH-30.4 MCHC-32.0 RDW-14.3 RDWSD-49.7* Plt ___
___ 04:58PM BLOOD Neuts-67.6 Lymphs-18.7* Monos-9.7 Eos-2.5
Baso-0.5 Im ___ AbsNeut-4.14 AbsLymp-1.14* AbsMono-0.59
AbsEos-0.15 AbsBaso-0.03
___ 08:10AM BLOOD ___ PTT-31.4 ___
___ 08:10AM BLOOD Glucose-104* UreaN-21* Creat-0.9 Na-141
K-4.6 Cl-104 HCO3-26 AnGap-11
___ 04:58PM BLOOD Glucose-142* UreaN-29* Creat-0.9 Na-142
K-4.4 Cl-105 HCO3-24 AnGap-13
___ 08:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:59PM BLOOD cTropnT-<0.01
___ 04:58PM BLOOD cTropnT-<0.01
___ 08:10AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1
___ 04:58PM BLOOD Calcium-9.9 Phos-3.9 Mg-2.2
CTA chest: ___
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with sob, pleuritic CP, elevated
d-dimer// ? pe
COMPARISON: Chest radiographs from earlier the same day
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. No dissection of the thoracic aorta is seen.
There is coronary artery
calcification. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is moderate centrilobular emphysema, worse
in the upper lobes. There are multiple calcified granulomas in
the right lung. Lungs are otherwise clear without masses or
areas of parenchymal opacification. The airways are patent to
the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Hiatal hernia is large. There are scattered
millimetric
hypodensities in the liver which are too small to characterize
but may
represent cysts or hamartomas. 1.4 cm hypodensity in the left
hepatic lobe may represent a hemangioma. 2 cm hypodensity in
the spleen may represent a cyst. Included portion of the upper
abdomen is otherwise unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
DISH is again seen along the spine. Sternal wires are again
seen. The
inferior-most sternal wire is fractured.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Moderate centrilobular emphysema.
Chest xray: ___
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ with PMH of post-operative AF, CAD s/p
CABG who presents with chest pain.
# Atypical chest pain/CAD: Patient with intermittent chest pain
on left anterior chest, reproducible with palpation to site and
gets worse with inspiration and when he twists from side to
side. Denies nausea, vomiting, diaphoresis or dyspnea. Evaluated
with CTA in the ED, which showed no PE nor acute aortic
abnormality. ECG without ischemic changes, troponin negative x2.
Suspect musculoskeletal in etiology, currently without pain.
- continue all home medications including ASA, atorvastatin and
metoprolol succinate
- ___ with Dr. ___ in 2 weeks
# ELEVATED D DIMER: Elevated to 2500s in the ED, without
evidence of acute infarction or PE. Other possible causes
including CVA, DIC, liver disease, renal disease, AF, not
supported by history or lab testing.
# BPH:
-continue tamsulosin and finasteride
# INCIDENTAL FINDINGS:
Noted on CTA chest to have 1.4cm L hepatic lobe hemangioma, 2cm
hypodensity in spleen likely cyst. Unclear if further follow-up
needed. Will fax discharge summary to PCP and Dr. ___
___ Note: Mr ___ admitted for chest pain and
observation in the context of prior history of CAD/s/p bypass
surgery. He has done exceptionally well ever since, active in
physically demanding work in the interim. W/U including CT scan
for r/o PE (elevated D-Dimer and with no other ostensible cause)
showed no evidence of pulmonary thromboemboli. ECG remained
unchanged and no evidence of myocardial infarction and chest
pain symptoms atypical. Subsequently determined that his symptom
of chest pain was atypical and quite likely musculoskeletal and
he was able to evoke a pain response himself, Discharged to my
followup for stability and resolution of chest pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Finasteride 5 mg PO QHS
3. Metoprolol Succinate XL 75 mg PO QAM
4. Tamsulosin 0.4 mg PO QHS
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Finasteride 5 mg PO QHS
5. Metoprolol Succinate XL 75 mg PO QAM
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___
because you had chest pain. Your EKG was unchanged and your
blood work did not show any heart attack. We did a CT scan of
your lungs to rule out a blood clot there.
Incidental finding during the scan showed a hemangioma (or
noncancerous growths that form due to an abnormal collection of
blood vessels) in one of the liver lobes. It also showed a
possible cyst on your spleen. These findings should be reviewed
by your primary care doctor and he will decide if further
imaging is warranted.
Continue all your current medications.
Please call Dr. ___ office to make a close follow up with
him to be seen in the next 2 weeks.
If you have any urgent questions that are related to your
recovery from your medical issues or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
It was a pleasure to take care of you. We wish you the best with
your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10726881-DS-4
| 10,726,881 | 29,490,398 |
DS
| 4 |
2159-09-19 00:00:00
|
2159-09-21 23:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Confusion and balance problems
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ was reportedly found by her husband this morning 9:30am,
confused, with slurred speech, and with ataxia on ambulation.
She was normal when she went to bed last night. No known
ingestions, no known history of IVDU but does drink several
drinks of ETOH daily, only medication is an antihypertensive.
She arrived at ___, and febrile to 102, reported
slurred speech, with no focal neurologic deficits with the
exception of again ataxia on ambulation. She was subsequently
given a banana bag with thiamine and folate. She had a head CT
that was reportedly negative, a lumbar puncture that had LP
opening pressure 16, CSF gram stain neg, ___ WBC, 46 RBC, prot
40, glucose normal. Toxicology was consulted, but she is on no
medications that would be concerning for serotonin syndrome or
NMS, therefore they had no specific recommendations. A TSH was
also sent, which was 4.6 making thyrotoxicosis unlikely. CXR and
UA were negative. Her initial lactate was 4.4.
Past Medical History:
- Hyperthyroidism
- Hypoglycemia
- Hypertension
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: T:98.4 BP:146/89 P:108 R:20 O2:100RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Exopthalmos
bilaterally, worse on left
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular tachycardia, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mild distention, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact. Visual fields intact. PERRLA. Negative
nystagmus. Strength 5 throughout. Positive asterixis and ataxia.
Physical Exam on Discharge:
Vitals: T:98.7 BP:146/84 P:72 R:19 O2:100RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Exopthalmos
resolved
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular tachycardia, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, no distention, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact. Visual fields intact. PERRLA. Negative
nystagmus. Strength 5 throughout. Negative asterixis and ataxia.
Pertinent Results:
Labs on Admission:
___ 02:55PM BLOOD WBC-8.5 RBC-3.61* Hgb-12.6 Hct-34.3*
MCV-95 MCH-34.9* MCHC-36.7* RDW-14.4 Plt ___
___ 02:55PM BLOOD Neuts-78.2* Lymphs-16.2* Monos-5.0
Eos-0.2 Baso-0.4
___ 02:55PM BLOOD ___ PTT-UNABLE TO ___
___ 02:55PM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-144
K-4.1 Cl-110* HCO3-22 AnGap-16
___ 02:55PM BLOOD ALT-13 AST-35 AlkPhos-62 TotBili-0.6
___ 05:20PM BLOOD CK(CPK)-842*
___ 02:55PM BLOOD Lipase-30
___ 05:20PM BLOOD CK-MB-5
___ 02:55PM BLOOD Albumin-4.3 Calcium-8.5 Phos-3.2 Mg-2.3
___ 05:20PM BLOOD Osmolal-297
___ 05:20PM BLOOD Ammonia-26
___ 05:20PM BLOOD T4-7.2 T3-145
___ 05:20PM BLOOD Cortsol-35.1*
___ 02:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:05PM BLOOD ___ pO2-110* pCO2-28* pH-7.51*
calTCO2-23 Base XS-0 Comment-GREEN TOP
___ 03:05PM BLOOD Lactate-2.3*
Labs on Discharge:
___ 07:45AM BLOOD WBC-5.6 RBC-3.64* Hgb-12.6 Hct-35.6*
MCV-98 MCH-34.7* MCHC-35.4* RDW-13.7 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-102* UreaN-8 Creat-0.9 Na-138
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 07:45AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
IMAGING
MRI HEAD: FINDINGS: The ventricles, sulci, subarachnoid spaces
are normal in size and configuration. There is no mass lesion,
mass effect, or shift of normal midline structures. There is no
decreased diffusion to indicate acute or subacute ischemia, and
no evidence of acute or subacute hemorrhage. Mucosal thickening
is noted in the left maxillary sinus. The visualized paranasal
sinuses, mastoids, and the orbits are otherwise unremarkable.
PITUITARY MRI FINDINGS: The pituitary gland is normal in size
and appearance
without focal T2 hyperintense lesion or focal area of abnormal
enhancement.
The infundibulum inserts midline.
MRI ORBITS: The intraocular muscles, the orbital fat, and the
globes are
normal. There is no abnormal enhancement of the optic nerves or
other
abnormal enhancing focus within the orbits bilaterally.
FINDINGS:
No acute intracranial abnormality.
No pituitary tumor.
No orbital abnormality.
EEG: IMPRESSION: This is an abnormal EEG due to the presence of
a slow,
disorganized background with frequent generalized bursts of
semi-rhythmic high amplitude delta activity. These findings are
indicative of a moderate encephalopathy which suggests
widespread cerebral dysfunction but is non-specific as to
etiology. No focal or epileptiform features were seen.
Brief Hospital Course:
Assessment and Plan: ___ with confusion, slurred speech, and
ataxia on ambulation.
Presented at the ___ ED, patient was flushed with temp 100.7
and heart rate in the 120s. She was extremely distracted but
responded properly to questions demonstrated no aphasia and had
an ___ stroke scale of zero. Exam notable for impressive
asterixis, puffy, exopthalmic eyes bilaterally, hyperreflexia
and increased tone with inattention on mental status exam.
# Encephalopathy - Despite thorough workup, etiology remained
unclear. CT head which was unrevealing. She had an LP which
showed a normal opening pressure, 1 WBCs, 46 RBC. She had a
negative toxicology screen and infectious workup, and no
metabolic abnormalities. TSH was WNL. She received empiric
treatment in our ED with vancomycin and cefepime. She was
evaluated by neurology who recommended MRI and EEG. MRI showed
no acute process and EEG showed findings were consistent with
encephalopathy. She was empirically started on IV acyclovir
given concern for possible HSV meningitis with elevated RBC
count in the CSF. However, this was discontinued prior to
discharge given low suspicion, and OSH CSF studies eventually
came back negative for HSV and lyme. She was monitored overnight
and treated supportively with IVF and antiemetics. Over the next
2 days, her mental status and gait completely improved to normal
despite. She was discharged with plans to follow up with her
PCP.
# alcohol abuse - patient was placed on a CIWA scale but did not
require any benzodiazepines. She was also started on a
multivitamin, thiamine and folate. She did not show any clear
evidence of alcoholism, but was encouraged to decrease drinking
# Hypertension - Maintained on home dose of amlodipine 5mg with
blood pressures stable in the 130s.
TRANSITIONAL ISSUES
- Follow up appointments with PCP and ___
PENDING STUDIES
- Final read of repeat EEG
- Final read of blood cultures
CODE: FULL
Medications on Admission:
Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
hold for SBP<100
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Encephalopathy
Secondary diagnoses: hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___. You were transfered to ___ for
confusion, fever and difficulty walking. The neurology evaluated
you and recommended several tests including and MRI and EEG. The
MRI did not show any abnormalities and the EEG did not show any
signs of seizure. You were started on an antiviral medication
initially, however, given a low suspicion for this infection,
this medication was discontinued. Your vital signs and mental
status improved dramatically through the rest of your hospital
course. Although the exact cause of your confusion was not
identified, you clinically improved and were judged to be safe
for discharge with close follow up by your outpatient physician.
You were also scheduled to follow up with neurology. You should
stop drinking alcohol.
The following changes have been made to your medication regimen:
Please START taking:
- multivitamin, thiamine, folate
Please continue taking all your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
|
10727822-DS-21
| 10,727,822 | 27,175,369 |
DS
| 21 |
2179-05-13 00:00:00
|
2179-05-13 18:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking M with PMH significant for AAA s/p
endovascular repair in ___, HTN, HLD, BPH who presents with
bilateral flank pain and hematuria. The bilateral flank pain
started ___ days ago. The pain is described as constant, feels
like someone is punching him. He also complains of suprapubic
pain. Patient has been feeling constipated, last BM 1 week ago.
Patient also reports 3 episdoes of hematuria, which started last
night. Associated with subjective fevers, dysuria, increased
frequency, but decreased urine output. Patient also repors
decreased PO intake.
In the ED, initial vitals were: T98.7, BP148/65, P94, RR16,
SpO298% RA. Labs were notable for Hct 33 (baseline 38.8), Cr 3.7
(baseline 1.9-2.0), UA with moderate blood, positive nitrate,
and large leukocytes, >182 WBCs. FAST scan was negative. DRE
revealed enlarged prostate but nontender. Vascular surgery
surgery was consulted d/t concern for endoleak. Duplex doppler
was negative. Patient started on ceftriaxone.
On the floor, patient appeared very comfortable.
Review of systems:
(+) Per HPI. Reports ___ lb weight loss from 2 months ago,
this was around the time of his AAA repair.
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea.
Denies arthralgias or myalgias.
Past Medical History:
Chronic prostatitis
AAA s/p repair in ___
CKD
DM
HTN
HLD
BPH
PVD
GERD
Social History:
___
Family History:
Brother with prostate cancer.
Physical Exam:
ON ADMISSION:
Vitals: T99.2, BP154/81, ___, RR20, SpO2 97% RA
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, distended, tender to palpation in suprapubic
area. No guarding, no rebound tenderness.
Back: No CVA tenderness
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
ON DISCHARGE:
Vitals: T98.7, BP111/61, P94, RR26, SPO2 98% 2L
General: Awake and alert. NAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, nondistended, nontender to palpation over
suprapublic region. No rebound tenderness.
Back: No pain with palpation over spinous processes or lower
paraspinal muscles.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII grossly intact.
Pertinent Results:
ON ADMISSION:
___ 09:15AM BLOOD WBC-9.8 RBC-4.23* Hgb-11.6* Hct-33.9*
MCV-80* MCH-27.5 MCHC-34.3 RDW-13.8 Plt ___
___ 09:15AM BLOOD Neuts-76.0* Lymphs-11.5* Monos-6.1
Eos-5.9* Baso-0.4
___ 09:15AM BLOOD ___ PTT-25.5 ___
___ 09:15AM BLOOD Glucose-134* UreaN-75* Creat-3.7*# Na-137
K-4.9 Cl-101 HCO3-21* AnGap-20
___ 09:15AM BLOOD ALT-19 AST-37 AlkPhos-70 TotBili-0.3
___ 09:15AM BLOOD Albumin-3.5 Calcium-9.5 Phos-4.3 Mg-2.1
___ 09:21AM BLOOD Lactate-1.1
ON DISCHARGE:
___ 07:15AM BLOOD WBC-13.1* RBC-3.90* Hgb-10.3* Hct-31.3*
MCV-80* MCH-26.4* MCHC-32.9 RDW-14.3 Plt ___
___ 06:30AM BLOOD Neuts-68.4 Lymphs-16.2* Monos-8.7
Eos-6.3* Baso-0.3
___ 07:15AM BLOOD Glucose-84 UreaN-73* Creat-3.0* Na-139
K-4.1 Cl-106 HCO3-19* AnGap-18
___ 07:40AM BLOOD CK(CPK)-386*
___ 04:05PM BLOOD CK-MB-13* cTropnT-0.07*
___ 07:15AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
___ 06:30AM BLOOD PSA-11.9*
___ 06:50AM BLOOD C3-152 C4-26
MICROBIOLOGY
URINE CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ (___) AT 1308
___.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION Cefazolin interpretative
criteria are
based on a dosage regimen of 2g every 8h.
PREVIOUSLY REPORTED AS MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
STUDIES:
CT ABD & PELVIS
Limited study as only distal aneurysm sac visualized. However
within the visualized aspect, at no evidence of acute
DUPPLEX DOPPLER ABD/PELVIS
Limited study as only the distal aneurysm sac is visualized.
However, within the visualized aneurysmal sac, there is no
evidence of an endoleak.
Brief Hospital Course:
___ yo M with PMH significant for AAA s/p repair, DM, HTN, BPH
who presents with bilateral flank pain and hematuria.
# UTI/chronic prostatitis:
Given history of dysuria, increased urinary frequency,
tenderness to palpation in suprapubic area, and dirty UA.
Prostate was also tender to palpation and PSA elevated to 12,
which can be elevated in chronic prostatitis. Urine cultures
grew E. coli (>100,000 colonies), enterococcus and diptheroids
(10,000-100,000 colonies), pansensitive. Patient treated with
ceftriaxone IV and transitioned to amoxicillin. Per Urology, he
should continue this for ___ weeks. Patient was discharged with
30 day supply.
# Hematuria:
Likely ___ cystitis. Per chart review patient had previous
episodes of hematuria. Cystoscopy at that time revealed friable
vessels. Patient did not have any further episodes of hematuria
while hospitalized. Given his smoking history, ___ also
consider bladder cancer as an etiology.
# AoCKD:
Baseline Cr 1.9-2.0, Cr on admission 3.7. BUN:Cr >20, which
indicates a pre-renal etiology, however FENa 2.35%. Given
patient's history of BPH and decreased urinary output, there was
concern for obstructive nephropathy. CT abdomen did not reveal
hydronephrosis and post void residual was 53cc. Other DDx
considered include contrast nephropathy (last contrast exposure
___, hypoperfusion intra-operatively, atherothrombotic
disease, AIN, and endovascular leak. When looking back at the
patient's anesthesia record for his AAA repair, he did require
phenylephrine for hypotension. Unfortunately, we did not have
records of his Cr post-operatively. Atherothrombotic disease
less likely as C3/C4 levels were not decreased, and patient's Cr
trended down. Endovascular leak was ruled out with aortic
duplex. Lastly AIN ___ omeprazole was considered due to
peripheral eosinophilia, however this is not a new medication,
and he did not have any fever or rash. Patient's Cr trended down
to 2.9 during hospitalization. Patient would benefit from
outpatient renal follow up.
# NSTEMI:
Patient developed 2 episodes of chest pain. Both episodes were
located in his anterior chest and described as tight. Troponin
peaked to 0.1 and later trended down to 0.7. EKG did not have
any ST-changes. Chest pain resolved with TUMs and sublingual
nitroglycerine. NSTEMI thought to be ___ demand-supply mismatch
vs thrombotic disease. Anticoagulation was held due to concern
for endovascular leak. Consider outpatient stress testing for
further cardiac risk stratification.
# BPH: Noted on DRE. CT shows enlarged prostate with
calcifications. PSA 11.9. Urology was consulted regarding
management of BPH: uptitrating medications vs surgical
management. Patient currently on maximal medical management with
doxazosin and finasteride. As patient was not having obstructive
symptoms Urology did not feel strongly about surgical
management. Patient may benefit from follow up with outpatient
Urology regarding resolution of chronic prostatitis and elevated
PSA.
# Flank/lower back pain:
Patient initially presented with bilateral flank pain, but
complained of right flank pain during hospitalization. Although
patient did have CVA tenderness, he did not have fevers or
leukocytosis, therefore we did not believe pyelonephritis was
the etiology of his pain. On further questioning, patient's back
pain started approximately 2 weeks ago. He has had chronic back
pain in the past due to the nature of his occupation
(___). Aortic duplex ruled out endovascular leak.
Patient's pain improved with lidoderm patch, therefore it was
thought his pain is most likely musculoskeletal. Patient may
benefit from physical therapy as an outpatient.
# HTN: Continued home medications.
# GERD: Continued on omeprazole.
# HLD: Cont home medications.
# DM2: Last HbA1c 6.5% in ___. Fingersticks were within normal
limits.
TRANSITIONAL ISSUES:
* New sub 4-mm left lower lobe pulmonary nodule. Follow up chest
CT is recommended in 12 months in a high risk patient.
* CT Abdomen: The prostate is enlarged with calcifications. PSA
11.9 in setting of chronic prostatitis. Recommend trending PSA
after resolution of infection.
* Patient on maximal BPH medications. ___ benefit from follow
up with urology as an outpatient.
* Patient had 2 episodes of chest pain with troponin leak
(peaked at 0.1 and trended down to 0.07). EKG without
ST-changes. Consider outpatient stress testing.
* Cr on admission 3.7, previous baseline 1.9-2.0. Cr trended
down to 2.9 during hospitalization. Patient would benefit from
renal follow up from outpatient.
* Patient complained of lower back pain, present for 2 weeks.
Likely musculoskeletal. Patient would benefit from ___ as an
outpatient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Doxazosin 2 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Isosorbide Dinitrate 20 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. GlipiZIDE 5 mg PO DAILY
10. Gabapentin 100 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Doxazosin 2 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. Isosorbide Dinitrate 20 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
10. GlipiZIDE 5 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Chronic prostatitis
- Hematuria
- Acute on chronic kidney disease
- NSTEMI
SECONDARY DIAGNOSIS
- Chronic back pain
- BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You came in because of blood in your urine. You
were found to have an infection in your kidney and prostate. We
treated you with IV antibiotics, and will discharge you with
oral antibiotics. You should take this medication for at least 4
weeks.
As for your back pain, this is most likely musculoskeletal. We
recommend you have physical therapy, which can be coordinated by
your PCP. You can take tylenol for the pain. Please avoid NSAIDs
(ex. ibuprofen, advil, motrin) as they can damage your kidneys.
We recommend you to stay active with walking and stretching.
We let Dr. ___ you are in the hospital and are
unable to make your radiology appointment (scheduled for ___.
Your rdaiology test has been rescheduled and the appointment is
listed below.
Followup Instructions:
___
|
10727986-DS-6
| 10,727,986 | 24,244,647 |
DS
| 6 |
2122-08-24 00:00:00
|
2122-08-24 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w no PMH presenting with abdominal pain and cramping.
Pain started on ___ and has persisted since that time. The
patient comes in stating that he has been having lower abdominal
pain and cramping that is sharp in nature. He reports that this
is the first time he has had such pain. He was able to tolerate
a diet but yesterday did not eat anything as he was feeling
unwell. All movements have been the same. Any fevers or
chills.
The patient has no nausea or vomiting. No diarrhea. His last
colonoscopy was in ___ that showed benign colonic polyps.
Past Medical History:
Past Medical History:
Asthma
Past Surgical History:
Laparoscopic appendectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: ___ 80 123/82 80 percent on room air
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, focally tender in lower quadrants with
rebound and guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical exam:
VS: 97.8 PO 121 / 80 70 18 98 Ra
GEN: alert, pleasant and interactive.
HEENT: PERRL, EOMI, mucus membranes pink/moist.
CV: RRR
PULM: Clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended, active bowel sounds.
EXT: Warm and dry. 2+ ___ pulses.
NEURO: A&Ox3, follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 07:05AM BLOOD WBC-5.9 RBC-4.68 Hgb-13.4* Hct-39.7*
MCV-85 MCH-28.6 MCHC-33.8 RDW-12.8 RDWSD-39.6 Plt ___
___ 07:30AM BLOOD WBC-6.8 RBC-4.60 Hgb-13.1* Hct-39.1*
MCV-85 MCH-28.5 MCHC-33.5 RDW-12.8 RDWSD-39.5 Plt ___
___ 07:15AM BLOOD WBC-5.7 RBC-4.36* Hgb-12.5* Hct-37.4*
MCV-86 MCH-28.7 MCHC-33.4 RDW-13.1 RDWSD-41.0 Plt ___
___ 09:58AM BLOOD WBC-11.1* RBC-4.90 Hgb-14.1 Hct-41.5
MCV-85 MCH-28.8 MCHC-34.0 RDW-13.2 RDWSD-40.5 Plt ___
___ 07:05AM BLOOD Glucose-85 UreaN-12 Creat-1.0 Na-145
K-4.3 Cl-105 HCO3-22 AnGap-18*
___ 07:30AM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-106 HCO3-20* AnGap-16
___ 07:15AM BLOOD Glucose-88 UreaN-9 Creat-0.9 Na-143 K-4.2
Cl-107 HCO3-23 AnGap-13
___ 09:58AM BLOOD Glucose-89 UreaN-12 Creat-1.0 Na-139
K-4.7 Cl-103 HCO3-23 AnGap-13
___ 07:05AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8
___ 07:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
___ 07:15AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1
___ 09:58AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
___ 10:16AM BLOOD Lactate-1.1
___ CT A/P:
1. Acute sigmoid diverticulitis likely complicated by
microperforation. No drainable abscess.
2. An intermediate density lesion is seen in the lower pole of
the left
kidney, of unknown etiology, for which outpatient MRI is
recommended for
further evaluation.
3. Indeterminate cystic lesion arising from the pancreatic tail
also warrants further evaluation with MRI on an outpatient
basis.
Brief Hospital Course:
Mr. ___ is a ___ yo M admitted to the Acute Care surgery
service on ___ with abdominal pain. He underwent CT scan
that showed acute sigmoid diverticulitis with likely
microperforation. White blood cell count was elevated at 11.1.
He was made NPO, given IV fluids, and IV antibiotics and
admitted to the floor.
On HD2 he was kept NPO with IV fluid and IV antibiotics.
On HD3 abdominal pain resolved, white blood cell count was
normal, and therefor diet was advanced to regular with good
tolerability. On HD4 IV antibiotics were transitioned to PO with
continued good tolerability.
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
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Incidental CT findings:
2. An intermediate density lesion is seen in the lower pole of
the left kidney, of unknown etiology, for which outpatient MRI
is recommended for further evaluation.
3. Indeterminate cystic lesion arising from the pancreatic tail
also warrants further evaluation with MRI on an outpatient
basis.
Outpatient MRI is recommended for further evaluation of
intermediate density lesion in the lower pole of the left kidney
and cystic structure arising from the pancreatic tail.
Medications on Admission:
Flovent HFA 110 mcg/actuation aerosol inhaler
1 puff inhaled twice a day Rinse mouth after use
ProAir HFA 90 mcg/actuation aerosol inhaler
2 puff inhaled every ___ hours as needed for wheezing
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4000 mg acetaminophen/24 hours.
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Diverticulitis with microperforation
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 and a part
of your intestine called the diverticulum in the sigmoid colon.
You were given bowel rest, IV fluids, and IV antibiotics and
your pain resolved. You were then transitioned to a regular diet
and oral antibiotics with continued good effect. You are now
doing better, afebrile, tolerating a regular diet, and ready to
be discharged to home to continue your recovery.
Please note the following discharge instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10728002-DS-9
| 10,728,002 | 29,706,049 |
DS
| 9 |
2181-02-15 00:00:00
|
2181-02-15 22:54:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gluten / seasonal allergy
Attending: ___.
Chief Complaint:
Petechiae, easy bruising, night sweats, headaches
Major Surgical or Invasive Procedure:
bone marrow biopsy, left subclavian central venous line
History of Present Illness:
___ with history of Stage I breast cancer s/p XRT completed
___, HTN who presents from ___'s office with leukocytosis of
382. Several months ago, pt began to notice some left-sided
abdominal pain. No changes in bowel habits and no issues with
nausea/vomiting. Over the past few weeks, has noticed worsening
fatigue and DOE, as well as a headache, bruising, and drenching
night sweats. In the past few days, DOE and fatigue has become
very limiting. She has also noticed a blurry spot in her vision.
Went to PCP morning prior to admission for these issues, had
blood work done that was remarkable for leukocytosis to 382, and
was sent to the ED for further work-up.
Seen by ___ in the ED, who recommended q6hr monitoring of tumor
lysis labs and DIC labs. Bone marrow biopsy was done, revealing
concentrated blasts.
In the ED, initial vitals: T 98.8, BP 125/64, HR 89, RR 16,
SpO2 96/RA
- Exam notable for:
- Labs were notable for: WBC 395.2, H/H ___, plt 27, uric
acid 8.5, LDH 1341, fibrinogen 242, INR 1.2, Cr 1.0
- Imaging: none
- Patient was given: 2L NS, 10mg IV metoclopramide, 300mg PO
allopurinol, 1g PO acetaminophen, 1g hydroxyurea
- Consults: ___
On arrival to the MICU, pt is stable and reports that her
headache and blurry vision has subsided. Vitally stable.
Review of systems:
As per HPI
Past Medical History:
breast cancer - R invasive carcinoma with tubular features, s/p
partial mastectomy, sentinel node biopsy and radiation
atypical Celiac's disease
hypertension
anxiety
arthritis
cervical spondylosis with myelopathy
Social History:
___
Family History:
father with 'heart disease', died ___ of possible CHF,
grandfather died MI early ___ no history of early MI, CHF,
arrhythmia.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 98.2, BP 97/75, HR 73, RR 20, SpO2 96/RA
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, good dentition
NECK: no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in major muscle groups,
sensation is grossly intact
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.8 PO 100 / 60 73 18 98 RA
24Hr I/O: 2036/650 wt: 183.29 (wt 7 days ago: 182.3 lb)
Gen: Pleasant, calm female in NAD, lying in bed wearing hat
HEENT: No conjunctival pallor. No icterus. MMM. OP clear without
thrush.
NECK: JVP flat. Normal carotid upstroke without bruits.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: Small ecchymosis on L dorsal forearm, R elbow, all stable.
Otherwise no rashes/lesions.
NEURO: CN II-XII intact. A&Ox3.
LINES: Left Hickman, c/d/I mild oozing of blood, no tenderness
to palpation.
Pertinent Results:
ADMISSION LABS
==============
___ 02:30PM WBC-382.0*# RBC-2.66*# HGB-7.7*# HCT-26.2*#
MCV-99*# MCH-28.9 MCHC-29.4*# RDW-21.2* RDWSD-56.2*
___ 02:30PM NEUTS-0* BANDS-3 LYMPHS-2* MONOS-0 EOS-1
BASOS-0 ___ METAS-1* MYELOS-0 BLASTS-93* OTHER-0
AbsNeut-11.46* AbsLymp-7.64* AbsMono-0.00* AbsEos-3.82*
AbsBaso-0.00*
___ 02:30PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+
POLYCHROM-NORMAL
___ 02:30PM UREA N-17 CREAT-0.9 SODIUM-140 POTASSIUM-3.7
CHLORIDE-99 TOTAL CO2-29 ANION GAP-16
___ 02:30PM ALT(SGPT)-26 AST(SGOT)-39 ALK PHOS-87
___ 02:30PM CALCIUM-9.4
___ 02:30PM TSH-1.1
___ 02:30PM GLUCOSE-104*
___ 09:53PM RET AUT-1.7
___ 09:53PM QUAN G6PD-17.6*
___ 09:53PM ___ 09:53PM ___ PTT-27.5 ___
PERTINENT LABS/MICROBIOLOGY/PATHOLOGY
=====================================
___ 01:00AM BLOOD Fibrino-69*#
___ 09:53PM BLOOD QG6PD-17.6*
___ 09:53PM BLOOD Ret Aut-1.7
___ 09:53PM BLOOD ALT-26 AST-44* LD(LDH)-1341* CK(CPK)-59
AlkPhos-83 TotBili-0.5
___ 12:40AM BLOOD ___
___ 09:00PM BLOOD TSH-0.52
___ BONE MARROW BIOPSY: hypercellular bone marrow with
extensive involvement by B lymphoblastic leukemia
___ BONE IMMUNOPHENOTYPING: CD34+ blasts comprise 97% of
total analyzed events. Cell marker analysis demonstrates that
the majority (97%) of the cells isolated from this peripheral
blood/bone marrow are in the CD45-dim/low side-scatter "blast"
region. They express CD38, immature antigens CD34, ___, nTdT
(subset), and lymphoid associated antigens CD19, cCD79a (small
subset). They lack B and T cell associated antigens, are CD10
(cALLa) negative, and are negative for CD13, CD33, CD14, CD64,
CD117, cMPO, cCD3, cCD22, and CD15. The CD19+ blasts are
negative by cKappa and cLambda.
___ CYTOGENETIC DIAGNOSIS:
46,XX,t(4;11)(q21;q23)[9]/46,XX[9], FISH negative for BCR/ABL,
positive for MLL rearrangement, negative high grade lymphoma
panel
DISCHARGE LABS
==============
___ 12:00AM BLOOD WBC-1.2* RBC-2.44* Hgb-7.2* Hct-21.3*
MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 RDWSD-43.4 Plt ___
___ 12:00AM BLOOD Neuts-45 Bands-3 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-0.58* AbsLymp-0.54*
AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD ___ PTT-24.8* ___
___ 12:00AM BLOOD Glucose-118* UreaN-14 Creat-0.6 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-70* AST-28 LD(LDH)-230 AlkPhos-75
TotBili-0.4
___ 12:00AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.7* Mg-2.2
IMAGING
=======
TTE ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 70%). Right ventricular chamber size and free
wall motion are normal. 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. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
findings are similar.
CT HEAD WITHOUT CONTRAST ___
No acute intracranial abnormalities.
CHEST PA/LAT ___
Low lung volumes with suspected atelectasis in the left lung
base.
MRI HEAD ___
No evidence of hemorrhage, edema, mass, mass effect, or acute
infarction.
U/S RIGHT FOOT ___
1.9 x 1.5 cm cystic structure corresponding to the palpable
abnormality is most consistent with a ganglion.
TUNNELED CENTRAL LINE ___:
Successful placement of a triple-lumen tunneled line via the
left internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use.
Brief Hospital Course:
___ with history of breast cancer, HTN who presents with
significant leukocytosis in the setting of night sweats, weight
loss, easy bruising with blasts in periphery and bone marrow
consistent with acute leukemia.
#ACUTE LEUKEMIA: Leukocytosis to 395 on admission. Seen by ___
in ED and continued to follow while in the ICU. Bone marrow
biopsy shows high blast count, no Auer rods. She was started on
allopurinol and hydroxyurea in ED. Initial labs not concerning
for tumor lysis syndrome or DIC and were trended every 6 hours
through her ICU course. She was started on fluid resuscitation
with urine output maintained at over 100cc/hr. Head CT and CXR
were performed that showed no acute processes. Ophthalmology
consult performed and found retinal hemorrhage on the L which
corresponds to her area of endorsed blind spot. Bone marrow
biopsy x 2 was performed. FISH, flow cytometry, cytogeneics,
rapid heme panel were performed and were significant for Ph
negative pre-B ALL. She was given one dose of rasburicase,
started on prednisone, and hydrea. During ICU course WBC count
down from 385K to 115K without signs of tumor lysis in ICU. She
was given prophylaxis with acyclovir, PPI, and allopurinol.
She was subsequently transferred to the floor under the ___
service. She was enrolled in ___ clinical trial ___, which
entails: Cytarabine (IT day 1); Daunorubicin (days 1, 8, 15,
22); Vincristine (days 1, 8, 15, 22); Dexamethasone (days ___
Methotrexate (IT day 14). TTE was obtained prior to chemo and
showed LVEF 70%. She began chemotherapy on ___ and tolerated
it well. She was continued on IVF to target UOP of 100cc/hr.
Allopurinol was continued for TLS prevention (days ___, per
protocol). She was diuresed as needed for volume overload. She
refused transfusion as necessary to treat her anemia and
thrombocytopenia. Ciprofloxacin and Fluconazole were also
started for prophylaxis.
#ALL: Ph- pre-B ALL, with MLL. Patient is D25 of induction
chemotherapy as per protocol. She has been enrolled in trial
___, which entails: Cytarabine (IT day 1); Daunorubicin (days
1, 8, 15, 22); Vincristine (days 1, 8, 15, 22); Dexamethasone
(days ___ Methotrexate (IT day 14). TTE ___ with EF
70%. Notably, she did not receive Peg-asparaginase as she is
>___. Bone marrow biopsy was done prior to discharge, results are
pending and will be followed by Dr. ___. Given ANC > 500
will Ciprofloxacin and Fluconazole were discontinued.
#NAUSEA: will discharge with zofran ODT 4 mg, ativan 0.5mg PO as
needed for nausea.
CHRONIC ISSUES
==========================
#TRANSAMINITIS. Labs notable for ALT 50-70 chronically otherwise
WNL. Possibly due to Ciprofloxacin, Fluconazole. Also possible
effect of chemotherapy. Will continue to monitor.
#INSOMNIA. Pt currently taking home Melatonin, but reports
ongoing insomnia despite receiving this as well as Trazodone.
She was also given Diphenhydramine ___ qhs PRN. Finally
relief was achieved with ambien.
#HYPERTENSION: on nadolol and hydrochlorothiazide at home. SBPs
90-110s on arrival to ___. Held nadolol and HCTZ.
#HEADACHE. Patient reported headache intermittently. She was
given Fioricet for symptomatic relief. Opiates were avoided.
#RIGHT FOOT NODULE. Previously noted to have nodule on dorsal R
foot, believed to be consistent with ganglion cyst. No
discomfort, pain, itching from this. U/s obtained ___ and was
consistent with ganglion.
#OXYGEN REQUIREMENT. Pt reports a history of OSA, but does not
use CPAP at home. Respiratory therapy consulted ___ and
offered CPAP, but pt declined. She used nasal cannula oxygen
overnight.
#HISTORY OF VESTIBULITIS. Unclear nature of her
vestibulitis/ataxia, but per report, she may have been diagnosed
by her previous oncologist, Dr. ___, with atypical celiac
disease, with neurological manifestations. So far no
documentation has been found regarding this. Symptoms resolved
without intervention (per patient). We spoke to Dr. ___
___ ___ they stated she has never been seen by him (had a
new patient appt on ___.
#DEPRESSION. Well controlled on Cymbalta. Continued home
Cymbalta.
TRANSITIONAL ISSUES
====================================
[ ] follow-up with line care training at home
[ ] follow-up appointment on ___ with Dr. ___ for
ongoing ALL management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL,
DAILY:PRN
5. Cetirizine 10 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Docusate Sodium 100 mg PO Frequency is Unknown
8. Senna 8.6 mg PO BID:PRN constipation
9. flaxseed oil 1,000 mg oral unknown
10. lutein 6 mg oral unknown
11. lysine 1,000 mg oral unknown
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1
capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0
2. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. melatonin 4 mg oral QHS
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea Duration: 5 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
6. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 125 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
8. Zolpidem Tartrate 5 mg PO QHS
RX *zolpidem 5 mg ` tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
10. Cetirizine 10 mg PO DAILY
11. DULoxetine 60 mg PO DAILY
12. flaxseed oil 1,000 mg oral unknown
13. lutein 6 mg oral unknown
14. lysine 1,000 mg oral unknown
15. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL,
DAILY:PRN
16. Nadolol 20 mg PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*10
Tablet Refills:*0
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until told to by
your primary care doctor or oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Acute lymphocytic leukemia
SECONDARY:
Pancytopenia
Headache
Transaminitis
Obstructive sleep apnea
Ganglion cyst
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
You were in the hospital because of a very high white blood cell
count. We found that this was due to leukemia. You received a
course of chemotherapy, we monitored your cell counts and gave
you transfusions as needed. We did bone marrow biopsies and
placed a line to help deliver some of your medications.
What happened to me in the hospital?
We gave you chemotherapy to treat your leukemia. We did bone
marrow biopsies and placed a line to help deliver medications.
What should I do when I leave the hospital?
You should continue to take your medicines, and attend all your
doctor's appointments. Do NOT get your catheter wet (coil it and
cover it), if it gets wet it needs to be changed right away.
Change your dressing, flush your catheter, change the cap on the
end of the catheter.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10728110-DS-7
| 10,728,110 | 21,394,756 |
DS
| 7 |
2120-02-17 00:00:00
|
2120-02-17 13:04:00
|
Name: ___ ___ 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:
PRIMARY DIAGNOSIS: Hepatocellular carcinoma with lymph node and
presumed bone metastases
PRIMARY ONCOLOGIST: Dr ___ COMPLAINT: Fever, cough
HISTORY OF PRESENT ILLNESS:
Dr. ___ is a pleasant ___ w/ CAD s/p PCI, T2DM, HCV s/p liver
transplant ___, multifocal HCC on C2 of gemcitabine/cisplatin
who p/w DOE x ___ days, fevers x ___ days, productive cough
worsening over the last few days. Tmax 102.2. Had loose stool
yesterday but none since then. Has a rash from 8 days ago that
is
somewhat spreading but attributed to gemcitabine. Notes sig
pruritis. No N/V. No abd pain. No ___. Wife notes new confusion
and weakness. Son notes grandson was ill recently w/ enlarged
posterior cervical node and improved on abx.
In the ED, T max 101.7, HR 122-->90, BP 123/59, 97% on RA. WBC
1.2 w/ ANC of 660. LFTs up from baseline. No acute findings on
CXR or RUQ US. Received Vanc/Cef.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ developed HCC in the setting of HCV. He underwent
hepatic transplantation in ___ in ___. At
the time HCC was identified and outside ___ criteria. Dr. ___
presented in ___ with slow continued weight loss since the time
of his surgery but more profound over the year prior associated
with exercise intolerance, fatigue and dyspnea on exertion
compared to his baseline. These symptoms prompted further
evaluation by his primary care provider and hepatologist, and
ultimately imaging studies which identified intrahepatic and
extrahepatic masses, concerning for malignancy. His AFP was
notably elevated. He underwent MRI followed by biopsy of a
perihepatic lymph node conglomerate mass by endoscopic
ultrasound, which confirmed recurrent metastatic hepatocellular
carcinoma. He initiated palliative systemic therapy with
lenvatinib ___. Surveillance MRI ___ showed
progression of multifocal liver disease and lymphadenopathy with
associated increase in AFP. Lenvatinib dose was increased to
12mg. Surveillance imaging ___ showed progression, and he
was transitioned to cabozantinib ___ but discontinued by
___ due to fatigue, tongue soreness and intolerance. He
initiated gemcitabine/cisplatin ___ cisplatin dose reduced
to 75% given CKD.
PAST MEDICAL HISTORY (per OMR):
1. Hepatitis C virus, status post allogeneic hepatic transplant
___
2. History of pyelonephritis ___
3. History of hypercholesterolemia
4. Status post MI with PCI to LAD at ___ ___
5. History of colon polyps ___
6. History of type IV renal tubular acidosis related to
tacrolimus complicated by hyperkalemia
7. History of childhood asthma
8. Status post right knee surgery
9. Status post right inguinal hernia repair
10. Status post TURP ___
11. History of chronic normocytic anemia
12. Type 2 diabetes mellitus secondary to prednisone use
following hepatic transplantation
Social History:
___
Family History:
The patient's mother died at ___ years with cognitive
impairment/dementia. His father died at ___ years with coronary
artery disease. He was treated for colon cancer at ___ years and
had a history of squamous cell skin cancer. His brother had CAD
and MI in his ___, and died in his ___. He also has diabetes
mellitus and hypertension. His sister has obesity. He has 3
children, who had childhood asthma
Physical Exam:
VITAL SIGNS: 98.3 PO 143 / 70 74 20 96 RA
General: NAD, sitting upright in bed comfortably, frail
HEENT: MM less dry, OP appears less erythematous today
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress, intermittent
cough, dry
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: scattered discrete red pruritic papules on the upper
chest, back, abdomen, proximal upper ext, sparing the
mouth/palms/soles, of various sizes from pinpoint to macule
NEURO: CN III-XII intact, strength b/l ___ intact but
generally weak
speech is clear and fluent, good insight
PSYCH: Thought process logical, linear, future oriented
ACCESS: RUE PIV
Pertinent Results:
___ 06:26AM BLOOD WBC-6.3 RBC-3.08* Hgb-9.4* Hct-27.5*
MCV-89 MCH-30.5 MCHC-34.2 RDW-19.0* RDWSD-62.4* Plt ___
___ 04:47AM BLOOD WBC-1.2* RBC-3.34* Hgb-10.2* Hct-30.7*
MCV-92 MCH-30.5 MCHC-33.2 RDW-18.9* RDWSD-63.2* Plt ___
___ 06:26AM BLOOD Neuts-67.3 Lymphs-14.4* Monos-15.5*
Eos-0.5* Baso-0.6 Im ___ AbsNeut-4.27 AbsLymp-0.91*
AbsMono-0.98* AbsEos-0.03* AbsBaso-0.04
___ 06:30AM BLOOD Neuts-69.7 Lymphs-13.1* Monos-14.7*
Eos-0.0* Baso-0.5 Im ___ AbsNeut-3.09 AbsLymp-0.58*
AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02
___ 04:47AM BLOOD Neuts-53.3 ___ Monos-14.5*
Eos-0.8* Baso-0.8 NRBC-1.6* Im ___ AbsNeut-0.66*
AbsLymp-0.33* AbsMono-0.18* AbsEos-0.01* AbsBaso-0.01
___ 06:26AM BLOOD Glucose-107* UreaN-36* Creat-1.4* Na-128*
K-4.1 Cl-92* HCO3-22 AnGap-14
___ 04:47AM BLOOD Glucose-120* UreaN-49* Creat-1.7* Na-127*
K-4.6 Cl-88* HCO3-24 AnGap-15
___ 06:26AM BLOOD ALT-123* AST-114* LD(LDH)-213
AlkPhos-546* TotBili-0.9
___ 04:47AM BLOOD ALT-232* AST-194* AlkPhos-705*
TotBili-1.5
___ 04:47AM BLOOD Lipase-25
___ 06:26AM BLOOD Albumin-2.6* Calcium-8.0* Phos-2.3*
Mg-2.5
___ 06:30AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.3
Mg-1.5*
___ 04:47AM BLOOD Albumin-3.5
___ 06:26AM BLOOD tacroFK-2.0*
___ 06:30AM BLOOD tacroFK-<2.0*
___ 04:57AM BLOOD Lactate-1.0
___ 06:30AM BLOOD CMV VL-NOT DETECT
CXR
FINDINGS: PA and lateral views of the chest provided. There is
no focal consolidation, pleural effusion or pneumothorax.
Paracardiac interstitial opacities are likely secondary to mild
chronic parenchymal changes and right middle lobe bronchiectasis
as seen on prior CT. Cardiomediastinal contours are normal.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
___ w/ CAD s/p PCI, T2DM, HCV s/p liver transplant ___,
multifocal HCC on C2 of gemcitabine/cisplatin who p/w febrile
neutropenia.
# Febrile Neutropenia
Suspect etiology likely bacterial vs viral PNA in light of his
productive cough. Reassuringly CXR and lung sounds clear. He
improved on IV vanc and cefepime. He requested to transition to
hospice at home so discharged him on levofloxacin to complete a
7 day course.
# HCC
Neutropenia likely from the chemo, as is the macularpapular rash
on torso and proximal ext. He will forgo further chemo. Will
cont sarna for the rash.
# History of liver transplant
# Elevated LFTS
Reassuringly US revealed patent vasculature and no biliary
dilitation. Likely the elevated lfts due to solid intra and
extrahepatic mets. Diff also includes rejection. Was seen by the
liver transplant team.
- cont tacro 0.5 1mg qhs, 1 mg qam
- cont fludrocortisone MWF
# ? Delirium
Wife notes subtle confusion. He also admits to intermittent
confusion. He was clear at the time of discharge.
# Hyponatremia
Likely from poor po intake and concominant chlorthalidone use.
Improved with hydration.
# Deconditioning: ___ consulted and did well with them ambulating
stairs
# Poor PO intake: consulted nutrition, rec'd Ensure Enlive
# T2DM: did not require any insulin while he is here so stopped
# CAD: cont asa, metoprolol, stopped atorvastatin in light of
goals of care
# HTN: stopped chlorthalidone as did not need it inpatient
# CKDIII: Had ___ but improved with hydration, holding
chlorthalidone
FEN: Regular diet
CODE STATUS: DNR/DNI, home w/ hospice
DISPO: Onco-Hosp
BILLING: >30 min spent coordinating care for discharge
________________
___, D.O.
Heme/___ Hospitalist
p: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheezing
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Chlorthalidone 100 mg PO DAILY
7. Codeine Sulfate ___ mg PO Q8H:PRN pain
8. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
9. Glargine 5 Units Bedtime
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Pantoprazole 40 mg PO DAILY:PRN heartburn
12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
14. Tacrolimus 0.5 mg PO QPM
15. Tacrolimus 1 mg PO DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Magnesium Oxide 280 mg PO QPM:PRN muscle cramps
18. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. GuaiFENesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
watch for constipation or sedation with this
RX *codeine-guaifenesin [Coditussin AC] 10 mg-200 mg/5 mL ___
ml by mouth q6hrs prn Refills:*0
2. LevoFLOXacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth q48 hrs Disp #*4
Tablet Refills:*0
3. Sarna Lotion 1 Appl TP Q2H:PRN pruritis
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply thin
film q1hrs prn Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheezing
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Codeine Sulfate ___ mg PO Q8H:PRN pain
8. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Magnesium Oxide 280 mg PO QPM:PRN muscle cramps
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
14. Pantoprazole 40 mg PO DAILY:PRN heartburn
15. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
16. Tacrolimus 0.5 mg PO QPM
17. Tacrolimus 1 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr ___,
___ was a pleasure caring for you in the hospital. You were
admitted with febrile neutropenia and a respiratory infection,
most likely a pneumonia. You received IV vancomycin and cefepime
and improved. You were discharged on an oral antibiotic. You
also made the decision to pursue hospice care and we fully
support that.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10728333-DS-14
| 10,728,333 | 22,391,563 |
DS
| 14 |
2122-12-25 00:00:00
|
2122-12-25 20:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
labetalol
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with stent trial on ___
Bronchoscopy ___
History of Present Illness:
___ Female with history of trachebronchoomalacia, asthma, HTN,
chronic back pain s/p fusion and anxiety presenting w/gradually
worsening respiratory distress.
Patient notes that she's had dyspnea with exertion for many
months. she was last seen by pulmonologist ___ ___ at which
point inhalers were optimized with plan for re-stenting for TBM
if symptoms do not improve. She's noted that over the past month
she's had a steady and slow worsening of dyspnea symptoms with
worsening cough and increase ___ congestion/mucuous production
over the past ___ days. Denies chest pain though has mild chest
tightness with breathing. Notes symptoms worsen significantly
with activity. + sore throat for a few days. No mylagias or
rhinorrhea. Felt warm over the past week though no clear fevers.
Patient reported to the ___ with stridor and wheezing
while sating 97% on RA. CXR was normal. She received IV
solumedrom 125mg and nebs prior to transfer to ___. Her ABG
did not show evidence of hypercapnia (___.2) but she was
transferred on BIPAP given concern for breathing status.
- ___ the ___, initial vitals were: T 99.2 HR 90 BP 137/86 RR 20
sat 96% shovel mask
- Exam was notable for: General: Upper respiratory wheezes
heard, appears mildly uncomfortable Pulmonary: Mild wheezes but
seems to be upper respiratory sounds transmitted
- Labs were notable for: CBC, LFT, BNP, coags wnl VBG:
7.41/41/40 UA: negative with 300 glucose Urine hcg: negative
Lipase 25 Trop <0.01
- Studies were notable for: CXR: Suspected left lower lobe
pneumonia.
- The patient was given no medications.
On arrival to the floor, patient confirms history above. Notes
that breathing has improved since receiving steroids at the
outside ___. Notes that she used to be on 4L O2 at home up until
___ when it was discontinued.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Tracheobronchomalacia
Hypertension
Asthma
Chronic back pain s/p cervical fusion ___
Hyperglycemia
Anxiety
Social History:
___
Family History:
Hypertension Father
Kidney cancer Father
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
T 98.1 BP 132/79 HR 93 RR 18 Sat 96% 2L
GENERAL: Alert and interactive. No acute respiratory distress or
work of breathing though audible inspiratory sounds
HEENT: PERRL, EOMI. MMM.
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Loud diffuse rhonchi throughout with expiratory wheezes
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants. No organomegaly.
EXTREMITIES: No ___ edema. warm, well perfused
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously.
DISCHARGE EXAM
==============
VS: ___ 2350 Temp: 97.3 PO BP: 123/71 HR: 91 RR: 18 O2 sat:
94% O2 delivery: Ra
GENERAL: Sitting comfortably ___ bed, no acute distress
HEENT: No conjunctival pallor, anicteric sclera, MMM
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: Moderate expiratory wheezing bilaterally, no increased WOB
on room air.
___: Soft, non-tender, no distention, BS normoactive
EXTREMITIES: Warm, well-perfused, no lower extremity edema
NEURO: A/Ox3, otherwise grossly intact, moving all four
extremities
Pertinent Results:
ADMISSION LABS
==============
___ 08:58PM BLOOD WBC-8.0 RBC-4.35 Hgb-12.3 Hct-38.2 MCV-88
MCH-28.3 MCHC-32.2 RDW-12.8 RDWSD-41.1 Plt ___
___ 08:58PM BLOOD Neuts-87.7* Lymphs-7.5* Monos-2.4*
Eos-0.5* Baso-0.6 Im ___ AbsNeut-7.00* AbsLymp-0.60*
AbsMono-0.19* AbsEos-0.04 AbsBaso-0.05
___ 08:58PM BLOOD ___ PTT-31.0 ___
___ 08:58PM BLOOD Glucose-223* UreaN-13 Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-24 AnGap-13
___ 08:58PM BLOOD ALT-33 AST-23 AlkPhos-96 TotBili-0.4
___ 08:58PM BLOOD cTropnT-<0.01
___ 08:58PM BLOOD Lipase-25
___ 06:17AM BLOOD Calcium-9.9 Phos-3.1 Mg-1.8
___ 08:58PM BLOOD Albumin-4.6
___ 09:03PM BLOOD ___ pO2-40* pCO2-41 pH-7.41
calTCO2-27 Base XS-0 Intubat-NOT INTUBA
___ 09:03PM BLOOD O2 Sat-72
DISCHARGE LABS
===============
___ 08:16AM BLOOD WBC-16.8* RBC-4.35 Hgb-12.4 Hct-38.0
MCV-87 MCH-28.5 MCHC-32.6 RDW-13.1 RDWSD-41.0 Plt ___
___ 08:16AM BLOOD Glucose-147* UreaN-19 Creat-0.6 Na-138
K-4.3 Cl-99 HCO3-24 AnGap-15
IMAGING
=======
CHEST PA AND LATERAL (___)
FINDINGS: There are low bilateral lung volumes. An opacity is
seen at the left lung base. No pleural effusion or
pneumothorax. The size of the cardiac silhouette is within
normal limits. Cervical fusion hardware is present. Multilevel
degenerative changes are seen ___ the thoracic spine
IMPRESSION: Suspected left lower lobe pneumonia.
CHEST AP (___)
Single frontal view of the chest shows the costophrenic angles
to be sharp.
The lungs are clear. The previously seen left basilar opacity
has resolved. Anterior cervical spine fusion hardware is
partially visualized. The heart isnormal ___ size.
IMPRESSION: Interval resolution of left basilar opacity.
C-SPINE ___
IMPRESSION:
1. Postsurgical changes from ACDF of C5-C7.
2. Normal vertebral alignment with no significant change on
flexion and extension views.
3. Mild to moderate degenerative changes, as detailed above.
CXR ___
IMPRESSION:
Tracheobronchial stent is ___ place. Lungs are clear. There is
no appreciable
pleural effusion or pneumothorax. No pulmonary edema.
CXR ___
IMPRESSION:
Comparison to ___. The airways stents are ___ stable
position. No
pneumothorax. Minimal elevation of the right hemidiaphragm with
minimal right
basilar atelectasis. No larger pleural effusion, pneumonia.
CXR ___
IMPRESSION:
Low lung volumes are noted with unchanged elevation of the right
hemidiaphragm. The airway stents are ___ stable positions.
Linear opacities ___ the lung bases most likely represent
subsegmental atelectasis. There is no focal consolidation, large
pleural effusion or pneumothorax. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities are identified. There is anterior fusion hardware
___ the cervicothoracic junction.
CXR ___
IMPRESSION:
Lungs are low volume with subsegmental atelectasis ___ the
left-lateral base. Subsegmental atelectasis ___ the right lower
lobe has resolved. There is evidence of internal fixation of
the cervical spine. No pneumothorax.
CXR ___
IMPRESSION:
A Y stent remains ___ place. Lungs are low volume. There are
stable small bilateral effusions left greater than right.
Cardiomediastinal silhouette is stable. No pneumothorax.
CXR ___
IMPRESSION:
Comparison to ___. A tracheal stent is no longer
visualized. The bronchial stents have also been removed.
Stable low lung volumes. No overinflation. No evidence of
pneumonia, pulmonary edema or pleural effusions. A previous
partial left lower lobe atelectasis is completely resolved.
STUDIES/PROCEDURES
====================
BRONCHOSCOPY ___
Severe malacia ___ mid and distal trachea, RMSB/BI and SMSB
Mild stenosis with moderate malacia at stoma site. Balloon
dilation and airway stent placement.
BRONCHOSCOPY ___
Inflamed airways with mucus and early granulation tissue
development consistent with tracheobronchitis
BRONCHOSCOPY ___
Diffuse airway inflammation with thick mucus. Stents removed.
MICROBIOLOGY
=============
___ 2:18 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 9:35 am BRONCHIAL WASHINGS TRACHEOBNCHIAL WASH.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
STAPH AUREUS COAG +. >100,000 CFU/mL.
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.
MORAXELLA CATARRHALIS. 10,000-100,000 CFU/mL.
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
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Final ___:
YEAST.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
___ 1:15 pm BRONCHIAL WASHINGS TRACHEAL BROCHIAL
WASHING.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 CFU/mL.
Susceptibility testing performed on culture # ___
___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
YEAST.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
___ 7:48 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 4:17 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
Brief Hospital Course:
PATIENT SUMMARY
===============
Mrs. ___ is a ___ never smoker with w/ hx of
tracheobronchomalacia, asthma, presenting with subacute
worsening of dyspnea likely secondary to an asthma exacerbation
complicated by tracheobronchomalacia. She was stented on ___,
with subsequent worsening of respiratory status and mucous
plugging. She was transferred to the ICU for bi-level positive
airway pressure respiratory support and removal of stents, with
subsequent improvement. She was treated for an asthma
exacerbation with IV methylprednisolone and transitioned to PO
prednisone at discharge. Insulin was administered for management
of hyperglycemia while inpatient, and discharged on NPH.
TRANSITIONAL ISSUES
===================
#Asthma exacerbation:
[] Continue prednisone taper:
- ___: 50mg
- ___: 40mg
- ___: 30 mg
- ___: 20 mg
- ___: 10 mg
- ___: off (unless otherwise specified by pulmonology doctor)
[] Bactrim PCP prophylaxis should be stopped once steroid taper
complete
#Hyperglycemia
[] Started on NPH 32 units daily to cover hyperglycemia from
prednisone use.
[] Taper NPH as follows (instructions given to patient at
discharge):
- ___: 32u
- ___: 26u
- ___: 20u
- ___: 14u
- ___: 8u
*****
[] Please note that Diabetes consult recommendations were not
available at the time of discharge. The recommended increasing
NPH to 34 units daily while on current 50mg prednisone dose.
They also recommended adding Humalog 6 units before breakfast,
10 units before lunch and supper and sliding scale for
correction 150/50/2/2. If patient presents to PCP appointment
and fingerstick glucose levels are significantly elevated,
consider prescribing humalog insulin per above instructions.
[] If difficulty controlling blood glucose levels, can schedule
this patient for a follow up at the ___,
please contact ___ Central Appointment ___ or
email ___ for immediate
response.
*****
#Tracheobronchomalacia
[] Follow up with interventional pulmonary team and thoracic
surgery
#CODE: Full confirmed
#CONTACT: ___ ___
ACTIVE ISSUES
=============
#Tracheobronchomalacia/Tracheobronchitis
#Asthma exacerbation
Patient with known asthma (confirmed on PFTs) and severe
tracheobronchomalacia who presented with subacute/acute
worsening of dyspnea. She underwent distal tracheal and RMS/LMS
bronchial stents on ___ with worsening of symptoms secondary
to overlying tracheobronchitis (growing coag positive staph and
Moraxella on BAL) requiring ICU stay for BiPAP. Despite
restarting high dose steroids and antibiotics, symptoms did not
improve and subsequently underwent rigid bronchoscopy and
removal of three stents on ___. Hypoxia improved and patient
felt better after removal of the stents. She was treated for her
tracheitis for a total of 7 days with vancomycin first and then
Augmentin. She was continued on a prednisone taper, started on
monteleukast, increased fluticasone/salmeterol, and duo/saline
nebs with improvement ___ her respiratory symptoms and was able
to ambulate with mild wheezing and O2 sats ___ the mid-90s. She
has close follow-up scheduled with interventional pulmonary and
with thoracic surgery.
#Hyperglycemia:
#Diabetes:
Glucose rose to 400s ___ the setting of steroids for asthma
exacerbation, HgbA1c 6.9%. She was started on daily NPH insulin
and metformin and discharged on a NPH taper also with her
steroid taper. (Please see details above, including
post-discharge modification to plan, which include addition of
sliding scale and meal associated insulin, which was
communicated to the patient and PCP office after discharge)
CHRONIC/STABLE ISSUES
=====================
# HTN
Continued amlodipine 10mg daily. Metoprolol gradually tapered
and then discontinued due to relative contraindication ___ asthma
and lack of clear indication
#Insomnia
Continued home doxepin
# Chronic back pain
S/P cervical fusion ___ with post operative complications
eventually resulting ___ trach and peg ___ ___. She was seen
by the neurosurgery team and was cleared for rigid bronchoscopy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
2. amLODIPine 10 mg PO DAILY
3. Doxepin HCl 50 mg PO HS
4. Gabapentin 800 mg PO TID
5. Sodium Chloride 3% Inhalation Soln 5 mL NEB BID
6. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
7. Cetirizine 10 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath
9. Metoprolol Tartrate 50 mg PO BID
10. Omeprazole 40 mg PO BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone propion-salmeterol 500 mcg-50 mcg/dose 1 PUFF
INH twice a day Disp #*1 Disk Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. NPH 32 Units Breakfast
RX *insulin NPH isoph U-100 human [Humulin N NPH Insulin
KwikPen] 100 unit/mL (3 mL) AS DIR 32 Units before BKFT; Disp
#*10 Syringe Refills:*0
4. Ipratropium-Albuterol Neb 1 NEB NEB Q8H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL
INH every eight (8) hours Disp #*90 Ampule Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO QPM
RX *metformin 500 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. PredniSONE 10 mg PO DAILY
5 PILLS ___, 4 PILLS ___, 3 PILLS ___, 2 PILLS
___, 1 PILL ___
Tapered dose - DOWN
RX *prednisone 10 mg 5 tablet(s) by mouth once a day Disp #*70
Tablet Refills:*0
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tab-cap by mouth once a day Disp #*15 Tablet Refills:*0
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q8H
RX *sodium chloride 3 % 15 INH every eight (8) hours Disp #*90
Vial Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath
RX *albuterol sulfate 90 mcg ___ puff inh every four (4) hours
Disp #*1 Inhaler Refills:*0
11. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Cetirizine 10 mg PO DAILY
RX *cetirizine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
13. Doxepin HCl 50 mg PO HS
RX *doxepin 50 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*0
14. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
15. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*0
16. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
17. HELD- Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB This
medication was held. Do not restart Acetylcysteine 20% until you
see your pulmonologist (you did not require this medicine while
___ the hospital).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Tracheobronchomalacia
Asthma
Secondary diagnoses:
Hypertension
Chronic back pain status post fusion
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had shortness of breath.
What happened while I was ___ the hospital?
====================================
- You were seen by the interventional pulmonology team.
- You underwent a procedure called a bronchoscopy and a stent
was placed to help support your airways.
- You were having trouble with increased mucus production so
another bronchoscopy was performed to look at the stent and
remove mucus
- You needed to be transferred to the ICU for respiratory
support
- Your stent was removed and you improved significantly.
- You were treated with IV steroids, and then oral steroids, for
an asthma exacerbation
- You were given insulin to help control your sugars while on
steroids.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed ___ discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10728419-DS-19
| 10,728,419 | 26,868,786 |
DS
| 19 |
2131-01-24 00:00:00
|
2131-01-24 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Spironolactone / Ace Inhibitors
Attending: ___.
Chief Complaint:
dirrhea, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ gentleman with type 2 diabetes and hypertension,
status post two renal transplants, most recent in ___. He has
chronic allograft nephropathy and stage III chronic kidney
disease with baseline creatinine in the mid 1s on an
immunosuppressive protocol made up of tacrolimus and
mycophenolate mofetil. He was found to elevated BUN/Cr on
routine labs and directed to come in for evaluation.
He reported that he had been feeling well and denied symptoms
of any kind though he did say that when he drinks lots of water
he tends to get loose frequent stools, which happens to him at
least weekly.
In the ED, initial vitals were: T98.2 HR73 BP135/83 RR16
SaO296% RA
Labs notable for Na144 K3.2 BUN29 Cr2.0
Imaging notable for renal transplant US:
1. Worsening renal pelvic fullness.
2. Increase in systolic velocity, measuring up to 180 cm/s,
previously 78.1
cm/s.
3. Normal arterial waveform with resistive indices ranging from
0.64-0.75.
Renal was consulted and recommended: Renal US, UA, U lytes, U
prot/Cr ratio, Urine BK virus, admit
Patient was not given anything in ED
Decision was made to admit for management of worsening renal
function
Vitals prior to transfer: T98.0 HR65 BP144/99 RR18 SaO299% RA
On the floor, patient was feeling well.
Past Medical History:
- ESRD ___ HTN ___ CRT ___ c/b delayed graft function. Graft
positive for hepatitis B and C. ___ second cadaveric kidney
transplant ___
- Hypertension
- Diabetes mellitus, followed at ___.
- Hepatitis C: followed by Dr. ___. Bx before ___ without
fibrosis. Type ___,559,407 in ___. Was
not felt that ribavarin/interferon ideal given immuopsuppresion
and
elevated creatinine.
- Hepatitis B
- CVA in ___ with residual left sided weakness
- Depression/anxiety
- Erectile dysfunction
- Left arm radiocephalic AV fistula ___
- Ventriculoperitoneal shunt ___ for hydrocephalus from
thalamic hemorrhage and intraventricular hemorrhage
- ex-lap in ___ for ___
Social History:
___
Family History:
HTN: mother and father.
father died at the age of ___ of heart attack
panic attacks: brother
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: T97.7 PO Bp146/75 HR75 RR20 SaO295RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Protuberant, 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 grossly intact, ___ strength upper/lower
extremities, grossly normal sensation.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 98.2 | 154/83 | 74 | 18| 97%RA
GENERAL: Alert, laying in bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Large, soft, non-tender, non-distended, bowel sounds
present, no rebound or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Face symmetric, moving all extremities with purpose
against gravity
Pertinent Results:
ADMISSION LABS
==============
___ 08:46PM BLOOD WBC-6.6 RBC-4.36* Hgb-12.1* Hct-38.6*
MCV-89 MCH-27.8 MCHC-31.3* RDW-16.0* RDWSD-51.8* Plt ___
___ 08:46PM BLOOD Neuts-50.4 ___ Monos-9.8 Eos-1.2
Baso-0.8 Im ___ AbsNeut-3.35 AbsLymp-2.49 AbsMono-0.65
AbsEos-0.08 AbsBaso-0.05
___ 08:46PM BLOOD Glucose-100 UreaN-29* Creat-2.0* Na-144
K-3.2* Cl-103 HCO3-29 AnGap-15
DISCHARGE LABS
===============
___ 09:20AM BLOOD WBC-5.0 RBC-4.30* Hgb-12.1* Hct-37.5*
MCV-87 MCH-28.1 MCHC-32.3 RDW-16.0* RDWSD-50.9* Plt ___
___ 09:20AM BLOOD Glucose-149* UreaN-17 Creat-1.4* Na-144
K-3.5 Cl-106 HCO3-27 AnGap-15
___ 09:20AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.7
IMMUNOSUPPRESSION
================
___ 04:51AM BLOOD tacroFK-7.4
___ 09:20AM BLOOD tacroFK-7.3
STUDIES
========
___ RENAL TRANSPLANT ULTRASOUND IMPRESSION:
1. Slight worsening of renal pelvic fullness.
2. Increase in renal artery peak systolic velocity, measuring up
to 180 cm/s, previously 78.1 cm/s.
3. Normal intrarenal arterial waveform with resistive indices
ranging from
0.64-0.75.
Brief Hospital Course:
___ yo M with DM2 on insulin, HTN, ESRD ___ 2 renal transplants,
most recent in ___ with chronic allograft nephropathy and stage
III chronic kidney disease with baseline creatinine ~1.4 on
tacrolimus/mycophenolate mofetil who was noted to have diarrhea
and BUN/Cr elevation on routine labs. He was hydrated and it
improved to baseline.
___ on CKD: Noted to have a Cr of 2.0 with baseline of 1.4,
likely due to diarrhea given Na <20. Improved to baseline prior
to DC.
#Renal Transplant: Tacro was mildly above his ___ goal at 7.4
(transplant note says preferably closer to 5), dose was reduced
to 4.5mg BID. Elevated systolic renal transplant arterial
pressures seen on US likely not clinically significant at this
point given improvement to baseline. Continued Cellcept and
Prograf (decreased prograf dose to 4.5 BID from 5 BID due to
levels of ~7.5). BKI Virus pending at discharge.
# HTN: Continued amlodipine, minoxidil, and labetalol with
normal/mildly elevated BP's. Restarted ___ on day of DC.
=====================================
TRANSITIONAL ISSUES
=====================================
* MED CHANGES: TACRO down to 4.5mg BID
* PENDING: BK virus urine level pending at discharge.
* Get labs drawn this week
* Monitor Diarrhea, Stay hydrated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. BusPIRone 10 mg PO TID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Labetalol 600 mg PO TID
6. Minoxidil 5 mg PO BID
7. Mycophenolate Mofetil 500 mg PO BID
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tacrolimus 5 mg PO Q12H
10. ammonium lactate 12 % topical DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Losartan Potassium 100 mg PO DAILY
14. Vitamin B Complex 1 CAP PO DAILY
15. Lantus (insulin glargine) 16 units subcutaneous DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. ammonium lactate 12 % topical DAILY
4. Atorvastatin 40 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. BusPIRone 10 mg PO TID
7. Escitalopram Oxalate 20 mg PO DAILY
8. Labetalol 600 mg PO TID
9. Lantus (insulin glargine) 16 units SUBCUTANEOUS DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Minoxidil 5 mg PO BID
12. Mycophenolate Mofetil 500 mg PO BID
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 4.5 mg PO Q12H
RX *tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
15. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
===================
PRIMARY
===================
- Acute on Chronic Renal dysfunction
- Dehydration
- Renal transplant recipient
- hypokalemia
========================
SECONDARY
========================
- Hypertension
- Diabetes mellitus on insulin
- CVA in ___ with residual left sided weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I IN THE HOSPITAL?
*Because your kidney function was impaired and you were having
loose stools.
*Given the improvement back to your baseline with fluids, we
believe this was due to dehydration.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
*You were given fluid through the IV to rehydrate.
*Your renal function was closely monitored.
*A renal ultrasound was performed, no signs of infection.
*Your tacro levels were monitored and were mildly high.
WHAT SHOULD I DO WHEN I GO HOME?
*Continue to take your medications as listed below, with the
decreased dose of tacrolimus.
*Stay well hydrated.
*Follow up with your transplant team for labs this week (you
have a standing order). MAKE SURE YOU GO IN BEFORE TAKING YOUR
DOSE OF TACRO (IN THE MORNING WHEN THE LAB OPENS) SO WE CAN GET
A TRUE TROUGH.
It was a pleasure being a part of your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10729116-DS-10
| 10,729,116 | 24,481,173 |
DS
| 10 |
2174-09-14 00:00:00
|
2174-09-16 10:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents to ED with abdominal pain.
She felt sudden onset lower middle abdominal pain around 130pm.
It became significantly worse and was accompanied by nausea and
sweating. She went to urgent care and had rebound tenderness on
exam. Given this she was advised to present to ___. She had
pain in the car ride when going over bumps. She describes it as
"feeling sensitive".
At ___, she had CT scan showing no evidence of appendicitis but
questionable torsion. She then had a PUS which showed a dilated
fallopian tube and complex material with possible torsion.
Recommendation made for OB/GYN consultation.
Now, patient states her pain has improved and is ___. She has
not required pain meds in the ED. She is ambulating without
difficulty. No fevers, chills, emesis. No recent weight loss.
Of note, patient had a similar episode of pain in ___. She
had acute onset pain and discomfort that lasted ___ hours then
spontaneously resolved. That pain episode was accompanied by
nausea but no emesis. She did not seek care as she was on
vacation.
ROS negative except as noted above.
Past Medical History:
POBHx: G4P3
- 1 SAB
- 3 SVD
PGynHx
- menarche at ~age ___ with regular menses prior to IUD -> now
amenorrheic
- contraception: ___ IUD for ___ years total ___ years for one,
new one in place ___ years)
- h/o abnormal pap smears, last normal in ___
- denies h/o STIs
- sexually active w/ ___ male partner, husband
PMH: hypertension
PSH: L hip replacement
Meds: red yeast rice 600mg, glucosamine 500mg, turmeric,
lisinopril, Vitamin D2, fish oil
All: NKDA
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
98.4, 67, 126/89, 16, 95% RA
Gen: NAD
Lungs: No resp distress
Abd: soft, mild tenderness to palpation in lower abdomen, no
rebound or guarding
SSE: normal external genitalia, cervix with IUD strings visible,
no discharge or blood in vault
SVE: small uterus, + R adnexal tenderness, no adnexal masses
palpated
Physical Exam on Discharge:
24 HR Data (last updated ___ @ 253)
Temp: 98.4 (Tm 98.4), BP: 122/78, HR: 84, RR: 18, O2 sat:
95%, O2 delivery: RA
Fluid Balance (last updated ___ @ 254)
Last 8 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
*one unmeasured void
General: NAD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, mild tenderness to palpation,
greatest in right lower quadrant. Marked rebound tenderness,
right>left. No guarding.
Extremities: no edema, no TTP
Pertinent Results:
___ 05:10PM BLOOD WBC-14.6* RBC-4.84 Hgb-15.1 Hct-44.7
MCV-92 MCH-31.2 MCHC-33.8 RDW-11.9 RDWSD-40.2 Plt ___
___ 05:10PM BLOOD Neuts-84.1* Lymphs-7.5* Monos-7.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-12.26* AbsLymp-1.10*
AbsMono-1.08* AbsEos-0.06 AbsBaso-0.04
___ 01:10PM BLOOD WBC-11.4* RBC-4.14 Hgb-12.9 Hct-38.7
MCV-94 MCH-31.2 MCHC-33.3 RDW-11.8 RDWSD-40.5 Plt ___
___ 01:10PM BLOOD Neuts-77.1* Lymphs-13.7* Monos-7.9
Eos-0.6* Baso-0.3 Im ___ AbsNeut-8.79* AbsLymp-1.56
AbsMono-0.90* AbsEos-0.07 AbsBaso-0.03
___ 05:10PM BLOOD Glucose-105* UreaN-18 Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-28 AnGap-11
___ 05:10PM BLOOD ALT-13 AST-18 AlkPhos-72 TotBili-0.4
___ 05:10PM BLOOD Lipase-25
___ 05:10PM BLOOD Albumin-4.4
___ 05:18PM BLOOD Lactate-1.4
___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 06:10PM URINE RBC-4* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-1
___ 06:10PM URINE Mucous-MOD*
___ 06:10PM URINE Hours-RANDOM
___ 06:10PM URINE UCG-NEGATIVE
___ 5:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:20 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CT Abdomen/Pelvis (___):
IMPRESSION: Heterogeneous cystic mass in the cul de sac
concerning for adnexal mass or hydrosalpinx. Associated small
volume ascites. Torsion difficult to exclude and pelvic
ultrasound is advised.
U/S Pelvis (___):
IMPRESSION:
1. Findings are concerning with left hydrosalpinx containing
complex material. Currently there is no evidence of torsion
though intermittent torsion not excluded.
2. Mild to moderate free fluid.
U/S Pelvis (___):
IMPRESSION:
1. No substantial change in findings likely reflecting left
hematosalpinx.
2. Unchanged hyperemia of the normal size left ovary. Normal
arterial and
venous flow without evidence of torsion.
3. Moderate volume complex pelvic free fluid.
Brief Hospital Course:
Ms. ___ presented to the ED with abdominal pain since the
afternoon of ___. She had CT scan showing no evidence of
appendicitis but questionable torsion. She then had a PUS which
showed a dilated fallopian tube and complex material with
possible torsion. Pain improved to ___ at time of OB/GYN
consult, without requirement for pain medication. Given imaging
reassuring against torsion, plan made for admission for
observation overnight.
The next morning, labs were stable without concern for infection
or bleeding. She remained stable without further pain medication
requirement overnight, so plan was made for discharge home with
outpatient followup.
Medications on Admission:
Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not take more than 4000 mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
take with food. Alternate every three hours with Tylenol for
pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*1
3. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematosalpinx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the gynecology service at ___ for pain
management and observation of a possible ovarian torsion and
hematosalpinx (blood and fluid in the fallopian tube). We
repeated imaging on the second day of your stay, which
demonstrated that the fluid collection in your fallopian tube
and your abdomen was unchanged since ___ were admitted. Your
blood counts remained stable as well, indicating that ___ were
likely not continuing to bleed into your abdomen or fallopian
tube. Your pain was well controlled on Tylenol and your vital
signs remained stable. The team has determined that ___ are
stable for discharge with close outpatient follow up with your
primary OBGYN for further evaluation and definitive treatment.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where ___ are unable to keep down fluids/food
or your medication
Followup Instructions:
___
|
10729252-DS-10
| 10,729,252 | 21,310,787 |
DS
| 10 |
2155-09-10 00:00:00
|
2155-09-10 17:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with history of HTN on ACEI who
awoke from sleep around midnight overnight with shortness of
breath, tongue swelling, and drooling. She arrived to the ED at
___ by car, she was noted to be stridorous, only speaking
in 1 word sentences. She had a protruded, swollen tongue and
difficulty managing her secretions. Surgery was called
emergently for assistance in managing airway.
Patient received Epinephrine, Solumedrol, Firazyr (Icatibant),
and FFP. An OR was set up for intubation and a cric kit was
placed at bedside. The patient subsequently stabilized there
with improvement in her symptoms and was deemed safe to transfer
to ___ for airway monitoring in the absence of an ICU bed for
close airway monitoring.
Per anesthesia note, patient on initial exam at 0600 was noted
to have some difficulty articulating words, no respiratory
distress. Tongue was not protruding but was swollen, secretions
were well managed.
In the ___ ED, initial vitals: Temp not recorded, P 60, BP
156/63 RR 18 98% RA
On transfer, vitals were: 98.1 65 175/83 20 96%RA
On arrival to the MICU, patient notes that the tongue swelling
is improved. Overnight she was unable to put her tongue in her
mouth, now she is able to close it. She does not feel like she
is having difficulty breathing. She denies chest pain. She
does feel like there is continued swelling in her neck and under
her chin.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
diabetes
hypertension
hyperlipidemia
vitamin D deficiency
depression
anxiety
Social History:
___
Family History:
No hx of neurological disease including strokes, seizures, brain
tumors, both parents with heart problems.
Physical Exam:
On Admission:
Vitals: T:98.3 BP:152/60 P:52 R:18 O2:93-94% RA
GENERAL: Alert, oriented, no acute distress, able to swallow
secretions
HEENT: Mildly edematous tongue
NECK: supple, JVP not elevated, no LAD
LUNGS: Coarse breath sounds bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm and dry
NEURO: Alert and oriented x3
Discharge:
Afebrile HR 50-60s BP 140-170/60-80s ___ 98%RA
I&Os: 1183/1250
Awake and alert
Apthous ulcer. No signs of angioedema.
CTAB, no w/r/r. No stridor
RRR, no murmur
Pertinent Results:
On Admission:
___ 08:24AM BLOOD WBC-11.2*# RBC-3.25* Hgb-9.8* Hct-30.6*
MCV-94 MCH-30.2 MCHC-32.0 RDW-13.7 RDWSD-46.6* Plt ___
___ 08:24AM BLOOD Glucose-223* UreaN-19 Creat-0.8 Na-139
K-4.1 Cl-104 HCO3-21* AnGap-18
___ 08:24AM BLOOD Calcium-9.0 Phos-2.8# Mg-1.4*
Imaging:
___ CXR
In comparison with the study of ___, there is
opacification at the right base. This could represent merely
atelectasis, though in the
appropriate clinical setting superimposed pneumonia could be
considered.
Cardiac silhouette is within normal limits and there is no
appreciable
pulmonary vascular congestion or pleural effusion.
Brief Hospital Course:
Ms. ___ is a ___ yo female with PMH significant for HTN, HLD,
DM who is now presenting with significant tongue/upper airway
swelling, concerning for angioedema, transferred to the MICU for
ongoing airway monitoring.
# Angioedema: Likely secondary to lisinopril. She was in no
respiratory distress on arrival and symptoms resolved s/p
Epinephrine, Solumedrol, Firazyr (Icatibant), and FFP. She was
monitored in the ICU for 24 hours and remained NPO. C1 esterase
inhibitor was sent. Lisinopril was held and was listed as an
allergy.
# HTN: Patient was hypertensive on admission to the ICU to the
160s systolic. Her lisinopril was held in the setting of
angioedema. She was continued on atenolol 25 and HCTZ 25 mg. Her
home amlodipine of 2.5 mg was increased to 7.5 mg daily.
# DM II: On glipizide, pioglitazone, and metformin at home. Oral
meds held while she was NPO. She was continued on insulin
sliding scale. Discharged on home meds.
Transitional:
Transitional Issues
-- Will need further titration of blood pressure given
discontinuation of lisinopril total daily dose of 40mg
-- Follow up CXR finding:
In comparison with the study of ___, there is
opacification at the right base. This could represent merely
atelectasis, though in the appropriate clinical setting
superimposed pneumonia could be considered.
-- Lisinopril added to allergy list
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO BID
2. Atenolol 25 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. Pioglitazone 30 mg PO DAILY
6. GlipiZIDE XL 5 mg PO QAM
7. GlipiZIDE XL 2.5 mg PO QHS
8. Aspirin 81 mg PO DAILY
9. Amlodipine 2.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
6. Pioglitazone 30 mg PO DAILY
7. GlipiZIDE XL 2.5 mg PO QHS
8. GlipiZIDE XL 5 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Angioedema
Hypertension
Anemia
Secondary:
Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted after you developed
swelling of your tongue and throat. The concern was that this
was something called "angioedema" that was related to your
medication Lisinopril. This is unfortunately a reaction to the
Lisinopril that can happen at any time, despite the fact that
you have taken this medication for years. You were given
medications at ___ that helped to improve the swelling.
We have added lisinopril to your allergy list.
We increased your Amlodipine in place of your Lisinopril while
you were here in the hospital. It is important that you follow
up with your primary care doctor to help further titrate your
blood pressure medications in the outpatient setting.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
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10729692-DS-11
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| 11 |
2141-09-18 00:00:00
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2141-09-18 20:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Compazine / Reglan / Haldol
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 813)
Temp: 98.0 (Tm 98.8), BP: 130/85 (101-130/63-85), HR: 57
(57-72),
RR: 18, O2 sat: 99% (96-100), O2 delivery: Ra
GEN: sitting comfortably in NAD
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi, good air movement
GI: + BS, soft, NT, ND, no HSM
GU: No foley
EXT: Lower ext warm without edema
NEURO: AOx3, CNII-XII intact, ___ strength in upper and lower
ext, nl gait
SKIN: no rashes or lesions
ADMISSION/SIGNIFICANT LABS:
=======================
___ 06:46PM BLOOD WBC-25.0* RBC-4.74 Hgb-13.7 Hct-41.4
MCV-87 MCH-28.9 MCHC-33.1 RDW-15.0 RDWSD-48.1* Plt ___
___ 06:46PM BLOOD Neuts-71.6* Lymphs-18.9* Monos-8.8
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.87* AbsLymp-4.73*
AbsMono-2.20* AbsEos-0.01* AbsBaso-0.05
___ 06:46PM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-139
K-3.7 Cl-97 HCO3-21* AnGap-21*
___ 06:46PM BLOOD ALT-14 AST-20 AlkPhos-86 TotBili-0.5
___ 06:46PM BLOOD Lipase-12
___ 06:46PM BLOOD Albumin-4.9
___ 06:55AM BLOOD %HbA1c-5.7 eAG-117
___ 06:55AM BLOOD TSH-0.74
LABS ON DISCHARGE:
=================
___ 07:10AM BLOOD WBC-11.5* RBC-4.10 Hgb-12.1 Hct-36.9
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.6 RDWSD-47.7* Plt ___
___ 07:10AM BLOOD Glucose-94 UreaN-11 Creat-0.9 Na-144
K-4.1 Cl-105 HCO3-25 AnGap-14
LFTs WNL
Lipase 12
A1c 5.7%
TSH 0.74
UCG neg
UA: neg bld, neg nit, neg ___, 3 RBCs, 3 WBCs, 40 ketones
UCX: mixed flora
IMAGING:
=========
EKG (___):
SB at 45 bpm, borderline LAD, PR 124, QRS 104, QTC 406, TWI III,
incomplete RBBB (no prior for comparison)
CT A/P w/cont (___):
No acute intra-abdominal process identified. Specifically, the
appendix is normal. Prominence of the gonadal vessels suggests
pelvic congestion.
Brief Hospital Course:
___ is a ___ female with a history of GERD,
depression/anxiety, episodic cyclic vomiting who presents with 4
days of nausea/vomiting and abdominal pain.
#Nausea/vomiting:
#Abdominal pain:
Patient reports intermittent episodes of vomiting over the last
___
years, for which she has been hospitalized at ___ and ___,
last
in ___ per patient. Per patient, prior w/u, including EGDs,
without abnormalities and negative for H.pylori. She presented
this admission with 4-days of her typical symptoms, with
abdominal discomfort and cyclic vomiting. Upreg neg, LFTs/lipase
WNL, and CT A/P without acute pathology. Ddx includes viral
gastritis vs cannabinoid hyperemesis syndrome given significant
marijuana use (~2g/d, although patient reports that her symptoms
have not improved previously with cessation of cannabinoid use),
less likely gastritis given patient report of negative EGD
previously in setting of similar symptoms. She was treated
supportively with bowel rest, IVFs, and analgesics/anti-emetics,
with complete resolution of her symptoms, and she was tolerating
a regular diet without pain or N/V at the time of discharge. She
will be discharged on her home Zofran, omeprazole, and
ranitidine
(provided a 7d supply on discharge). Marijuana cessation was
encouraged. Patient to schedule short-interval outpatient f/u
with her PCP and with ___ gastroenterologist at ___ after
discharge.
#Leukocytosis:
WBC 25 on presentation, likely in setting of viral gastritis
with
contribution from hemoconcentration. Improved to ___ at the
time of discharge. Low suspicion for bacterial infection,
including C.diff in absence of diarrhea. CT A/P w/cont negative
for intra-abdominal source, and no other localizing
signs/symptoms of infection. Would repeat CBC at outpatient f/u
to document complete resolution of leukocytosis.
#Depression/anxiety:
Continued home amitriptyline.
#GERD:
Continued home omeprazole. She will establish outpatient care
with ___ gastroenterologist as above.
** TRANSITIONAL **
[ ] repeat CBC at outpatient f/u to document resolution of
leukocytosis
[ ] f/u with ___ gastroenterologist for further w/u of chronic
cyclic vomiting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO TID
2. Omeprazole 40 mg PO BID
3. Ranitidine 150 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Amitriptyline 25 mg PO TID
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*14
Capsule Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*15 Tablet Refills:*0
4. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp
#*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea/vomiting
Abdominal pain
GERD
Depression/anxiety
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 recurrent vomiting and
abdominal pain, similar to your prior episodes. The cause of
these symptoms was unclear, but may be due to a viral illness or
related to your marijuana use. Your symptoms improved with
supportive care, and you are being discharged home.
We would recommend that you discontinue marijuana use, which can
contribute to a cyclic vomiting syndrome.
Please take the remainder of your medicines as prescribed and
follow-up with your primary care doctor and with a
gastroenterologist after discharge.
With best wishes,
___ Medicine
Followup Instructions:
___
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2141-06-06 16:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
ORIF
History of Present Illness:
HPI: ___ female unrestrained driver presents with R acetabular
fracture and posterior hip dislocation s/p MVC. Pt traveling at
70 mph when she slammed into the back of a semi truck. Pt
reports
+ HS, no LOC. + Airbags deployed. Removed herself from car.
Reportedly GCS 15 at scene. Brought first to ___ then
transferred here. CT head and C spine negative. XRs demonstrated
R acetabular fracture with posterior hip dislocation on R. CT
with mild R SI joint widening and posterior ilium fx at SI
joint.
Pt reported some pain in R knee also. No pain elsewhere. No
numbness, tingling, weakness, paresthesias. R knee CT
unremarkable.
Past Medical History:
- TDWB RLE, posterior hip precautions
- LVX
- Standard pain regimen
- Periop Ancef
- ___
Social History:
___
Family History:
nc
Physical Exam:
general: comfortable
MSK: RLE: dressing is c/d/I. fires gastroc, TA, ___,
EDL/FDL. SILT distally. WWP. soft compartments
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an acetabluar fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for 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 rehabilitaion ___ 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 in the RLE extremity, and will be discharged on lovonox 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:
see admit orders
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*100 Tablet Refills:*1
2. Enoxaparin Sodium 40 mg SC DAILY VTE prophylaxis Duration:
26 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily Disp #*26
Syringe Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
wean this medication as tolerated
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed for pain Disp #*80 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp
#*40 Tablet Refills:*0
5. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth as needed for insomnia
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acetablular fracture
Discharge Condition:
Discharge Condiiton:
AVSS
NAD, A&Ox3
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovonox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
weight bearing as tolerated
Treatments Frequency:
dressing changes PRN
Followup Instructions:
___
|
10729873-DS-5
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| 5 |
2139-12-18 00:00:00
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2139-12-17 09:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
peanuts
Attending: ___
Chief Complaint:
neck pain x 3 weeks
Major Surgical or Invasive Procedure:
___ - C5, C6 anterior corpectomy, C4-7 fusion
History of Present Illness:
Ms. ___ is a ___ year old woman with history of IVDU,
cirrhosis, CHF, COPD, emphysema who presents with a 3 week
history of neck pain. She sought medical attention on ___,
and was sent home with some pain medications. She states that
the neck pain has been worsening over the past 3 weeks and that
for the last few days she couldn't get out of bed or walk
because
of the pain. Today she presented to ___, where
an MRI without contrast demonstrated C4/C5
discitis/osteomyelitis. Blood cultures were drawn and she was
given a single dose of vancomycin, then transferred to ___ for
further care. She states that she had some chest pain earlier
today, likely due to anxiety, that has now resolved.
She states that movement worsens the pain and that the valium
and
acetaminophen she was given for the pain do not help. She has
pain in both shoulders as well that worsens when she raises her
arms. She does not feel that she has any leg weakness and
hasn't
noticed any hand or arm weakness.
She denies any numbness, tingling, urinary or fecal
incontinence,
saddle region anesthesia, fevers/chills, coughing, sneezing,
abdominal pain, diarrhea, vomiting, dysuria.
Past Medical History:
cirrhosis, COPD, emphysema, hepatitis C, CHF, anxiety, panic
disorder
Social History:
___
Family History:
NC
Physical Exam:
T: 97.6 BP: 136/73 HR: 82 R 18 O2Sats 98%
Thin, tearful, states she is in pain.
Poor dentition, multiple scars on her limbs.
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 IO 4+/5, L IO ___
Sensation: Intact to light touch bilaterally.
Reflexes: normal throughout
Toes downgoing bilaterally
No ___, no clonus.
Pertinent Results:
CT C-Spine ___:
1. Destruction of the C5-C6 disc space and inferior end plate of
C5 and
superior end plate of C6 compatible with history of cervical
discitis and
osteomyelitis. 6 mm retropulsion of C5 into the spinal canal
with moderate spinal canal stenosis. Widening of the facet
joints at this level worrisem for joint infection.
2. Extensive prevertebral soft tissue swelling highly concerning
for
prevertebral abscess. Epidural abscess cannot be excluded.
Urgent MRI is
recommended for further evaluation.
3. Severe bullous emphysema in the right lung apex.
Brief Hospital Course:
Patient presented to ___ as a transfer from an OSH She was
seen and evalauted in the emergency department and was found to
have C5-6 presumed osteomyeltitis and discitis with kyphotic
deformity. She was admitted to the floor and was ordered for MRI
of the cervical spine with contrast. She was also placed in a
hard cervical collar. She was brought to the MRI machine however
she was unable to toelrate it despote pre-medication with
Ativan. She remained stable overnight into ___.
On ___ she was scheduled again for MRI which she ultimately
refused. She also was scheduled for an ___ guided biopsy/FNA of
the C5-6 disc space which will occur on ___. The patient later
went to the OR on ___ for a C5 and C6 corpectomy/ C4-7
fusion procedure. See operative procedure note for further
details. Postoperatively Mrs. ___ was instructed to remain
wearing her cervical collar at all times. Gram stain wound
culture sent on ___, preliminary results show no growth to
date. Mrs. ___ was seen by Infectious Disease with the
recommendation for antibiotic therapy with Vancomycin and
Cefepime 2gm IV Q8H which began on ___.
On ___, the patient's hemovac was removed. Bedside PICC
placement failed. ___ was consulted for PICC placement for her
outpatient antibiotic regimen, and placed her PICC on ___.
___ evaluated and worked with the patient. Her IJ was removed on
___. On ___, she was discharged on 6 weeks of cefepime IV
per ID/OPAT.
Medications on Admission:
zantac 150 daily, symbicort 160/4.5 - 2 puff bid, MVI daily,
methadone 50 daily
Discharge Medications:
1. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
2. Methadone 50 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN pain, fever
5. Cyclobenzaprine 10 mg PO TID:PRN spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID:PRN Disp #*40
Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID:PRN Disp
#*50 Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*70
Tablet Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID:PRN Disp
#*50 Tablet Refills:*0
9. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 1 dose IV every eight (8) hours
Disp #*42 Vial Refills:*3
10. Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, TB, ALK PHOS,
ESR/CRP
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical diskitis/osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
Your incision is closed with dissolvable sutures underneath
the skin and steri strips. You do not need suture removal. Do
not remove your steri strips, let them fall off.
Please keep your incision dry for 72 hours after surgery.
Please avoid swimming for two weeks.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your hard cervical collar at all times. You may
remove it briefly for skin care and showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
for 2 weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation
Followup Instructions:
___
|
10730662-DS-10
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2185-03-10 00:00:00
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2185-03-11 16:25:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / shellfish derived
Attending: ___
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
transfusion with 1 U pRBCs (___)
esophagogastroduodenoscopy (___)
History of Present Illness:
___ hx cirrhosis, chronic pancreatitis with known pseudocyst and
chronic abdominal pain, s/p selective angiography of bleeding
splenic artery pseudoaneurysm with embolization at OSH earlier
this month, chronic EtOH, presents from OSH for recurrent GIB.
Of note, she had a recent stay ___, originally transfered
for cystogastrostomy evaluation in the setting of GIB with her
pseudocyst having been drained in the past. Drainge was not
performed as collection was thought to be stable. EGD at OSH
___) prior to transfer showed no varices, only gastritis
and severe duodenitis, that likely contributed to hematemesis
that was original reason for transfer at that time. She had a
splenic artery pseudoaneursym that had been embolized by time of
transfer to ___.
This visit, she endorsed ___ tarry stool 3d ago, but none
since. She endorsed worsening DOE and L-shoulder pressure. She
denied nausea or vomiting or hemetemesis, c/w last UGIB earlier
this month. She had chronic abdominal pain due to her chronic
pancreatitis which she said was unchanged. She denied fevers,
chills, or urinary symptoms. She initial presented to ___
___, where she received 1u PRBCs for Hct 18, and was
transfered to ___.
In the ___ ED, initial vitals: 98.4 96 115/71 16 99%RA. She
had diffuse abdominal tenderness on exam, large brown stool that
was guaiac positive w/o fresh blood. Initial labs notable for
WBC 9.6, H/H 8.5/28.7, nl PLT [0830p]. Chem7 with Bicarb 20
(BUN/Cr ___, AP 150 (nl AST/ALT/TB), Alb 2.7, Lipase 81.
Trop neg. Lactate 1.7. INR 1.4. UA with LG Leuks, POS Nitrites,
WBC 107, MOD Bacteria. CTAP showed: (1) peripancreatic
inflammation and fluid compatible with pancreatitis; (2) 4.6 cm
peripancreatic fluid collection along the pancreatic body and
abuts the stomach; (3) Hepatic steatosis. CTX was given for UTI,
along with total 2mg IV Ativan, 4mg IV Zofran, 5mg IV Morphine,
and 80mg IV PPI.
After signed out to Medicine ___ while awaiting floor bed, pt
had repeat CBC that showed H/H drop to 5.6/18.4, with WBC 11.6
at 0530. Another CBC showed similar values at 0620. Bed request
was changed to MICU and add'l 1u PRBCs ordered. ___ discussed
case with ___, who recommended ___ consultation. ___
reviewed CT from earlier in the night, could not identify
source, recommended KUB to evaluate contrast travel through the
bowel.
On transfer, vitals were: 98.5 ___ 16 99%RA.
On arrival to the MICU, pt essentially endorses the story above,
and includes that she felt 3d of worsening dyspnea with exertion
accompanied by generalized weakness, lightheadedness, and
palpitations. She did have urinary frequency and urgency over
the last few days as well. She did have a tarry stool 3d ago,
but no dark stools or frank blood via rectum or os since
Past Medical History:
-pancreatitis: Admitted to ___ in ___ with severe
pancreatitis requiring an ICU stay and complicated by MSSA PNA
and portal vein thrombosis s/p completed a six-month course of
coumadin) with subsequent pseudocyst, which was ultimately
sampled on ___ to assess for infection (cultures negative).
s/p sphincterotomy and pancreatic duct stent placement
-chronic alcoholism
-anxiety
-depression
-GERD
-HTN
-diverticulitis, s/p partial colectomy
-?tongue lesions
-gastritis and severe duodenitis
PAST SURGICAL HISTORY:
-lap cholecystectomy approx ___ years ago
-open right colectomy for diverticulitis (patient is unsure when
she had surgery, CT scan shows staple line consistent with a
right colectomy
- s/p selective angiography of bleeding splenic artery
pseudoaneurysm with embolization in early ___
Social History:
___
Family History:
Father had EtOH abuse, "abdominal problems", heart disease.
Mother with heart disease, as well as 3 different cancers,
thinks one was esophageal cancer, died last year.
Siblings and children without medical issues that the patient is
aware of, apart from son with ___.
Physical Exam:
Admission Exam:
Vitals- T: 99.4 BP: 106/67 P: 76 R: 28 O2: 94%RA
GENERAL: Alert, oriented, no acute distress
HEENT: NCAT, anicteric sclera, pale conjunctiva, dry MM, clear
OP
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rate and rhythm, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
BACK: no bruising, no CVAT
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no bruises, no CVAT
NEURO: CN II-XII intact, moving all four limbs appropriately
Discharge Exam:
Vitals: 98.6, 136-169/92-106, 80-84, 18, 98 on RA
General: WDWNWF. A&O x 3 in NAD. Lying in bed, speaking in full
sentences, NAD
HEENT: EOMs intact. MMM. no oral ulcers. no pharyngeal erythema
or tonsillar exudates, neck supple, no JVD
Lymph: no LAD
CV: RRR. S1/S2. ___ SEM at RUSB. no gallops/rubs.
Lungs: mild inspiratory crackles bilaterally
Abdomen: soft, mild ttp in epigastrium. no guarding/rebound.
+BS. no appreciable HSM
GU: no foley
Ext: warm, dry. no c/c/e
Neuro: no asterixis. no focal deficits
Skin: no palmar erythema or spider angiomas
Pertinent Results:
Labs on Admission:
___ 08:30PM BLOOD WBC-9.6# RBC-3.52* Hgb-8.5* Hct-28.7*
MCV-82 MCH-24.0*# MCHC-29.4* RDW-17.5* Plt ___
___ 08:30PM BLOOD Neuts-88.0* Lymphs-7.1* Monos-3.8 Eos-1.0
Baso-0.2
___ 05:30AM WBC-11.6* RBC-2.28*# HGB-5.6*# HCT-18.4*#
MCV-81* MCH-24.6* MCHC-30.4* RDW-17.7*
___ 06:20AM PLT COUNT-324
Pertinent Labs:
___ 12:18AM BLOOD ___ PTT-23.5* ___
___ 05:30AM BLOOD Ret Man-5.1*
___ 05:07AM BLOOD ALT-47* AST-71* LD(LDH)-188 AlkPhos-214*
TotBili-0.3
___ 08:30PM BLOOD Lipase-81*
___ 08:30PM BLOOD cTropnT-<0.01
___ 08:30PM BLOOD Hapto-126
___ 08:38PM BLOOD Lactate-1.7
Labs on Discharge:
___ 07:02AM BLOOD WBC-3.8* RBC-3.28* Hgb-8.4* Hct-27.9*
MCV-85 MCH-25.6* MCHC-30.1* RDW-17.0* Plt ___
___ 07:02AM BLOOD Glucose-126* UreaN-7 Creat-0.4 Na-138
K-4.4 Cl-108 HCO3-19* AnGap-15
___ 07:02AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7
Microbiology:
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
CT Abdomen/Pelvis ___:
FINDINGS:
THORAX: The visualized lung bases are clear with no pleural
effusions,
pneumothorax or focal opacities. The visualized heart and
pericardium are
normal.
LIVER: Hypoattenuation of the liver is compatible with hepatic
steatosis. No
focal hepatic lesions are noted. The portal and hepatic veins
are patent, and
there is no intra or extrahepatic biliary duct dilatation. The
SMV is patent,
and the splenic vein appears thrombosed as noted on prior exams.
GALLBLADDER: The patient is status post cholecystectomy.
SPLEEN: The spleen is normal in size and shape.
PANCREAS: Fluid and peripancreatic stranding is compatible with
pancreatitis
with an edematous pancreas. There is a 1.9 x 4.6 cm fluid
collection along the
pancreatic body abutting the stomach, though decreased in size
from prior
exams (5:33).
ADRENALS: The adrenal glands are normal in size and shape.
KIDNEYS: The kidneys are normal in size and shape. The kidneys
have
appropriate contrast enhancement and excretion bilaterally. A
left lower pole
renal hypodensity is too small to characterize but statistically
likely to
represent a cyst (5:48). There is no hydronephrosis or
perinephric stranding.
BOWEL: The stomach is mildly distended with oral contrast, and
there is
gastric wall thickening along the region abutting peripancreatic
fluid
collection. No distinct fat plane separates the stomach and the
peripancreatic
fluid collection. There is also wall thickening of the duodenum
in the region
of pancreatitis. The small bowel opacifies with oral contrast
without
obstruction or focal wall thickening. The appendix is not
visualized, but
there are no secondary findings to suggest appendicitis. The
large bowel
contains feces without wall thickening or evidence of
obstruction. There is no
intra-abdominal free air.
LYMPH NODES: A 1.4 cm porta hepatic lymph node is noted (5:33).
PELVIS: The bladder is moderately distended without focal wall
thickening.
There is no pelvic free fluid. There are no pathologically
enlarged pelvic
sidewall or inguinal lymph nodes by CT size criteria. The rectum
is
unremarkable.
VESSELS & SOFT TISSUE: There is moderateatherosclerotic disease
without
aneurysmal dilatation of the abdominal aorta. The aorta and its
major branches
are patent. There are no hernias.
BONES: There are no suspicious lytic or sclerotic osseous
lesions to suggest
malignancy.
IMPRESSION:
1. Edematous pancreas and peripancreatic inflammation and fluid
compatible
with pancreatitis. 4.6 cm peripancreatic fluid collection along
the pancreatic
body that abuts the stomach.
2. Hepatic steatosis.
KUB ___:
FINDINGS:
The oral contrast bolus seen within the small bowel on recent CT
of ___ has progressed to the large bowel, now
predominantly within the
transverse and descending colon. Intravenously-administered
contrast has now
pooled within the bilateral collecting systems and the bladder.
No contrast
is seen outside of the bowel or collecting system.
There are no abnormally dilated loops of small or large bowel.
There is no evidence of pneumoperitoneum.
Osseous structures demonstrate mild dextroscoliosis and a left
iliac bone
island.
IMPRESSION:
Oral contrast now within the large bowel. No contrast outside
of the bowel or
collecting system is detected.
CXR ___:
FINDINGS:
Portable AP upright chest film ___ at 01:01 is
submitted.
IMPRESSION:
The heart remains enlarged. Mediastinal contours appear somewhat
widened but
are unchanged since ___ and therefore likely reflect a
combination of
prominent vascular structures and patient rotation. There is
subtle streaky
opacity in the retrocardiac region which may represent focal
atelectasis,
although early pneumonia or aspiration should also be
considered. Followup
imaging may be helpful. No pleural effusions, pulmonary edema or
pneumothorax.
EGD ___:
Impression:
One cord of grade 1 varices seen in distal esophagus. Moderate
esophagitis seen in distal esophagus.
Small hiatal hernia. Mosaic pattern of gastric body mucosa
compatible with portal hypertensive gastropathy.
Normal mucosa in the duodenum
No fresh or old blood seen during the EGD.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ history chronic pancreatitis with known pseudocyst and
chronic abdominal pain, s/p selective angiography of bleeding
splenic artery pseudoaneurysm with embolization at OSH earlier
this month, chronic EtOH abuse, presents from OSH for recurrent
GI bleed with anemia and Hct drop. Patient required ICU level of
care, received 1U packed red blood cells. Endoscopy did not show
acute signs of bleeding, therefore possible re-bleed into
pancreatic pseudocyst. Patient's hematocrit remained stable
without further bleeding. Patient tolerated full solid diet and
was discharged to home with plan to follow up with Dr. ___
(___) for potential ___.
ACTIVE MEDICAL ISSUES:
# Anemia, likely secondary to GIB: Patient with history of
splenic artery bleed requiring embolization as well as gastritis
and duodenitis presenting with melena and Hgb 5.6. No evidence
of hemolysis. Admitted to ICU, started on IV PPI, transfused 1U
PRBC. EGD showed grade I varices, mild esophagitis and
gastritis. No evidence of active bleeding. Potential source of
blood loss is re- bleeding into known pancreatic pseudocyst.
Patient remained hemodynamically stable with stable hematocrit
and no further evidence of bleeding. Transitioned to PO PPI.
Followed closely by GI and ___. Patient tolerated advancing diet
without abdominal pain, nausea, vomiting. Without active
bleeding, plan for repeat CT Abdomen and Pelvis as outpatient on
date of follow up with Dr. ___ potential ___.
# UTI: Patient complaining of dysuria, found to have positive
UA, with urine culture growing enterobacter sensitive to
ceftriaxone. Treated with IV ceftriaxone for total 3 day course.
# Hepatic Steatosis: Patient with history of alcohol abuse, LFTs
suggestive of hepatocellular injury with mildly elevated
AST/ALT, synthetic dysfunction with low albumin and mildly
elevated INR. CT abdomen and pelvis demonstrated
hypoattenuation of the liver compatible with hepatic steatosis.
Evidence of portal gastropathy and Grade 1 varices on EGD
suggestive of portal congestion. Patient does not have history
of biopsy proven cirrhosis though given these findings and
history of alcohol abuse, consider alcohol related cirrhosis.
Viral hepatitis testing negative in ___. Continued home
lactulose and rifaximin. Home spironolactone was held in the
setting of acute blood loss anemia. Consider restarting
spironolactone and further work up of cirrhosis including
fibroscan as outpatient.
# EtOH Abuse: Patient with history of alcohol abuse, monitored
throughout hospitalization for signs of withdrawal and given
thiamine, B12, Folate. Patient also met with social work to
discuss alcohol abuse during this admission.
# Pancreatitis: Chronic, attributed to chronic alcoholism.
Complicated by pancreatic pseudocyst. Patient continued on home
pancrelipase.
CHRONIC MEDICAL ISSUES:
# Anxiety and Depression: Continued on her home home
citalopram, mirtazapine, lorazepam throughout admission.
=============
Transitional Issues:
=============
[] GI bleed- no evidence of luminal bleed, possibly recurrent
bleed into pancreatic cyst, will need repeat CBC at PCP follow
up to ensure stability, repeat CT abdomen and pelvis (to be
performed on date of visit with Dr. ___ and follow up with Dr.
___ to evaluate for potential ___
[] holding spironolactone in setting of acute blood loss anemia,
consider restarting at PCP follow up
[] consider further work up for cirrhosis, fibroscan
[] continue to encourage abstinence from alcohol
-full code
-contact: Patient, Sister ___: ___,
lives in ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Citalopram 40 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Pantoprazole 40 mg PO Q12H
7. Thiamine 100 mg PO DAILY
8. Cyanocobalamin 50 mcg PO DAILY
9. Lactulose 30 mL PO TID
10. Pancrelipase 5000 1 CAP PO TID W/MEALS
11. Rifaximin 550 mg PO BID
12. Spironolactone 100 mg PO DAILY
13. Lorazepam 0.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Citalopram 40 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Lorazepam 0.5 mg PO QHS:PRN insomnia
8. Mirtazapine 7.5 mg PO QHS
9. Pancrelipase 5000 1 CAP PO TID W/MEALS
10. Rifaximin 550 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-acute blood loss anemia
-urinary tract infection
Secondary Diagnosis:
-chronic pancreatitis
-chronic alcoholism
-anxiety/depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came here from ___
after having worsening fatigue at home. You were found to have
low a red blood cell count that was causing your weakness. It
was not clear what caused this bleeding, but was likely from
your GI tract. You were given blood transfusions to increase the
red blood cells in your body, which led to an improvement in
your energy status. You were monitored closely and you did not
have any further bleeding.
You were also found to have an infection in your urine for which
you were given a full course of antibiotics.
Your medications were adjusted while you were here. Please see
the attached sheet for an updated list and follow up with your
primary care doctor to make further changes.
Please follow-up with the appointments listed below and take
your medications as instructed below. It is very important that
you stop drinking alcohol to prevent any further damage to your
pancreas and liver.
Wishing you the best,
Your ___ Care team
Followup Instructions:
___
|
10730662-DS-5
| 10,730,662 | 25,917,043 |
DS
| 5 |
2182-07-11 00:00:00
|
2182-07-13 13:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Iodine
Attending: ___.
Chief Complaint:
Bacteremia, Pseudocyst
Major Surgical or Invasive Procedure:
CT guided aspiration of pancreatic pseudocyst
History of Present Illness:
___ yo female w/ history chronic ETOH abuse (sober x 1 month),
prior pancreatitis complicated by pseudocysts who was
hospitalized ___ on the liver service for evaluation
of newly identified pseudocysts, largest 7.2cm x 3.2cm. Given
her clinical stability, she was discharged with anticipated
oupatient drainage. Blood culture from ___ returned ___
GPR in the aerobic bottle. She was instructed to return to
hospital ___ but refused to do so until today, after she saw
Dr. ___ this morning in his clinic. She is admitted
for anticipated drainage of pseudocyst, and to rule out infected
pseudocyst. She denies any subjective fevers, though has
occasional sweats at night. Her chronic lower abdominal pain is
unchanged and ranges from ___ throughout the day, is
non-radiating, and usually located in the bilateral lower pelvic
area. She has chronic anorexia, but is eating with Ensure
supplements. She continues to have chronic ___ weeks of dyspnea
with mild pleurisy. A CTA chest in the ED premilimarily shows
no PE. She does, however, note recent increase in size of R
calf vs her L calf, with some symptoms of tightness there. She
is s/p Right Tib-Fib fracture in ___ with repair, though
notes she has a resultant limp and is less active than
previously.
ROS: (+) chronic diarrhea x ___ wks, anorexia, chronic abd pain.
Other 13 point detail review is negative except for above.
Past Medical History:
- Alcohol abuse (last drink 1 mo ago)
- Chronic pancreatitis, intubated ___ and c/b:
- splenic vein thrombosis --> chronic
- non-obstructing portal vein thrombosis --> resolved
- pulmonary embolus(distal R, RUL/RLL, LLL) s/p 6 months
of coumadin, stopped by her PCP ___ months ago
- MSSA pneumonia
- complicated by pseudocysts, largest 7.2 x 3.2cm
- Anxiety, depression (recently started Cymbalta ___ ago)
- Remote (> ___ years ago) history of acute viral hepatitis. She
is not sure which one of the viral hepatitis. She does however
remember she was severely jaundiced. Since her anti-HBc is (+),
she likely had acute hep B.
- known ventral abdominal hernia
- GERD with Duodenal ulcer, gastritis, reflux esophagitis ___GD)
- Hypertension
- Iron deficiency anemia
- a/p Lap Cholecystectomy
- fracture of right tibia and fibula s/p ORIF at BWH ___
- aniscoria - left pupil 2 mm larger than right, both reactive
to light although left less brisk.
- bilateral eyelid dehiscence - left greater than right.
- s/p partial colectomy for "colitis"
Social History:
___
Family History:
FATHER: alcoholism, lung CA, COPD in the father, as well as
hypertension and depression.
MOTHER: CAD
Physical ___:
Admission PE
97.9, 144/102, 82, 18, 98% on RA
GEN: well in NAD. Pain ___
HEENT: anicteric, OP clear w/o lesions, neck supple, no ___
LUNGS: decreased bs at bases, no rales, rhonchi, wheezes
COR: RRR, soft ___ HSM at LUSB, no gallops, nl PMI
ABD: soft, NT, ND no masses or organomegaly
EXT: R calf larger vs left w/o edema, no C/C/E
SKIN: no lesions
NEURO: grossly normal, non-focal
PSYCH: calm, pleasant, fluent nl speech and cognition
.
Discharge PE
VSS
General: AAOX3 in NAD, eager to go home
HEENT: OP clear, MMM
CV: ___ HSM at ___
Lungs: CTAB, no WRR
Abdomen: soft, NTND, active BS, stable small LUQ echhymosis from
CT guided aspiration
Neuro: CN and MS wnl, ___ and sensation wnl
.
Pertinent Results:
___ 12:32PM LACTATE-2.3*
___ 12:15PM GLUCOSE-90 UREA N-7 CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
___ 12:15PM estGFR-Using this
___ 12:15PM ALT(SGPT)-30 AST(SGOT)-44* ALK PHOS-223* TOT
BILI-0.2
___ 12:15PM LIPASE-171*
___ 12:15PM ALBUMIN-3.2*
___ 12:15PM WBC-7.0 RBC-4.72 HGB-11.7* HCT-41.2 MCV-87
MCH-24.9* MCHC-28.5* RDW-16.7*
___ 12:15PM NEUTS-69.9 ___ MONOS-7.8 EOS-2.7
BASOS-0.9
___ 12:15PM PLT COUNT-491*
.
Micro:
___ 10:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 16:15 ON
___.
GRAM POSITIVE ROD(S).
.
___ 11:55 am FLUID,OTHER Source: pseudocyst fluid.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
BC from ___ and ___ NGTD
.
CTA Chest ___:
IMPRESSION:
1. No evidence for pulmonary embolism or acute intrathoracic
process.
2. Marked fatty infiltration of the liver.
.
TTE ___
IMPRESSION: No echo evidence of endocarditis. LVEF >55%
.
MRCP ___
Pancreatic pseudocysts in upper abdomen, largest 7.2 x 3.2cm, no
solid or cystic intrapancreatic masses. Moderate to severe
fatty depostion in liver. Upper pole L kidney ill-defined
abnormal signal intensity, may represent focal pyelonephritis,
clinical correlation recommended. Chronic thrombosis of splenic
vein, patent portal vein.
CT Abd & Pelvis ___
Hepatic steatosis. Loculated fluid collection in the upper abd
c/w pseudocyst (6.3 x 3.8 x 2.8cm). Large ventral hernia.
Normal unremarkable kidneys. Small ascites in pelvis.
Compression deformity L1 vertebral body.
ABD US ___
Small amount of upper abd ascites. Fatty liver, cirrhosis not
excluded. Hepatomegaly 17cm. Non-visualization of adenexa -->
recommend Pelvic US
PELVIC US ___
Moderate ascites. Due to patient discomfort, adenexa not
visualized, recommend CT for further evaluation.
EKG ___ (from ER): NSR at 89, nl intervals, nl axis, no
ischemic changes.
Brief Hospital Course:
This is a ___ yo F with a PMHx of alcoholism following a divorce
c/b chronic pancreatitis, splenic vein thrombosis s/p 6 months
of coumadin and multiple pseudocysts who was recently discharge
now re-presents due to GPR in blood cultures with chronic cp and
abdominal pain, GPR speciated as diptheroids with subsequent
cultures showing no growth
.
# Bacteremia w/ pseudocyst:
The patient did not fulfill criteria for SIRS or sepsis. No
leukocytosis, fever, or significant change was found from her
baseline. Patient received IV Vancomycin & Amp-Sulbactam in ED.
Vanco BID and Amp-Sulbactam Q6hr was continued until 24 hours
prior to discharge, at which point it was discontinued due to
negative cultures and the high probability that her positive
blood culture was a contaminant. Diptheroids are often
contaminants and the patient reports that she is often difficult
to draw blood from requiring multiple sticks. The patient also
received a CT guided aspiration of her pseudocyst which showed
no WBCs and the cultures were negative at the time of this
report. The final result of the pseudocyst cultures and blood
cultures need follow up. Due to the presence of a murmur, which
the patient says has been present in the past but was not noted
in the last admission PE, an TTE was done which showed no signs
of endocarditis. The patient was observed for 24 hours off
antibiotics and was a febrile without a leukocytosis. She was
discharged to home with close follow up. The liver service and
Dr. ___ was following while in house and agreed with the above
plan.
.
# subacute chest pain:
The patient reports this has been going on for 1 month and that
she has received an extensive work up at ___ which was negative.
CTA was done in the ED which showed no PE but fatty
infiltration of the liver. At this point, her pain may be due
to uncontrolled GERD vs. inflammation from pancreas causing
diaphragm irritation vs. anxiety related. She was discharged on
PPI once a day, this can be uptitrate if symptoms persist.
.
# Chronic Pancreatitis: Clinically stable. Continue Oxycodone
5mg q6hr prn. Given bowel regimen to prevent constipation.
.
# HTN,benign: Had not taken Lisinopril in ___ days. Restarted
Lisinopril ___ and BP was still above goal. Denied taking
Nifedipine. Would consider uptitrating lisinopril to 40 QD as
outpatient.
.
# Normocytic Anemia: Baseline anemia around ___. Admitted
with Hgb 11.7 and was down to 10.3 on discharge. This was
around her baseline and she showed no clinical signs of
bleeding. Her Hgb was stable on the day of discharge.
.
# R calf size discrepancy: Subjectively new. ___ negative
for DVT, given only SQ Heparin TID for prophylaxis.
.
# Anxiety: Cymbalta (Duloxetine) dose corroborated with
outpatient pharmacy - 20mg daily.
.
# Chronic ETOH: Currently sober x 1 month. No active signs of
withdrawal.
.
# Transitional Issues:
-Please follow up blood cultures and pseudocyst fluid cultures
-Should follow up at the ___ in ___ weeks and with PCP
___ ___ weeks
-please note she CA-125 was elevated from her prior admission.
Should consider repeating this value and if still elevated,
should work up further.
Medications on Admission:
Lisinopril 20mg daily (last taken 5 day ago)
Thiamine 100mg daily (not taking)
Folic acid 1mg daily (not taking)
Duloxetine 20mg daily
Vitamin B Complex daily
Oxycodone 5mg q6hr prn (takes usually once at night)
Omeprazole 20mg daily
Denies taking Nifedipine 30mg daily
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 7 days.
Disp:*15 Tablet(s)* Refills:*0*
6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatic pseudocyt s/p drainage
chronic pancreatitis
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to ___ with positive blood cultures and subacute
chest pain. You had a CT scan which did not show any evidence
of a pulmonary embolus and dopplers of your lower extremities
which also did not show a clot. Your chest pain may be due to
uncontrolled GERD or irritation from your pancreas. You had
your pancreatic pseudocyst aspirated and were placed on
antibiotics. You showed no active signs of infection and your
cultures remained negative. You were observed for 24 hours
after discontinuation of your antibiotics and then discharged.
Medications changes:
1) please re-start your lisinopril at 20 QD, and discuss with
your PCP increasing to 40 QD
2) stop your vitamin B complex vitamins and replace with a
multivitamin
3) start docusate to prevent constipation while on pain
medications
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Iodine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of severe pancreatitis complicated by psuedocyst now
with increased abdominal pain, nausea and vomiting over the past
___ days. Denies fevers but reports abdominal pain requiring
tylenol every ___ hours for the last day. She denies recent
alcohol (last drink was 6 weeks ago).
In brief, Ms. ___ was admitted to ___ in ___ with severe
pancreatitis requiring an ICU stay and complicated by MSSA PNA
and portal vein thrombosis. She recovered well from that
episode (completed a six-month course of coumadin) and started
to experience increased abdominal pain again approximately 2
months ago. She was admitted to the hospital in late ___ with
repeat imaging showing a pseudocyst, which was ultimately
sampled on
___ to assess for infection (cultures are negative). Since
the aspiration she has felt well except until ___ days ago when
she started experiencing the symptoms as above.
Past Medical History:
PMH: anxiety, alcohol dependence, depression, GERD, HTN,
?diverticulitis
PSH: lap cholecystectomy approx ___ years ago, open right
colectomy for diverticulitis (patient is unsure what or when she
had surgery, CT scan shows staple line consistent with a right
colectomy)
Social History:
___
Family History:
no pancreatic disease
Physical Exam:
At time of discharge:
VS: Afebrile, vital signs stable
Gen: NAD, alert and oriented
CV: RRR, nl s1, s2
Resp: CTAB
Abd: soft, non-tender, non-distended, unincarcerated hernia
Ext: warm, well perfused
Pertinent Results:
___ 09:30AM BLOOD Glucose-85 UreaN-7 Creat-0.4 Na-134 K-4.3
Cl-103 HCO3-24 AnGap-11
___ 11:30AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-1.6
___ 11:30AM BLOOD Lipase-351*
___ 09:30AM BLOOD Lipase-134*
___ 11:30AM BLOOD ALT-46* AST-88* AlkPhos-196* TotBili-0.6
___ 09:30AM BLOOD ALT-37 AST-46* AlkPhos-178* Amylase-142*
TotBili-0.3
Brief Hospital Course:
The patient was admitted to the ___ surgical service with
adominal pain. The patient was made NPO, started on IV fluids,
pain controlled with IV pain medication. On HD 2 the patient was
started on a clear liquid diet after laboratory work showed her
lipase to be down trending, which she tolerated well. On HD 3
the patient was transitioned to oral pain medication, started on
a full liquid diet.
At time of discharge on HD 3 the patient was ambulating without
assistance, pain controlled on oral pain medication, tolerating
a full liquid diet, voiding with difficulty.
Medications on Admission:
duloxetine 20', thiamine 50', lisinopril 2.5', omeprazole
10', folic acid
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ surgical service with abdominal
pain. You abdominal pain has improved and you have been
tolerating a full liquid diet. You are now ready to continue
your recovery at home.
Medications:
Please resume all of your home medications as prescribed. You
have been given a prescription for pain medication. Please take
this medication as prescribed. Do not drive while taking this
medication. Please take stool softener while taking this
medication as it can be constipating.
Diet: You should continue on a low fat diet as tolerated. Make
sure to drink plenty of fluids.
Activity: You may resume your normal daily activities.
Follow up:
Please call Dr. ___ ___ to schedule a
follow up appointment in ___ weeks.
Please call Dr. ___ ___ to schedule a
follow up appointment in regard to your questions regarding your
CA-125 levels and endometrial biopsy.
You have the following scheduled appoitments:
Provider: ___, ___ ___
___ 2:00
Provider: ___, MD ___
___ ___
You should call Dr. ___ office to move up your appoint to
the next ___ weeks.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Iodine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP/EGD
History of Present Illness:
.
___ year old female with history of pancreatitis complicated by
pseudocyst and recent pancreatic duct stenting on ___,
atrial fibrillation, presenting with 2 day history of worsening
abdominal pain.
.
Patient reports diffuse upper quadrant abdominal pain sharp that
is constant and radiates up her bilateral sides. Associated
nausea and NB/NB emesis. Loose stool without BRBPR or melena.
No f/c. SOB without CP that patient reports is not related to
pain.
.
ED Course:
- Initial Vitals/Trigger: 97 147 124/79 16 100%
- surgery and ERCP consulted in ED
- anion gap of 29, lactate 1.5, serum tox pending at time of
transfer
.
At time of transfer:
Mental Status: alert and oriented x 3, ___ and independent
Lines & Drains: 22G L FA
Fluids: #1L NS infusing
Drips: none
Precautions: universal
Belongings: w/pt
Most Recent Vitals: 97.6, 106, 125/76, 16, 100 RA
Due the patient's recurrent pancreatitis she will likely undergo
ERCP for further diagnostic testing with the GI service.
Surgery will continue to follow her and will admit her to
medicine for management of her pain and further monitoring of
her pancreatitis.
.
Upon arrival to the floor, patient denied abdominal pain. No
nausea/vomiting/diarrhea. No other complaints, and was asking
for water. Additional history reveals that the patient's
symptoms started on ___, four days prior to arrival. She
used left over opiates for pain control initially, and over the
past 24 hours has used eight extra-strength Tylenol, along with
Tylenol ___. Last dose of Tylenol was around 10:00 on ___.
.
12 point ROS notable for lack of chest pain, cough, dyspnea,
weight loss, anorexia, and was otherwise negative.
.
Past Medical History:
-pancreatitis c/b pseuodocyst (see below) and pancreatic duct
stent placement
-alcoholism-currently in remission according to the patient
-anxiety
-depression
-GERD
-HTN
-diverticulitis, s/p partial colectomy
-Admitted to ___ in ___ with severe pancreatitis requiring
an ICU stay and complicated by MSSA PNA and portal vein
thrombosis s/p completed a six-month course of coumadin)
-started to experience increased abdominal pain again
approximately 2 months ago. She was admitted to the hospital in
late ___ with repeat imaging showing a pseudocyst, which was
ultimately sampled on ___ to assess for infection (cultures
negative). Admission one month ago, s/p sphincterotomy and
pancreatic duct stent placement
PSH:
-lap cholecystectomy approx ___ years ago,
-open right colectomy for diverticulitis (patient is unsure when
she had surgery, CT scan shows staple line consistent with a
right colectomy)
Social History:
___
Family History:
Father had EtOH abuse, "abdominal problems"
Mother with heart disease
Physical Exam:
Admission VS
VS: 97.9 122/74 HR 106 RR 18 100% RA
General: pleasant female, fatigued, no distress
HEENT: anicteric sclerae
Cardiac: RRR, normal S1, S2, dynamic precordium, no m,r,g
Pulm: clear bilaterally, slightly diminished at left base
Abdomen: soft, non-distended. ventral hernia noted. mild
epigastric tenderness. no RUQ tenderness, no guarding or
rebound
Ext: 2+ radial and DP pulses, no c/c/e
Neuro: CNs II-XII intact, ambulatory without assistance. No
asterixis. Alert and oriented x 3
.
Discharge PE
VSS
Abdomen: ND, mild TTP in epigastrum to deep palpation, otherwise
non tender, no HSM, no rebound
Extremities: multiple ecchymoses on bue and an area of erythema
on LUE in antecubital fossa below elbow (5 cm X3 cm) no
induration, not TTP
CV: ___ systolic murmur
Lungs: CTAB, no WRR
Pertinent Results:
CT abdomen/pelvis ___
IMPRESSION:
1. Resolution of prior ascites and pleural effusions.
2. Interval placement of a pigtail stent across the main
pancreatic duct.
Stent appears in standard expected position.
3. Change in morphology of the large complex fluid collection
adjacent to the
pancreatic body and tail. Overall, the collection appears more
septated and
loculated, though likely smaller in size. New small foci of air
seen within
superior portions of the collection may be due to recent stent
placement or
superinfection. No evidence of pancreatic necrosis.
4. Unchanged bowel-containing ventral hernia. No evidence of
obstruction or
bowel inflammation.
5. Diffuse fatty infiltration of the liver.
.
CXR ___
CONCLUSION:
There is no pneumonia.
.
.
___ Labs:
COLOR-Yellow APPEAR-Hazy SP ___
BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE EPI-6
HYALINE-37*
GLUCOSE-102* UREA N-18 CREAT-1.1 SODIUM-137 POTASSIUM-3.6
CHLORIDE-99
TOTAL CO2-9* ANION GAP-33*
ALT(SGPT)-214* AST(SGOT)-664* ALK PHOS-339* TOT BILI-0.6
LIPASE-117*
cTropnT-<0.01
ALBUMIN-2.9*
LACTATE-1.5
WBC-20.8* RBC-3.95* HGB-8.3* HCT-29.7* MCV-75* MCH-21.0*
MCHC-28.0* RDW-17.8*
NEUTS-88.8* LYMPHS-7.6* MONOS-2.3 EOS-1.1 BASOS-0.3
PLT COUNT-1160*#
ASA-NEG ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
PO2-116* PCO2-21* PH-7.41 TOTAL CO2-14*
Acetaminophen 137 four hours after last dose, and 36 thirteen
hours after last dose
.
Brief Hospital Course:
___ year old female with history of alcohol dependence, recurrent
acute pancreatitis complicated by pseudocyst, with recent
hospitalization s/p sphincterotomy and pancreatic stent
placement presents with two days of nausea, vomiting, and
abdominal pain in setting of anion-gap acidosis with recent
acetaminophen use, transaminitis, and measurable acetaminophen
level, with concern for acetaminophen hepatotoxicity.
.
# Transaminitis ___ to Tylenol toxicity and alcoholic liver
injury
There was signifcant concern for acetaminophen toxicity given
transaminitis, recent use. Four hour level in safe area of
nomagram, thirteen hour level of 36 within range of
hepatotoxicity. No evidence of encephalopathy on exam. INR was
elevated to 2.5. Regarding her acid-base status, pH 7.41 with
bicarb of 14, suggesting mixed picture with primary respiratory
alkalosis with compensatory metabolic acidosis, although
difficult to interpret pH after IVF. Suspect metabolic acidosis
is a primary process due to acetaminophen and ethanol
ketoacidosis. Lactate 1.5. NAC was started promtly on her
arrival to the floor and she received a total of 4 doses.
Toxiclogy was consulted and followed the patient. Alcohol level
was negative on admission. Her labs were followed and her
transaminitis improved. Hepatology was also consulted for
further management and followed during her course.
.
# Acute pancreatitis c/b pancreatic pseudocyst s/p stent
placement
The patient presented with sympytoms consistent with prior
episodes of pancreatitis and a lipase in the 400 range. She had
no clear exacerbating factors, no biliary ductal dilation,
denies etoh use, no new medications, her stent appears to be in
appropriate position and ___ are wnl. She was made NPO, given
IV fluids and her pain gradually improved. Dr. ___ was
following the team in house and recommended outpatient follow up
for consideration of surgical treatment of her pseudocyst. ERCP
team was following the patient and decided to take the patient
for an ERCP. They discovered a persistent leak when her
pancreatic duct stent was removed. Thus they replaced this with
a new one. The patient will need a ERCP with stent removal in 6
weeks. The patient was strongly advised to continue alcohol
cessation as she says she has over the last 4 months. She was
offered resources through our social workers and psychiatry
services.
.
# Acute on chronic abdominal pain
The patient has had multiple episodes of pancreatitis in the
past and that is the most likely etiology of her current
exacerbation. She says there has been times between her
multiple hospitalizations that she has been pain free. In house
her pain was treated with narcotics in the acute setting. The
patients pain requirement eventually went down with the addition
of lyrica to her regimen. The patient had seen the pain service
as an outpatient and they suggested using this medication. The
patient was deemed a poor long term narcotic candidate by the
pain service and recently she ran out of narcotics. The patient
understood that she should not be on narcotics long term. The
team clearly illustrated that the patient should take tylenol
below 3 g total a day and NSAIDs for mild pain, tramadol for
moderate pain and oxycodone for severe pain.
.
# Microcytic anemia
The patient presented with a Hgb of 9.1, which dropped to 6.7.
There was no obvious source of bleeding, her hemoccult was
negative, her blood smear showed no schistocytes and her labs
showed no evidence of hemolysis. Iron labs showed a mixed
picture with low iron levels and a low TIBC and high ferritin.
The spleen was also a normal size on imaging. The thought was
that the patient likely had some slow oozing from an upper GI
source. The patient underwent on EGD for further work up and
this did not reveal a bleeding source. The patient was
transfused 2 units of PRBC's with an appropriate bump. Her Hgb
was stable on the day of discharge. The patient was sent home
on iron TID with vitamin C and instructed not to take this
within 2 hours of her cipro. She was also sent home on a PPI.
.
#Leukocytosis
In the begining of the hospitalization, the patient had a
leukocytosis and this was thought to be due to her acute
pancreatitis. UA was normal, CXR was clear, CT showed no
obvious signs of necrotizing pancreatitis and blood cultiures
showed no growth. She had a recurrent leukocytosis on the day
of discharge. This was likely reactive due to her ERCP the
prior day. As part of prophylaxis from this procedure, she was
placed on cipro/metronidazole for 7 days. C. difficle was also
considered but the patient had no fevers and 2 episodes of
diarrhea on the day of discharge. The patient was unable to
produce another stool sample prior to her discharge. Her PCP
was ___ about this issue. She will be sent home with a
prescription for a CBC in 1 sweek. If the patient continues to
have diarrhea, she can have her course of metronidazole extended
by her PCP after testing for c. diff.
.
# ARF
This was likely due to dehydration and corrected with IV fluids.
.
# Thrombocytosis
This was likely reactive due to the acute inflammation
associated with her acute pancreatitis. This was followed and
improved over time.
.
# Alcohol dependence
Most of her medical problems due in large part to alcohol
dependence. Patient attends AA and has therapists but the
patients seems to be out of touch with them. The medical team
inquired about arranging an appointment with a new provider and
the patient declined. Both the social work and psychiatry teams
offered the patient their assistance and the patient declined.
The patient was sent out on folate and thiamine.
.
# Depression
The patients mood waxed and waned during the admission with
frequent episodes of crying and wanting to leave. She denied
that her overuse of tylenol was a suicide gesture and said that
she simply did know how much she should take. Her duloxetine
was re-started. The patient was informed about the risk of
serotonin syndrome with tramadol. She had no signs and symptoms
of this while in house and was told to continue her duloxetine
and tramadol at the current doses as an outpatient. The paitent
was also encouraged to follow up with her behavioral health
providers as an outpatient.
.
# Transitional Issues:
-Follow up blood cultures from ___
-Follow up with PCP ___ ___ weeks, ERCP in 6 weeks for stent
removal and GI in ___ weeks
.
Medications on Admission:
duloxetine 20 mg Capsule, Delayed Release(E.C.) daily
folic acid 1 mg daily
thiamine HCl 100 mg daily
oxycodone 10 mg Tablet Extended Release Q12H
oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H PRN pain
omeprazole 20 mg Capsule BID
docusate sodium 100 mg BID
lisinopril 5 mg Tablet daily
atenolol 25 mg daily
Discharge Medications:
1. Ascorbic Acid ___ mg PO TID
RX *ascorbic acid ___ mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
2. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Duloxetine 20 mg PO DAILY
RX *Cymbalta 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Ferrous Sulfate 325 mg PO TID
please take with vitamin C
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*120 Tablet Refills:*0
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
10. Multivitamins W/minerals 1 TAB PO DAILY
RX *Vitamins & Minerals 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
11. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*0
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
14. Pregabalin 50 mg PO BID
RX *Lyrica 50 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
15. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
You tolerated this medication in house with your duloxetine. If
you experience tremor, agitation, diaphoresis, hyperreflexia,
clonus, tachycardia, hyperthermia, and muscle rigidity please
call your docotr, this can be a sign of a serious side effect
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*80 Tablet Refills:*0
17. Outpatient Lab Work
please draw a cbc w/ diff in 1 week and fax to PCP ___ at
___ (anemia 285.9)
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic pancreatitis
acetaminophen toxicity with acute liver injury
microcytic anemia
depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain and were found to
have acute pancreatitis and high level of tylenol in your blood.
You were treated with IV fluids, made NPO and your pain slowly
improved. You were also treated with a medication to remove the
tylenol from your blood. During your hospital course your red
cell level was found to be low and you were given transfusions.
Endoscopy was done to try and find a source of bleeding but none
was found. Your pancreatic duct stent was replaced. You
tolerated a diet and will be discharged home on pain medications
as needed for pain.
.
Medications changes and new med's, see below, take other
medications as previously prescribed
1) metronidazole 500 mg Q8 hours-please take for 7 days, do not
drink alcohol
2) ferrous sulfate 325 mg three times a day-please take over two
hours apart from cipro dose
3) ascorbic acid ___ mg three times a day-please take with the
iron
4) ciprofloxacin 500 mg twice a day-please take for 7 days,
please take at least 2 hours away from iron
5) tramadol 50 Q6 hours prn for moderate pain
6) tylenol ___ Q8 hours prn for mild to moderate pain-please DO
NOT take more then 3 g a day-can be bought over the counter
7) ibuprofen 400 mg Q6hours prn for mild to moderate pain-can be
bought over the counter
8) lyrica 50 mg twice a day for pain
9) oxycodone 5 mg Q6 hours for severe pain
10) polyethylene glycol 17 g QD prn constipation
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
heparin / codeine / Statins-Hmg-Coa Reductase Inhibitors / cat
dander / dog dander
Attending: ___.
Chief Complaint:
uremia and initiation of dialysis
Major Surgical or Invasive Procedure:
Left IJ dialysis cath (temporary)
Left tunneled dialysis line
Dialysis initiation
History of Present Illness:
___ ___ y/o F w/ PMHx of CKD from polycystic kidney
disease diabetes, hypertension, and coagulopathy admitted for R
flank and abdominal pain and ___ concerning for recurrent cyst
rupture. Patient blood chemistries indicated a need for
semi-urgent dialysis. Patient was dialyzed on day 3 of
admission. Dialysis access was c/b supratherapeutic INR on
admission requiring initial placement of temp left IJ dialysis
line followed by left tunneled dialysis line on ___ once her INR
<2.0.
Past Medical History:
PAST MEDICAL HISTORY:
1. Polycystic kidney disease.
2. Diabetes mellitus type 2, on insulin. Most recent
hemoglobin
A1c is decreasing from 11 to 9. She is currently on Lantus and
Humalog.
3. History of cervical intraepithelial neoplasia class IV at
the
age of ___, which was treated with cryotherapy, close OB/GYN
followup since then.
4. Hypertension, well treated.
5. History of thoracic aneurysm, status post repair.
6. History of multiple thrombotic events as outlined above.
7. Hyperlipidemia.
8. Recurrent episodes of throbbing headaches status post MRI x
2
to rule out aneurysms, reportedly normal.
Social History:
___
Family History:
FAMILY HISTORY:
Significant for mother who died from Bright's disease at the age
of ___. She also had a father who she was estranged from, who
reportedly died from kidney problems at the age of ___. The
patient has no siblings. There is no significant history of
cancer in the family.
Physical Exam:
VS: T 97.8 HR 83 BP 149/71 RR 20 SAT 98% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: NCAT, missing teeth
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, distended, tender to palpation of RLQ
EXT: Warm, well perfused, trace lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
___ 05:00AM BLOOD WBC-9.4 RBC-2.39* Hgb-6.9* Hct-22.9*
MCV-96 MCH-28.9 MCHC-30.1* RDW-14.0 RDWSD-49.3* Plt ___
___ 12:55PM BLOOD ___ PTT-57.4* ___
___ 05:00AM BLOOD Glucose-140* UreaN-40* Creat-4.6*# Na-136
K-4.4 Cl-95* HCO3-25 AnGap-16
___ 05:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.9
___ 02:59PM BLOOD ALT-11 AST-11 AlkPhos-77 TotBili-0.3
___ 02:59PM BLOOD Lipase-116*
___ 05:15AM BLOOD calTIBC-225* Ferritn-210* TRF-173*
___ 05:31AM BLOOD ___-___*
Brief Hospital Course:
___ ___ y/o F w/ PMHx of CKD from polycystic kidney
disease diabetes, hypertension, and coagulopathy admitted for R
flank and abdominal pain and ___ concerning for recurrent cyst
rupture. Patient blood chemistries indicated a need for
semi-urgent dialysis. Patient was dialyzed on day 3 of
admission. Dialysis access was c/b supratherapeutic INR on
admission requiring initial placement of temp left IJ dialysis
line followed by left tunneled dialysis line on ___ once her INR
<2.0.
Acute medical issues addressed
___ on CKD V
#Anuric Renal failure
Patient presented to OSH w/ R flank and abd pain. Labs reported
from OSH revealed a Cr of 9.83 and BUN of 87. Renal U/S
unremarkable. Presentation concerning for renal cyst rupture.
Patient transferred to ___ for question of need for RRT.
Patient required access for initiation of dialysis, this was c/b
a supratherapeutic INR of 4.8. At this time, patient sent for
temporary IJ dialysis access ___ and dialysis was initiated the
following day ___. Dialysis initiation planned for ___nd was completed ___. Tunneled line placed on ___.
#Coagulopathy of undetermined etiology
Patient has a history of blood clots when sub-therapeutic.
Required argatroban bridging while in hospital to prevent
recurrent blood clotting. Ultimately, it was decided that since
the history of HIT is so remote, argatroban bridging was not
needed and she could be discharged on her home dose of warfarin.
#Metabolic derangement
Developed typical chemical sequelae of renal failure with
elevated Cr, Phos, K, BUN and a low bicarb. Also developed AGMA,
all of which resolved following HD.
Chronic issues managed
=======================
# Diabetes
Takes 60u of premixed 70/30 qam and qpm. Converted to Lantus and
dose-reducing given poor PO intake.
# Hypertension
- Continued amlodipine 10mg nightly
# Anemia:
-Hb at goal, did not require EPO
# HLD
Reportedly intolerant of statins. Did not start a statin.
# Tobacco use
- Nicotine patch
Transitional issues
#Transplant w/u
- PFTs
- Chest CT to rule out lung cancer
- Hematology evaluation at ___
- MRI head if not done in past ___ years
- Echo and Stress with imaging done at ___
- Smoking cessation
# CODE: full (presumed)
# CONTACT: ___
Relationship: Friend
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. 70/30 60 Units Breakfast
70/30 60 Units Dinner
3. amLODIPine 10 mg PO HS
4. Warfarin 2.5 mg PO 6X/WEEK (___)
5. Warfarin 5 mg PO 1X/WEEK (WE)
6. LORazepam 0.5 mg PO DAILY:PRN anxiety
7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
9. Sodium Bicarbonate 650 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL
DAILY:PRN skin abrasions
12. Mupirocin Ointment 2% 1 Appl TP BID for skin sores
Discharge Medications:
1. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth one per day Disp #*90 Capsule Refills:*0
2. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth take one a
day Disp #*90 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. amLODIPine 10 mg PO HS
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Severe
7. 70/30 60 Units Breakfast
70/30 60 Units Dinner
8. LORazepam 0.5 mg PO DAILY:PRN anxiety
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Mupirocin Ointment 2% 1 Appl TP BID for skin sores
11. Warfarin 2.5 mg PO 6X/WEEK (___)
12. Warfarin 5 mg PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
========
Polycystic Kidney Disease
Anuric Renal failure
Hyperphosphatemia
Coagulopathy
AGMA
Secondary
=========
Diabetes
Asthma
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a ruptured cyst in your kidney and
kidney failure.
What was done for me while I was in the hospital?
- You were given medications to help with your pain.
- You underwent dialysis because your kidneys were not working.
- You had a permanent dialysis line placed.
What should I do when I leave the hospital?
- You should continue to take the medications that we prescribed
to you and follow up with your upcoming appointments with your
doctors.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10731211-DS-9
| 10,731,211 | 25,526,710 |
DS
| 9 |
2148-02-13 00:00:00
|
2148-02-13 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
This ___ has a h/o HTN, CAD, s/p
stenting in the past, and DM and is s/p CABGx5 on ___. He
did
well postoperatively and was discharged to home ___. He had
been slowly improving until 2 days ago when he became fatigued.
This AM he was lightheaded and short of breath and called ___.
He was taken to ___ and vomited blood. He
also had a dark stool. He denies abdominal pain but has had a
decreased appetite. His INR was 5.6 and his hct was 21. He was
given 1UPRBC and was transferred to ___ ED.
Past Medical History:
AS
Hypertension
PPM
Diabetes Mellitus type II
Dyslipidemia
Gout
GERD
Paroxysmal Atrial fibrillation on Coumadin
Appendectomy
Social History:
___
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 78 Resp: 16 O2 sat: 100% 2 liters O2
B/P ___ mmHg
Height: 5'8" Weight:158 lbs
Independent in ADLs
___:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] well healing sternotomy
incision
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right:- Left:-
Pertinent Results:
___ 11:23AM BLOOD WBC-11.1* RBC-2.25* Hgb-6.6* Hct-21.7*
MCV-96 MCH-29.3 MCHC-30.4* RDW-14.4 RDWSD-50.2* Plt ___
___ 01:22AM BLOOD WBC-12.2* RBC-2.44* Hgb-7.1* Hct-22.5*
MCV-92 MCH-29.1 MCHC-31.6* RDW-14.8 RDWSD-49.5* Plt ___
___ 11:46AM BLOOD Hct-29.3*#
___ 05:46AM BLOOD WBC-10.8* RBC-2.96* Hgb-8.7* Hct-26.8*
MCV-91 MCH-29.4 MCHC-32.5 RDW-15.6* RDWSD-50.5* Plt ___
___ 11:40AM BLOOD Hct-28.3*
___ 05:22AM BLOOD WBC-9.1 RBC-2.62* Hgb-7.7* Hct-24.2*
MCV-92 MCH-29.4 MCHC-31.8* RDW-15.2 RDWSD-49.2* Plt ___
___ 05:08AM BLOOD WBC-9.5 RBC-2.80* Hgb-8.1* Hct-25.7*
MCV-92 MCH-28.9 MCHC-31.5* RDW-15.1 RDWSD-49.1* Plt ___
___ 05:08AM BLOOD ___
___ 05:22AM BLOOD ___ PTT-25.9 ___
___ 05:46AM BLOOD ___ PTT-25.5 ___
___ 01:22AM BLOOD ___ PTT-33.1 ___
___ 07:25PM BLOOD ___ PTT-34.0 ___
___ 11:23AM BLOOD ___ PTT-33.9 ___
___ 05:08AM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-142
K-3.5 Cl-105 HCO3-25 AnGap-16
___ 05:22AM BLOOD Glucose-92 UreaN-26* Creat-0.8 Na-143
K-4.0 Cl-107 HCO3-27 AnGap-13
___ 05:08AM BLOOD Mg-1.9
Brief Hospital Course:
The patient was transferred from ___ for further management
of GI bleed. INR was reversed. GI consulted and EGD revealed
duodenal ulcer which was treated endoscopically. He will remain
on Protonix BID for a minimum of two months, then daily
indefinitely per GI recommendations. He was cleared to resume
aspirin and Coumadin 48 hours after intervention. Coumadin will
be titrated slowly- as his pre-op dosing regimen resulted in
supratherapeutic INR. His PPM generator battery was low and the
___ generator was changed by EP. He will be discharged to
complete a course of prophylactic antibiotics. He is instructed
to follow-up w his own Cardiologist in device clinic next week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Warfarin 5 mg PO 6X/WEEK (___)
6. Warfarin 2.5 mg PO 1X/WEEK (___)
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
8. Docusate Sodium 100 mg PO BID
9. GuaiFENesin ER 600 mg PO Q12H
10. Metoprolol Tartrate 37.5 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Furosemide 20 mg PO DAILY
14. Allopurinol ___ mg PO BID
15. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q8H Duration: 3 Days
RX *cephalexin 500 mg 7 tablet(s) by mouth every eight (8) hours
Disp #*9 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
q12h for at least two months, then may reduce to daily dosing
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*2
3. QUEtiapine Fumarate 12.5 mg PO QHS:PRN insomnia
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth hs Disp
#*15 Tablet Refills:*0
4. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
5. Warfarin 2 mg PO DAILY16
dose to change daily per Dr. ___ goal INR ___, dx:
AFib
RX *warfarin 2 mg ___ tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
6. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
7. Allopurinol ___ mg PO BID
RX *allopurinol ___ mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
8. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
9. Aspirin EC 81 mg PO DAILY
RX *aspirin [Aspirin Low Dose] 81 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
10. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*1
11. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
GI bleed
PMH:
Coronary artery disease s/p Coronary artery bypass graft x
Past medical history:
Hypertension
PPM
Diabetes Mellitus type II
Dyslipidemia
Gout
GERD
Paroxysmal Atrial fibrillation on Coumadin
Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: none
Leg Right and Left - healing well, C/D/I
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10731439-DS-9
| 10,731,439 | 25,997,628 |
DS
| 9 |
2190-07-03 00:00:00
|
2190-07-04 20:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Lisinopril
Attending: ___
Chief Complaint:
L eye vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right handed woman who
presented
to the ___ ED in the setting of an acute loss of vision in her
left eye. She states that she was in her usual state of health
and was driving to her new PCP appointment at ___ when at
approximately 11:55 am she felt a sudden shade come down over
her
left eye and she was no longer able to see out of that eye. She
stopped the car and came into the ED. She was called as an acute
stroke for the sudden monocular vision loss and was taken to CT.
Her NIHSS was 0 however it was noted that she had left monocular
vision loss. Given her current anticoagulation and no large
vessel artery occlusion on CTA the decision was made to not use
IVtpa and she was given fluid boluses. After she was in the ED
for approximately 1 hour she felt that she was starting to see
shadows and light again in the left eye. She noted no other
neurologic deficits associated with the vision loss. Her
fingerstick was 102.
She has had a similar presentation to this in the past.
Approximately ___ year ago she was admitted to ___ after an
episode
of left monocular vision loss. She had carotid studies at the
time and there was a report of a significant stenosis of the
left
ICA, however upon repeat testing done in ___ at ___ there
was no stenosis of the carotid arteries seen. She had a cardiac
ultrasound which had noted a PFO. She was initially
anticoagulated on Lovenox and then Coumadin but eventually she
transition to dabigatran which she states that she is still
taking.
On neuro ROS, the pt denies headache, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Prior history of left monocular blindness at ___ in ___
PFO
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Father - CHF, ___ in ___
Mother - died in ___ with Alzheimer's
3 brothers all deceased - 1 from AIDS, 1 suicide, 1 from
gunshot;
1 sister deceased from EtOH complications, 1 sister - alive with
Down's syndrome
Physical Exam:
ADMISSION LABS:
Vitals: 97.8 66 185/97 18 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, 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 4 to 2mm and brisk. VFF to confrontation on right
eye.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. Left eye acuity was ___ right ___
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. Romberg
absent.
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, 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. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation on right
eye.
Left eye acuity was ___ right ___, no red desturation on
either side
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. Romberg
absent.
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-8.7 RBC-4.80 Hgb-14.3 Hct-43.9 MCV-91
MCH-29.8 MCHC-32.7 RDW-14.5 Plt ___
___ 01:30PM BLOOD Neuts-52.2 ___ Monos-3.8 Eos-9.1*
Baso-0.9
___ 01:30PM BLOOD ___ PTT-31.7 ___
___ 07:25PM BLOOD ESR-8
___:30PM BLOOD Glucose-92 UreaN-15 Creat-1.4* Na-143
K-4.1 Cl-105 HCO3-27 AnGap-15
___ 04:45AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 Cholest-180
___ 04:45AM BLOOD %HbA1c-5.7 eAG-117
___ 04:45AM BLOOD Triglyc-185* HDL-39 CHOL/HD-4.6
LDLcalc-104
___ 04:45AM BLOOD TSH-4.9*
___ 06:40AM BLOOD T4-6.1 T3-120 Free T4-0.96
___ 07:25PM BLOOD CRP-1.9
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-7.1 RBC-4.62 Hgb-13.7 Hct-43.0 MCV-93
MCH-29.8 MCHC-32.0 RDW-14.3 Plt ___
___ 06:40AM BLOOD ___ PTT-49.4* ___
___ 06:40AM BLOOD Glucose-110* UreaN-14 Creat-1.1 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
REPORTS:
CTA HEAD AND NECK ___: IMPRESSION:
1. No acute thrombosis, dissection or aneurysm.
2. No evidence of infarction or hemorrhage.
3. Evidence of remote occlusion or hypoplasia of right
vertebral artery.
4. Mild atherosclerotic disease without stenosis at the
bilateral carotid bifurcations and bilateral cavernous portions
of the internal carotid arteries. Mild-to-moderate stenosis at
the takeoff of the right external carotid artery.
5. Stable right upper lobe cystic pulmonary nodule. As was
noted in the
prior CT on ___, follow up in one year (___)
with a
dedicated chest CT is recommended to ensure stability.
MR HEAD ___: IMPRESSION: No acute intracranial abnormality.
Few scattered white matter signal changes, which are
nonspecific and may represent small vessel ischemic disease.
ECHO ___: Conclusions
The left atrium is normal in size. A stretched patent foramen
ovale is present with a right-to-left shunt across the
interatrial septum seen both at rest and with cough after
administration of agitated saline contrast. The estimated right
atrial pressure is ___ mmHg. 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) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Stretched PFO with evidence of right to left
shunting by saline contrast study. Preserved biventricular
regional and global systolic function.
MR ORBITS ___: IMPRESSION:
1. Normal, symmetric appearance of the orbits, globes, optic
nerves, and
periorbita. Specifically, there is no evidence of retrobulbar
or periorbital mass.
2. Patent bilateral ophthalmic arteries.
3. Trace mucosal thickening within the bilateral maxillary
sinuses.
Brief Hospital Course:
___ is a ___ year-old right handed woman with prior
episode of vision loss who presented to ___ in the setting of
an acute loss of vision in her
left eye persisted but improved on this admission.
# NEURO: patient was taking pradaxa prior to admission, but her
PTT on admission was not elevated, which may be suggestive of
some non-compliance with her pradaxa. In addition, patient
stopped taking her pradaxa for 2 weeks 1 week prior to admission
for an "H. Pylori diagnosis", which could have also contributed
to her unelevated PTT. We continued patient's ASA 81mg QD.
Opthalmology came to see that patient and recommended MRI of the
orbits, which were done, but showed no abnormality. The patient
will get visual evoked potentials and will follow up with optho
and neuro.
# CARDS: patient was found to have a PFO on her TTE, which may
be a possible source of embolism. While here, we monitored her
on telemetry and noted no events. We held her HCTZ while an
inpatient and only gave her a ___ dose of labetalol. We
continued her home dose clonidine to prevent reflex
hypertension, but on discharge she was restarted on her prior
home meds.
# ENDO: we continued pt on her home dose atorvastatin 80mg QD.
While here she was put on an ISS which was stopped at discharge.
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient will need close neurological and opthalmological
follow-up to ensure either resolution of her sx or further
workup of the possible source of her vision loss.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. CloniDINE 0.2 mg PO BID
4. Dabigatran Etexilate 150 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN back
pain
8. Labetalol 200 mg PO TID
9. Lorazepam 0.5-1 mg PO BID PRN anxiety
10. Omeprazole 20 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. ___ Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO HS
2. Cyanocobalamin 500 mcg PO DAILY
3. ___ Oil (Omega 3) 1000 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Aspirin 81 mg PO DAILY
7. CloniDINE 0.2 mg PO BID
8. Dabigatran Etexilate 150 mg PO BID
9. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN back
pain
10. Lorazepam 0.5-1 mg PO BID PRN anxiety
11. Amlodipine 10 mg PO DAILY
12. Hydrochlorothiazide 25 mg PO DAILY
13. Labetalol 200 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Monocular Vision Loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
NEURO EXAM: L eye ___, R eye ___, otherwise nonfocal
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for loss of vision in your left
eye. You were evaluated with an MRI of your brain and an MRI of
your orbits, which were both essentially normal. You began to
improve during this hospitalization and we hope that you will
continue to improve with time. You will follow-up with
opthalmology for further eye tests as well as with the EEG lab
here for better testing of your optic nerve function. Please
bring your ___ records to your neurology follow-up appointment.
It is very important that we also get this information. In
addition, you should not drive until your eye doctor tells you
it is alright to do so.
We made no changes to your medications.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
___
|
10731700-DS-17
| 10,731,700 | 29,296,714 |
DS
| 17 |
2129-05-27 00:00:00
|
2129-05-27 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Keflex / Ketorolac / Ciprofloxacin
Attending: ___.
Chief Complaint:
Finger pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with mixed connective tissue disease and CAD with chronic
dry gangrene of the ___ distal phalynx planning for amputation
by hand surgery in the near future presenting for worsening pain
admitted for pain control.
In the ED, she was evaluated by the hand team who felt that
there was no infection, she should f/u as scheduled in clinic on
___, and need to clarify an ongoing need for clopidogrel as
this would be a high intra-operative risk. She received 5mg IV
morphine and 1.5mg IV hydromorphone with moderate relief.
Vitals prior to transfer were: 97.7 64 96/60 16 100% RA
Upon admission to the floor she has received 2mg IV morphine
with continued ___ pain.
Past Medical History:
- LV aneurysm- discovered ___, continued on coumadin but no
clear course of anticoagulation for this.
- Ischemia of digit - vasospasm versus clot. Currently on
coumadin.
- Mixed Connective tissue disorder (Originally diagnosed with
SLE at age ___. Also previously carries the diagnosis of
rheumatoid arthritis, s/p treatment with Plaquenil, Imuran,
Prednisone. Antibody panels most consistent with MCTD with a
scleroderma predominance.)
- History of MI in ___ at ___. S/p PCI. Pt reports
that she was "put under a medical coma for 2 weeks.
- Anoxic brain injury - ___ cardiac arrest
- Hx. of leukopenia and thrombocytopenia
- History of right hand cellulitis (___)
- Recurrent episodes of osteomyelitis of the digits (approx 12
episodes)
- Bilateral AVN necrosis in hips.
- Shincter of Oddi dysfunction ERCP with sphincterotomy and
stone/sludge extraction ___
- Calcinosis
- Microcytic anemia
- Hiatal hernia
- COPD
- Chronic pain syndrome
- Depression
- Fibromyalgia
Social History:
___
Family History:
Father with rheumatoid arthritis and died of MI at age ___.
Mother with heart disease, breast and lung cancer and died of
lung CA at age ___.
Aunt with lupus. Cousins with rheumatoid arthritis.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.9 94/64 74 17 100 RA, 56 Kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, has gry gangrene of ___ right hand digit. Has several
ulcers on remaining digits, has swan neck deformities.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
=========================
___ 10:50PM BLOOD WBC-5.6 RBC-4.83 Hgb-10.4* Hct-35.2*
MCV-73* MCH-21.6* MCHC-29.6* RDW-18.7* Plt ___
___ 10:50PM BLOOD Neuts-45.2* Lymphs-46.2* Monos-5.5
Eos-2.2 Baso-0.9
___ 10:50PM BLOOD ___ PTT-66.0* ___
___ 10:50PM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-136
K-5.3* Cl-98 HCO3-26 AnGap-17
___ 07:50AM BLOOD Na-140 K-4.3 Cl-103
___ 11:05PM BLOOD Lactate-1.9
MICROBIOLOGY
=========================
___ Blood Culture - no growth to date
IMAGING/STUDIES
=========================
___ Right Hand XRay
FINDINGS:
Three views of the right hand were reviewed. Since the recent
prior study, there is no significant change in the second digit
or elsewhere. Again seen are erosive or postsurgical changes
involving the thumb and ring fingers distally. Soft tissue
calcifications are also again seen along the ulnar aspect of the
distal carpal row and adjacent to the first distal phalanx.
Ossifications along the second DIP and third PIP joints are also
noted. Joint spaces are preserved.
IMPRESSION:
No significant change from the recent prior study. The
differential is broad and the findings can be seen in the
setting collagen vascular diseases (CREST, sleroderma) or due to
ischemic of infectious etiologies.
___ ECG
Sinus rhythm. RSR' pattern in leads V1-V2, probable normal
variant. Delayed R wave transition. Non-specific anterior and
lateral ST-T wave changes. Slightly prolonged Q-T interval.
Compared to the previous tracing of ___ the RSR' pattern is
new. Anteroseptal ST-T wave changes are more pronounced.
DISCHARGE LABS
=========================
Brief Hospital Course:
___ with right index finger dry gangrene who presents with
worsening pain without concern for infection.
ACTIVE ISSUES
# Right second digit dry gangrene:
This is a chronic issue for her and has been seen in the hand
surgery clinic with plans for future amputation. On admission,
evaluation by the hand surgery team did not note any concern for
infection or new ischemia. Inadequate pain control was her
primary complaint. She already had follow-up scheduled in Dr.
___ on ___ with the goal to determine a date for
amputation. However, in speaking with the surgical team, they
were concerned about her being on aspirin, clopidogrel, and
warfarin and had been having difficulty determining her ongoing
needs for these anti-platelet and ant-coagulant agents. This was
clarified with the patient's primary care provider who noted no
ongoing need for clopidogrel, so this was discontinued. She
underwent amputation on ___.
# Pain and narcotics use
She has been on methadone prescribed by her PCP as well as
oxycodone PRN. She received 24 tabs of 2mg Dilaudid at an ED
visit on ___ that she had completed. We spoke with her primary
pharmacy and they have several red flags and concerns about her
narcotics use. She has tried to fill prescriptions early in the
past that were all denied override by her PCP. We verified her
current methadone prescription with her PCP. We continued her on
methadone 30mg three times a ___. For breakthrough pain she was
initially given IV morphine and hydromorphone but was quickly
transitioned to PO hydromorphine ___ every 3 hours for
breakthrough pain.
# Mixed Connective Tissue Disease (MCTD):
Pos RNP, anti-centromere. Her only current medication was
immediate release nifedipine, which given her concurrent CAD was
a high-risk medication and this was initially changed to
extended release nifedipine. However, given that this was
started for possible vasospasm as a cause of her digit ischemia
and that this had progressed to gangrene despite treatment, we
discontinued the nifedipine altogether. The patient requested
follow-up with rheumatology at ___, and this was arranged
prior to discharge.
# History of Coronary Artery Disease:
She has a history of a VF arrest in the setting of MI resulting
in anoxic brain injury. She is s/p stent in ___ which was
complicated by restnosis and restenting in ___. She had been on
aspirin, clopidogrel, and simvastatin. As described above,
accorind to her PCP she no longer has ongoing need for
clopidogrel so this was discontinued.
CHRONIC ISSUES
# Anxiety
She was continued on clonazepam.
TRANSITIONAL ISSUES
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Methadone 30 mg PO TID
6. NIFEdipine 10 mg PO Q8H
7. Warfarin Dose is Unknown PO DAILY16
8. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
9. Clindamycin 300 mg PO Q6H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 1 mg PO TID
3. Simvastatin 20 mg PO DAILY
4. Methadone 30 mg PO TID
5. Warfarin 2.5 mg PO DAILY16
6. Acetaminophen 1000 mg PO Q8H
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID:PRN constipation
9. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4)
hours Disp #*70 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: dry gangrene of right second distal phalynx
Secondary: mixed connective tissue disease, coronary artery
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 caring for you during your stay at ___. You
were admitted with worsening pain of your finger, which was
likely due to lack of blood flow. It was felt you had "dry
gangrene" of this finger. There was no evidence of infection.
Your pain was controlled with a slightly higher dose of your
home oral pain medications. You underwent amputation of your
finger on ___ that was uncomplicated. You were kept overnight
for observation and pain control. You were discharged on POD1,
___.
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower upon discharge,
but please keep the dressing clean and dry until follow up.
7. After speaking with your PCP, we have stopped your Plavix
that you were taking pre-operatively. Additionally, your PCP
has asked that you address your need for Coumadin
post-operatively. Please ensure to mention this at your ___
rheumatology visit.
Followup Instructions:
___
|
10731752-DS-16
| 10,731,752 | 22,515,460 |
DS
| 16 |
2139-07-28 00:00:00
|
2139-07-28 18:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L hip fracture s/p fall, ETOH withdrawal
Major Surgical or Invasive Procedure:
___ Left hip hemiarthroplasty
History of Present Illness:
___ year old male w/ PMH of HTN and etoh abuse (8 drinks/day)who
complains of L Hip pain, s/p Fall. He had a slip and fall 2 days
ago while in ___ onto his left side. He was unable to bear
weight. He returned to ___ and presented to ___ where he
was found to have a displaced femoral neck fracture and admitted
to the Ortho service where they continued home metoprolol, held
ACE/HCTZ, and placed him on an Ativan CIWA. While in the
hospital he was noted to have elevated Cr and persistent
hypertension to 170. Medicine consult was initially requested
for assistance managing his hypertension and ___.
Of note patient was on a CIWA on the floor and did not require
any ativan per EMR. Upon further discussion with Ortho, there
was concern that patient was confused and visually hallucinating
immediately prior to surgery.
Patient was in OR when MERIT consult was placed, so was seen in
PACU post procedure by this service. Per report on their first
evaluation ~5pm in PACU, patient was delirious with SBP 140-170s
and HR in 100s. Thought was patient may have some confusion ___
anesthesia, and plan was to re-evaluate when woke up further.
While in the PACU, patient's heart rates increased to 130s and
became increasingly agitated requiring IV Ativan. ___ was
called and on re-evaluation ~645pm determined patient was in
alcohol withdrawal given confusion, hallucination, and
tachycardia, with concern for possible DTs and initiated ICU
transfer for possible phenobarbital protocol and closer
monitoring.
On MICU interview and exam in the PACU, patient somnolent and
minimally responsive after receiving lorazepam 4 mg IV and an
unknown amount of Haldol.
On arrival to the unit floor, interview with family including
HCP and daughter revealed significant drinking history with
daily alcohol consumption of ___ mixed drinks/day for at least
the past ___ years. Reported history of arm "shakes" when going
"too long without a drink." No reported history of witnessed
seizures. No prior hospitalizations for alcohol withdrawal. No
current benzodiazepine use. Per wife report, last drink was on
airplane back from ___ yesterday evening.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hypertension
Social History:
___
Family History:
No family history of alcohol abuse per wife.
Physical Exam:
On Admission to ___:
==================================
GENERAL: Somenlent, minimally responsive to verbal command
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, well profused. Dressing over L hip C/D/I
DISCHARGE EXAM:
======================================
Vitals: T 99 HR ___ BP ___ RR 18 97-100 RA
General: Alert, oriented to person, place, year, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel, no rebound
tenderness or guarding
Ext: Warm, well perfused, no edema. L hip with dressing in
place, clean dry intact. Not tender to palpation. Left MTP joint
minimally swollen, very mildly tender to palpation
Pertinent Results:
ADMISSION LABS:
======================
___ 06:55PM BLOOD WBC-11.04* RBC-3.87* Hgb-UNABLE TO
Hct-34.0* MCV-83 MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO
RDWSD-UNABLE TO Plt ___
___ 06:55PM BLOOD Neuts-78.7* Lymphs-7.1* Monos-13.0
Eos-0.2* Baso-0.2 NRBC-0.0 Im ___ AbsNeut-8.69*
AbsLymp-0.78* AbsMono-1.44* AbsEos-0.02* AbsBaso-0.02
___ 06:55PM BLOOD Glucose-169* UreaN-33* Creat-2.0* Na-133
K-4.0 Cl-91* HCO3-24 AnGap-22*
___ 06:55PM BLOOD Calcium-9.2 Phos-3.0 Mg-1.4*
PERTINENT INTERVAL LABS:
======================
___ 02:35AM BLOOD ALT-32 AST-39 AlkPhos-37* TotBili-1.2
___ 10:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:25PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-4* pH-6.5 Leuks-SM
___ 10:25PM URINE RBC-175* WBC-6* Bacteri-FEW Yeast-NONE
Epi-0
___ 10:25PM URINE CastHy-1*
___ 10:25PM URINE Mucous-RARE
___ 11:51PM URINE Hours-RANDOM Creat-89 Na-85 K-34 Cl-80
___ 11:51PM URINE Osmolal-563
___ 08:04PM URINE Hours-RANDOM UreaN-361 Creat-60 Na-160
K-17 Cl-122
___ 08:04PM URINE Osmolal-484
LABS ON DISCHARGE:
======================
___ 05:50AM BLOOD WBC-10.3* RBC-2.64* Hgb-8.0* Hct-22.2*
MCV-84 MCH-30.3 MCHC-36.0 RDW-14.8 RDWSD-45.3 Plt ___
___ 05:50AM BLOOD Glucose-131* UreaN-18 Creat-1.3* Na-131*
K-4.5 Cl-96 HCO3-26 AnGap-14
___ 05:50AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
MICROBIOLOGY:
======================
__________________________________________________________
___ 10:25 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:02 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
PATHOLOGY:
=====================
Report not finalized.
Logged in only.
PATHOLOGY # ___
FEMORAL HEAD, OTHER THAN FRACTURE
IMAGING/STUDIES:
======================
PELVIS (AP ONLY)Study Date of ___ 7:33 ___
There is a left subcapital/femoral neck fracture with slight
varus angulation of the femoral head and slight foreshortening
of the left femoral shaft. No additional fracture of the left
femur is seen. There is no dislocation. Mild degenerative
changes at both hip joints are noted. There are also
degenerative changes along the partially imaged lower lumbar
spine. No suprapatellar joint effusion is seen. The pubic
symphysis and sacroiliac joints are intact.
IMPRESSION:
Left femoral neck/subcapital fracture. No additional fracture
seen of the
more distal left femur.
CHEST (PRE-OP AP ONLY)Study Date of ___ 7:33 ___
No acute cardiopulmonary process.
BILAT LOWER EXT VEINSStudy Date of ___ 9:39 AM
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
PELVIS (AP ONLY) PORTStudy Date of ___ 3:26 ___
There has been interval surgery with placement of a left hip
hemiarthroplasty.Alignment appears appropriate. No
periprosthetic fracture seen. Small amount subcutaneous air is
consistent with recent surgery. Trace degenerative changes in
the right hip. No additional fracture seen.
IMPRESSION:
Expected appearances following left hip hemiarthroplasty.
CHEST (PORTABLE AP)Study Date of ___ 12:25 ___
No acute cardiopulmonary process.
OPERATIVE REPORT:
=====================
PROCEDURE IN DETAIL: The patient was identified in the
preoperative holding area, and the correct lower extremity
was marked. He was then transferred to the operating room
and given a general anesthetic and a Foley catheter. Then
positioned in lateral decubitus position with the left side
facing upward. He was given vancomycin and Ancef. The left
hip was prepared and draped in the standard sterile
technique. A surgical time-out was performed, confirming the
correct patient, operation, operative site, operative side,
DVT and antibiotic prophylaxis, and presence of equipment and
radiographs. Following the time-out, a lateral incision was
made on the left hip. This was in the region of the
abrasion, which was unavoidable due to the size of it. The
abrasion measured approximately 10 x 8 cm. The subcutaneous
tissue was incised in line with skin incision. The fascia
was incised. A ___ approach was taken by elevating the
anterior one-third of the gluteus medius with a small bony
attachment off of the trochanter. The capsule was incised.
The hematoma was evacuated. The femoral neck was visualized,
and a fresh femoral neck cut was made. The femoral head was
removed with the corkscrew. This was sized and found to be a
size 52. The hip was then externally rotated and adducted.
The first awl was used in the canal, followed by the reamers.
We then broached the canal up to a size 7, at which point in
time an excellent press-fit was achieved. The 132 neck angle
was placed with a femoral head trial and a bipolar 52 mm
trial, and the hip was reduced and put through range of
motion with excellent range of motion, stability and
alignment. Leg lengths were found to be equal. The trial
stem was removed, and the actual was placed and impacted with
20 degrees of anteversion. The femoral heads were trialed,
and the 0+ was found to most appropriately achieve equal leg
length and excellent range of motion and stability. The
trial head was removed, and the 0 mm, 28 mm head was placed
and impacted, as well as a 52 mm bipolar head. This was
reduced, put through range of motion and found to have
excellent range of motion, stability and equal leg length.
The hip was irrigated with copious amounts of sterile saline.
The abductors were repaired with #5 Ethibond sutures through
bone. The wound was closed in layers. The skin was closed
with staples. Dressings were applied. The patient was
allowed to wake up from the general anesthetic and was
transferred to his bed in the postop unit in stable
condition. There were no complications.
ESTIMATED BLOOD LOSS: 300 mL.
FLUIDS USED: 1200 cc.
URINE OUTPUT: 300 cc.
Brief Hospital Course:
Mr. ___ is a ___ yo man with a history of HTN and heavy EtOH
use ___ drinks daily) who presented to ___ with left hip pain
s/p fall, found to have a L femoral neck, who underwent L hemi
arthroplasty ___, whose post operative course was complicated
by severe alcohol withdrawal and agitated delirium requiring ICU
transfer and phenobarbital protocol transitioned to an oral
phenobarbital regimen and stable on the general medicine ward.
#ETOH withdrawal/agitated delirium
The patient endorsed a significant alcohol use history, and
preoperatively it was thought that he was confused and
hallucinating prior to surgery despite being on a CIWA protocol.
The patient developed severe agitation and tachycardia to the
130s, as well as hypertension with SBPs in the 140s-170s in the
PACU. He required IV Ativan and was transferred to the MICU for
initiation of a phenobarbital protocol for alcohol withdrawal.
He improved after phenobarbital loading and was transitioned to
PO phenobarbital. He continued on this regimen on transfer from
the MICU to the general medicine ward with resolution of his
tachycardia and agitation. He was alert and oriented x3 on the
general medicine floor. He was started and continued on folate,
thiamine and a multivitamin.
# Left femoral neck fracture status post left hip
hemiarthroplasty
The patient was found to have a left femoral neck fracture after
a fall in ___, when he presented to ___. He underwent an
uncomplicated left hemiarthroplasty with orthopedic surgery on
___. Post operatively he had an acute blood loss anemia as
further described below. He was evaluated by physical therapy
during the admission. He was noted to be orthostatic while
working with physical therapy. He was started on enoxaparin 40
mg SC for 1 month for DVT prophlaxis. On discharge his pain was
well managed on oral oxycodone.
# Acute blood loss anemia
Post operatively the patient developed acute blood loss anemia
with a hemoglobin/hematocrit nadir of ___ on ___ from
11.___.2 preoperatively. He was transfused 1uPRBC on ___ with
an appropriate bump in hemoglobin/hematocrit. His
hemoglobin/hematocrit was stable on discharge.
#Fever:
Patient spiked new fever post operative, to 102.9. This was
thought to be most likely due to be multifactorial including
post operative fever, atlectasis, possibly compounded by his
alcohol withdrawal. He spiked again on the day prior to
discharge to 100.2, again thought to be multifactorial as above,
with a possible contribution from mono articular arthritis
likely gout as described below. There were no other localizing
signs or symptoms to suggest infection, a CXR was negative, and
urine and blood culures were negative. Given the low suspicion
for infection he was not started on antibiotics.
# Hypertension:
The patient develop systolic blood pressures up to the 170s post
operatively. This was thought to be due to acute alcohol
withdrawal as well as the holding of his home HCTZ/ace inhibitor
in the setting of his ___ and ___ PO intake. His home
medications were restarted, and his pressures improved on
phenobarbital. Of note the patient was orthostatic while working
with physical therapy during the admission.
# ___ - resolved
Patient admitted with Cr of 2 though to be hypovolemic in the
setting of his hip fracture. This down trended throughout the
admission. On the day of discharge his Cr was 1.3 thought to be
possibly due to re starting his home lisinopril. This will need
to be closely monitored on discharge.
# Hyponatremia
The patient was found to be hyponatremic with a nadir of 130.
Urine lytes were sent and the patient was found to have elevated
Uosm and Na, consistent with a picture of increased ADH
secretion, likely secondary to pain and his post operative
course. He was started on a 2L fluid restriction. On discharge
his Na was 131.
# Left ___ MTP joint pain
The patient developed left toe pain overnight on ___,
concerning for gout given the location of the monoarticular
arthritis, his history of heavy alcohol use, as well as the
stress of surgery. He was given a 1x dose of colchicine with
significant improvement. Consideration should be had as an
outpatient about starting allopurinol.
TRANSITIONAL ISSUES:
===========================
- Check CBC on ___ - trending hemoglobin/hematocrit to assure
no further post operative drop
- Check chem 7 on ___ - trending Na given hyponatremia, as well
as Cr given ___
- Continue Lovenox 40 mg SC daily for DVT prophylaxis for 1
month post operatively (L hemiarthroplasty ___ - if the
patients Cr rises to 1.4, consider transitioning to Heparin SC
5000 U TID
- Continue fluid restriction until Na normalizies
- Consider long term allopurinol for gout
- Continue phenobarbital taper as ordered: 20mg dose on
___ 10mg BID x 2 doses on ___, and 5mg BID x 2 doses
on ___, then stop.
- Follow up with orthopedic surgery in 2 weeks for evaluation,
and staple removal
- Follow up with substance abuse counseling after discharge from
rehab for treatment of alcohol use
- Consider discontinuing HCTZ if creatinine continues to rise
and blood pressures are well controlled
# CODE: Full (confirmed)
# CONTACT: HCP: ___ (wife/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*30 Tablet
Refills:*0
5. Thiamine 100 mg PO DAILY
6. Enoxaparin Sodium 0 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Aspirin 81 mg PO DAILY
8. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 20 mg
PO/NG ONCE Duration: 1 Dose
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 4 tapered doses
11. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 10 mg
PO/NG BID Duration: 2 Doses
Start: After 20 mg ONCE tapered dose
This is dose # 2 of 4 tapered doses
12. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 6 mg
PO/NG BID Duration: 2 Doses
Start: After 10 mg BID tapered dose
This is dose # 3 of 4 tapered doses
13. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg
PO/NG BID Duration: 0 Doses
Start: After 6 mg BID tapered dose
This is dose # 4 of 4 tapered doses
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
===================
displaced left femoral neck fracture status post left
hemiarthroplasty
severe alcohol withdrawal
hypertension
Acute kidney injury
Hyponatremia
Monoarticular arthritis
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were found to have a fracture of your left hip after your fall
in ___. This was repaired by the orthopedic surgeons and you
underwent a procedure called a left hemiarthroplasty. You will
need to follow up with the orthopedic surgeons in clinic in two
weeks to evaluate the wound and to remove the staples. You will
need to take shots of a blood thinner to help prevent blood
clots from forming after surgery for one month.
After the surgery you were found to be suffering from severe
alcohol withdrawal. You were started on a medication called
phenobarbital which helped with your symptoms. You will need to
continue a taper of this medication. It is important that you
work to stop drinking alcohol given the severe negative effects
it has on your health.
You will be going to a rehabilitation facility after discharge
to help you regain your strength after the surgery.
Your medication list is included in your discharge paper work.
Your post discharge appointments are also listed below. The
orthopedic surgery team left their post operative instructions
below.
We wish you the best!
- Your ___ Care Team
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT with posterior hip precautions
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 as prescribed
WOUND CARE:
- please apply betadine BID to the wound and apply a dry sterile
dressing. could use adaptic over excoriated skin wound as
needed.
- 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.
- If applicable, Splint must be left on until follow up
appointment unless otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10731982-DS-5
| 10,731,982 | 27,833,976 |
DS
| 5 |
2119-09-17 00:00:00
|
2119-09-17 15:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
___ L craniotomy for aneurysm clipping
___ R EVD placement
___ R EVD replacment
History of Present Illness:
___ presents as a transfer from ___ for a
subarachnoid hemorrhage. He had a syncopal event today where he
felt lightheaded and cold and then fell. He does not number
hitting his head. CT at the outside hospital showed a
subarachnoid hemorrhage in the suprasellar cistern. He denies
any
weakness or numbness.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
?psychiatric: does not report any psychiatric diagnoses, but has
one previous suicide attempt and subsequent 1 month inpatient
hospitalization.
PPD positive: does not know if had CXR findings, has not been
treated
No prior surgery or medical hospitalizations.
Social History:
___
Family History:
FAMILY HISTORY:
Does not report any family medical history.
Physical Exam:
On Admission:
AVSS
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Awake, oriented x3
follows commands throughout
PERRL, EOMI, FSTM
No drift
MAE ___
sensation intact to light touch
On Discharge:
A&Ox3, PERRL, EOMI, Face symmetrical,
No drift, MAE ___
Incision cd&i. 2 staples at ___ EVD site.
Pertinent Results:
CTA HEAD W&W/O C & RECONS ___
IMPRESSION:
1. 8 mm x 4 mm multi obulated aneurysm arising from the anterior
communicating artery which projects anteriorly and inferiorly.
2. Diffuse subarachnoid hemorrhage is better evaluated on prior
noncontrast head CT. The ventricles are stable in size.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
3:52 ___ IMPRESSION:
1. Right frontal ventriculostomy catheter terminates in the
frontal horn of the right lateral ventricle. The ventricles have
decreased in size, and third ventricular hemorrhage has
resolved. 2. Stable diffuse subarachnoid hemorrhage. 3. Status
post left craniotomy and anterior communicating artery aneurysm
clipping, with left greater than right extra-axial
pneumocephalus, resulting in mild left frontal sulcal effacement
and new mild rightward shift of midline structures. Minimal left
extra-axial blood. 4. Aerosolized secretions in the paranasal
sinuses, new compared to ___ though similar compared to ___, which may be secondary to prolonged supine
positioning or acute inflammation. Please correlate clinically.
Cardiovascular Report ECG Study Date of ___ 1:21:24 AM
Sinus rhythm. Wandering baseline and baseline artifact.
Prominent precordial voltage for left ventricular hypertrophy.
Compared to the previous tracing of ___ the rate has
slowed. There are more prominent U waves. Otherwise, no
diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 136 80 ___ 50
___ ECHOCARDIOGRAPHY REPORT ___
FINAL Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
___ EKG
Sinus bradycardia. Normal ECG. Compared to the previous tracing
of ___ the rate is slower.
___ CXR
Heart size and mediastinum are stable. Minimal right basal
opacity is noted, potentially representing improving infection.
Rest of the lungs are essentially clear. No pleural effusion or
pneumothorax appreciated.
___ CTA
In comparison with CTA obtained ___, there is diffuse
narrowing of the intracranial vessels which may represent some
degree of
vasospasm status post clipping of anterior communicating artery
aneurysm.
Within this limitation, there is no evidence of residual
aneurysm. There is hardware artifact associated with clip, which
obscures nearby anatomic
structures. Otherwise, the visualized circle of ___
vasculature is patent without evidence of occlusion.
___ NCHCT
1. Interval placement of right frontal approach ventriculostomy
catheter, with tip terminating in the anterior horn of the right
lateral ventricle. Small amount of air along the tract of the
catheter and in the anterior horn of the right lateral
ventricle.
2. Interval resolution of subarachnoid hemorrhage. No new areas
of hemorrhage. No mass effect.
___ ECHO
Normal study.Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No
structural heart disease or pathologic flow identified.
___ CTA
1. Postoperative changes of anterior communicating artery
aneurysm coiling including left craniotomy with underlying
subdural blood products and air along with stable right
transfrontal introduced ventriculostomy catheter.
2. Improved narrowing of the vessels of the posterior
circulation,
intracranial internal carotid arteries, portions of the ACAS,
and portions of the MCAs, compatible with persistent although
decreased vasospasm.
Brief Hospital Course:
This is a ___ year old male status post syncopal episode presents
from OSH with SAH. CTA head was performed and showed ACOM
aneurysm. He was admitted to the ICU for close monitoring and
then taken to the OR on ___ for L craniotomy for clipping of
aneurysm and R EVD placement. Post operatively, patient remained
stable on exam. EVD leveled at 10cmH2O. Post op head CT shows R
EVD in R lateral ventricle and pneumocephalus.
On ___, ___ patient's fluid volume status was kept even. The
external ventricular drain was elevated to 20 H2O above the
tragus. The intravenous fluid was continued at 125 cc hr.
Transcranial doppler studies were perfomed to assess for
vasospasm and were negative. The patient was neurologically
intact on exam. An ECHOcardiogram was performed and was found
to be normal (LVEF >55%).
Patient remained stable in the ICU on ___ his evd was clamped.
On ___ it was noted that his icps were 28 to 30 at rest.
Patient was examined and was neurologically intact. EVD was
unclamped for one hour and re-clamped.
On ___, the EVD was opened at 15 for high ICP's, patient
reported headache and RN noted leakage around the drain site. He
was started on salt tabs 2GM BID and fluid were 500ml positive
overnight. He was also Febrile and a workup was started. A CXR
was negative for PNA, csf (gram negative rods), blood and urine
cultures sent. TCDs were negative for spasm, but showed increaes
in velocity in proximal basilar artery. Infectious disease was
consulted regarding the positive csf and recommended starting
Meropenem as well as Vancomycin.
___, per the recommendation of infecious disease who were
consulted on ___, the EVD was replaced on the right side using
the same burr hole as previously used. A non-contrast HCT was
obained which confirmed placement in the right lateral
ventricle. A CTA was obtained for a noted exam change of slight
weakness in the left upper extremity as well as a left pronator
drift. The CTA showed spasm in the left MCA and ICA. He was
started on pressors to achieve a systolic blood pressure between
180 and 200. A PICC line was placed for the ability to give
hypertonics to treat his low sodiums. An arterial line was
placed to closely monitor his pressures.
___, the patient's systolic blood pressure sustained an 80-100
point drop after the administration of nimodipine. The
nimodipine was held in addition to the continued use of pressors
to keep his systolic over 140. The sodium continued to drop
despite salt tabs 3% sodium iv fluids. The 3% was increased to
50cc and urine lytes were ordered.
___, the 3% was again increased. Per infectious disease, the
vancomycin was discontinued and Meropenem was continued. Due to
continued issues with systolic blood pressure drops, the
nimodipine continued to be held.
___, Mr. ___ sodium was ___ on 3%; the serum
sodiums continued to be checked every six hours. His EVD was
increased to 20 above the tragus and repeat csf cultures were
sent to evaluate his ventricilitis after the EVD change out and
the start of antibiotics. His nimodopine was restarted. His left
craniotomy sutures were removed. Mr. ___ was started on
antibiotics for a clostridium dificile infection. Overnight, he
disconnected his EVD which was reconnected in a sterile faction.
___: The patient was agitated and requesting to leave against
medical advice. Due to his agitation and low ICP's, his EVD was
clamped in the morning. The intracranial pressures were low
throughout the day and we was mentating well. He continued
intermittently on two to three pressors to maintain a systolic
blood pressure over 140. His TCDs showed elevated velocities in
the bilateral MCAs consistent with mild vasospasm on the R and
hyperemia on the L. Also elevated velocities in the left PCA and
bilateral vertebral arteries.
On ___, the patient remained neurologically stable on
examination. He underwent a CTA of the brain which showed
improved spasm without any signs of hydrocephalus. The pressors
were being weaned off. The drain was clamped and ICPs were
continued to be monitored.
On ___, the patient's examination remained stable. The EVD was
discontinued and his BP goal was liberalized to 90-180. He
underwent TCDs which showed no evidence of vasospasm. The
hypertonic saline was weaned with a serum Na goal of 135-145.
On ___, the patient's neurologic examination remained stable
and intact. The morning sodium level was 141. The hypertonic
saline was stopped. It was determined he would be transferred to
the floor with twice daily serum sodium checks. He was started
on Normal Saline IV fluids at 30cc/hour.
On ___, the patient reamined neurologically stable. His
Nimodipine tabs,and sodium tablets were discontinued. His IVFs
and Fludrocort were also discontinued. He was transferred to the
floor in stable conditions.
On ___, the patient remained neurologically and
hemodynamically intact. However, he was attempting to leave to
go home, but was easily redirected.
On ___ the patient remained stable. He found safe to be
discharged home by physical therapy. He was set up with ___ for
IV antibiotic management. The patient expressed readiness for
discharge home. He was discharge home in stable conditions. All
discharge instructions and follow up were given prior to
discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not exceed more than 4 grams in 24hrs.
2. Bisacodyl 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4hrs Disp #*60
Tablet Refills:*0
5. Meropenem ___ mg IV Q8H
Stop after last dose on ___.
RX *meropenem 1 gram 2 grams three times a day Disp #*28 Vial
Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Stop 7 days after last dose of meropenem. On ___.
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*33 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
SAH
ACOM aneurysm
meningitis
hydrocephalus
C dificile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Dr. ___
___
___ your neurosurgeons office and speak to the Nurse
Practitioner if you experience:
-Any neurological issues, such as change in vision, speech or
movement
-Swelling, drainage, or redness of your incision
-Any problems with medications, such as nausea vomiting or
lethargy
-Fever greater than 101.5 degrees Fahrenheit
-Headaches not relieved with prescribed medications
Activity:
-Start to resume all activities as you tolerate but start
slowly and increase at your own pace.
-Do not operate any motorized vehicle for at least 10 days
after your surgery your Nurse Practitioner can give you more
detail at the time of your suture removal.
Incision Care:
-Keep your wound clean and dry.
-Do not use shampoo until your sutures are removed.
-When you are allowed to shampoo your hair, let the shampoo run
off the incision line. Gently pad the incision with a towel to
dry.
-Do not rub, scrub, scratch, or pick at any scabs on the
incision line.
Post-Operative Experiences: Physical
-Jaw pain on the same side as your surgery; this goes away
after about a month
-You may experience constipation. Constipation can be
prevented by:
oDrinking plenty of fluids
oIncreasing fiber in your diet by eating vegetables, prunes,
fiber rich breads and cereals, or fiber supplements
oExercising
oUsing over-the-counter bowel stimulants or laxatives as
needed, stopping usage if you experience loose bowel movements
or diarrhea
-Fatigue which will slowly resolve over time
-Numbness or tingling in the area of the incision; this can
take weeks or months to fully resolve
-Muffled hearing in the ear near the incision area
-Low back pain or shooting pain down the leg which can resolve
with increased activity
Post-Operative Experiences: Emotional
-You may experience depression. Symptoms of depression can
include
oFeeling down or sad
oIrritability, frustration, and confusion
oDistractibility
oLower Self-Esteem/Relationship Challenges
oInsomnia
oLoneliness
-If you experience these symptoms, you can contact your Primary
Care Provider who can make a referral to a Psychologist or
Psychiatrist
-You can also seek out a local Brain Aneurysm Support Group in
your area through the Brain Aneurysm Foundation
oMore information can be found at ___
Followup Instructions:
___
|
10731984-DS-4
| 10,731,984 | 25,707,431 |
DS
| 4 |
2149-04-26 00:00:00
|
2149-05-06 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Central venous line placement (IJ) ___
Bone marrow biopsy ___
Skin biopsy over dorsum of right foot ___
History of Present Illness:
Ms. ___ is a ___ with no PMH who was recently seen in ED ___
for c/o fever who was discharged with diagnosis of viral illness
and monospot was negative. She returns to the ED today with
reported fever of 103.1. Patient reports 2 weeks of fever,
chills, arthralgias, night sweats and sore throat associated
with general myalgia and mild abdominal pain. Patient has been
taking Tylenol and Ibuprofen with temporary resolution of most
of her symptoms.
Patient was seen 4 times at ___ in addition to
ED on ___. Also notes chest pain and SOB when having fever.
Patient also notes chest pain during fever and night sweats as
well as an itchy rash on her extremities that comes and goes.
Patient also says she has some positional dizziness,
conjunctivitis, joint pain in hands, and nonbloody diarrhea.
Patient not certain if she has weight loss. Patient reports that
vaccines are up to date, and is not sure she had TB testing.
In the ED, her initial vitals were: 99.4 ___ 20 97%. Her
initial labs were significant for a normal WBC, H/H 11.3/33.6,
PLT 138, normal Chem7, transaminitis with ALT/AST 86/139 (nl AP,
last TB 0.3 on ___, LDH 656, Ca 8.3, CRP 101.4. bHCG negative.
Lactate 1.4. While in the ED, she had a negative monospot and a
preliminary ID work-up with initiated. She was started on
empiric doxycycline given the report that she was recently in
___ and that she was spending time at a farm. She denies
any sick contacts, no hx of infectious mono. No new foods or
medication. She reports having a diffuse maculopapular rash that
appears when she has high fevers or a hot shower, itchy, self
resolves in an hour. No other complaints reported.
She was initially admitted to the Medicine floor for further
workup of FUO, including CT of her neck, chest, abdomen, and
pelvis. Her vitals on arrival to the floor were T: 101.5 BP:
113/77 HR: 98 RR: 26 02 sat: 100%RA. Shortly after admission,
she became hypotensive with SBPs in the ___ and was
transferred to the MICU for septic shock. She had received
roughly 7L IVF upon arrival to the ICU. Of note, she was briefly
treated with peripheral Neo and Levo during transport.
Past Medical History:
None
Social History:
___
Family History:
No family history of autoimmune illness, cancers, heart or
respiratory conditions. Parents are alive and healthy in ___.
___ grandparents are alive and well; patient unsure what the ___
died from.
Physical Exam:
Admission physical exam
Vitals: T 101.5 BP 113/77 HR 98 RR 26 02 sat 100%RA
GENERAL: rigoring in bed, worse when blankets pulled back or
with movement, better with relaxation, anxious affect though
pleasant and cooperative, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, clear OP without ulcers or lesions, good dentition
NECK: markedly tender on palpation of her tonsils allowing only
limited exam, remainder of neck with small tender adenopathy, no
thyromegaly
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, slightly tachypneic,
better with reassurance
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, no stigmata of endocarditis
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength ___ though this seems
effort-dependent
SKIN: warm and well perfused, no excoriations or lesions, no
rashes at this time.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5F 98/50 60 18 100%RA
General: well-appearing, NAD
HEENT: PERRL, sclera clear
Neck: no LAD
Lungs: CTAB, no crackles or wheezes. no cough with deep
insiration
CV: RRR, nl S1,S2, no murmurs, rubs, or gallops
Abdomen: soft, non-tender, non-distended, no rebound or guarding
Neuro: CN II-XII intact, passive and active ROM of the wrists,
MCP joints intact, strength ___ UE bilaterally
Pertinent Results:
On admission:
___ 07:01PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.3* Hct-32.5*
MCV-89 MCH-31.1 MCHC-34.8 RDW-12.6 Plt ___
___ 11:59PM BLOOD Neuts-81* Bands-11* Lymphs-5* Monos-1*
Eos-0 Baso-0 ___ Metas-2* Myelos-0
___ 11:59PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL Tear Dr-OCCASIONAL
___ 11:59PM BLOOD ___ PTT-76.1* ___
___ 07:09PM BLOOD Lactate-3.2*
___ 06:02AM BLOOD CRP-101.4*
___ 06:02AM BLOOD ___ * Titer-1:40 ___
___ 08:00AM BLOOD ___ Echo:
Normal global and regional biventricular systolic function. Mild
mitral regurgitation. Borderline pulmonary hypertension.
___. Prominent cervical lymph nodes bilaterally. These may be
reactive in nature however exact etiology is difficult to
determine. 2. The right sternocleidomastoid muscle is enlarged
and there is some stranding posteriorly, likely due to central
line placement
___ CT A/P
1. Prominent cervical lymph nodes bilaterally. These may be
reactive in nature however exact etiology is difficult to
determine.
2. The right sternocleidomastoid muscle is enlarged and there is
some
stranding posteriorly, likely due to central line placement
___ CT chest
1. Moderate nonhemorrhagic, bilateral pleural effusions with
adjacent
atelectasis. 2. Significant consolidations within the left and
right lower lobes. Findings may represent lobar atelectasis,
however, superimposed infection cannot be excluded. 3.
Non-obstructing, right hilar lymphadenopathy. 4. Enlarged
thymus, probably reactive.
Significant Labs:
___ 01:41AM BLOOD IgG-746 IgA-164 IgM-59
___ 08:00AM BLOOD RheuFac-12
___ 06:02AM BLOOD ___ * Titer-1:40 ___
___ 06:02AM BLOOD CRP-101.4*
___ 10:00AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 05:50AM BLOOD Cortsol-2.4
___ 05:50AM BLOOD TSH-1.2
___ 06:00AM BLOOD Ferritn-1506*
Discharge labs:
___ 07:30AM BLOOD WBC-15.1* RBC-3.36* Hgb-10.2* Hct-30.6*
MCV-91 MCH-30.4 MCHC-33.4 RDW-16.3* Plt ___
___ 07:30AM BLOOD Plt ___
___ 06:00AM BLOOD ___
___ 07:30AM BLOOD Glucose-96 UreaN-11 Creat-0.3* Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
___ 06:00AM BLOOD ALT-134* AST-67* LD(LDH)-447* AlkPhos-104
TotBili-0.5
___ 07:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2
Brief Hospital Course:
This is a ___ no significant PMHx recently seen in ED ___
for c/o fever, who re-presents for fever to 103.1, with multiple
physical complaints, as well as elevated CRP, transaminitis,
elevated ferritin and new leukocytosis.
MICU COURSE
# Septic shock / FUO: Met ___ SIRS criteria at admission and
required pressors briefly until ___. Received about 11L fluids.
Initial differential included infectious, autoimmune,
malignancy. Her hemophagocytic process (elevated LDH, ferritin)
was concerning for hemophagocytic lymphohistiocytosis (HLH).
Patient was seen by ID, heme/onc, and rheumatology. Bone marrow
biopsy was performed, which showed hemophagocytosis.
Presentation was felt to be most likely due to HLH vs macrophage
activation syndrome secondary to Still's disease. CT
neck/abdomen/pelvis was performed given tender lymphadenopathy
and to rule out occult malignancy or abscess. CT showed
nonspecific lymphadenophathy and gallbladder wall edema (likely
secondary to volume overload). Echo for vegetations was
negative. Infectious workup to date has been unrevealing. Beta
glucan was elevated, but was felt to be a false positive given
no clinical signs of fungal infection and improvement on
steroids. Patient was started on broad spectrum antibiotics of
___ per ID recommendations on ___ which was
d/c on ___. Patient was given 1g solumedrol daily for 3
days, followed by 60mg prednisone. She was started on Anakinra
on ___. Meropenem was continued because of immunosuppression on
high dose steroids. Patient was also started on bactrim for PCP
prophylaxis on ___.
# Coagulopathy: Patient presented to ICU with low platelets,
elevated FDP, elevated ___ concerning for DIC. Labs were
trended and patient did not require transfution of FFP or
pRRBCs. Labs improved during MICU course and while on floor.
#Transaminitis / ___: Likely multifactorial, related to
inflammation from underlying process and shock. LFTs were
followed and downtrended appropriately.
# ___: Cr 1.3 in setting of septic shock and volume depletion.
UA with bland sediment. Cr returned to baseline during MICU
course and stayed at normal levels while on floor
# Hypoxia: Patient had new O2 requirement in the setting of
aggressive volume resuscitation. Unlikely to be PNA as she did
not have any previous localizing symptoms except a sore throat.
Was initially started on broad spectrum antibiotics as above,
but O2 requirement decreased as patient self-diuresed and was
weaned to room air on ___.
GENERAL MEDICINE FLOOR COURSE
1. HLH/MACROPHAGE ACTIVATION SYNDROME: As discussed, Ms. ___ was
admitted with fever without localizing signs requiring a MICU
admission for hypotension, pressors and broad spectrum
antibiotics. She also was found to have a transaminitis,
elevated LDH, and rapid ferritin elevation to ___ concerning
for hemophagocytic lymphohistiocytosis with unclear precipitant.
Given the clinical suspicion for HLH, a bone marrow biopsy was
performed. Aspirate smear was reviewed with heme pathology and
was significant for hemophagocytosis, consistent with a
diagnosis of HLH. Given the patient's clinical status with
worsening ferritin and LFTs, prompt steroids were initiated. We
believe that she has a form of HLH known as Macrophage
activation syndrome (MAS) which is associated with juvenile
idiopathic arthritis and other rheumatologic conditions. MAS is
a subset of HLH in which successful therapy of the underlying
condition may produce a good response and allow the patient to
avoid HLH-specific therapy. Therefore, pulse dose steroids as
recommended by rheumatology were continued, to which indefinite
anakinra was added.
2. Fevers/Adult Stills: Ms. ___ had fevers with evanescent rash,
pharyngitis, very high ferritin and questionable LAD that best
fit a diagnosis of Adult Stills Disease. She responded to
Stills treatment including pulse-dose steroids. It is possible
that that was triggered by a viral infection, but if so, that
virus had resolved by the time of her hospitalization.
Infectious work-up did not reveal any infectious causes of the
fevers. A quantiferon gold was indeterminate, EBV serology
consistent with prior infection, CMV with no prior infection and
no evidence of Parvo B19, RSF, Erlichia, Anaplama, Lyme
infection. She was started on Bactrim prophylaxis and high dose
IV steroids were started on ___. On ___ Anakinra ___ was
initiated and she was switched to PO Pred 60mg with a plan to
taper by 5mg weekly.
3. ___: As above, her Cr had initially increased to 1.2, but
then restored to 0.5 with fluids as clinical symptoms improved.
She was mildly dizzy without orthostatic vital signs during the
several days before she was discharged and received small
amounts of fluids with good effect.
4. Hypoxemia: As discussed above, Ms. ___ received large amounts
of IV Fluids so this oxygen requirement was most likely related
to fluid overload. No crackles or decreased breath sounds on
exam, but non-productive cough present. This gradually resolved
on its own and she was without an oxygen requirement and with
good oxygen saturation on discharge.
5. DIC: Her fibrinogen was monitored for possible continued low
grade DIC. These lab values steadily improved and did not
require intervention on the floor.
TRANSITIONAL ISSUES
- Ms. ___ is being discharged on both steroids (Prednisone 50mg
per day X 1 week with a planned 5mg per week taper thereafter)
and self-administered injections of Anakinra
- Ms. ___ will ___ with Rheumatology within 1 week
following her discharge
- Ms. ___ will also ___ with a new Primary Care doctor at
___ for management of her other medical
issues
- Please ___ result of IL-2 receptor test
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort
Discharge Medications:
1. anakinra 100 mg SC DAILY
RX *anakinra [Kineret] 100 mg/0.67 mL 1 syringe daily Disp #*30
Syringe Refills:*2
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*2
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort
6. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
7. PredniSONE 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hemophagocytic Lymphohistiocytosis, Adult
Onset Still's Disease
Secondary Diagnosis: Shock, Acute Kidney Injury, Disseminated
Intravascular Coagulation
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
with fever, rash and joint pain and found to have a disease
called Adult Onset Still's Disease and HLH. You were treated for
this problem with steroids and anakinra. You will ___ with
your doctors in ___ and ___ Care Associate's here at
___ for management of this problem going forward.
Plaese continue your prednisone at 50mg a day until directed to
decrease the dose by your Rheumatology doctor.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10732000-DS-17
| 10,732,000 | 20,028,545 |
DS
| 17 |
2169-05-29 00:00:00
|
2169-05-29 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Major leg swelling
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/ PMH of HTN, DM2, CKD presents due to leg swelling.
Patient
was seen at urgent care at ___ today due to
worsening lower extremity swelling and oozing from her stasis
ulcers. She was sent in to rule out DVT as well as wound care
for
her ulcers. Patient describes worsening lower extremity pain and
redness but not swelling for about 1 week, left worse than
right.
She went to urgent care today and was referred to ED for
evaluation. Reports prior hx ___ cellulitis, typically treated
with PO abx. She denies recent fevers, chest pain, shortness
breath, pleuritic pain.
On arrival to the floor, she is quite tearful and notes that her
husband is likely throwing all of her belongings away. They are
in the process of moving into ___ which is sad for her. Says
she does not have a blood clot but wishes she did as she has
nothing to live for. Denies active SI.
-In the ED, initial vitals were:
97 78 118/46 20 99% RA
-Exam was notable for:
Con: Well appearing, in no acute distress
HEENT: NCAT. no icterus.
Resp: Breathing comfortably on RA. No incr WOB, CTAB.
CV: RRR. No murmurs.
Abd: Soft, Nontender, Nondistended.
MSK: 2+ DP pulses b/l, b/l ___ are warm to touch, erythematous,
and edematous. Scattered ulcerations with mild weeping
Skin: No rash, Warm and dry.
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
Labs were notable for:
Hgb 10.8
WBC 9.4
Lactate 1.5
Studies were notable for:
b/l LENIs: IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins to the popliteal level. Calf veins not seen
bilaterally due to body habitus and lower extremity edema.
- The patient was given:
Vancomycin
Unasyn
Past Medical History:
HTN
CKD
OSA
DM2
Hypothyroidism
Venous stasis
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM
==============
GENERAL: tearful initially, later engaged and alert.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. 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, obese, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: nonpitting edema to knee with diffuse warmth and
erythema b/l; several scattered 1-2cm crusted ulcers without
exudate or weeping; diffusely TTP
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE EXAM
==============
General: Alert, oriented, and in no acute distress, sitting on
side of bed with pants off
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. 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, obese, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: nonpitting edema to ___ inches below knee with
diffuse warmth and erythema b/l improved since yesterday;
several
scattered 1-2cm debrided ulcers with some weeping; diffusely
TTP,
though less tender than yesterday.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 01:30AM BLOOD WBC-9.4 RBC-3.61* Hgb-10.8* Hct-34.7
MCV-96 MCH-29.9 MCHC-31.1* RDW-13.4 RDWSD-47.6* Plt ___
___ 01:30AM BLOOD Glucose-244* UreaN-26* Creat-1.0 Na-137
K-4.1 Cl-95* HCO3-29 AnGap-13
___ 09:17AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
DISCHARGE LABS
==============
___ 09:18AM BLOOD WBC-7.3 RBC-3.94 Hgb-11.7 Hct-38.2 MCV-97
MCH-29.7 MCHC-30.6* RDW-13.3 RDWSD-47.8* Plt ___
___ 09:18AM BLOOD Glucose-191* UreaN-19 Creat-1.0 Na-146
K-4.4 Cl-102 HCO3-27 AnGap-17
___ 09:18AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0
IMAGING STUDIES
===============
___ Bilateral Lower Extremity Ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins to the popliteal level. Calf veins not seen bilaterally
due to body
habitus and lower extremity edema.
Brief Hospital Course:
___ w/ PMH of HTN, DM2, CKD presents with b/l leg pain and
erythema, likely representing chronic venous stasis/dermatitis.
TRANSITIONAL ISSUES
===================
[] There is significant concern that patient may have some
underlying psychiatric/cognitive issues resulting in her
inability to fully care for herself at home. We also were
concerned her husband may not be able to help provide her care,
and perhaps may not be a healthy relationship. Our social worker
filed a report with elder services, who intend to further
investigate her case following discharge.
[] TSH noted to be 18. This will be further managed by
outpatient Endocrinologist.
ACUTE ISSUES
============
#. Chronic Venous Stasis:
Patient was initially started on Vanc and Zosyn in setting of
concern for cellulitis, however this was discontinued given
patient lacked systemic signs/symptoms of infection. U/s of
lower extremities without evidence of DVT. Wound care and
podiatry evaluated lower extremity wounds, and did not feel
patient required surgical intervention/debridement. ___ and OT
cleared patient for discharge, with continued exercises at home.
#. Concern for Poor Personal Care/Social Issues
Patient with reported passive SI on admission, though seemed to
have resolved on reevaluation. On exam, there was concern
patient may not have ability to care for herself, given poor
hygiene and possible psychiatric/cognitive issues. Social work
evaluated the patient, and filled a report with elder protective
services, who intend to evaluate patient at home following
discharge.
CHRONIC/STABLE ISSUES:
======================
#. DM2
Patient continued on insulin while inpatient.
#. CKD:
Cr at baseline.
#. HTN:
Cont home regimen
#. Hypothyroidism:
Cont home T4 regimen.
[] ___ noted to be 18. This will be further managed by
outpatient Endocrinologist.
#. OSA:
Continue CPAP.
.
.
.
.
.
Time in care: >30 minutes in discharge-related activities today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. detemir 30 Units Bedtime
2. Levothyroxine Sodium 400 mcg PO 1X/WEEK (___)
3. Levothyroxine Sodium 200 mcg PO 6X/WEEK (___)
4. Simvastatin 40 mg PO QPM
5. CARVedilol 25 mg PO BID
6. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
7. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
8. mirabegron 25 mg oral daily
9. Amitriptyline 150 mg PO QHS
10. lisinopril-hydrochlorothiazide 40-25 mg oral daily
Discharge Medications:
1. detemir 30 Units Bedtime
2. Amitriptyline 150 mg PO QHS
3. CARVedilol 25 mg PO BID
4. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
5. Levothyroxine Sodium 400 mcg PO 1X/WEEK (___)
6. Levothyroxine Sodium 200 mcg PO 6X/WEEK (___)
7. lisinopril-hydrochlorothiazide 40-25 mg oral DAILY
8. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
9. mirabegron 25 mg oral daily
10. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Chronic Venous Stasis
SECONDARY
=========
DMII
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital due to concerns for wounds
to your legs.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- We evaluated your legs, and found that you likely did not have
an infection. Our wound care nurses cleaned your wound.
- After evaluation by our physical and occupational therapists,
we felt it was appropriate to discharge you.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10732040-DS-5
| 10,732,040 | 23,599,833 |
DS
| 5 |
2160-07-05 00:00:00
|
2160-07-05 11:17:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
simvastatin
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of HTN, HLD,
type 2 non insulin dependent DM, who presents with 1 week
history
of intermittent vertigo, which worsened this morning. History
provided by patient.
Ms. ___ reports she was in her usual state of health until 6
days ago, on ___, when she developed gradual onset of
generalized malaise, fatigue, and poor PO intake. In this
context
she had intermittent dizziness that is described as
room-spinning
vertigo. The vertigo was intermittent, lasting for 10 minutes at
a time. It occurred ___ times a day over the last 6 days until
this morning. The vertigo would improve after sitting down and
resting; it was exacerbated by getting up and walking. The
vertigo was mild in intensity. She was able to continue working
throughout this time period.
Over the last 6 days, she continued with generalized malaise,
poor p.o. intake and fatigue. The vertigo remained
intermittent.
She did have one day when there was no vertigo at all.
Last night, she went to bed at approximately 10 ___. When she
woke up this morning at 5 AM, she woke up with a severe
headache.
The headache did wake her up from sleep. Headache was
holocephalic, sharp in quality, 10 out of 10 in severity. She
also noticed upon awakening that the room spinning vertigo was
persistent, unlike before when it was intermittent. It was
present even when lying down. The only thing that seemed to
make
it go away was causing her eyes when lying down. Concerned, she
called an ambulance and came to the emergency department.
While en route to the emergency department, the patient did
vomit
once in route. She also vomited a second time upon arriving to
the emergency department. She did have some chest pain
associated with 1 of the episodes of emesis, which resolved.
She
received 0.25 mg of lorazepam and IV fluid bolus with some
improvement. She notes that the headache is now resolved
completely. The vertigo has also improved, and currently is
only
present when she gets up to walk; it is not present when lying
supine.
Throughout this time, she denies any other associated symptoms
such as loss of vision, double vision, hearing loss, tinnitus,
focal weakness, numbness or sensory changes. Apart from her
generalized malaise and poor p.o. intake, no other systemic
symptoms such as fevers/chills or night sweats.
Prior to the above, patient denies any recent triggers or
changes
to her routine that may have caused this. Denies any recent
trauma. Denies any recent new or missed medications. Reports
that her blood sugars have been well controlled and in the
typical range.
Of note, patient reports that she has had vertigo before. This
was ___ years ago, when she had intermittent room spinning vertigo
that lasted for ___ minutes at a time. She does not recall
the
diagnosis that she was given, but her primary care physician
advised her to do an exercise which led to symptom resolution.
Past Medical History:
HTN
Type 2 DM - non insulin dependent
HLD
Social History:
___
Family History:
Mother had a "mini stroke" in elderly age. No family
history of neurologic disease or strokes otherwise.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Orthostatic Vital Signs
Supine HR 74, BP 154/72
Seated HR 89, BP 155/74
Standing HR 86, BP 151/82
General: Awake, well appearing, joking and pleasant, appears
comfortable, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to examiner. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. Gaze is conjugate.
On
primary gaze there is persistent left beating nystagmus. EOMI
with persistent left beating nystagmus in all directions of
gaze,
most prominently in leftward gaze. No vertical or torsional
nystagmus. Normal saccades. VFF to confrontation via finger
counting. Fundoscopic exam revealed crisp disc margins without
papilledema, otherwise unable to visualize other parts of the
fundus due to persistent nystagmus. Head impulse test is
indeterminate given persistent nystagmus.
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, proprioception
throughout. No extinction to DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 0 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No overshoot on cerebellar mirroring. No dysmetria
on FNF bilaterally. No truncal ataxia.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Is unsteady with turns, though does not sway in a
particular direction. Has significant difficulty walking in
tandem. Romberg negative.
DISCHARGE PHYSICAL EXAM:
Unchanged but with stable gait. +Unterberger to the R.
Drifts/veers to the R when walking
Pertinent Results:
___ 04:48AM BLOOD WBC-6.8 RBC-4.25 Hgb-11.2 Hct-36.6 MCV-86
MCH-26.4 MCHC-30.6* RDW-12.2 RDWSD-38.1 Plt ___
___ 08:54AM BLOOD WBC-6.1 RBC-4.43 Hgb-11.4 Hct-38.3 MCV-87
MCH-25.7* MCHC-29.8* RDW-12.1 RDWSD-38.1 Plt ___
___ 04:48AM BLOOD Neuts-63.9 ___ Monos-7.2 Eos-0.6*
Baso-0.1 Im ___ AbsNeut-4.31 AbsLymp-1.88 AbsMono-0.49
AbsEos-0.04 AbsBaso-0.01
___ 08:54AM BLOOD Neuts-74.2* Lymphs-17.6* Monos-6.1
Eos-0.5* Baso-0.3 Im ___ AbsNeut-4.51 AbsLymp-1.___*
AbsMono-0.37 AbsEos-0.03* AbsBaso-0.02
___ 04:48AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
IMAGING:
MRI BRAIN:
1. No acute intracranial abnormality.
2. No acute infarction.
3. Paranasal sinus disease , as described.
CTA HEAD AND NECK:
Noncontrast CT head: No acute intracranial abnormality.
Brief Hospital Course:
Ms. ___ is a ___ woman with history of vascular risk
factors (HTN, HLD, DM) who presented with 1 week history of
intermittent room spinning vertigo, which became persistent
since this morning. Initially in the ER, She had some
improvement s/p 1L IVF bolus and lying down in ED. On her
admission exam she has left beating nystagmus persistently on
primary gaze and in all directions of gaze, worsened on leftward
gaze. No truncal or appendicular ataxia but she had drift to the
R and positive unterberger (veering to the R). She could walk
independently but not in tandem.
She underwent work-up in the ER notable for CT head and CTA
head/neck without
evidence of acute process or significant vertebrobasilar
disease.
She was admitted to the stroke team for rule out of posterior
circulation stroke though the leading diagnosis was peripheral
vertigo given the lateralizing signs on examination (R ear
pathology).
While admitted to the stroke service, the patient improved
significantly with IV fluids and anti-emetics. She underwent an
MRI brain which was negative for any stroke or other acute
pathology. She was able to ambulate on her own and was
discharged to home with PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. Januvia (SITagliptin) 25 mg oral DAILY
4. Pravastatin 80 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Januvia (SITagliptin) 25 mg oral DAILY
3. lisinopril-hydrochlorothiazide ___ mg oral DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. Pravastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted after you developed symptoms of headache,
room-spinning/dizziness (called vertigo), and nausea with
difficulty walking. You were evaluated in the emergency room and
had a cat scan which did not show any major bleeds or
abnormalities. You were then admitted to the hospital to the
neurology stroke team to evaluate for a stroke. You had an MRI
brain which DID NOT SHOW any stroke or other abnormalities which
is good news.
Your symptoms improved drastically overnight and you were able
to walk on your own. Though you are still having symptoms, we
suspect that they will improve within the next few days. Most
likely your vertigo is from an imbalance in the fluid in your
inner-ear, and will return to normal soon. We recommend that you
follow-up with your primary care physician this week to ensure
that you are back to normal.
Please take all of your medications as prescribed. We have not
made any changes to your home medications.
We wish you all the best!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10732427-DS-13
| 10,732,427 | 20,379,365 |
DS
| 13 |
2146-09-13 00:00:00
|
2146-09-13 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sudden onset abdominal pain
Major Surgical or Invasive Procedure:
___ Interventional radiology embolization of the splenic
artery and left hepatic artery
History of Present Illness:
___ with a history of ETOH abuse, pancreatitis, coronary artery
disease and known right iliac a aneurysm presents to OSH with
acute onset diffuse and severe abdominal pain at 6am this
morning. He felt lightheaded in the shower but denies LOC, fall
or any other trauma. At the OSH, he was hypotensive with a hct
of 18 and was found to have a positive fast exam. Given the
concern for massive intra-abdominal hemorrhage, he was
transferred to ___ for further management. He had a CTA of the
abdomen which demonstrated active extravasation in the spleen
with significant intra-abdominal hemorrhage. There was no
evidence of external trauma and the patient denies any history
of trauma, MVC, recent illness or malignancy. He arrived with a
bp in the 110's but it dropped as low as 60's systolic. He
received 4u prbc at the outside hospital.
Past Medical History:
Past Medical History:
CAD s/p stent ___ on ASA, plavix
HTN
HLD
EtOH abuse
Pancreatitis
Gout
Past Surgical History:
Back surgery ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 66 119/73 21 100% RA
GEN: A&O, pale appearing male
HEENT: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, distended and tender throughout. No evidence of
external trauma/ecchymosis/or abrasion
Ext: No ___ edema, ___ cool. Palpable Femoral and DP pulses
bilaterally
Discharge Physical Exam:
VS: 98.2, 93, 151/89, 16, 94 RA
Gen: Pleasant and interactive.
HEENT: No deformity. PERRL, EOMI. Mucus membranes pink/moist.
neck supple, trachea midline.
CV: RRR
Pulm: Bilateral scattered rhonchi
Abd: Soft, mildly tender to palpation, mildly distended.
Ext: Warm and dry. 2+ ___ pulses. No edema.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong.
Pertinent Results:
___ ECG: Sinus rhythm. Baseline artifact and wandering
baseline. Low precordial lead voltage. Slight QTc interval
prolongation. No previous tracing available for comparison. A
repeat tracing of diagnostic quality is suggested.
___ CTA: 1. Splenic laceration with moderate
intraperitoneal hemorrhage. Punctate hyperdensities within the
spleen on the postcontrast exam compatible with pseudoaneurysms
versus active extravasation of contrast.
2. Partially thrombosed right common iliac artery saccular
aneurysm without findings to suggest rupture.
3. Superior endplate compression deformities of T5-T8 vertebrae
are noted
without CT evidence to suggest acuity. Recommend clinical
correlation to
determine chronicity of fractures.
4. Chronic pancreatitis.
5. The study is limited by arterial phase contrast-enhanced
technique for
evaluation of additional intra-abdominal injuries
___ CTA abd/pelv: 1. No evidence of active extravasation.
Large amount of hemoperitoneum appears slightly improved
compared to prior examination.
2. Punctate focus of arterial enhancement in the left lobe of
the liver likely represents a residual pseudoaneurysm.
3. Post treatment changes after embolization of the spleen and
the left lobe of the liver.
___ 05:15AM BLOOD WBC-11.2* RBC-2.75* Hgb-7.3* Hct-23.7*
MCV-86 MCH-26.5 MCHC-30.8* RDW-20.7* RDWSD-64.3* Plt ___
___ 05:25AM BLOOD WBC-13.2* RBC-2.77* Hgb-7.4* Hct-23.7*
MCV-86 MCH-26.7 MCHC-31.2* RDW-20.8* RDWSD-64.5* Plt ___
___ 05:35AM BLOOD WBC-15.5* RBC-2.62* Hgb-7.0* Hct-22.2*
MCV-85 MCH-26.7 MCHC-31.5* RDW-20.6* RDWSD-63.7* Plt ___
___ 05:40AM BLOOD WBC-16.5* RBC-2.93* Hgb-7.9* Hct-24.5*
MCV-84 MCH-27.0 MCHC-32.2 RDW-20.0* RDWSD-62.0* Plt ___
___ 09:40PM BLOOD WBC-17.5* RBC-3.11* Hgb-8.4* Hct-25.9*
MCV-83 MCH-27.0 MCHC-32.4 RDW-19.7* RDWSD-58.5* Plt ___
___ 05:40AM BLOOD ___ PTT-25.7 ___
___ 04:27PM BLOOD ___ PTT-25.9 ___
___ 01:10PM BLOOD ___ PTT-25.4 ___
___ 05:15AM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-137
K-3.8 Cl-100 HCO3-32 AnGap-9
___ 05:25AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-134
K-3.4 Cl-97 HCO3-26 AnGap-14
___ 05:45AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-134 K-3.7
Cl-98 HCO3-28 AnGap-12
___ 05:35AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-133
K-3.5 Cl-99 HCO3-27 AnGap-11
___ 05:40AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
___ 09:40PM BLOOD Glucose-124* UreaN-9 Creat-0.6 Na-137
K-4.1 Cl-104 HCO3-23 AnGap-14
___ 01:40AM BLOOD Glucose-102* UreaN-9 Creat-0.8 Na-139
K-4.0 Cl-107 HCO3-24 AnGap-12
___ 01:40AM BLOOD ALT-44* AST-59* AlkPhos-61 TotBili-0.4
___ 01:10PM BLOOD ALT-6 AST-11 AlkPhos-47 TotBili-0.5
___ 05:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8
___ 05:45AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
___ 05:35AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
___ 05:40AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
___ 09:40PM BLOOD Calcium-8.3* Phos-3.8 Mg-2.0
___ 04:27PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.5*
MRSA SCREEN (Final ___: No MRSA isolated.
Brief Hospital Course:
Mr. ___ is a ___ with history of ETOH abuse, pancreatitis,
CAD and known right iliac aneurysm on aspirin and plavix who
presented to an outside hospital with acute onset diffuse,
severe abdominal pain. He was lightheaded and hypotensive with a
hematocrit of 18. He received 4 units of packed red blood cells
at the outside hospital. Upon arrival his vital signs were
stable with systolic blood pressure 110's. He was transferred to
___ for further management. He had a CTA that showed splenic
extravasation and hemoperitoneum including left hepatic lob
subcapsular bleeding. He was emergently taken to interventional
radiology for a left common femoral artery approach embolization
of the splenic artery and left hepatic artery. He was admitted
to the ICU for further close hemodynamic monitoring.
He remained hemodynamically stable with a stable hematocrit. On
HD2 the patient was transferred to the surgical floor for futher
management.
The remainder of his hospital course is summarized below.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV Dilaudid
and then transitioned to oral oxycodone and Tylenol once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient initially required supplemental oxygen in
the setting of abdominal distension and pain. He was gradually
weaned to room air as tolerated. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO with IV fluids. On
HD2 the diet was advanced to regular which was tolerated well.
Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. Visiting nursing services were arranged. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
ASA 81 mg daily
Plavix 75mg daily
amlodipine 2.5 mg daily
lisinopril 40mg daily
metoprolol XL 50mg daily
omeprazole 40mg BID
atorvastatin 80mg qhs
ferrous sulfate 325mg BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply to affected area once a day Disp #*30
Patch Refills:*0
10. Lisinopril 40 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Omeprazole 40 mg PO BID
13. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
14. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
15. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Splenic laceration with moderate intraperitoneal hemorrhage
2. Chronic pancreatitis
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 at ___ on
___ with acute onset of abdominal pain. You had a CT scan
that revealed a splenic hemorrhage. You were given red blood
cells and emergently taken to interventional radiology to stop
the bleeding with embolization. You were taken to the intensive
care unit and closely monitored. You blood levels remained
stable, you are tolerating a regular diet, and your pain is
better controlled. You are now ready to be discharged to home
with the following discharge instructions.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until your follow-up.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10732537-DS-12
| 10,732,537 | 24,783,483 |
DS
| 12 |
2174-08-04 00:00:00
|
2174-08-04 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea/fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS ___, 4 HPI or status of 3
chronic)
History obtained directly from the patient and with phone
interpreter. Mrs ___ is a pleasant ___ with hx pT3N1a,
stage IIIB sigmoid colon adenocarcinoma currently on
capecitabineon chemotherapy for resected colon CA who p/w nausea
and s/p an unwittnessed fall. Pt states that she slipped, fell
to the ground without hitting her head or loss of conciousness,
however was unable to stand up on her own and therefore called
her son for help. The patient states she feels fine and did not
want to go to the hospital, but her family insisted on taking
her. She has been increasingly nauseaous over the past 3 days
but is tolerating PO's, however with some decreased intake. She
denies emesis, CP, SOB, palpitations focal weakness or numbness,
bloody stool, dysuia.
In the ED, initial vs were pain score 0 97.8 81 124/71 18 95%.
Labs were remarkable for hyponatremia, hypomg, hypophos. CXR
showed no acute CP process. Patient was given 1 L NS bolus.
Vitals on transfer were pain score 0 98 77 134/99 18 100%.
On the floor, pt has no complaints other than mouth dryness.
She states she wants to go home in the morning.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
(per chart, confirmed with pt):
Type II Diabetes Mellitus
GERD
Hypertension
Hyperlipidemia
Osteoarthritis
Denies hypothyroidism
(per last onc note by Dr ___:
"pT3N1a, stage IIIB sigmoid colon adenocarcinoma, seen
today on cycle 2, day 12 adjuvant capecitabine.
ONCOLOGIC HISTORY: ___ initially presented with
constipation and was referred for sigmoidoscopy. This study
performed ___ showed a mass in the proximal sigmoid colon
at 40 cm concerning for malignancy. She was taken to the
operating room ___ and underwent robotic assisted
laparoscopic left colectomy. Pathology showed a 6 cm low grade
adenocarcinoma. One of 18 lymph nodes was involved. No
perineural and vascular invasion was seen. Preoperative CEA
measured 2.5 ng/mL. Ms. ___ began adjuvant capecitabine
1500 mg p.o. q.12h. for 14 days of a 21 day cycle on
___
Social History:
___
Family History:
(per chart, confirmed): The patient's mother was treated for
breast
cancer and died at ___ years. Her father died of an MI at ___
years. She has no siblings. Her one son has no health
concerns.
Physical Exam:
Vitals: T:97.5 BP:137/69 P:81 R:22 O2:96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, decreased BS, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no lesions or ecchymoses
Neuro: aaox3. CNs ___ intact. Strength and sensation grossly
intact
Psych: pleasant, appropriate
Pertinent Results:
Labs on admission:
___ 10:00PM LACTATE-1.2
___ 09:55PM GLUCOSE-142* UREA N-11 CREAT-0.7 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16
___ 09:55PM ALBUMIN-3.2* CALCIUM-7.3* PHOSPHATE-2.6*
MAGNESIUM-1.5*
___ 09:55PM WBC-5.3 RBC-3.72* HGB-10.5* HCT-31.7* MCV-85
MCH-28.3 MCHC-33.2 RDW-20.3*
___ 09:55PM NEUTS-45* BANDS-2 ___ MONOS-16* EOS-0
BASOS-1 ___ MYELOS-0
___ 09:55PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
___ 09:55PM PLT SMR-NORMAL PLT COUNT-257
___ 09:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
___ 09:55PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
.
Labs on discharge:
___ 06:45AM BLOOD WBC-3.8* RBC-3.27* Hgb-9.5* Hct-27.5*
MCV-84 MCH-29.0 MCHC-34.5 RDW-20.9* Plt ___
___ 06:45AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-137
K-2.9* Cl-107 HCO3-25 AnGap-8
___ 06:45AM BLOOD Calcium-7.5* Phos-2.5* Mg-2.4
.
MICRO: none
.
STUDIES: CXR with no acute CP process
EKG: NSR, no acute ST/TWI
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
This is an ___ yo female with colon adenocarcinoma on Xeloda now
presenting with nausea and mechanical fall who was admitted
after a mechanical fall and found to have electrolyte
abnormalities including hypomagnesemia, hypokalemia,
hyponamtremia and hypocalcemia. She was volume rescussitated and
give electrolyte repletions overnight. The following morning she
left against medical advice prior to completion of her
electrolyte repletion, repeat labs.
ACTIVE ISSUES:
# Fall: The patient's decription of the fall appeared to be
mechanical in nature. Given her significant electrolyte
disturbances, dehydration was concerning. Orthostatics were
negative. There was no evidence of infection on chest xray,
complete blood count or urinalysis. She had a normal neurologic
exam. A physical therapy consult was placed but not completed.
She left against medical advice the following morning.
# Electrolyte Disturbances: Hypophosphatemia, hypomagnesemia and
hypocalcemic on admission. Likely secondary to poor po intake
although patient denies nausea while taking capecitabine and her
weight has apparently been stable. She was repleted with
magnesium overnight and received part of her potassium the
following morning before leaving. She was given information on
high potassium and magnesium diet.
# Hyponatremia: Resolved with fluid rescussitation overnight.
INACTIVE ISSUES
# Colonic adeno on xeloda: s/p resection. On capecitabine.
Unclear when next cycle begins.
# Type II Diabetes Mellitus w/o complications. Metformin held on
admission. She was continued on aspirin.
# Anemia: at ___, likely anemia of chronic disease.
# GERD: stable. She was continued on her ppi.
# Hyperlipidemia: She was contineud on atorvastatin.
# Osteoarthritis: Stable. She was continued on
acetaminophen/tramadol.
# Glaucoma: Stable. She was continued on her eye drops.
# Hypothyroidism: Per pt, she is not on levothyroxine at home.
Will hold for now, call pharmacy/speak with family to confirm
meds in AM. Patient left before medications could be confirmed.
TSH 5.8 in a moderately hemolyzed specimen.
# Insomnia: She was continued on lorazepam as needed.
# Chronic constipation: She was continued on docusate as needed.
TRANSITIONAL ISSUES:
### LEFT AGAINST MEDICAL ADVICE ###
Ms. ___ before completing her potassium and calcium
supplementation and before repeat laboratory results. She
understood that severe electrolyte disturbances including
hypokalemia can cause weakness, fatigue, muscle weakness and in
severe cases cardiac arrythmias and death. Attempts were made
to schedule follow-up and close laboratory checks which the
patient declined- and preferred to arrange herself. She was
given information sheets on high potassium and magnesium diets.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO TID
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO BID
5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
This is a narcotic.
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Zolpidem Tartrate 10 mg PO HS
11. esomeprazole magnesium *NF* 40 mg Oral daily
12. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Docusate Sodium 100 mg PO BID
15. Lorazepam 0.5 mg PO HS:PRN anxiety/insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. esomeprazole magnesium *NF* 40 mg Oral daily
7. Lorazepam 0.5 mg PO HS:PRN anxiety/insomnia
8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
9. Vitamin D ___ UNIT PO DAILY
10. Atorvastatin 10 mg PO DAILY
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
12. Levothyroxine Sodium 75 mcg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Metoprolol Succinate XL 25 mg PO BID
15. Zolpidem Tartrate 10 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
1. mechanical fall, hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after a fall. You were noted to have
abnormalities with your electrolytes (potassium and sodium) in
your blood which we corrected with fluid and intravenous
supplementation. The reason for your fall was not felt to be
secondary to an abnormality with your heart or brain.
We would have liked to re-check your blood potassium levels to
be reassured that you were sufficiently supplemented. You
indicated to us that you did not want to stay for repeat blood
work and would arrange on your own, outpatient blood work. You
did not want assistance with arranging this for you. Therefore,
leaving before blood work means that you are leaving against our
medical advice. Abnormalities in potassium can cause muscle
aches, weakness and occasionally abnormalities in your heart
rhythm which if left without treatment can cause death.
We recommend that you continue to drink lots of fluid and eat.
Please arrange follow-up with your primary care physician to
have repeat blood work performed.
Followup Instructions:
___
|
10732875-DS-19
| 10,732,875 | 21,946,880 |
DS
| 19 |
2138-05-29 00:00:00
|
2138-05-29 19:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, transfer
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ patient with history of idiopathic dilated
cardiomyopathy, diabetes, complete heart block s/p pacemaker,
unexplained VF arrest in ___ followed by ICD implant, and
atrial
fibrillation on warfarin last known normal 28 hours prior to
presentation, presents as a transfer from ___
for persistent altered mental status.
Per ED records: Reportedly night prior to presentation, around 5
___, he was noted to be confused. At his baseline he is alert and
oriented x3. However his confusion progressed to the point that
he was extremely agitated. He was continuing to move all of his
extremities, however he was not redirectable, and he was alert
and oriented Ã-0. Prior to this the only thing he complained of
was a headache. He did receive a CT scan at the outside hospital
that was negative for subarachnoid within 6 hours of his
presentation. Otherwise, he remained afebrile, had overall
negative lab workup, and was unable to get an MRI of the brain
due to pacemaker being in place.
He was treated with 5 mg of Zyprexa IM as well as 2 mg of Ativan
IM due to his agitation, and he arrives obtunded and unable to
provide any additional information.
Neurology was consulted in the ED. They felt his symptoms were
likely toxic-metabolic. They felt an LP would be low yield.
In the ED, initial VS were: T 98.9 BP 138/78 HR 102 RR 20 O2
99%
on 6L NC
Exam notable for:
"GCS of 8, only moving the right upper and right lower
extremity."
ECG:
Compared to prior dated ___. No clear P waves, ventricular
pacing spikes best appreciated in V3-V6. Intermittent ectopy.
Stable 1mm ST elevations in V2-V5.
Compared to prior ECG, there is increased ectopy.
Labs showed:
-Hb 12.8, WBC 11.5
-INR 2.6
-Cr 1.4 (baseline 1.5), glucose 248, AG 12
-Trop 0.04
-Lactate 2.3
-VBG 7.___
Imaging showed:
CXR:
1. Retrocardiac opacification likely represents an underlying
focal pneumonia with concurrent atelectasis.
2. Extremely low lung volumes causing prominence of the
bronchovascular structures limiting evaluation for edema.
Consults:
-Neurology:
"- PNA treatment per primary team
- delirium precautions
- consider EEG if mental status does not clear; he currently
seems to be improving."
Patient received:
-1L NS
-Home insulin
-Vanc/ceftriaxone
-10mg IV furosemide
Transfer VS were:
T 100.2 BP 142/129 HR 78 RR 30 O2 97% on 3L O2 NC
On arrival to the floor, patient is unable to provide a history.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
1. HTN
2. SSS status post AICD
3. Atrial fibrillation on warfarin
4. HLD
5. DM
6. Hypothyroidism
7. Idiopathic CM EF 35-40%
8. Psoriatic arthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
======================
VS: 99.7 AdultAxillary 113 / 48 R Lying 66 22 97 3L
GENERAL: unresponsive except to strong sternal rub
HEENT: AT/NC, NC in place
NECK: Resists manual flexion, no JVD appreciated
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Trace crackles on R, not participating in exam
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
GU: Foley in place
EXTREMITIES: no cyanosis, clubbing, or edema. Dry scale on L
NEURO: A&Ox0, moved both arms with purpose to strong sternal rub
DISCHARGE EXAM:
================
Temp: ___ ___ Temp: 97.4 PO BP: 151/75 HR: 71 RR: 18 O2
sat: 98% O2 delivery: RA FSBG: 155
GENERAL: sitting up, appears well
HEENT: R pupil > L pupil, reactive bilaterally
CV: RRR, no m/r/g
PULM: clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended
EXTREMITIES: Venous stasis changes, without edema
NEURO: Alert and oriented to name, place, and month, cranial
nerves grossly intact, ___ bilaterally, able to do days of the
week backwards
Pertinent Results:
ADMISSION LABS:
==========================
___ 09:25PM BLOOD WBC-11.5* RBC-5.09 Hgb-12.8* Hct-43.6
MCV-86 MCH-25.1* MCHC-29.4* RDW-18.2* RDWSD-55.9* Plt ___
___ 09:25PM BLOOD Neuts-81.1* Lymphs-9.4* Monos-8.4
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.34* AbsLymp-1.08*
AbsMono-0.97* AbsEos-0.03* AbsBaso-0.04
___ 09:25PM BLOOD ___ PTT-40.6* ___
___ 09:25PM BLOOD Glucose-248* UreaN-41* Creat-1.4* Na-136
K-5.2 Cl-98 HCO3-26 AnGap-12
___ 09:25PM BLOOD ALT-30 AST-38 AlkPhos-147* TotBili-1.1
___ 09:25PM BLOOD cTropnT-0.04*
___ 09:25PM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.8 Mg-2.0
___ 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:58PM BLOOD ___ pO2-22* pCO2-46* pH-7.40
calTCO2-30 Base XS-1
___ 09:58PM BLOOD Lactate-2.3*
TROPONINS:
___ 09:25PM BLOOD cTropnT-0.04*
___ 01:00AM BLOOD cTropnT-0.06*
___ 06:39AM BLOOD CK-MB-9 cTropnT-0.09*
DISCHARGE LABS:
===============
___ 06:28AM BLOOD WBC-9.9 RBC-4.48* Hgb-11.5* Hct-39.5*
MCV-88 MCH-25.7* MCHC-29.1* RDW-18.6* RDWSD-59.2* Plt ___
___ 06:28AM BLOOD ___ PTT-36.2 ___
___ 06:28AM BLOOD Glucose-157* UreaN-43* Creat-1.5* Na-141
K-4.8 Cl-106 HCO3-23 AnGap-12
___ 10:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
MICRO:
========
Urine culture negative
Blood culture x3 negative
Legionella antigen negative
MRSA screen negative
IMAGING:
=========
CXR ___:
1. Retrocardiac opacification likely represents an underlying
focal pneumonia with concurrent atelectasis.
2. Extremely low lung volumes causing prominence of the
bronchovascular
structures limiting evaluation for edema.
CT Head ___
There is no evidence of large territorial
infarction,hemorrhage,edema,or mass effect. There is prominence
of the ventricles and sulci suggestive of involutional changes.
Periventricular white matter hypodensities are most compatible
with the sequela of chronic small vessel ischemic disease,
stable since ___.
There is no evidence of fracture. Mucosal thickening is noted
of the ethmoid air cells and left maxillary sinus. The middle
ear cavities and mastoid air cells are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION: No acute intracranial abnormality
Brief Hospital Course:
___ patient with history of idiopathic dilated
cardiomyopathy, diabetes, complete heart block s/p pacemaker,
unexplained VF arrest in ___ followed by ICD implant, and
atrial fibrillation on warfarin last known normal 28 hours prior
to presentation, presented with acute confusion in setting of
pneumonia, improved with antibiotics, hospital course c/b
prolonged encephalopathy which improved, then requiring bridging
for low INR, now discharged on enoxaparin.
#Altered Mental Status:
Patient initially presented with two days altered mental status
on transfer from ___, with fever in ED. His CT
at OSH was negative for acute stroke. He was followed by
neurology here; their team had low suspicion for stroke,
seizure, meningitis. Was thought to be most likely
toxic-metabolic encephalopathy in setting of CXR consistent with
pneumonia. He was initially started on antibiotics for bacterial
meningitis and later transitioned to regimen of IV
vancomycin/ceftriaxone and PO azithromycin for pneumonia. His
mental status drastically improved on the morning of ___ from
very obtunded and somnolent (only arousable on sternal rub) to
alert and oriented to name/place and conversational with medical
team and family.
#Pneumonia:
He was found to CXR findings consistent with left lower lobe
pneumonia upon admission, and started on broad-spectrum
antibiotics. Eventually, he was narrowed to regimen for
community-acquired pneumonia. He finished a course of
ceftriaxone and azithromycin.
#Atrial Fibrillation:
We adjusted his warfarin dose per pharmacy with goal INR ___.
Initial doses of warfarin were too low, so was started on
heparin drip with home warfarin doses (5mg MWF, 7.5 other days).
Given his renal function was stable, discharged on lovenox ___
BID.
#Chronic Kidney Disease: His creatinine was elevated to 1.8 from
baseline 1.3 - 1.6. Thought to be secondary to pre-renal
imrpoved with PO intake.
CHRONIC ISSUES
===============
#Hypertension:
#Cardiomyopathy:
#Hyperlipidemia:
We held his home valsartan and furosemide initially, home
medications resumed closer to discharge. Furosemide currently at
40 mg MWF, continue to assess, euvolemic on discharge.
#Type II Diabetes: initially on lower insulin, resumed to home
glargine dose
TRANSITIONAL ISSUES:
======================
-Discharge creatinine: 1.5
-Discharge WBC: 9.9
-Discharge INR: 1.5
-NEW MEDICATIONS: enoxaparin 100 mg BID for bridging for Atrial
Fibrillation with high stroke risk, home warfarin regimen as
above
-HELD Medications: recommend holding glipizide given pt's
metformin, trulicity, and glipizide were held with stable sugars
on mainly insulin.
-Recommend outpatient followup with CXR PA/lateral by ___
given focal pneumonia (retrocardiac)
-Recommend outpatient continuation of ___ services, OT, and ___
-Please aid family to find local elder services for additional
help
-Please obtain ___ on ___
ICD-10: Atrial fibrillation I48.91
Please fax to ___, ATTN: Anti-coagulation
Management Services ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Cyanocobalamin 250 mcg PO DAILY
5. DULoxetine 60 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Methotrexate 2.5 mg PO ___ AM AND ___ ___
10. Multivitamins 1 TAB PO DAILY
11. Valsartan 160 mg PO BID
12. Warfarin 5 mg PO 3X/WEEK (___)
13. Furosemide 40 mg PO 3X/WEEK (___)
14. GlipiZIDE XL 10 mg PO DAILY
15. Magnesium Oxide 400 mg PO DAILY
16. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
17. Esomeprazole (esomeprazole magnesium) 40 mg ORAL DAILY
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
19. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous EVERY
___
20. Warfarin 7.5 mg PO 4X/WEEK (___)
21. Metoprolol Succinate XL 50 mg PO DAILY
22. Glargine 22 Units Bedtime
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC BID
RX *enoxaparin 100 mg/mL 100 mg SC BID (twice a day) Disp #*20
Syringe Refills:*0
2. Glargine 22 Units Bedtime
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Cyanocobalamin 250 mcg PO DAILY
7. DULoxetine 60 mg PO DAILY
8. Esomeprazole (esomeprazole magnesium) 40 mg ORAL DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO 3X/WEEK (___)
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Magnesium Oxide 400 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
15. Methotrexate 2.5 mg PO ___ AM AND ___ ___
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
19. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous EVERY
___
20. Valsartan 160 mg PO BID
21. Warfarin 5 mg PO 3X/WEEK (___)
22. Warfarin 7.5 mg PO 4X/WEEK (___)
23. HELD- GlipiZIDE XL 10 mg PO DAILY This medication was held.
Do not restart GlipiZIDE XL until you see your primary care
doctor to ensure your sugars are stable
24.Outpatient Lab Work
Please obtain ___ on ___
ICD-10: Atrial fibrillation ___
Please fax to ___, ATTN: Anti-coagulation
Management Services ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Community Acquired Pneumonia
-Encephalopathy
-Subtherapeutic INR
Secondary:
-Dilated cardiomyopathy
-ICD implant
-Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
You were admitted to the hospital because you became very
confused while you were at home.
What was done for me while I was in the hospital?
You were found to have an infection of your lungs (pneumonia)
while you were in the hospital. You were given antibiotics to
treat this infection, and we think that helped resolve your
confusion. Sometimes infections can lead to people feeling more
disoriented or confused than normal.
Your INR was also low, so you needed a heparin drip which is a
blood thinner, and then transitioned to LOVENOX which will help
keep your blood thin as your INR rises.
What should I do when I leave the hospital?
-It will be very important to follow up with Dr. ___.
Please call his clinic on ___ at to schedule followup
-You will need your INR monitored frequently as you use LOVENOX
and WARFARIN. Please have your nurses send over the information
to Dr. ___
Your Warfarin dose is the same, 5 mg on ___, ___,
___, and 7.5 mg on other days
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10733118-DS-5
| 10,733,118 | 24,213,713 |
DS
| 5 |
2161-12-03 00:00:00
|
2161-12-04 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / ACE Inhibitors / amoxicillin /
cephalexin / erythromycin base / hydralazine / Hytrin / Isordil
/ levofloxacin / losartan / Macrobid / olmesartan / simvastatin
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
ORIF Right distal femur ___ ___
History of Present Illness:
___ presented with Right distal femur fracture.
Past Medical History:
Hypertension
Hypothyroidism
Social History:
___
Family History:
non-contributory
Physical Exam:
General: no acute distress
CV: well-perfused
Resp: non-labored
Abd: non-distended
RLE: brace in place, incisional dressing clean, dry, and intact;
SILT distally, fires TA, ___, ___, EDL/FDL; warm and
well-perfused
Pertinent Results:
Please see OMR for pertinent lab/radiology data.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right distal femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right distal femur, 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. She received 2 units of PRBCs on the floor for immediate
post-operative Hct of 19. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
Of note, patient had poor PO intake and was refusing medications
on POD1. This was further complicated by IV infiltration and
several unsuccessful attempts to replace peripheral IV or draw
blood for morning labs. It was decided that long-term access (at
least until patient was discharged home) was the best course of
action. A PICC was placed on ___.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the right lower extremity in locked ___ w/ no ROM,
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. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Ondansetron ODT 4 mg PO Q8H:PRN nausea
4. Metoprolol Tartrate 100 mg PO BID
5. irbesartan 75 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Take for baseline pain control.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*100 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice daily
Disp #*80 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Take for 4 weeks post-operatively to prevent blood clots.
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 1 syringe subcutaneously
daily Disp #*26 Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Don't take before driving, operating machinery, or with alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*40 Tablet Refills:*0
5. Senna 8.6 mg PO DAILY
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *sennosides 8.6 mg 2 tablets by mouth every evening Disp #*40
Tablet Refills:*0
6. irbesartan 75 mg oral BID
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. Ondansetron ODT 4 mg PO Q8H:PRN nausea
10. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB RLE in locked ___, no ROM
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-operatively.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
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 Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
TDWB RLE in locked ___, no ROM of Right knee
WBAT LLE (knee immobilizer provided for comfort when out of bed
as patient has non-acute tibial plateau fracture--but bracing
with immobilizer is not required)
NWB + ROMAT LUE
Treatments Frequency:
Incision may be changed as needed. Please keep covered with dry
sterile dressing and tape until follow-up.
Followup Instructions:
___
|
10733193-DS-7
| 10,733,193 | 29,609,893 |
DS
| 7 |
2158-01-29 00:00:00
|
2158-01-29 12:49:00
|
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 upper extremity pain
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation of left distal
radius, Closed reduction of right ___ carpometacarpal joint
___: Open reduction internal fixation of right ___
carpometacarpal joint
History of Present Illness:
___ was involved in a MCC the evening of ___. Patient
reports that he was cut off while attemting to drive down
___. He feels that he remembers the whole incident
however not sure about LOC. No pain in head or neck. Severe pain
in left upper arm and some pain in the left wrist. No other
extremity pain. Denies numbness or tingling.
Past Medical History:
ADHD
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
In general, the patient is alert and oriented, moderate distress
due to upper arm pain
Vitals: 87 143/78 15 98% RA
Right upper extremity:
- Minor skin abrasions
- Significant swelling at thumb with decreased ROM
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- Deformity at mid upper arm with significant swelling. Not
tense to palpation
- Soft, non-tender forearm
- Does not tolerate any ROM of arm
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Superficial abrasions
- 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:
- Superficial abrasions
- 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
Pertinent Results:
___ 11:45PM WBC-8.8 RBC-5.15 HGB-15.3 HCT-43.9 MCV-85
MCH-29.7 MCHC-34.9 RDW-12.7 RDWSD-39.6
___ 11:45PM PLT COUNT-313
___ 11:45PM ___ PTT-24.8* ___
___ 11:45PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:45PM BLOOD UreaN-14 Creat-0.9
___ 05:55AM BLOOD WBC-7.8 RBC-4.28* Hgb-12.4* Hct-37.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-13.2 RDWSD-41.1 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal radius fracture and right ___
carpometacarpal fracture/dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of the left distal radius and closed reduction of the right
thumb by Dr. ___, which the patient
tolerated well. On ___, the patient was taken to the
operating room for open reduction internal fixation of the right
___ carpometacarpal joint by Dr. ___ Surgery).
For full details of the procedures 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. Per patient, his only home medication is Adderall,
which was held during this hospitalization. The patient worked
with ___ who determined that discharge to home with services was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in splints in the bilateral upper
extremities, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
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:
Adderall
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp
#*30 Syringe Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Left distal radius fracture
2. Right ___ carpometacarpal fracture/dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing in splint for your left upper extremity.
- Nonweightbearing in splint for your right upper extremity.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splints must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splints wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your orthopaedic surgeon's team (Dr.
___, with ___, NP in the Orthopaedic Trauma
Clinic ___ days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your plastic surgeon's team (Dr. ___ in
the Hand Surgery Clinic ___ days post-operation for
evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Left upper extremity: Non-weight bearing
Right upper extremit: Non-weight bearing
Please remain in splints on both left and right sides until
follow-up appointments.
Treatments Frequency:
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.
- Splints must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splints wet
- Please keep both arms elevated to reduce swelling
Followup Instructions:
___
|
10733714-DS-6
| 10,733,714 | 25,949,149 |
DS
| 6 |
2116-02-26 00:00:00
|
2116-03-10 19:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Placement of IVC filter - ___
History of Present Illness:
___ with a history of NSCLC (ROS+) on crizotinib with known
intracranial metastatic
disease s/p XRT (last dose ___ who presented to OSH with
syncope, and was found to have a new DVT, PE and intracranial
hemorrhage, transferred to ___ for neurosurgical evaluation.
In the ED, she was seen by neurosurgery who recommended holding
anticoagulation pending stability of ICH on NCHCT, which was
demonstrated in the ED.
During this time, she underwent placement of an IVC filter to
prevent further pulmonary embolism.
On arrival to the floor, she has leg pain, and complains of
nausea as well, related to crizotinb. She has been taking
crizotinib since ___, but vomits every time she takes it.
She is followed by Dr. ___ primary ___ care. She denies fevers, chills, headache,
nausea, vomiting, diarrhea, bony pains. She lost 7 lbs in 2
weeks, and has had an earache since starting radiation. She has
difficulty walking on her RLE.
Past Medical History:
PAST MEDICAL HISTORY:
- NSCLC Stage IV (see Onc Hx below)
- HTN
- HLD
- PE/DVT on warfarin
- S/p IVC filter ___
PAST ONCOLOGIC HISTORY
- ___: ___ Stage IV is diagnosed
- ___: undergoes brain radiation therapy at ___
(details, exact dates unknown)
- ___: begins taking oral crizotinib (Xalori; TKI
indicated for metastatic lung cancer that is ALK-positive or
ROS1-positive)
Social History:
___
Family History:
Non-contributory to presenting complaint
Physical Exam:
ADMISSION EXAM:
Vitals: 98.7, 101 / 44, 67 18 94 Ra
GENERAL: fatigued appearing, NAD
HENT: MMM, NC/AT
EYES: No scleral icterus, PERRLA, EOMI
NECK: no JVD. Well-healed incision right supraclavicular area
LYMPH: no palpable submandibular, ant/post cervical, supraclav,
or axillary LAD
CARDIAC: RRR. NMRG.
LUNGS: CTAB
ABDOMEN: nabs. mild diffuse ttp. no rebound/guarding
EXTREMITIES: WWP. There is asymmetric 1+ pitting edema of RLE >
LLE extending to the lower shin. The R calf is TTP.
NEUROLOGIC: AOX3, CN II-XII intact, strength ___ in UEs and ___. Stable gait, but limping to unweight R leg
SKIN: no obvious lesions or rashes
DISCHARGE EXAM:
Vitals: T 98.6, BP 116 / 63, HR 74 RR 18 O2 96% Ra
GENERAL: tired-appearing, NAD
HENT: MMM, NC/AT
EYES: No scleral icterus, PERRLA, EOMI grossly intact
NECK: Well-healed incision right supraclavicular area
CARDIAC: RRR. NMRG.
LUNGS: crackles at L lung base with decreased breath sounds
ABDOMEN: nabs. Soft, slightly distended, mildly tender
throughout
EXTREMITIES: WWP. trace ___ edema bilaterally, R>L
NEUROLOGIC: PERRLA, CN II-XII intact, strength ___ in UEs and
___.
SKIN: no obvious lesions or rashes
Pertinent Results:
ADMISSION RESULTS:
___ 06:55PM BLOOD WBC-8.7 RBC-3.89* Hgb-11.0* Hct-32.9*
MCV-85 MCH-28.3 MCHC-33.4 RDW-13.0 RDWSD-40.0 Plt ___
___ 06:55PM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-139
K-3.8 Cl-100 HCO3-27 AnGap-16
RELEVANT IMAGING:
___ CT Torso:
===================
IMPRESSION:
1. Extensive bilateral pulmonary emboli. No evidence of right
heart strain.
2. Right upper lobe opacity anteriorly with distortion with an
appearance most
suggestive of scarring. Comparison to prior imaging would be
helpful to
confirm this. If prior imaging cannot be obtained, evaluation
with PET/CT
would be reasonable.
3. Borderline enlarged mediastinal and hilar lymph nodes. If a
PET/CT is
negative or not obtained, follow up chest CT in 3 months is
recommended to
assess for resolution of this finding.
RECOMMENDATION(S): Comparison to prior chest CT and if not
available,
consideration for PET-CT or follow-up CT chest in 3 months is
recommended. If
PET-CT is obtained and negative then a follow up Chest CT in 3
months should
still be performed to follow-up borderline mediastinal and hilar
adenopathy.
___ CT Head:
=================
IMPRESSION:
A 6 mm hyperdense focus in the left frontal lobe appears
slightly less
prominent compared to the prior study and likely represents a
focus of
intraparenchymal hemorrhage. No new areas of hemorrhage are
detected.
Alternatively this could be a small hemorrhagic lesion. MRI can
be obtained
for further evaluation as clinically indicated.
RECOMMENDATON MRI to further evaluate left frontal hyperdense
lesion.
___ CT Head
==================
IMPRESSION:
4 mm hyperdense focus in the left frontal lobe is unchanged in
appearance in
size from head CT ___ and may represent a tiny area of
intraparenchymal hemorrhage or cavernous malformation. No new
or worsening
intracranial haemorrhage.
DISCHARGE RESULTS:
___ 06:50AM BLOOD WBC-8.6 RBC-3.50* Hgb-9.8* Hct-30.5*
MCV-87 MCH-28.0 MCHC-32.1 RDW-13.3 RDWSD-41.9 Plt ___
___ 06:50AM BLOOD Glucose-196* UreaN-14 Creat-0.6 Na-139
K-4.4 Cl-103 HCO___ AnGap-___
Brief Hospital Course:
Key Information for Outpatient ___ year old woman with
non-small cell lung cancer, known intracranial metastases s/p
brain radiation, presented to ___ after a syncopal
event, found to have new DVT, PE, and small focus of
intracerebral hemorrhage. She was transferred to ___ for
neurosurgery evaluation. Neurosurgery saw the patient and
recommended no surgical intervention for her intracerebral
hemorrhage and no initial anticoagulation, so she underwent
immediate placement of IVC filter with interventional radiology.
Her head CT was repeated ~12 hours after her initial head CT and
her hemorrhage was stable. At that time, neurosurgery felt she
was OK for systemic anti-coagulation and recommended
heparin/Coumadin given their reversibility. She was started on a
heparin drip and bridged to Coumadin for goal INR ___. On ___
she underwent a repeat head CT due to a headache, on which her
intracerebral hemorrhage was noted to be stable. While
inpatient, she was seen by the oncology consult team, who
recommended holding her crizotinib for a few days while she was
at risk for developing worsening hemorrhage. It was restarted on
___, and nausea was controlled with Zofran, Compazine, and
Ativan. During her hospital stay, she was noted to have some
abdominal pain and belching, which improved with a more
aggressive bowel regimen and enemas. At discharge INR was 2.1,
and Coumadin dose was 4mg daily. The inpatient team discussed
the patient's goals of care with her and her daughter, and she
clearly stated that she would like to be full code with a
limited trial of life-sustaining treatment. She would not want
transfusion of any blood products.
# Intraparenchymal Hemorrhage:
Most likely post-radiation bleeding. Less likely traumatic as
no recent history of falls. ___ consulted, initially
recommended against anti-coagulation. Repeat head CT documented
improvement, NSGY then said OK for heparin gtt with bridge to
coumadin. Has had intermittent headaches throughout admission
but always
non-focal neuro exam. NCHCT on ___ again demonstrated stability
of ICH. No need for NSGY follow-up unless develops neurologic
symptoms or concerning headaches
# RLE DVT
# Pulmonary Embolism:
Provoked I/s/o active malignancy. Her pulmonary embolism is
without strain pattern on ECG, cardiac biomarkers/BNP are not
elevated, and her PA is not enlarged relative to the aorta on
CTPA. Thus her PE is not massive or submassive. She has no
symptoms from her PE, including no tachycardia, dyspnea, or
chest
pain. s/p IVC filter placement with ___ on ___. Per NSGY recs
started anticoagulation with heparin gtt bridge to Coumadin, and
discharged on coumadin 5mg daily with plan for follow-up through
___ clinic associated with PCP.
#Abdominal pain: Improved with aggressive bowel regimen.
# NSCLC, metastatic:
Treated at ___ Cancer ___ with Dr. ___.
Recently received whole brain radiation Oncology consulted re:
anticoagulation and dosing of crozotinib. Recommended holding
crizotinib initially, then restarting with observation. Nause
was managed with zofran, compazine, and ativan.
# Goals of care: Per discussion with patient and daughter
___, pt clearly expressed that she would want to be
resuscitated and intubated if needed, but only with a short-term
trial of life-sustaining treatment. She also stated that she
does not want blood transfusions, because she would want "fate
to take its course." When explained that blood transfusions
might be helpful in the future to help her feel better, she
still stated she would not want a transfusion.
CHRONIC ISSUES:
#HTN: held home lisiniopril/HCTZ given normotensive
#HLD: continue home atorva on discharge
TRANSITIONAL ISSUES:
-Started on Coumadin 5mg daily, should have INR checked on ___
and Coumadin adjusted accordingly
-Patient underwent placement of IVC filter; she should have
follow up with ___ with plan for removal in 3 months
-Started on Ativan 0.5mg, Zofran ___ for nausea control
-Can consider switching patient to ___ for anticoagulation
in ___ months if she has not developed any worsening/concerning
neurologic symptoms
-HELD: lisinopril-HCTZ given normotension, restart as needed
CODE: Full, with limited trial of life-sustaining treatment. (No
blood products)
CONTACT/HCP:
___
Relationship: sister
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. crizotinib 250 mg oral DAILY
3. Metoclopramide 10 mg PO Q6H:PRN nausea
4. Atorvastatin 20 mg PO QPM
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Fleet Enema (Saline) ___AILY:PRN constipation
RX *sodium phosphates [Disposable Enema] 19 gram-7 gram/118 mL 1
enema(s) rectally daily Refills:*3
3. LORazepam 0.5 mg PO Q6H:PRN nausea
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every six (6)
hours Disp #*12 Tablet Refills:*0
4. Ondansetron ODT ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*20 Tablet Refills:*0
5. Senna 17.2 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Atorvastatin 20 mg PO QPM
8. crizotinib 250 mg oral DAILY
9. Omeprazole 20 mg PO DAILY
10. HELD- lisinopril-hydrochlorothiazide ___ mg oral DAILY
This medication was held. Do not restart
lisinopril-hydrochlorothiazide until you follow up with your
primary care doctor
11.Outpatient Lab Work
Please check INR, fax results to PCP:
___ (___)
Fax: ___
ICD-10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Pulmonary embolism
-Intracerebral hemorrhage
SECONDARY DIAGNOSES:
-Deep vein thrombosis
-Non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were transferred to our hospital after you were diagnosed
with blood clots in your legs and lungs.
While you were here:
-You were seen by our neurosurgeons who felt that you did not
need brain surgery
-You had a filter put into your veins to help prevent more blood
clots from traveling to the lungs
-You were started on a medicine called Coumadin to prevent more
blood clots from forming
When you leave the hospital:
-You should take Coumadin (also called warfarin) every day
-You should maintain a diet with consistent levels of Vitamin K
-You should see your oncologist to discuss your continued
treatment for your cancer
It was a pleasure participating in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10733714-DS-8
| 10,733,714 | 21,746,618 |
DS
| 8 |
2116-04-22 00:00:00
|
2116-04-23 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
lumbar puncture ___
Ommaya Placement ___
History of Present Illness:
Ms. ___ is a ___ y/o woman with PMH notable for ___ c/b
brain mets s/p whole brain radiation, treated with crizotinib
and recently diagnosed DVT/PE s/p IVC filter on Coumadin,
presenting with nausea and vomiting for 4 days. She initially
presented to ___ CT which showed new brain bleed. He was
transferred to ___ ED for neurosurgical evaluation.
The patient has been admitted twice to ___ over the past 2
months. She was initially admitted ___ - ___ for
syncope. She was found to have a new DVT and extensive bilateral
PE as well as a small focus on intracranial hemorrhage. She was
evaluated by neurosurgery with recommendations for conservative
management, not surgical candidate. Her anticoagulation was
initially held and she underwent IVC placement on ___.
Subsequent NCHCT showed stable head bleed and prior to
discharge, she was restarted on home Coumadin with heparin
bridge. Of note, her home crizotinib was held briefly ___
bleeding risk, but restarted as well prior to discharge.
En route home in the ambulance, the patient was noted to have
severe vomiting in the EMS with subsequent blood pressures of
60's/palp. As her blood pressure had spontaneously normalized to
120's systolic upon return to the ___ ED, this was felt to be
most likely a vasovagal event. She was re-admitted for further
work-up/management. During this hospital course (___),
the patient's home crizotinib was again held, this time due to
rising LFTs and persistent nausea felt to be associated with the
medication. She also had extensive fatigue treated with
dexamethasone, down-titrated to 4mg PO daily at time of
discharge. She did have a repeat CTA showing essentially stable
thrombotic burden with possibly increased DVT's in her legs,
treated conservatively with compression stockings. She was
continued on warfarin with goal INR ___. Hospital course was
otherwise notable for hypovolemic hyponatremia, which improved
with improved nutritional intake, leukocytosis felt secondary to
dexamethasone initiation, and binocular vision loss, which per
discussion with ophthalmology was unlikely to be but possibly a
complciation of crizotinib. With regards to this last issues,
she was felt to be ok for outpatient work-up. As such, she was
provided the outpatient number for follow-up after discharge.
Of note, the patient had multiple ___ discussions during these
hospitalizations with ultimate decision that the patient remain
full code with limited trial of resuscitative efforts.
In the ED, initial vitals: 97.8 82 118/71 18 97% RA
- Exam notable for: none performed
- Labs notable for: 7.7 (previously 17.7) INR 1.8 chem panel
notable for Cl 95
- Imaging notable for:
CT head ___:
============
1. Stable frontal lobe white matter hyperdensities concerning
for metastases. 2. No evidence of new hemorrhage or acute large
territory infarction.
CT head ___:
============
1. New 8 mm hyperdense lesion in the left centrum semi ovale
with surrounding vasogenic edema is concerning for metastasis,
possibly hemorrhagic.
2. Additional 5 mm hyperdense lesion in the medial left frontal
lobe is unchanged from prior exams and may represent a
metastasis or cavernoma.
- Pt given:
___ 22:48 IVF NS ___ Started
___ 00:28 IVF NS 500 mL White,Roxane P Stopped (1h ___
___ 01:00 PO Acetaminophen 1000 mg White,Roxane P
___ 09:00 PO Dronabinol ___ Not Given
___ 09:00 PO OxyCODONE SR (OxyconTIN) ___
Not Given
___ 09:00 PO Pantoprazole ___ Not Given
___ 09:00 PO/NG Lisinopril ___ Not Given
___ 09:00 PO/NG Hydrochlorothiazide ___
Not Given
___ 10:49 PO Dronabinol 2.5 mg ___
___ 10:49 PO OxyCODONE SR (OxyconTIN) 10 mg
___
___ 10:49 PO Pantoprazole 40 mg ___
___ 10:49 PO/NG Lisinopril 20 mg ___
___ 10:49 PO/NG Hydrochlorothiazide 12.5 mg
___
- Neurosurgery was consulted and recommend:
- No urgent surgical intervention is indicated
- Recommend admission to Medicine/Oncology
- Please repeat CT in the morning to ensure stability of
hemorrhage before resuming Coumadin. Please do not take Coumadin
without clearance from neurosurgery.
- Vitals prior to transfer: 98.2 79 99/61 18 95% RA
On arrival to the floor, pt reports that she had been in rehab
until last week. When she got home from rehab she felt fine for
about 24 hrs. The next day however she started to have nausea
that was not responsive to metoclopramide. She had about two
episodes of vomiting per day; there was no blood in the vomitus.
She had no associated fevers but did feel chills. Given that her
symptoms were not improving, she went to see her PCP who
recommended that she be seen in the ED.
She denies any diarrhea or belly pain but has not had a bowel
movement since ___ (~ 4 days). She denies any dysuria. She
feels generalized weakness but no focal weakness. She has a
small headache at the moment.
ROS:
as per HPI
Past Medical History:
PAST MEDICAL HISTORY:
- NSCLC Stage IV (see Onc Hx below)
- HTN
- HLD
- PE/DVT on warfarin
- S/p IVC filter ___
PAST ONCOLOGIC HISTORY
- ___: ___ Stage IV is diagnosed
- ___: undergoes brain radiation therapy at ___
(details, exact dates unknown)
- ___: begins taking oral crizotinib (Xalori; TKI
indicated for metastatic lung cancer that is ALK-positive or
ROS1-positive)
- ___: Hospitalization ___ - ___ for multiple PEs,
Intraparenchymal hemorrhage, DVTs s/p IVC filter, now on
coumadin
Social History:
___
Family History:
No known family history of chronic lung disease or cancer.
Physical Exam:
Admission Physical Exam:
=======================
Vitals: 98.9 PO 100 / 63 86 18 96 RA
General: Alert, oriented, chronically ill appearing, no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles throughout, no wheeze
CV: RRR, Nl S1, S2, No MRG
Abdomen: hypoactive bowel sounds
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Discharge Physical Exam:
========================
General: Alert, oriented, chronically ill appearing, no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheeze
CV: RRR, S1 + S2 present, No MRG
Abdomen: SNTND, +BS, no rebound/guarding
GU: no foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CN2-12 intact, generalized weakness but no focal findings
Pertinent Results:
Admission Labs:
==============
___ 06:25PM BLOOD WBC-7.7# RBC-3.78*# Hgb-10.4*# Hct-32.6*#
MCV-86 MCH-27.5 MCHC-31.9* RDW-13.8 RDWSD-43.3 Plt ___
___ 06:25PM BLOOD Neuts-60.6 ___ Monos-12.1 Eos-1.9
Baso-0.5 Im ___ AbsNeut-4.68# AbsLymp-1.86 AbsMono-0.94*
AbsEos-0.15 AbsBaso-0.04
___ 06:25PM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-135
K-3.9 Cl-95* HCO3-27 AnGap-17
___ 06:25PM BLOOD ALT-9 AST-14 AlkPhos-116* TotBili-0.5
___ 06:25PM BLOOD Lipase-33
Discharge Labs:
===============
___ 05:35AM BLOOD WBC-13.0* RBC-3.56* Hgb-9.9* Hct-30.2*
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.0 RDWSD-46.2 Plt ___
___ 05:35AM BLOOD Glucose-341* UreaN-29* Creat-0.6 Na-133
K-4.6 Cl-93* HCO3-22 AnGap-18*
___ 05:35AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
Imaging:
=======
CT head w/o contrast ___. New 8 mm hyperdense lesion in the left centrum semi ovale
with
surrounding vasogenic edema is concerning for metastasis,
possibly hemorrhagic.
2. Additional 5 mm hyperdense lesion in the medial left frontal
lobe is unchanged from prior exams and may represent a
metastasis
or cavernoma.
CT head w/o contrast ___. Unchanged 8 mm left frontal lobe hyperdensity, concerning for
metastasis, possibly hemorrhagic and 5 mm left frontal
hyperdensity, either a metastasis or cavernoma.
2. No evidence of new hemorrhage or acute large territory
infarction
MRI Head w/ and w/o contrast ___. Redemonstration of multiple intraparenchymal lesions, some of
which appear stable to slightly decreased in size as described
above.
2. New nonenhancing hemorrhagic 6 mm FLAIR hyperintense left
frontal lesion, suspicious for hemorrhagic metastasis.
Attention on follow-up is recommended.
3. No evidence of new enhancing mass or abnormal enhancement.
No evidence of acute infarction or intracranial hematoma.
CT Head w/o contrast ___. Interval placement of a right-sided Ommaya reservoir, with
expected
pneumocephalus.
2. Known left supratentorial hemorrhagic metastases measuring
5-6 mm each. Other parenchymal lesions are better assessed on
the recent MRI.
MICRO
=====
___ 3:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:12 pm URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 11:06 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:20 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
___ 04:20PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-1 Polys-4
___ Macroph-6
___ 04:20PM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-145 ___ Misc-BODY FLUID
Brief Hospital Course:
Ms. ___ is a ___ yo woman with PMH notable for NSCLC c/b
brain mets s/p whole brain radiation, treated with crizotinib
and recently diagnosed DVT/PE s/p IVC filter on Coumadin,
presenting with nausea and vomiting for 4 days found to have new
L hemorrhagic met and leptomeningeal involvment s/p Ommaya
placement and plan to initiate outpt IT chemo.
# Left Hemorrhagic Metastasis: New left hemorrhagic metastasis
iso NSCLC previously on crizotinib, confirmed by MRI. No focal
neurologic deficits or midline shift. Neurosurgery was consulted
and recommended no surgical intervention. Met evolved after
crizotinib was d/c'd, but after talking to outpt oncologist,
patient adamantly refuses to restart the medication as she
believes n/v and many of her symptoms are ___ to the med despite
multiple conversations. LP cytology positive for malignant cells
indicating likely leptomeningeal involvement. After ___
discussion with patient and family, agreed to Ommaya placement,
done on ___. Will f/u with neurosurgery and neuro-onc as
outpatient, the latter to start IT chemo. Will need follow up
MRI in 4 weeks per neuro onc recs. Originally started on
dexamethasone 4mg q6hrs when the new met was discovered, this
was downtitrated to 4mg BID at time of d/c. Further management
of steroids per oncologists.
# Thrombocytopenia: Newly developed on ___. Last received
heparin on ___ (was getting heparin as bridge for active PE
since warfarin initially held given hemorrhagic brain lesion).
Heme consulted. They were only mildly suspicious of HIT given
the fact that the platelets continued to downtrend on subsequent
days despite no heparin use. PF4 antibodies negative. Blood
smear w/ rare large plts c/f possible ITP, but pt already on
dexamethasone as above anyways. Plts uptrended to normal in
house w/o intervention.
# Hyponatremia: slowly downtrending throughout admission. Likely
combination of poor PO intake and SIADH. Started on salt tabs 1g
TID, fluid restriction, and sodium stable in low 130s.
# Leukocytosis: Likely ___ steroids and malignancy, no s/s
infection.
# Pulmonary Embolism/RLE DVT:
# Bilateral ___ DVTs, extensive: Provoked PE in the setting of
active malignancy during previous admission. S/p IVC filter. INR
supertherapeutic at decreased dose of 3.5mg daily. Held warfarin
and heparin gtt I/s/o Ommaya placement ___. Per neurosurgery
recs, needs to hold all anticoagulation for 7 days s/p Ommaya.
Can restart AC on ___. Can be bridged back to warfarin w/
lovenox vs left on lovenox given active malignancy w/ no CKD.
# Nausea, vomiting: Improved during admission. Likely ___
malignancy, although constipation may be contributing. Ensure
regular BMs.
# Hyperlipidemia: Continued home atorvatatin
# HTN: Continued lisinopril and HCTZ
TRANSITIONAL ISSUES
==================
[ ] patient is ___ speaking only, consider interpreter
vs asking ___ (contact info below) for translation
[ ] holding anticoagulation after Ommaya placement per neuro
recs, restart on ___, can be bridged back to warfarin w/
lovenox vs left on lovenox given active malignancy w/ no CKD.
(Lovenox dosing 1mg/kg BID, if going back to ___, would use
2.5mg daily given supertherapeutic INR on 3.5mg daily)
[ ] f/u with neuro-surgery and neuro-onc scheduled on ___
starting at 10:30 AM
[ ] should also f/u with regular oncologist Dr. ___
number on discharge worksheet
[ ] s/p IVC filter in ___, please consider referral to
vascular for removal whenever clinically indicated
[ ] ensure regular BMs daily, patient has chronic issues with
constipation and may worsen her persistent nausea and vomiting
#CODE: full
#COMMUNICATION: patient, daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Ondansetron ODT ___ mg PO Q8H:PRN nausea
4. Warfarin 5 mg PO DAILY16
5. Dronabinol 2.5 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. Senna 17.2 mg PO DAILY
13. Melatin (melatonin) 3 mg oral QHS: PRN
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Dexamethasone 4 mg PO BID
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. Lactulose 30 mL PO DAILY
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Sodium Chloride 1 gm PO TID
8. Warfarin 3.5 mg PO DAILY16
9. Atorvastatin 20 mg PO QPM
10. Dronabinol 2.5 mg PO BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. lisinopril-hydrochlorothiazide ___ mg oral DAILY
13. Melatin (melatonin) 3 mg oral QHS: PRN
14. Ondansetron ODT ___ mg PO Q8H:PRN nausea
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
16. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
17. Pantoprazole 40 mg PO Q24H
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Non Small Cell Lung Cancer with Brain Metastasis
Thrombocytopenia
Hyponatremia
SECONDARY DIAGNOSIS
====================
Pulmonary Embolism/Deep Vein Thrombosis
Hyperlipidemia
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 ___ for having nausea and vomiting. We
did scans of your brain and found a new cancer lesion. We then
did a lumbar puncture to test the spinal fluid that surrounds
your brain and found that it contained cancer cells. Given these
new developments, we consulted the cancer doctors that
___ in the brain, and they reviewed your case and
determined that the only treatment that could be beneficial
would be intrathecal chemotherapy, which is chemotherapy
injected directly into the brain. After having conversations
with you and your family, you decided to agree to this
treatment. Therefore, you had an Ommaya placed, which is a port
on the head in which the chemotherapy can be injected. You have
follow up appointments with the brain and cancer doctors to
___ the treatments while you are at rehab.
We wish you the best of health,
Your ___ Care Team
Neurosurgery Instructions:
You underwent surgery to have an Ommaya Reservoir placed.
You dressing was removed on ___. Your incision should remain
open to the air unless otherwise instructed by a neurosurgeon.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
We recommend that you avoid heavy lifting, running, climbing, or
other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
Followup Instructions:
___
|
10734159-DS-13
| 10,734,159 | 26,286,187 |
DS
| 13 |
2189-09-16 00:00:00
|
2189-09-21 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rigth upper quadrant pain
Major Surgical or Invasive Procedure:
___: percutaneous cholecystostomy tube
History of Present Illness:
HPI: ___ w/h/o AF on coumadin p/w 5 days of RUQ pain. It has
not
gotten worse but has not improved either. She had one episode
of
N/V at the beginning of the course with slight improvement in
the
pain but has had no vomiting since. Her bowel habits are
normal.
No hematochezia/melena. No hematemesis. No f/c/ns. She has
not
had pain like this before
Past Medical History:
Glaucoma
HTN
Hyperlipidemia
Parox afib
osteopenia
Breast cancer
Moderate MR
___ keratoses of the face
Herpes Zoster ___
Psoriasis
Migraine
Varicose veins
R leg fracture
.
PSurgH:
Hernia repair
R inguinal hernia surgery
R breast lumpectomy for neoplasm,s/p rad tx
Social History:
___
Family History:
Father died in ___
Mother died in ___, dementia
Brother with pancreatic ca, HTN
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 97.2 HR: 88 BP: 124/74 Resp: 16 O(2)Sat: 99 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, significant tenderness right mid abdomen
with guarding and rebound.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Physcial examination upon discharge: ___:
vital signs: t=97.7, hr=77, bp=118/68, rr=18, oxygen saturation
98%
General: Sitting comfortably in chair
CV: ns1, s2, -s3, -s4, Grade ___ systolic murmur, 2n ICS, RSB,
LSB
LUNGS: clear
ABDOMEN: soft, non-tender, cholecystostomy tube right side
abdomen with golden drainage
EXT: no pedal edema bil., no calf tenderness bil.
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 05:00AM BLOOD WBC-7.7# RBC-4.56 Hgb-13.9 Hct-41.4
MCV-91 MCH-30.5 MCHC-33.6 RDW-12.5 Plt ___
___ 05:10AM BLOOD WBC-4.8 RBC-4.41 Hgb-13.4 Hct-39.9 MCV-91
MCH-30.5 MCHC-33.7 RDW-12.3 Plt ___
___ 03:00PM BLOOD WBC-8.8# RBC-4.66 Hgb-14.4 Hct-42.6
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.4 Plt ___
___ 03:00PM BLOOD Neuts-78.9* Lymphs-14.8* Monos-5.7
Eos-0.3 Baso-0.4
___ 05:00AM BLOOD ___
___ 03:00PM BLOOD Plt ___
___ 08:47PM BLOOD ___ PTT-34.1 ___
___ 05:00AM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-138 K-3.5
Cl-102 HCO3-26 AnGap-14
___ 05:10AM BLOOD Glucose-105* UreaN-8 Creat-0.5 Na-140
K-3.4 Cl-104 HCO3-24 AnGap-15
___ 05:00AM BLOOD ALT-13 AST-25 CK(CPK)-74 AlkPhos-52
TotBili-0.5
___ 05:00AM BLOOD Lipase-28
___ 04:45AM BLOOD Lipase-23
___ 05:10AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.1
___ 03:28PM BLOOD Lactate-1.4
ADD ON
CPK ISOENZYMES CK-MB cTropnT
___ 05:00 3 <0.011
___: cat scan of abdomen and pelvis;
IMPRESSION:
1. Acute cholecystitis. No biliary dilatation.
2. Stable 3.1 x 2.2 cm right adnexal cystic lesion, possibly a
cystadenoma.
This can be further assessed with a dedicated pelvic ultrasound.
3. Dilated left gonadal vein with left sided pelvic varices,
findings which can be seen with pelvic congestion syndrome.
Clinical correlation recommended.
4. Fibroid uterus.
5. Liver and renal cysts again identified
___: ___ drainage:
Technically successful ultrasound-guided percutaneous
cholecystostomy drainage catheter placement. 115 cc of
bile/purulent fluid was aspirated to near-complete collapse of
the gallbladder. Microbiology is pending
Brief Hospital Course:
___ year old female admitted to the hospital with right upper
quadrant pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. On cat scan of the
abdomen she was reported to have a distended gallbladder with
stones, pericholecystic fluid, and adjacent hyperemia. These
findings were suggestive of acute cholecystitis. She was started
on intravenous antibiotics and placed on bowel rest. Because of
the gallbladder dilitation and inflammation, she was taken to ___
on HD #4 for placement of a catheter into the gallbladder with
removal of 115cc of yellow drainage. The gram stain identified
budding yeaast with pseudohyphae and the fluid culture showed
rare growth of ___ albicans. After the patient returned
from ___, she resumed a regular diet including her home
medications. On HD # 5, she was reported to be in atrial
fibrillation with a rate of 150 with a compromised blood
pressure. She was given diltiazem and metoprolol with
conversion to normal sinus rhythm. Her electrolytes were
repleted and troponin levels were sent. The troponin levels
were normal. She had no further recurrence of atrial
fibrillation. Cardiology was consulted and were in agreement
with the current management and no further recommendations were
offerred. She resumed her coumadin and had close monitoring of
her INR. Her INR upon discharge was 1.2.
She was evaluated by physical therapy and recommendations made
for discharge to an extended care facility for additional
rehabilitation. On HD # 6, she was discharged with stable vital
signs. Follow-up appointment was made for drain removal and
discussion about interval cholecystectomy.
Medications on Admission:
torsemide 10', diltiazem 180', MVI, Calcium, Alphagan 0.1%,
Fish Oil, Lipitor 10', Latanoprost 0.005%, Coumadin 6'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 10 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose ___
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*10 Tablet Refills:*0
7. Senna 1 TAB PO BID
8. Torsemide 10 mg PO DAILY
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
12. Warfarin 6 mg PO DAILY16
please monitor INR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute cholecystitis
secondary: atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right upper quadrant
pain. You underwent a cat scan and you were found to have a
distended gallbladder with stones. You were taken to ___ for
placement of a drain into the gallbladder. You are slowly
recovering from your procedure and you are preparing for
discharge. You were seen by physical therapy who recommended
discharge to a rehabilitation facility where you can regain your
strength and mobilty.
Followup Instructions:
___
|
10734159-DS-15
| 10,734,159 | 25,111,183 |
DS
| 15 |
2189-11-17 00:00:00
|
2189-11-17 22:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wrist pain
Major Surgical or Invasive Procedure:
Joint aspiration ___
History of Present Illness:
___ with PMHx A Fib on warfarin and admitted ___ for lap
cholcystectomy ___ c/b A Fib with RVR represents with wrist
pain.
The pain started 2 days prior to admission. Sharp and not
relieved by flexiril and 20mg PO prednisone at Rehab facility.
Limited ROM. Patient denies any recent trauma to wrist. Just
recently noticed swelling. No issues in any other joints
including elbows, knees, and first MTP joins.
In rehabilitation she had a fever to 100.7, though she denies
any cough dysuria or increased urinary frequency. Per family,
she had migratory pains in her shoulder and knees in the last
few days although patient does not recall this
In the ED: Initial Vitals: 98.5 80 116/84 20 97% 4L Patient had
2 arthrocentesis procedures of wrist: first done by ED staff
prior to initiation of vanc/CTX. However, this sample was not
adequate for crystal analysis. Prior to arrival on floor, ortho
performed ssecond arthrocentesis.
Vitals on transfer: 97.8 84 118/92 16 95%
Of note, patient was admitted to ___ 1 week ago
for 1 day for A Fib wtih RVR. During hospitalization, diltiazem
was uptitrated and digoxin was restarted. Patient was sent back
to ___.
Shortly after being admitted to the floor, the patient went into
A Fib with RVR with rates in 160's. Patient mildly symptomatic
with feeling of heart racing. RVR was refractory to diltiazaem
5mg IV X3 and metoprolol 5mg IV X2, though patient dropped blood
pressure to 80/60. She was subsequently transferred to the MICU
for further monitoring.
While in the MICU, her long acting diltaizem was changed over to
short acting. She remained in A Fib with rates in 80's-100's
with systolic blood pressures 90's-100's. A Cardiology consult
was called, but they have not yet seen the patient.
ROS:
Denies fevers, chills, nightsweats, cough, SOB, chest pain,
abdominal pain, n/v/d, changes in urine or stool habits or leg
swelling. No recent travel or sick contacts.
Past Medical History:
Glaucoma
HTN
Hyperlipidemia
Parox afib
osteopenia
Breast cancer
Moderate MR
___ keratoses of the face
Herpes Zoster ___
Psoriasis
Migraine
Varicose veins
Septic R hip a/w group B srep bacteremia s/p 6 week course PCN.
S/p washout. TEE negative.
Social History:
___
Family History:
Father died in ___
Mother died in ___, dementia
Brother with pancreatic ca, HTN
Physical Exam:
ON ADMISSION
97.8, P-89, 95/62, RR-20, 92RA
GEN: Elderly female in no distress, alert, conversant
HEENT: thrush on tongue, otherwise no oral lesions
NECK: supple, no adenopathy, no thyromegaly
CHEST- Crackles at bases with trace wheezes
HEART- RRR, S1S2, no MRG appreciated
ABDOMEN- laproscopic scars noted on abdomen, normal BS, soft,
NT, ND, no rebound
Extrem- warm, no edema, varicose veins, L wrist wrapped with
splint, can make out diffuse swelling with no erythema ove
wrist. No pain, swelling or erythema over any other joints
Neuro- non-focal
ON DISCHARGE
97.7, P-58 regular, 108/60, RR-18, 96RA No tele events overnight
GEN: Elderly female in no distress, alert, conversant
HEENT: thrush on tongue, otherwise no oral lesions
NECK: supple, no adenopathy, no thyromegaly
CHEST- Crackles at bases with trace wheezes
HEART- regular, S1S2, no MRG appreciated
ABDOMEN- laproscopic scars noted on abdomen, normal BS, soft,
NT, ND, no rebound
Extrem- warm, no edema, varicose veins, L wrist wrapped with
splint, can make out diffuse swelling with no erythema ove wrist
that improved. No pain, swelling or erythema over any other
joints
Neuro- non-focal
Pertinent Results:
ON ADMISSION
___ 01:00PM WBC-11.3*# RBC-4.03*# HGB-12.3# HCT-36.4#
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.7
___ 01:00PM NEUTS-93.4* LYMPHS-4.8* MONOS-1.4* EOS-0.2
BASOS-0.1
___ 01:00PM GLUCOSE-130* UREA N-19 CREAT-0.5 SODIUM-135
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-30 ANION GAP-14
___ 01:00PM ALT(SGPT)-16 AST(SGOT)-17 ALK PHOS-81 TOT
BILI-0.5
___ 01:00PM LIPASE-35
___ 01:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.0
MAGNESIUM-2.2
___ 01:00PM CRP-165.8*
___ 01:00PM ___ PTT-47.6* ___
___ 01:00PM SED RATE-90*
___ 04:35PM JOINT FLUID ___ HCT-9.0* POLYS-91*
___ MACROPHAG-3
___ 06:20PM JOINT FLUID ___ HCT-27.0* POLYS-95*
___ MACROPHAG-2
___ 06:12PM URINE MUCOUS-RARE
___ 06:12PM URINE CA OXAL-RARE
___ 06:12PM URINE HYALINE-3*
___ 06:12PM URINE RBC-6* WBC-117* BACTERIA-NONE YEAST-NONE
EPI-7 TRANS EPI-4
___ 06:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
___ 06:12PM URINE COLOR-Yellow APPEAR-Hazy SP ___
Wrist/Hand x-ray
FINDINGS: Frontal, oblique, and lateral views of the left wrist
and left hand with a scaphoid view were obtained for a total of
7 images. There is no fracture or dislocation. A well
corticated osseous fragment at the dorsal radiocarpal joint is
likely sequelae of old trauma. Severe degenerative change is
seen at the first carpometacarpal joint with joint space
narrowing, endplate sclerosis and osteophytosis. Mild
degenerative change is seen in the DIP joints of the ___
and ___ digits with joint space narrowing. Mild calcifications
in the TFCC is likely related to chondrocalcinosis.
IMPRESSION: No fracture or dislocation.
CXR ___
IMPRESSION: Low lung volumes, mild pulmonary vascular
congestion, and bibasilar atelectasis. More focal consolidation
in the left lower lobe might represent left lower lobe
pneumonia. Small bilateral pleural effusions.
ECG ___ @3PM
Sinus rhythm. Possible left atrial abnormality. Cannot exclude
inferior
wall myocardial infarction, age indeterminate. Voltage criteria
for left
ventricular hypertrophy. Extensive non-specific ST-T wave
changes. Compared to the previous tracing of ___ the rhythm
has reverted to sinus. QRS voltage has increased in the limb
leads.
ECG ___ @8PM
Atrial fibrillation with a rapid ventricular response. Extensive
ST-T wave changes most prominent in the anterolateral leads
which may be ischemia mediated or rate-related. Compared to
tracing #1 the rhythm has reverted to atrial fibrillation and
extensive ST-T wave changes are new.
Labs on Discharge
___ 06:00AM BLOOD WBC-8.1 RBC-3.97* Hgb-11.8* Hct-36.2
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.4 Plt ___
___ 06:00AM BLOOD Glucose-88 UreaN-16 Creat-0.5 Na-139
K-3.7 Cl-100 HCO3-31 AnGap-12
___ 06:00AM BLOOD ___ PTT-50.2* ___
Brief Hospital Course:
___ with PMHx A Fib on warfarin and admitted ___ for lap
cholcystectomy ___ c/b A Fib with RVR represents with wrist
pain, hospital course c/b MICU stay for hypotension ___ A Fib
with RVR.
MICU COURSE:
Patient was transferred for an episode of a fib with RVR rates
to the 140s and systolic pressures in the ___ that did not
respond to IV diltiazem on the floor several hours after
admission. Upon arrival to the MICU pressures and rates had
improved without further intervention. Given unclear home rate
control regimen and appropriateness of digoxin cardiology was
consulted and recommended holding digoxin and starting
amiodarone 300 mg daily for 3 weeks.
#Atrial Fibrillation with RVR
Patient presented in NSR with a therapeutic INR. Several hours
after admission, she went into A Fib with RVR refractory to IV
metoprolol and diltiazem and subesequently dropped blood
pressures (see MICU course above). Evaluated by Cardiology who
discontinued digoxin and started amiodarone load. Patient, after
being sent back to the floor, reverted back to NSR. Throughout,
she remained asymptomatic. SHe will be kep on original diltiazem
dose 240mg Daily and now on amiodarone 200mg TID. Has ___
with Dr ___. INR elevated to 4.6 on discharge likely ___
amiodarone. Held on discharge with strict instructions to
recheck and decrease dose to 4mg daily upon restarting.
#Wrist Pain
Patient had joint tap X2 in ED. Was started on Vanc/CTX
empirically for septic arthritis. Joint taps revealed WBC ___
and ___ with negative gram stains and no growth to date.
Antibiotics discontinued upon negative gram stains. No crystals
visualized but given elevated WBC count and serum inflammatory
markers, was presumed to be pseudogout. Placed on Ibuprofen
600mng TID X 10 day course. Wrist symptoms imprved by discharge.
Sent home with wrist splint for comfort and Orthopedics
___.
#Insomnia
Mild per patient. Held mirtazapine and trazadone and patient
slept well. She will discontinue these on discharge.
#Hypertension
-Continued diltiazem and torsemide
#Hyperlipidemia
-continued pravastatin
#GERD
continud home omeprazole
#Thrush-
Was placed on nystatin with good effect. Discontinued on
discharge.
Transitional Issues
-Patient will ___ with Dr ___: Amiodarone dosing
moving forward after load.
-Will ___ with Orthopedics office to monitor wrist
syndromes. Can use wrist splint for comfort.
-**PATIENT WAS DISCHARGED HOME AGAINST MEDICAL ADVICE. TEAM FELT
SHE WOULD BE BEST FIT FOR REHAB BUT PATIENT AND FAMILY REFUSED.
COULD NOT ARRANGE PCP ___ AS OFFICE WAS CLOSED. SPOKE
VERBALLY TO HCP THAT SHE NEEDS REPEAT INR TOMORROW (___) TO
TITRATE WARFARIN.
-Documented DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
3. Diltiazem Extended-Release 240 mg PO DAILY
Hold for SBP<100, HR<60
4. Docusate Sodium 100 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Torsemide 10 mg PO DAILY
9. Warfarin 6 mg PO ___ a-fib
10. Warfarin 7 mg PO ___ a-fib
please monitor INR
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
12. Cyclobenzaprine 5 mg PO TID
13. Digoxin 0.125 mg PO DAILY
14. Gabapentin 100 mg PO TID
15. Mirtazapine 7.5 mg PO HS
16. Omeprazole 20 mg PO DAILY
17. traZODONE 25 mg PO HS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides 8.6 mg 1 Tablet by mouth twice daily as needed
Disp #*40 Tablet Refills:*0
8. Torsemide 10 mg PO DAILY
9. Amiodarone 200 mg PO TID
Please see Dr ___ dosing in the future.
RX *amiodarone 200 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*0
10. Ibuprofen 600 mg PO Q8H Duration: 9 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*27 Tablet Refills:*0
11. Diltiazem Extended-Release 240 mg PO DAILY
12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every ___
hours as needed Disp #*10 Tablet Refills:*0
13. wheelchair *NF* 1 wheelchair Miscellaneous as needed
ambulation
For household distances
RX *wheelchair Use as needed per Physical Therapy
recommendations Disp #*1 Not Specified Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pseudogout
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital with a swollen wrist. Several tests
showed no signs of infection. We believe you have a condition
known as pseudogout which is treated with Ibuprofen.
While in the hospital, your heart rates from atiral fibrillation
became rapid and you required a one night stay in the ICU for
further monitoring. You were seen by the Cardiologists who
started you on a new medication called amiodarone. We are hoping
this medication will keep you out of this abnormal heart rhythm.
You will need to have your INR closely followed. It was a bit
elevated while you were in the hospital. You should have a
repeat INR checked tomorrow. Until that time, you should
continue to hold your warfarin.
You will ___ with Dr ___ as an outpatient.
Please see your medication changes below.
**THE MEDICAL TEAM FEELS YOU WOULD BENEFIT FROM SEVERAL DAYS OF
A REHAB FACILITY TO IMPROVE YOUR PHYSICAL STRENGTH. YOU AND YOUR
FAMILY HAVE DECIDED TO BRING YOU HOME. UNFORTUNATELY, THIS IS A
DISCHARGE AGAINST MEDICAL ADVICE.**
Followup Instructions:
___
|
10734242-DS-7
| 10,734,242 | 22,306,006 |
DS
| 7 |
2135-05-28 00:00:00
|
2135-05-30 06:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Fioricet / Fioricet
Attending: ___.
Chief Complaint:
Throbbing Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with history of anxiety who
presented with a headache. She reported that these were typical
symptoms of her migraines- she is nauseated, sensitive to light
and sound, and has severe pain. She cannot recall what her usual
migraine triggers are.
In the ED, initial vs were: ___ pain 98.4 110 ___ 100%
RA . Labs were remarkable for ucg negative. Patient was given 5
morphine, zofran 4 x2, ketorolac 15 x2, dilaudid 1mg x3. She had
a head CT that was negative and was admitted for pain control.
Per ED exam, there were no neuro deficits and no evidence or
concern for infection.
On examination on the floor, she was lying on her side with a
towel over her face and moaning loudly. She notes that she has
only had a migraine this bad once before, generally has
migraines every few months. She is tearful and notes ___ pain,
but dilaudid helped.
Past Medical History:
Anxiety
Migraines
Social History:
___
Family History:
grandmother with migraines
Physical Exam:
Admission Physical Exam
=======================
Vitals: 98.9 - 95/46 - ___ - 18 - 97RA wt 60.7 kg
General: uncomfortable appearing young lady lying on her side
HEENT: nc/at, no erythema of facial skin
Neck: supple, no meningismus
Lungs: clear to auscultation
CV: regular rate and rhythm, tachycardia
Abdomen: soft, non-tender
Ext: thin, no edema
Skin: tattoos, rash
Neuro: PERRL, EOMi, patellar reflexes 2+ bilaterally, moving all
4 extremities against resistance
Discharge Physical Exam
========================
Vitals- Tm 98.9 100s/50s ___ 18 97%
General- Alert, oriented, lying in bed in fetal position
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- 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:
___ 02:25PM URINE UCG-NEGATIVE
Imaging
CT Head without contrast ___
No acute intracranial abnormality.
Brief Hospital Course:
Assessment/Plan: ___ year old lady presenting with headache
typical of her migraines, with nausea, photophobia, and
phonophobia.
#Headache: In the emergency department her pain was treated with
IV pain medications. She had a CT of brain done that showed no
acute intracranial process. On the floor her nausea improved and
she was transitioned to oral pain medications and food with no
complaints. Her pain was moderate with NSAIDs, tylenol, and a
dose of sumatriptan. She was asked to follow with a primary care
doctor to evaluate whether she needed to be on a controller
medication for migraines.
#Nausea: She was initially treated with IV anti-emetics, and was
transitioned to PRN oral zofran with complete resolution of her
nausea.
#Anxiety: Continued on home dose of gabapentin and klonopin.
- gabapentin 800mg TID
- klonopin 0.5 mg BID PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Ibuprofen 400-600 mg PO Q8H:PRN pain
3. ClonazePAM 0.5 mg PO BID:PRN anxiety
4. ValACYclovir 500 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID:PRN anxiety
2. Gabapentin 800 mg PO TID
3. Naproxen 500 mg PO Q12H:PRN migraine
Please take when a migraine starts.
RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
4. Sumatriptan Succinate 50 mg PO BID:PRN migraine
RX *sumatriptan succinate 50 mg 1 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*12 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Migraines
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for headaches. We did a CT scan on
your head which did not show any abnormality. We gave you
medications for pain and nausea which seemed to help you feel
better. You should follow up with your PCP ___ 1 week to
reevaluate your migraines. Please ask if it would be appropriate
to start a medication that would be preventitive for migraines.
Followup Instructions:
___
|
10734315-DS-18
| 10,734,315 | 28,055,610 |
DS
| 18 |
2144-11-28 00:00:00
|
2144-12-01 09:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION:
===========
___ 10:10AM BLOOD WBC-9.5 RBC-4.11 Hgb-11.7 Hct-36.8 MCV-90
MCH-28.5 MCHC-31.8* RDW-12.8 RDWSD-41.9 Plt ___
___ 10:10AM BLOOD Neuts-68.2 ___ Monos-5.0 Eos-1.7
Baso-0.3 Im ___ AbsNeut-6.47* AbsLymp-2.28 AbsMono-0.47
AbsEos-0.16 AbsBaso-0.03
___ 10:10AM BLOOD ___ PTT-31.4 ___
___ 10:10AM BLOOD Glucose-125* UreaN-9 Creat-0.8 Na-131*
K-4.5 Cl-94* HCO3-18* AnGap-19*
___ 10:10AM BLOOD ALT-21 AST-31 AlkPhos-85 TotBili-0.3
___ 10:10AM BLOOD cTropnT-<0.01
___ 10:10AM BLOOD Lipase-31
___ 10:10AM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.4* Mg-1.4*
___ 10:10AM BLOOD Osmolal-268*
___ 10:23AM BLOOD ___ pO2-22* pCO2-34* pH-7.42
calTCO2-23 Base XS--2
___ 10:23AM BLOOD Glucose-122* Lactate-4.3* Creat-0.8
Na-129* K-3.6 Cl-102
___ 01:13PM BLOOD Lactate-2.2* Na-130*
___ 10:23AM BLOOD Hgb-12.1 calcHCT-36
DISCHARGE:
==========
___ 05:59AM BLOOD WBC-6.8 RBC-3.90 Hgb-11.2 Hct-33.7*
MCV-86 MCH-28.7 MCHC-33.2 RDW-13.2 RDWSD-41.2 Plt ___
___ 05:46AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-135 K-4.2
Cl-99 HCO3-22 AnGap-14
___ 05:46AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.6
IMAGING:
=========
CT A/P with contrast:
Mild pancolitis most notable along the ascending colon, with
proctitis.
CT head on admission:
No acute intracranial process.
CXR on admission:
No acute cardiopulmonary process.
Left hand X-ray:
Acute displaced avulsion fracture of the base of the ring finger
proximal phalanx.
Brief Hospital Course:
Ms. ___ is an ___
# Pancolitis
# Abdominal pain (resolved)
# Diarrhea (resolved)
# Lactic acidosis
As of floor arrival, pt's abdominal pain had resolved. On
further clarificaiton of Sx at home, had not had diarhrea or
vomiting since just after her return from ___, over a week before
arrival. Initially on contact isolation but given lack of
diarrhea and normal WBC, canceled C diff. On CTX/flagyl,
initially, transitioned to azithro/flagyl for short course,
stopped on discharge due to lower suspicion for bacterial cause.
Had been in ___ at time of onset of abdominal Sx,
at that time with abdominal pain, vomiting, diarrhea. Here
imaging findings suggesting colitis. Colitis did not appear
ischemic (mild downtrending lactate). Infectious etiology
seeming most likely. No hematochezia, so less likely
enteroinvasive. Intraluminal parasite possible given time spent
in countryside in ___, no e/o invasive infection; sent for
O&P but also empirically given x1 of albendazole. No studies
were collected as patient did not have a BM inpatient. Could
consider infectious workup if symptoms reoccur.
# Rehab refusal:
___ evaluated pt and recommended rehab but patient and family
declined, opted to take her home with ___ supervision from
family members. She was discharged with ___ for home safety
eval, ___, OT.
# Hyponatremia:
Urine electrolytes with osm 300, less c/w SIADH (though recently
thought to have this at OSH). Resolved with IVF, so likely some
mild volume depletion given her poor PO intake.
# Hypomagnesemia:
Improved with repletion, likely ___ diarrhea.
# Finger fracture:
Volar plate avulsion fracture at the mid phalanx of the ring
finger noted on X-ray, suffered fall while at ___,
forearm and hand wrapped in splint, but pt complained of arm
pain. OT evaluated patient and concerned for malpositioned
splint. Hand surgery consulted. Removed splint, revealing a
pressure injury on her hand. ___ and ___ fingers buddy taped,
further instructions below. Has outpatient followup. Initially
received APAP and Oxycodone for pain, discharged on short course
of standing APAP. Has ___ for assistance with management.
# Anorexia
# Subacute weight loss: this has been ongoing for 5 months per
family, and I suspect there is likely a component of depression
i/s/o dementia and prolonged adjustment to bereavement. Nothing
on CT imaging of abdomen to account for PO intake. It may be
worth considering outpatient EGD but no urgent inpatient consult
needed; communication sent to PCP. Tolerated regular diet.
# Diabetes: held home metformin inpatient, sliding scale insulin
# Hypertension: continue home amlodipine, losartan
# Hypothyroidism: will continue home levothyroxine
# Code status: Patient's daughter confirmed patient is DNR/DNI.
Would not want intubation under any circumstances. Attempted to
confirm with patient via ___ interpreter but she was unable
to fully participate in the conversation, suspect due to her
mild dementia. She did note not wanting to be on any machines.
Would further address and complete ___ as an outpatient.
# Central adrenal insufficiency: History of pituitary adenoma
resected ___ years ago at ___ no records. Not on any hormone
replacement otehr than levothyroxine.
# Cognitive impairment: Continued Donepezil
Contacts/HCP/Surrogate and Communication: ___ (daughter)
DNR/DNI
TRANSITIONAL ISSUES:
====================
[] for PCP: continue workup of weight loss and poor PO intake;
consider pharmacotherapy for depression, or if suspicious of
dysphagia, consider GI consult for EGD
[] confirm continued resolution of clinical signs of colitis
[] f/u orthopedics for finger fracture
[] incidental findings noted in body of CT report:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. A
0.8 cm hypodense lesion in segment VII is too small to
characterize (2; 15).
GASTROINTESTINAL: Small hiatal hernia.
BONES: Mild multilevel degenerative changes are noted in the
thoracolumbar spine.
There is grade 1 anterolisthesis of L4 on L5. Facet disease is
notable in the
lower lumbar spine.
SOFT TISSUES: Injection granulomas are seen in the subcutaneous
tissues of the
lower anterior abdominal wall.
Ortho instructions:
- Buddy tape ___ and ___ digits together until follow-up. Okay
to change buddy tape as needed if soiled or for bathing purposes
- Avoid pressure to lateral border of left hand
- Avoid weight bearing of the ___ and ___ fingers (ring and
small) until follow-up. Okay for ROM of these fingers to prevent
stiffness
>30 minutes spent on day-of-DC planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QHS
2. amLODIPine 10 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H Duration: 1 Week
2. amLODIPine 10 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancolitis
Hyponatremia
Hypomagnesemia
Acidosis
Volar plate avulsion fracture at the mid phalanx of the ring
finger
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because of inflammation of the colon.
It's not clear why you had this inflammation but you got better
quickly.
The hand surgeons also saw you because of your finger fracture.
They took your splint off and taped your fingers together.
Please follow their instructions:
- Buddy tape ___ and ___ digits together until follow-up.
- Okay to change buddy tape as needed if it gets dirty and when
you take a bath
- Avoid putting pressure on the outside of the left hand (such
as leaning the side of your hand on a table)
- Avoid putting pressure on the ___ and ___ fingers (ring and
small) until follow-up.
- You can wiggle the fingers to prevent stiffness
- Take tylenol for pain regularly until your followup
appointment.
Please see below for your followup appointments and medicines.
Please also talk to your doctor about filling out paperwork for
healthcare proxy and ___ form for DNR, DNI.
If your diarrhea starts again, please call your doctor or come
back to the emergency room for more testing.
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
10734449-DS-21
| 10,734,449 | 27,407,861 |
DS
| 21 |
2188-07-19 00:00:00
|
2188-07-21 09:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Effexor / NSAIDS ___ Drug) / bee
venom (honey bee)
Attending: ___
Chief Complaint:
Acute Liver Injury; Tylenol toxicity
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/hx of osteoporosis, depression and polysubstance abuse
reports taking ___ tylenol ___ hours x "over a year"
presented to ED with acute abdominal pain and vomiting since
___ as well as difficulty walking today. Patient initially
presented to ___ ED and was transferred to ___ ED
once her lab work showed evidence of liver failure.
In the ___ ED, initial vitals: 99 114/60 14 99% RA. Exam/labs
were notable for: AST 6300, ALT 3634, lipase 98, Alk phos 133,
tbili 4.8, Na 126, Cr 3.2 (unknown baseline), lactate 5.2.
Acetamin level 109, serum tox otherwise neg, UA with few bac, 15
WBC 91 RBC, hct 37.2, INR 4.2. CT head showed no acute process.
RUQ u/s Echogenic liver consistent with fatty infiltration,
however more advanc forms of liver disease/cirrhosis cannot be
evaluated on this study. Normal doppler evaluation, including
hepatorenal flow of the main portal vein. Patient was started on
NAC and 1L NS per toxicology recommendation. On transfer, vitals
were: 100 100/60 15 99% RA.
Past Medical History:
asthma, osteoporosis, arthritis, ___ deafness,
depression, PTSD, polysubstance abuse
Social History:
___
Family History:
Grandfather with ETOH liver disease
Physical Exam:
Admission:
----------
Vitals- 100 100/60 15 99% RA
___: A/Ox3, no acute distress
HEENT: Dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, tachy normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Papular, ___ rash on b/l upper
abd/flank area
Discharge:
----------
Physical Exam:
Vitals- T 97.6 BP 117/68 HR ___ RR 18 O2 >97RA
___- Sleepy, no acute distress
HEENT- Icteric sclera, mild L conjunctival hemorrhage, MMM,
oropharynx clear, pupils not dilated, visual fields full to
confrontation; PERRL; EOMI; remainder of CN exam intact
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, pleuritic sternal pain reproducible with palpation.
CV- regular, normal S1 + S2, systolic murmur at LLSB, no rubs or
gallops
Abdomen- soft, tender to percussion in all four quadrants,
especially in RUQ. ___, bowel sounds present. No
guarding.
Ext- warm, well perfused, 2+ pulses, no cyanosis or edema
Neuro- mild tremor in hands/tongue, but no asterixis, ___
strength intact in UE bilaterally
Pertinent Results:
Admission Labs:
----------------
___ 12:35AM ___
___
___ 12:35AM URINE ___
___
___ 12:35AM URINE ___
___ 12:35AM ___ HBs ___ HBc
___ IgM ___
___ 12:35AM HCV ___
___ 12:35AM ALT(SGPT)-3634* AST(SGOT)-6300* ALK ___
TOT ___
___ 06:10AM ALT(SGPT)-3437* AST(SGOT)-8886* ALK ___
TOT ___
___ 10:06AM ALT(SGPT)-3344* AST(SGOT)-8669* LD(LDH)-4230*
ALK ___ TOT ___
___ 10:06AM ___ UREA ___
___ TOTAL ___ ANION
___
___ 04:15PM ALT(SGPT)-3011* AST(SGOT)-6450* ALK ___
TOT ___
Discharge Labs:
---------------
___ 06:40AM BLOOD ___
___ Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___
___
___ 06:40AM BLOOD ___
___
___ 06:40AM BLOOD ___
Imaging:
--------
CT HEAD W/O ___
No acute intracranial abnormalities identified.
LIVER OR GALLBLADDER US (SINGLE ___
Echogenic liver consistent with fatty infiltration. More
advanced forms of liver disease including fibrosis/cirrhosis
cannot be excluded by this study. Normal Doppler assessment
including hepatopetal flow of the main portal vein.
CARDIAC ECHO ___
The left atrium is elongated. Late saline contrast is seen in
left heart suggesting intrapulmonary shunting. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
high (>4.0L/min/m2). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. Mild resting outflow tract gradient likely
from ___ left ventricular function. Moderate
pulmonary hypertension. Late bubbles during saline injection c/w
probable intrapulmonary shunting
Brief Hospital Course:
___ y/o s/p acute on chronic acetaminophen use resulting in acute
liver injury and ___.
Active issues:
--------------
#Acute Liver Injury: Tylenol ingestion as cause of liver injury
and elevated liver enzymes. Toxicology evaluated patient and
recommended NAC for tylenol induced liver injury (inital
tyelenol level ~100). Continued 21 hour NAC protocol (50mg/kg
over 4 hours, followed by 100mg/kg over 16 hours). Of note,
acetaminophen did not fall as quickly as expected, attributed to
diminished glutathione reserves from chronic malnutrition ___
gastric bypass surgery. NAC left on for longer than standard
course. Ultimately, NAC was discontinued when INR was less than
2 and APAP level was undetectable. All hepatitis serologies and
autoimmune lab tests were negative with exception of borderline
Hep B immunity. However, asterixis and bubbles during saline
injection on cardiac echo c/w probable intrapulmonary shunting
were concerning for underlying liver disease.
- follow up as outpatient with hepatology for further workup
- continue to use Sarna cream PRN for itching
- continue vitamins (Thiamine and Folate)
- discourage Tylenol use
___: Patient presented with Cr 3.2 with an unknown baseline,
likely secondary to dehydration. Continued IVF in the MICU and
on the floor, and Cr downtrended to 0.8 before discharge. Due to
concern for ___, we asked her to continue to avoid NSAIDs.
# Hypertension: SBPs in 180s in MICU, persisted with SBPs in
160s on the floor. Unclear if patient has history of HTN but has
known chronic EtOH abuse v. use. Started on Amlodipine 5 mg with
good effect.
#Arthralgias: Patient reported on admission she was taking
tylenol ___ Q4H for joint pain in hips, chest, shoulder, knee,
back, and hands. Given her comorbid psychiatric illness,
suspicion was high for fibromyalgia. No evidence of inflammatory
arthritis and history did not correlate with osteoarthritis.
Patient started on gabapentin 300 mg TID.
# Anxiety: Patient reported anxiety throughout hospitalization.
Received Ativan x 1 prior to discharge with good effect.
Discharged with short course of PRN ativan.
#Hyponatremia: Na 126 at presentation likely due to decreased PO
intake in the setting of nausea and abdominal pain, issue
resolved at time of transfer to the floor.
#Elevated lactate: Patient does not have focal source of
infection at this time and is likely ___ dehydration, issue
resolved at time of transfer to the floor.
#Gait Instability: Patient had head CT that was negative for
acute process. Patient reports her difficulty walking is her
normal baseline and she attributes it to pain in her lower
extremity.
#Pleuritic chest pain: Reported since admission. Reproducible
with palpation, implying MSK etiology. Likely costochondritis v.
fibromyalgia in the context of recent asthma attacks. Low
suspicion for acute cardiac or pulmonary etiologies given
unremarkable EKG.
Transitional Issues
--------------------
- continue gabapentin 300 mg TID
- continue Amlodipine 5 mg QD
- follow up with hepatology for further workup
- continue to use Sarna cream for pruritus from
hyperbilirubinemia
- continue vitamins (Thiamine and folate)
- discourage tylenol and other hepatically cleared pain meds and
anxiolytics
- continue Tramadol Q6H PRN for Right upper quadrant pain until
follow up with PCP
- use ativan PRN
- continue to avoid NSAIDs.
Medications on Admission:
adderall, cymbalta, topimax, estradiol patch, tylenol extra
strength (patient unsure of doses)
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
4. Sarna Lotion 1 Appl TP BID:PRN itching
Use as needed, up to 3 times a day.
RX ___ [Sarna ___ 0.5 %-0.5 % apply to
affected areas TID PRN Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Please do not drive or drink alcohol with this medication.
RX *tramadol 50 mg 1 tablet(s) by mouth q6h PRN Disp #*60 Tablet
Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
8. Lorazepam 1 mg PO Q4H:PRN CIWA >10
Please use sparingly. Do NOT take with alcohol. Do not use and
drive.
RX *lorazepam [Ativan] 1 mg 1 tab by mouth q8h PRN Disp #*10
Tablet Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth q6h PRN Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute liver injury
Acetaminophen toxicity
Hypertension
Acute Kidney Injury
Fibromyalgia
Secondary:
none
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You were admitted for Acute Liver Injury from
Tylenol toxicity. You were treated with a medicine called
___ in the Medical ICU and then on the medicine
floor until your blood tylenol level was undetectable and your
liver function tests began to normalize. You were evaluated by
the transplant, hepatology, and psychiatry teams who determined
that you did not require an emergent liver transplant. We
strongly recommend that you avoid tylenol, especially at doses
>2 grams in one day. It is very important that you stop drinking
alcohol to avoid further damage to your liver. It is also
important that you follow up with the liver specialists and your
primary care doctor after discharge for additional care.
We wish you the best and take care.
Sincerely,
SIRS Medical Service
___
Followup Instructions:
___
|
10734449-DS-22
| 10,734,449 | 23,479,595 |
DS
| 22 |
2189-04-16 00:00:00
|
2189-04-16 19:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Effexor / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / bee
venom (honey bee)
Attending: ___.
Chief Complaint:
Alcohol Detox
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH of acetaminophen-induced hepatitis (___), Alcoholism,
presents w/ ETOH Withdrawal and desire for inpatient detox
Pt noted that since her discharge in ___, pt has been
drinking daily, 750cc of spiced rum, w/ occasional shots, and
has become tremulous every time she withdraws, to the point
where she has been unable to walk, and has had multiple falls.
___ fall 1 month ago happened on ice on her porch, causing
bruises on her lower back. ___ fall was 1 week later, and caused
her to hit her head on railing leading to front door causing
bruising to both eyes and shoulders. When pt's partner was out
of room in ED, she stated there has been no physical abuse.
Today, she presented to liver clinic where they told her she
would "pass by ___ if she didnt change her ways. Accordingly,
she presented for inpatient detox. Pt noted that since ___,
has not taken any meds except for ativan and occasional
adderall.
After having valium, pt felt much improved. Pt noted that her
only complaint was abdominal pain, which is chronic, occuring
constantly throughout the day, sharp/stabbing, a/w bloating and
diarrhea. Pt noted that it actually improves w/ drinking.
In the ED, initial VS were: 10 98.3 ___ 18 95%, after
diazepam/hydralazine BP decreased to 140 systolic and
tachycardia resolved. Labs significant for WBC 3.6 (73% PMN),
Hgb 12.9, plt 105 (Baseline ), CHEM w/ K 2.7, BUN/Cr (___),
AST/ALT/AP 169/70/117, Lip 95, TB 1.3, Alb 4.2, Serum ETOH 32,
Serum/Urine tox negative, Coags normal.
Imaging significant for CT sinus/mandible showing chronic
appearing right zygomatic process fracture though apparently new
since ___. CT Head w/ approximately 9 mm hyperdensity
within the inferior right frontal lobe concerning for
intraparenchymal contusion. No significant mass effect, as well
as prominent right frontal extra axial space is new from prior
examination and suggestive of chronic subdural hematoma. RUQUS
identified echogenic liver consistent with steatosis and s/p
CCY. LLE U/S without DVT.
NSGY evaluated patient, felt was c/w trauma, rec'd admit to
medicine, goal SBP<140, q4h neuro checks, and repeat head CT in
morning. Pt was then given 40mg diazepam, Hydralazine, and 40
mEQ of potassium. Repeat K was 3.8, pt then admitted to
medicine.
Past Medical History:
asthma, osteoporosis, arthritis, left-sided deafness,
depression, PTSD, polysubstance abuse, EtOH abuse
Social History:
___
Family History:
Grandfather with ETOH liver disease
Physical Exam:
ADMISSION PE:
Vitals: 98.5; 158/106; 85; 18; 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear. Echymoses around bilateral eyes
Neck: Supple, JVP not elevated, no tonsillar or cervical
lymphadenopathy
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
Abdomen: Soft, diffuse tenderness to palpation, most notably in
RUQ and LLQ (notably, did not report significant pain with
stethscope test/palpation) non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly appreciated
Ext: Warm, well perfused, 1+ pulses, no edema
Skin: Multiple echymoses over bilateral shoulders, lower back,
legs
Neuro: A&Ox3. Mild tremor in bilateral upper extremities.
Tongue fasciculations. Strength ___ in bilateral upper
extremities.
DISCHARGE PE:
VS: 97.6; 157/109; 84; 20; 96RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation
HEART: RRR, no MRG
ABDOMEN: NABS, diffuse tenderness to mild palpation.
EXTREMITIES: WWP
NEURO: awake, A&Ox3. Toungue tremor, Bilateral fine tremor upper
hands
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-3.6* RBC-3.73* Hgb-12.9 Hct-36.6
MCV-98 MCH-34.6* MCHC-35.2* RDW-17.2* Plt ___
___ 05:00PM BLOOD Neuts-73.0* Lymphs-16.1* Monos-9.6
Eos-0.4 Baso-0.8
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-143
K-2.7* Cl-96 HCO3-28 AnGap-22*
___ 05:00PM BLOOD ALT-70* AST-169* AlkPhos-117* TotBili-1.3
___ 05:00PM BLOOD Lipase-95*
___ 05:00PM BLOOD Albumin-4.2
___ 05:00PM BLOOD ASA-NEG Ethanol-32* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-4.5# RBC-3.96* Hgb-13.9 Hct-39.7
MCV-100* MCH-35.0* MCHC-34.9 RDW-17.1* Plt ___
___ 05:30AM BLOOD Glucose-98 UreaN-8 Creat-0.5 Na-142 K-3.5
Cl-103 HCO3-30 AnGap-13
MICRO: None this admission
STUDIES/IMAGING:
LLE US: No evidence of deep venous thrombosis in the left lower
extremity veins.
CT Head/Sinus: Chronic appearing right zygomatic process
fracture though apparently new since study dated ___.
1. Approximately 9 mm hyperdensity within the inferior right
frontal lobe
concerning for intraparenchymal contusion. No significant mass
effect.
2. Prominent right frontal extra axial space is new from prior
examination and suggestive of chronic subdural hematoma.
RUQ US
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Status post cholecystectomy.
Brief Hospital Course:
___ PMH of acetaminophen-induced hepatitis (___), Alcoholism,
presents w/ ETOH Withdrawal and desire for inpatient detox.
# ETOH Withdrawal - Patient with significant EtOH dependency
who drinks 800cc spiced rum daily. Last drink ___ ~ lunch time.
Patient does not have history of withdrawel seizures. Responded
well to valium this admission. Initially required IV valium and
then transitioned to PO valium. Maintained on CIWA and scores
and benzo requirement steadily decreased this admission. Also
started patient on Thiamine, multivitamin and folate this
admission. SW provided patient with information on outpatient
EtOH programs.
# Transaminitis - pt noted to have transaminitis this admission.
Has known hx of hepatitis and significant EtOH hx. Follows in
liver clinic. AST/ALT trended down this admission. AP elevated,
but patient s/p cholycystectomy and RUQ US without evidence of
acute pathology. Patient plans to continue to follow with liver
clinic as an outpatient.
# Falls/Intraparenchymal Contusion - pt with multiple bruises of
different ages this admission. Noted to have zygomatic arch
fracture (old) and intraparenchmal contusion. Initially seen by
neurosurgery this admisison and repeated head CT which noted
stable contusion/intraparenchymal bleed. While patient
attributes falls to EtOH which was felt to be a reasonable
explanation, significant concern for intimate partner violence
this admission. SW and Dr. ___ met with patient and her
fiance and while there history is extremely high risk for IPV,
patient and fiance denied current abuse and demonstrated strong
coping mechanisms for arguments (see OMR note dated ___.
Regardless, patient was provided with information on where to
obtain support in the community if in fact IPV is a factor. Also
advised patient to call authorities if relationship were to
develop into IPV.
#HTN - patient reportedly hypertensive at baseline and also risk
for hypertesnive episodes with withdrawel. Started patient on
Amlodipine 5mg qD this admission and pressures remained stable
in the 140s systolic for most of her visit.
# CODE: FULL
# CONTACT: (___) Fiance/HCP ___
TRANSITIONAL ISSUES:
- F/u with hepatology
- f/u with neurosurgery in 1 month for repeat head CT
- Started on 5mg Amlodipine qD for hypertension this admission.
Can titrate up as needed
- Continue to encourage patient to enroll in outpatient EtOH
treatment programs
- Continue to monitor for further bruising/evidence of IPV and
provide support/counseling as able
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO DAILY:PRN tremulousness
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Diazepam 5 mg PO Q4H:PRN CIWA>10
RX *diazepam 5 mg 1 tab by mouth q6H:PRN Disp #*5 Tablet
Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*3
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Alcohol Withdrawel
Secondary Diagnosis:
- Hemorrhagic Brain Contusion
- Hypertension
- Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted for acute alcohol detoxification as well as a
possible bleed in your brain. The neurosurgeons saw you and you
had 2 head CTs performed which showed a stable bleed that may
have been old. You will need to follow up with the neurosurgeons
in 1 month.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10734591-DS-25
| 10,734,591 | 20,166,763 |
DS
| 25 |
2142-07-24 00:00:00
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2142-07-25 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / adhesive tape / Plavix / Lisinopril / Fish Oil /
erythromycin / latex / tramadol
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ ERCP
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ with multiple medical
problems including AF on apixiban and CVA with L-sideded
paralysis and CAD with angina, recently admitted for abdominal
pain and discharged ___ with new diagnosis of chronic
cholecystitis, presenting with return of abdominal pain.
In terms of his recent admissions, his first in ___
was negative for cardiac etiologies given presence in epigastrum
in addition to RUQ. He re-presented ___ and workup was notable
for no EKG changes, negative troponins, transaminitis and
elevated alk phos. Ultrasound showed chronic cholecystitis
without biliary duct dilation. HIDA scan confirmed the diagnosis
of chronic cholecystitis and did not show obstruction.
Percutaneous biliariy drain and surgery were discussed but
neither were ultimately offered.
Per patient, he was discharged able to only take a little bit of
bland food but had no significant pain. He had minimal appetite
or PO intake since discharge. On the morning of admission
(___), he had recurrence of severe epigastric pain,
non-radiating, accompanied by nausea. He thinks he may have
vomiting. He denies fevers, chills, diarrhea, chest pain, or
dyspnea. He does endorse dysuria for several days.
In the ED, initial vitals: 99 (Tm 101.8) | 79 | 134/62 | 22 |
95% NC
#EXAM notable for: Basilar rales; upper abdomen TTP
#LABS notable for:
- H/H 12.3/38.5
- WBC 12.6, 86% PMNs
- Na-136 | K-3.6 | Cl-98 | Bicarb-21 | BUN-25 | Cr-1.1 | AG 17
- AST 283 | ALT 245 | AP 669 | Tbili 2.9
- Lipase 9005 (up from 37 on ___
- Lactate 2.5
- pH 7.36 | CO2 43 | O2 44 | HCO3 25
- Blood and Urine cultures pending
#IMAGING showed:
___ CXR PA&LATERAL IMPRESSION: Low lung volumes, which
accentuate the bronchovascular markings. Persistent elevation of
the right hemidiaphragm. Bibasilar opacities most likely due to
atelectasis but consolidation from infection or aspiration not
excluded.
___ LIVER OR GALLBLADDER US IMPRESSION: Compared to ___, no significant change in sludge within the
gallbladder. No evidence of acute cholecystitis.
#PATIENT was given:
- 2mg morphine IV
- 10mg diltiazem IV
- 400mg ciprofloxacin IV
- 500mg metronidazole IV
- 500cc NS
#Consults included ERCP & Surgery.
In the ED he was given morphine for pain and within 20 minutes
became hypotensive to 68/39. He was started on levophed and
required as much as 1.8mcg/min, but was downtitrated to .124
(pressures 103/60-140/67) prior to transfer.
Due to hypotension, decision was made to admit the ICU with plan
for ERCP ___ AM.
Vitals on transfer were 77 | 128/58 | 21 | 99%NC
On arrival to the MICU, the patient is stable and was
immediately weaned to 0.03 levophed. He is mentating and not in
any pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Mild dyspnea. Mild ___ edema x months.
Denies chest pain or tightness, palpitations. No recent change
in bowel or bladder habits. No dysuria. Endorses dysuria.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
ATRIAL FIBRILLATION
CORONARY ARTERY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
MILD COGNITIVE IMPAIRMENT
DEPRESSION
INSOMNIA
LUMBAR SPONDYLOSIS
BILATERAL SHOULDER PAIN
OSTEOARTHRITIS
FRONTAL GAIT DISORDER
GASTROESOPHAGEAL REFLUX
HEARING LOSS
NOCTURNAL PERIODIC LEG MOVEMENT DISORDER
MODERATE SLEEP DISORDERED BREATHING
HIATAL HERNIA
ANNUAL WELLNESS VISIT
H/O CVA AND LEFT HEMIAPRESIS
H/O GASTROINTESTINAL BLEEDING
H/O PULMONARY NODULE
H/O MULTIPLE SCLEROSIS
H/O ALLERGIC RHINITIS
TONSILLECTOMY
TRANSURETHRAL PROSTATECTOMY
APPENDECTOMY
CATARACT SURGERY
Both eyes
Social History:
___
Family History:
Father - CAD, details unknown
Mother - gastric cancer.
No DM/HTN/thyroid disease in family known.
Physical Exam:
On Admission:
VITALS: 98.5 | 76 | 18 | 93% 2LNC
GENERAL: Alert, elderly man appearing well-nourished and in no
acute distress.
HEENT: Pupils equal and reactive. Dry mucous membranes.
NECK: Right IJ with evidence of ongoing slow bleed
CARDIAC: RRR, no m/r/g appreciated.
LUNG: Clear to auscultation of lateral fields
ABDOMEN: Distended but not tense. +active BS. Tender to
palpation epigastric region. Not tender to palpation of RUQ or
LUQ. RLQ scar tissue.
EXTREMITIES: WWP, 1+ pitting edema in bilateral ___.
PULSES: 2+ DP and radial pulses bilaterally
NEURO: Oriented to month, year, ___, but not day. Not
attentive to DOWB ___ over ___ seconds, then "I lost
track"). Remembered meeting admitting intern 2 hours later. Left
sided baseline wrist flexion. Left sided strength broadly ___
vs. ___ on the right.
On Discharge:
VITALS: 97.5 134/75 61 18 93% RA
GEN: Lying in bed, comfortable, but tired appearing
HEENT: EOMI, dry mucous membranes, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: Clear to auscultation
GI: Distended but soft, nontender throughout, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: Oriented to self, hospital, year, not date. Strength ___ in the LUE, ___ in the RLE, ___ in the LLE
PSYCH: Tired appearing, calm, cooperative
EXTREMITIES: WWP, no edema
Pertinent Results:
On Admission:
___ 08:45PM BLOOD WBC-12.6* RBC-4.06* Hgb-12.3* Hct-38.5*
MCV-95 MCH-30.3 MCHC-31.9* RDW-14.2 RDWSD-49.4* Plt ___
___ 02:42AM BLOOD ___ PTT-30.4 ___
___ 08:45PM BLOOD Glucose-124* UreaN-25* Creat-1.1 Na-136
K-3.6 Cl-98 HCO3-21* AnGap-21*
___ 08:45PM BLOOD ALT-245* AST-283* AlkPhos-669*
TotBili-2.9*
___ 08:45PM BLOOD Lipase-9005*
___ 05:11AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.6
___ 09:01PM BLOOD Lactate-2.5*
Interval:
___ 08:45PM BLOOD ALT-245* AST-283* AlkPhos-669*
TotBili-2.9*
___ 05:11AM BLOOD ALT-224* AST-214* AlkPhos-555*
TotBili-4.0* DirBili-3.6* IndBili-0.4
___ 04:26AM BLOOD ALT-133* AST-79* LD(LDH)-159 AlkPhos-382*
TotBili-1.1
___ 07:27AM BLOOD ALT-94* AST-41* LD(___)-201 AlkPhos-341*
TotBili-0.6
___ 08:45PM BLOOD Lipase-9005*
___ 04:26AM BLOOD Lipase-1556*
___ 07:27AM BLOOD Lipase-378*
___ 09:01PM BLOOD Lactate-2.5*
___ 07:03AM BLOOD Lactate-1.6
Imaging:
___ CXR
Low lung volumes, which accentuate the bronchovascular markings.
Persistent elevation of the right hemidiaphragm. Bibasilar
opacities most likely due to atelectasis but consolidation from
infection or aspiration not excluded.
___ RUQ US
Compared to ___, no significant change in sludge
within the
gallbladder. No evidence of acute cholecystitis.
___ CXR
In comparison to prior radiograph, the pulmonary edema appears
to be
improving. Left-sided central line terminates in the cavoatrial
junction. No focal consolidations concerning for pneumonia.
Mild bilateral pleural effusions. Bibasilar atelectasis.
___ 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 papillar appeared normal.
The CBD was successfully cannulated with the Hydratome
sphincterotome preloaded with a 0.035in guidewire.
The guidewire was advanced into the intrahepatic biliary tree.
Careful contrast injection revealed a CBD of approximately 8mm
and a small filling defect consistent with a stone in the mid
CBD.
The intrahepatic biliary tree appeared normal.
Sphincterotomy and stone extraction was not performed due to
patient's anticoagulation status and ongoing cholangitis.
A ___ X 5cm Advanix double pigtail biliary stent was
successfully placed across the ampulla.
Spontaneous drainage of pus material was noted.
The PD was not injected or cannulated.
Pertinent interval:
___ 08:45PM BLOOD ALT-245* AST-283* AlkPhos-669*
TotBili-2.9*
___ 05:11AM BLOOD ALT-224* AST-214* AlkPhos-555*
TotBili-4.0* DirBili-3.6* IndBili-0.4
___ 04:26AM BLOOD ALT-133* AST-79* LD(___)-159 AlkPhos-382*
TotBili-1.1
___ 07:27AM BLOOD ALT-94* AST-41* LD(___)-201 AlkPhos-341*
TotBili-0.6
___ 07:50AM BLOOD ALT-67* AST-30 AlkPhos-288* TotBili-0.5
___ 08:12AM BLOOD ALT-56* AST-36 AlkPhos-270* TotBili-0.5
___ 08:45PM BLOOD Lipase-9005*
___ 04:26AM BLOOD Lipase-1556*
___ 07:27AM BLOOD Lipase-378*
___ 08:12AM BLOOD Lipase-218*
Labs on Discharge:
___ 08:30AM BLOOD WBC-9.2 RBC-3.75* Hgb-11.7* Hct-35.9*
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.8 RDWSD-48.0* Plt ___
___ 08:30AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
___ 08:12AM BLOOD ALT-56* AST-36 AlkPhos-270* TotBili-0.5
___ 08:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.7
Brief Hospital Course:
Mr. ___ is an ___ year old man with complex PMHx including AF
on apixaban, hx of CVA resulting in L. sided paralysis, HTN,
HLD, and CAD with angina, who presents
after recent admission with diagnosis of chronic cholecystitis
(no CCY or percutaneous cholecystostomy tube performed)
initially admitted to the FICU with shock secondary to acute
gallstone pancreatitis, now s/p ERCP with biliary stent
placement, clinically improved and called out to the medicine
floor.
# Gallstone pancreatitis:
# Cholangitis:
# Septic shock:
Patient presented with septic shock initially requiring pressors
with elevated lipase to 9000 and a stone in the CBD. He
underwent ERCP with pus extraction, s/p stent placement.
Sphincterotomy not performed due to high risk of bleeding on
apixaban. He remains on antibiotics (PO). Septic shock resolved,
LFTs/lipase subsequently downtrended and he clinically improved.
Plan for 14 days of Cipro/flagyl (Day ___ through ___.
# Chronic cholecystitis: Patient has had intermittent abdominal
pain over the past several months. He was admitted on ___ and
ultrasound did not show biliary duct dilation. HIDA scan
confirmed the diagnosis of chronic cholecystitis and did not
show
obstruction. Percutaneous biliary drain and surgery were
discussed but neither were ultimately offered. He now represents
with complication of cholelithiasis (pancreatitis, cholangitis),
with pus noted on ERCP s/p stent placement. Ultimately needs
stone removal and CCY vs perc chole. Case complicated by
anticoagulation (needs apixaban due to high risk of CVA with
prior hx of CVA off apixaban) and cardiac history (stable
angina). He will need repeat ERCP in ___ weeks for stent pull
and stone removal as well as follow up with ACS in ___ weeks
post-discharge for consideration of CCY
# Mild fluid overload: Patient with new 02 requirement during
his admission, likely secondary to fluid resuscitation in the
ICU and component of atelectasis. He was diuresed and treated
with incentive spirometry and weaned off ___.
# Urinary retention: Patient with new urinary retention
requiring straight catheterization after transfer from the ICU.
Home tamsulosin has been on hold on admission given septic
shock. Tamsulosin was restarted. He failed a voiding trial on
___ and required straight catheterization given persistent post
void residual >500cc. His foley was replaced prior to discharge
to rehab. He should have a voiding trial in the next ___ days.
CHRONIC HOME ISSUES
======================
#S/P CVA: On apixaban. Patient is very concerned about being off
this for any time due to his concern for repeat CVA. Will need
to be bridged prior to repeat ERCP
#ATRIAL FIBRILLATION: Continued apixaban, metoprolol.
#HYPERTENSION: Continued on losartan once septic shock resolved
#GERD: Home omeprazole
#DEPRESSION, INSOMNIA: Continued sertraline, mirtazapine
# Code: DNR/DNI
Transitional:
- Cipro/flagyl through ___
- Repeat ERCP in ___ weeks for stent pull and stone removal,
patient to be called with appointment date/time
- F/U with ACS in ___ weeks post-discharge for consideration of
CCY. Phone number provided to patient/family.
- Please repeat voiding trial in the next ___ days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q12H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
3. Apixaban 5 mg PO BID
4. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Mirtazapine 30 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
13. Omeprazole 20 mg PO DAILY
14. Pravastatin 80 mg PO QPM
15. Sertraline 50 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
18. biotin 2 mg oral Q24H
19. flunisolide 25 mcg (0.025 %) nasal DAILY
20. Psyllium Powder 1 PKT PO DAILY
21. white petrolatum 454 gram topical Q24H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO Q8H
3. Acetaminophen ___ mg PO Q12H:PRN pain
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
5. Apixaban 5 mg PO BID
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
7. biotin 2 mg oral Q24H
8. Cyanocobalamin 1000 mcg PO DAILY
9. flunisolide 25 mcg (0.025 %) nasal DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Mirtazapine 30 mg PO QHS
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
17. Omeprazole 20 mg PO DAILY
18. Pravastatin 80 mg PO QPM
19. Psyllium Powder 1 PKT PO DAILY
20. Sertraline 50 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. Vitamin D 1000 UNIT PO DAILY
23. white petrolatum 454 gram topical Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Septic shock secondary to cholangitis
Gallstone pancreatitis
Secondary:
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a severe gastrointestinal infection. This
was caused by a stone in one of your bile ducts causing
obstruction. It was also causing severe inflammation of your
pancreas. You underwent a procedure to relieve this obstruction.
You were started on antibiotics with improvement in your
infectious symptoms.
You were evaluated by physical therapy who advised that you be
discharged to rehab.
During your hospitalization you were unable to void on your own.
This is not uncommon. You will be discharged with a foley and
will undergo another voiding trial when you are at rehab.
It was a pleasure to be a part of your care!
Your ___ treatment team
Followup Instructions:
___
|
10734591-DS-26
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DS
| 26 |
2142-08-10 00:00:00
|
2142-08-13 11:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / adhesive tape / Plavix / Lisinopril / Fish Oil /
erythromycin / latex / tramadol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man with history of CVA and
residual L sided paralysis, Afib on Apixaban, CAD, chronic
cholecystitis, and recent FICU admission for septic shock
secondary to gallstone pancreatitis/cholangitis and discharged
___ , who is presenting with left sided abdominal pain and
diarrhea, found to have C diff at rehab.
The patient shares that his symptoms began two days ago. He is
having left sided abdominal pain, and diarrhea. Patient has not
noted blood. He has had no fevers, chills, nausea or vomiting.
He has had bilateral testicular pain that started last night,
with no dysuria. Pain is much improved on the floor. Patient
found to have positive C diff at Rehab this morning.
Of note, patient was admitted ___ with gallstone
pancreatitis/cholangitis, course complicated by septic shock
requiring FICU admission. The patient underwent stent placement
___, and subsequently improved. He was discharged on a course
of cipro/flagyl, of which he finished on ___.
In the ED, initial vitals were: 99.6 81 111/42 16 94 RA. On exam
abdomen was tender in the LLQ, scrotal exam was notable for
tenderness of posterolateral aspect of the left testicle. Labs
were notable for WBC 13.5, Hb 11.6, Cr 1, K 4.6, Bicarb 24,
Lactate 1.1, LFTs wnl, Lipase 53. Scrotal US showed no
testicular torsion or hypervascularity. CT AP showed wall
thickening of sigmoid colon and rectom, and stranding in pelvis
and perirectal fat, c/w proctocolitis. He was given 2L NS and
started on IV flagyl 500 mg.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
ATRIAL FIBRILLATION
CORONARY ARTERY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
MILD COGNITIVE IMPAIRMENT
DEPRESSION
INSOMNIA
LUMBAR SPONDYLOSIS
BILATERAL SHOULDER PAIN
OSTEOARTHRITIS
FRONTAL GAIT DISORDER
GASTROESOPHAGEAL REFLUX
HEARING LOSS
NOCTURNAL PERIODIC LEG MOVEMENT DISORDER
MODERATE SLEEP DISORDERED BREATHING
HIATAL HERNIA
ANNUAL WELLNESS VISIT
H/O CVA AND LEFT HEMIAPRESIS
H/O GASTROINTESTINAL BLEEDING
H/O PULMONARY NODULE
H/O MULTIPLE SCLEROSIS
H/O ALLERGIC RHINITIS
TONSILLECTOMY
TRANSURETHRAL PROSTATECTOMY
APPENDECTOMY
CATARACT SURGERY
Both eyes
Social History:
___
Family History:
Father - CAD, details unknown
Mother - gastric cancer.
No DM/HTN/thyroid disease in family known.
Physical Exam:
Admission Physical Exam:
========================
Vital Signs: 98.5PO 137 / 66 96 16 92 ra
General: Sleeping, oriented, no acute distress. Pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear w/ poor
dentition, EOMI, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anterolaterally as
patient unable to turn
Abdomen: Soft, tender in LLQ, non-distended, negative ___,
no rebound or guarding
GU: No foley. No scrotal erythema or swelling. + scrotal
tenderness to palpation
Ext: Warm, well perfused, teds in place. No overt edema
Neuro: A&Ox3, EOMI, Able to squeeze with L hand. Wiggles both
toes, can't lift L leg.
Discharge Physical Exam:
========================
Vital Signs: 97.7 123/62 81 16 93 RA
General: Sleeping, oriented, no acute distress. Pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear w/ poor
dentition, EOMI, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anterolaterally as
patient unable to turn
Abdomen: Soft, tender in LLQ, non-distended, negative ___,
no rebound or guarding
GU: No foley. + scrotal tenderness to palpation, mild
irritation/erythema
Ext: Warm, well perfused, teds in place. No overt edema
Neuro: A&Ox3, EOMI, Able to squeeze with L hand. Wiggles both
toes, can't lift L leg.
Pertinent Results:
Labs:
=====
___ 02:20PM BLOOD WBC-13.5* RBC-3.71* Hgb-11.6* Hct-35.5*
MCV-96 MCH-31.3 MCHC-32.7 RDW-14.2 RDWSD-50.1* Plt ___
___ 08:28AM BLOOD WBC-13.5* RBC-3.50* Hgb-10.9* Hct-33.7*
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.3 RDWSD-50.6* Plt ___
___ 02:20PM BLOOD Neuts-77.5* Lymphs-9.9* Monos-9.1 Eos-2.1
Baso-0.4 Im ___ AbsNeut-10.46* AbsLymp-1.34 AbsMono-1.23*
AbsEos-0.28 AbsBaso-0.06
___ 02:20PM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-135
K-4.6 Cl-97 HCO3-24 AnGap-19
___ 08:28AM BLOOD Glucose-92 UreaN-16 Creat-0.8 Na-140
K-4.0 Cl-101 HCO3-23 AnGap-20
___ 02:20PM BLOOD ALT-12 AST-34 AlkPhos-91 TotBili-0.9
___ 02:20PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.5 Mg-1.7
___ 08:28AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8
___ 02:30PM BLOOD Lactate-1.1
Imaging:
========
Scrotal US:
No evidence testicular torsion or hypervascularity involving
either testicle.
0.5 x 0.4 cm extratesticular calcified structure most likely
represents a
scrotal pearl.
CT Abd/Pelvis:
1. Wall thickening and hyperemia involving the, ascending colon,
sigmoid colon and rectum as well as adjacent fat stranding in
the pelvic and perirectal fat consistent with proctocolitis,
likely inflammatory or infectious. No free air or drainable
fluid collection in the abdomen or pelvis.
Brief Hospital Course:
Mr. ___ is an ___ year old man with history of CVA and
residual L sided paralysis, Afib on Apixaban, CAD, chronic
cholecystitis, and recent FICU admission for septic shock
secondary to gallstone pancreatitis/cholangitis and discharged
___, who is presenting C diff proctocolitis and scrotal pain.
# C diff: CT notable for proctocolitis, consistent with recent
positive C diff culture. He had mild leukocytosis to 13.5. He
was started on PO vancomycin and clinical condition remained
stable. He will require at least a 10 day course of PO
vancomycin finishing ___
# Scrotal pain: US nonrevealing. Mild irritation/erythema likely
irritation in the setting of recent diarrhea
# Atrial fibrillation: continued apixaban 5 mg PO BID,
fractionated home metoprolol
# Chronic cholecystitis c/b h/o gallstone
pancreatitis/cholangitis: On presentation there were no acute
symptoms. Per prior notes:
- ERCP due in early ___
- Anticoag plan per outpatient notes:
1) Apixaban last dose in the evening of ___,
2) Lovenox 80mg BID from ___ and last dose in the morning of
___ (total of 3 doses),
3) ERCP and sphincterotomy on ___ ___
4) Resume Apixaban on ___ AM
- No additional abx at this time
# S/p CVA: Has residual L-sided weakness, ___: continued
apixaban
# HTN: continued home losartan, fractionated metoprolol as above
# Anemia: At baseline. Monitored
# GERD: continued home omeprazole
# Depression
# Insomnia: continued mirtazapine and sertraline
# CAD: continued pravastatin
# H/o urinary retention: continued tamsulosin
Transtional Issues:
====================
- discharged on PO vancomycin 125mg Q6h for 10 days (last day
___
- ERCP due in early ___
- Anticoag plan per outpatient notes:
1) Apixaban last dose in the evening of ___,
2) Lovenox 80mg BID from ___ and last dose in the morning of
___ (total of 3 doses),
3) ERCP and sphincterotomy on ___ ___
4) Resume Apixaban on ___ AM
- No additional abx at this time
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen ___ mg PO Q12H:PRN pain
2. Apixaban 5 mg PO BID
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
4. Cyanocobalamin 1000 mcg PO DAILY
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Losartan Potassium 25 mg PO DAILY
8. Mirtazapine 30 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D 1000 UNIT PO DAILY
14. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
15. biotin 2 mg oral Q24H
16. flunisolide 25 mcg (0.025 %) nasal DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
19. Pravastatin 80 mg PO QPM
20. Psyllium Powder 1 PKT PO DAILY
21. white petrolatum 454 gram topical Q24H
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
2. Acetaminophen ___ mg PO Q12H:PRN pain
3. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
4. Apixaban 5 mg PO BID
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
6. biotin 2 mg oral Q24H
7. Cyanocobalamin 1000 mcg PO DAILY
8. flunisolide 25 mcg (0.025 %) nasal DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Losartan Potassium 25 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Mirtazapine 30 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
16. Omeprazole 20 mg PO DAILY
17. Pravastatin 80 mg PO QPM
18. Psyllium Powder 1 PKT PO DAILY
19. Sertraline 50 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
21. Vitamin D 1000 UNIT PO DAILY
22. white petrolatum 454 gram topical Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
C difficile colitis
Scrotal dermatitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were sent in after you developed abdominal pain and
diarrhea. This is likely due to an infection called C diff. We
started you on antibiotics to treat the infection.
It was a pleasure taking care of you, and we are happy that you
are feeling better!
Followup Instructions:
___
|
10734591-DS-28
| 10,734,591 | 22,575,108 |
DS
| 28 |
2143-05-13 00:00:00
|
2143-05-13 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / adhesive tape / Plavix / Lisinopril / Fish Oil /
erythromycin / latex / tramadol
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Afib on apixaban, HTN, CVA with L sided paralysis,
CAD, h/o choloangitis, gallstone pancreatitis with septic shock
s/p ERCP with stent placement, and VRE in urine and recent
diagnosis of bullous pemphigoid on a prednisone taper who
presents with 10 days of increased fatigue, difficulty
swallowing, abdominal pain, nausea with a sudden worsening
today.
Per EMS report, patient was found laying in bed, tachypneic at
24bpm, speaking in ___ word sentences. Skin hot, dry, normal
color. Of note, the majority of his history is obtained from the
records and from report from his wife, and patient is somewhat
somnolent and confused, though he is able to answer questions
regarding symptoms, and notes currently no chest pain, abdominal
pain, or shortness of breath. No dysuria or diarrhea. Per
report, his wife claims he's had intermittent abdominal pain and
has had darkening of his urine the past few days. He has been
coughing every time he tries to drink recently and has decreased
PO in general.
In the ED, initial VS were: 101.5 101 126/54 10 94% RA
Exam notable for:
Con: alert, oriented to person and place, in no apparent
discomfort but wife states this is not baseline for him
HEENT: NCAT. PERRLA, no icterus. EOMI. erythematous tongue with
poor dentition
Neck: soft, supple, no LAD
Resp: poor air flow bilaterally with diminished sounds basilar
regions bilaterally. No incr WOB; no wheezes, rhonchi, or rales.
CV: RRR. Normal S1/S2. NMRG. 2+ radial pulse and DP pulses
bilaterally
Abd: Soft, Nontender, Nondistended.
MSK: ___ well perfused with no edema
Skin: left leg has blanchable erythematous rash present on
medial aspect of left leg with extension dorsally and inferiorly
distal to knee; warm to touch; no abrasions; no pus; No
petechiae
Neuro: AOx2 (person and place, but not time), answers simple
questions and responds to commands. Moves RUE and RLE; no LUE
and LLE movement (baseline after CVA) no obvious facial
asymmetry
Psych: altered from baseline
Labs showed:
Electrolytes were notable for Na of 130, K hemolyzed, 7.4, was
5.8 then 4.2 on repeat. Cr of 0.9. Lactate of 1.8. Normal UA.
INR of 1.4. CBC with WBC 19.6, H/H 12.2/36.7, Plts 184.
Imaging showed:
CT Abd and pelvis:1. No acute CT findings to correlate with
patient's reported symptoms, specifically, no colitis.
2. A locule of gas is seen at the level of the sphincter of
Oddi, which may be related to prior procedure. Please correlate
with patient's history.
3. Foley catheter is seen in a decompressed bladder.
RUQ u/s:
1. No evidence of cholecystitis. Gallstone better seen on recent
CT due to overlying bowel gas.
2. Multiple hepatic cysts, the largest is 3.7 cm in the left
hepatic lobe.
CXR:
IMPRESSION:
Bibasal atelectasis.
Patient received:
1l NS
Vanc and zosyn
IV Tylenol
Transfer VS were: 98.4 (Tm 102) 95 137/60 22 97% RA
On arrival to the floor, patient is lethargic but arousable. Is
not currently noting any pain. Knows the year and month, but
isn't sure about the year. Is able to tell me that he thinks he
has a skin infection. Able to tell me his home number but wrong
street. Notes no current pain, shortness of breath. ROS
otherwise per above.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Chronic cholecystitis
Cholangitis with septic shock
Gallstone pancreatitis
A-fib on Apixaban
CVA w/ residual L-sided weakness
CAD
HTN
HLD
GERD
OA
C diff
Anemia
Mild cognitive impairment
Depression
Insomnia
Sleep disordered breathing
BPH s/p TURP
Social History:
___
Family History:
Mother had gastric cancer
Father - CAD, details unknown
Mother - gastric cancer.
No DM/HTN/thyroid disease in family known.
Physical Exam:
===================
ADMISSION EXAM
===================
VS: 98.6 137/74 96 20 96% RA
GENERAL: A&Ox3, but confused about details about where he lives,
and not sure about the year (though says ___, in NAD.
HEENT: AT/NC, EOMI, PERRL, MMM, poor dentition
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: diminished air sounds anteriorly, no crackles, rhonchi.
+upper airway transmitted sounds. shallow breaths
ABDOMEN: nondistended, some tenderness in the RLQ, no tenderness
in the RUQ with deep palpation.
EXTREMITIES: No ___ edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3 (per above), Limited movement of LUE and LLE,
~II/V. able to move RUE and RLE. CNII-XII intact.
SKIN: Erythematous, warm rash on medial left leg, no abrasions
or drainage.
===================
DISCHARGE EXAM
===================
VS: 98.2 128 / 72 81 1893Ra
General: AOx3, in no acute distress
HEENT: Anicteric sclerae, moist mucous membranes
Resp: Lungs clear to auscultation bilaterally
CV: RRR
Abd: soft, nondistended, nontender.
Skin: Erythema of left leg significantly improved, now faint.
Erythema in right antecubital fossa resolved.
Neuro: CNII-XII grossly intact; moving LUE and R extremities.
Pertinent Results:
====================
ADMISSION LABS
====================
___ 06:18PM BLOOD WBC-19.6*# RBC-3.77* Hgb-12.2* Hct-36.7*
MCV-97 MCH-32.4* MCHC-33.2 RDW-15.6* RDWSD-54.8* Plt ___
___ 07:55AM BLOOD Neuts-79* Bands-3 Lymphs-11* Monos-3*
Eos-2 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-11.97*
AbsLymp-1.61 AbsMono-0.44 AbsEos-0.29 AbsBaso-0.15*
___ 06:18PM BLOOD ___ PTT-31.3 ___
___ 04:30PM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-130*
K-7.4* Cl-92* HCO3-23 AnGap-15
___ 04:30PM BLOOD ALT-19 AST-102* AlkPhos-63 TotBili-1.1
====================
PERTINENT RESULTS
====================
MICROBIOLOGY
====================
__________________________________________________________
___ 5:58 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
====================
IMAGING/STUDIES
====================
CXR (___): Bibasal atelectasis.
===
CT Abdomen/Pelvis With Contrast (___):
1. No acute CT findings to correlate with patient's reported
symptoms, specifically, no colitis.
2. A locule of gas is seen at the level of the sphincter of
Oddi, which may be related to prior procedure. Please correlate
with patient's history.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Foley catheter is seen in a decompressed bladder.
===
Left lower extremity ultrasound (___): No evidence of deep
venous thrombosis in the left lower extremity veins.
===
Videoswallow study (___): Penetration and silent aspiration
with thin liquids in neutral head position and with chin tuck
with large sips. Please refer to the speech and swallow division
note in OMR for full details, assessment, and recommendations.
====================
DISCHARGE LABS
====================
___ 08:25AM BLOOD WBC-11.4* RBC-2.92* Hgb-9.5* Hct-28.8*
MCV-99* MCH-32.5* MCHC-33.0 RDW-15.7* RDWSD-55.7* Plt ___
___ 08:25AM BLOOD Glucose-87 UreaN-11 Creat-1.0 Na-139
K-4.0 Cl-100 HCO3-27 AnGap-12
___ 08:25AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ y/o man with history of atrial fibrillation
on apixban, CVA with residual left-sided weakness, dependent of
ADLs and IADLs, who presented with altered mental status and
fever and was found to have left leg cellulitis. The patient was
treated with vancomycin and narrowed to Bactrim to complete a
14-day course (Last day: ___. The patient's cellulitis
resolved with antibiotic therapy, and with treatment of his
cellulitis his mental status improved. He had returned to
baseline by time of discharge. While hospitalized, the patient
also developed a pruritic eczematous rash on his torso.
Dermatology was consulted and recommended topical steroids, as
well resuming his medications for bullous pemphigoid.
=================
ACUTE ISSUES:
=================
# Toxic-metabolic encephalopathy
# Cellulitis: Patient presented with altered mental status and
fever and was found to have left lower extremity cellulitis. The
patient was treated with vancomycin and narrowed to Bactrim to
complete a 14-day course (Last day: ___. The patient's
cellulitis resolved with antibiotic therapy, and with treatment
of his cellulitis his mental status improved to baseline.
# Rash: While hospitalized, the patient also developed a
pruritic eczematous rash on his torso. He had no evidence of
bullae or pre-bullous lesions. This was thought to be a drug
rash. Dermatology was consulted and recommended topical
steroids, as well resuming his medications for bullous
pemphigoid.
===================
CHRONIC ISSUES:
===================
# Atrial fibrillation: Continued apixaban Held metoprolol due to
borderline low blood pressures.
# HTN: Held metoprolol. Held losartan.
# HLD: Continued pravastatin.
# Dementia: Continued memantine.
# Depression: Continued sertraline.
# GERD: Continued omeprazole.
=======================
TRANSITIONAL ISSUES:
=======================
- Patient to continue Bactrim for treatment of cellulitis (Last
day: ___
- Patient to continue doxycycline and niacin for bullous
pemphigoid; oral prednisone discontinued; he will follow up with
dermatology
- Metoprolol and losartan held during acute illness; please
check blood pressure at next PCP appointment and restart these
medications as appropriate
- Hoyer lift installed in home
- Consider discontinuing pravastatin and multivitamin given
patient's age and high pill burden
- Patient administered influenza vaccine on ___
- Communication: Wife ___ ___ (c)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Losartan Potassium 25 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Mirtazapine 30 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 80 mg PO QPM
13. Sertraline 50 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
16. Apixaban 5 mg PO BID
17. biotin 2 mg oral Q24H
18. flunisolide 25 mcg (0.025 %) nasal DAILY
19. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN
heartburn
20. PredniSONE Dose is Unknown PO DAILY
21. Memantine 10 mg PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth Twice a day Disp #*11 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN
heartburn
4. Apixaban 5 mg PO BID
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Eyes
6. biotin 2 mg oral Q24H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Doxycycline Hyclate 100 mg PO Q12H
9. flunisolide 25 mcg (0.025 %) nasal DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Memantine 10 mg PO DAILY
13. Mirtazapine 30 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Niacin (niacinamide) (niacinamide) 500 mg oral TID
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
17. Omeprazole 20 mg PO DAILY
18. Pravastatin 80 mg PO QPM
19. Sertraline 50 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
21. Vitamin D 1000 UNIT PO DAILY
22. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your regular
doctor tells you to restart
23. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your regular doctor tells you to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Cellulitis
- Toxic metabolic encephalopathy
SECONDARY:
- History of cerebrovascular accident with residual left-side
weakness
- Bullous pemphigoid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having fevers and
you were confused
WHAT HAPPENED IN THE HOSPITAL?
- We found that you had an infection of the skin of your leg
- We gave you antibiotics to treat this, as you felt better
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your antibiotics
We wish you the best of health,
- Your Care Team at ___
Followup Instructions:
___
|
10734591-DS-29
| 10,734,591 | 27,504,814 |
DS
| 29 |
2143-10-07 00:00:00
|
2143-10-07 18:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / adhesive tape / Plavix / Lisinopril / Fish Oil /
erythromycin / latex / tramadol
Attending: ___
___ Complaint:
chest pain/epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with h/o CAD, CVA w L sided paralysis, afib on
apixaban, h/o abdominal pain, constipation, HTN, HLD, mild
cognitive impairment, who presents for evaluation of abdominal
pain.
Patient was in his USOH until ___ when he woke up with acute
epigastric pain and chest pain. He presented to the ED where
symptoms were concerning for ACS. He had troponins checked and
stress MIBI which showed no evidence of ischemic disease. He had
CT abd/pelvis that was negative for any acute etiology of his
pain. He was discharged home. At home he reports feeling
slightly
improved until today when his symptoms returned.
Specifically he reports ___ abdominal pain, mostly
periumbilical
without radiation. Cannot further characterize as sharp, dull,
stabbing, etc. States it is "just pain." A/w nausea, dry heaves.
Denies chest pain specifically. Does endorse SOB which is mild.
Last BM was yesterday which is typical for him. He reports that
___ are always difficult for him in terms of constipation
because his caretaker is not there to ensure he has a BM and
cleans him. He has been taking Tylenol for the pain without
relief. EMS did give SL nitro (although clearly denies CP to me)
which did not provide relief.
In the ED, initial VS were: 97.9 68 142/56 15 96% RA
Exam notable for:
A+Ox3, skin PWD, speaks in full clear sentences.
Labs showed:
WBC 11.7
lipase 114
LFTs wnl
Cr 1.0
tropT <0.01
INR 1.3 PTT 32.3
Imaging showed:
RUQ U/S: 1. No evidence of cholecystitis. Unchanged gallbladder
sludge and gallbladder neck stone without distension or
gallbladder wall thickening.
2. Multiple hepatic cysts, largest measuring up to 2.6 cm in the
left hepatic lobe.
CXR: IMPRESSION: No acute cardiopulmonary process.
Consults: none
Patient received:
1L IVF
Tylenol 1g
Zofran 4 mg IV
Transfer VS were: pain 8 98.2 80 169/83 20 94% RA
Past Medical History:
Chronic cholecystitis
Cholangitis with septic shock
Gallstone pancreatitis
A-fib on Apixaban
CVA w/ residual L-sided weakness
CAD
HTN
HLD
GERD
OA
C diff
Anemia
Mild cognitive impairment
Depression
Insomnia
Sleep disordered breathing
BPH s/p TURP
Social History:
___
Family History:
Mother had gastric cancer
Father - CAD, details unknown
Mother - gastric cancer.
No DM/HTN/thyroid disease in family known.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VS: 97.6 ___ Ra
GENERAL: NAD, lying comfortably in bed. able to do days of week
backwards, knows ___, ___
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: moderately distended, TTP in lower abdomen, no
rebound/guarding
EXTREMITIES: no edema
PULSES: doppler DP pulses bilaterally
NEURO: A&Ox3, LUE w ___ strength; LLE w ___ strength; face
symmetric. Intact sensation to touch throughout
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
============================
VS: 98.3PO 94 / 49 82 18 92 Ra
GENERAL: NAD, lying comfortably in bed.
HEENT: anicteric sclera, pink conjunctiva, MMM
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes, breathing comfortably without use of
accessory muscles
ABDOMEN: Mildly distended, non-tender, no rebound/guarding
EXTREMITIES: no edema , wwp
NEURO: A&Ox3, CN III-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
===================
___ 08:14PM BLOOD WBC-11.7* RBC-4.16* Hgb-13.5* Hct-41.1
MCV-99* MCH-32.5* MCHC-32.8 RDW-13.2 RDWSD-48.2* Plt ___
___ 08:14PM BLOOD Neuts-78.8* Lymphs-10.3* Monos-5.2
Eos-3.6 Baso-0.9 Im ___ AbsNeut-9.24* AbsLymp-1.21
AbsMono-0.61 AbsEos-0.42 AbsBaso-0.10*
___ 08:34PM BLOOD ___ PTT-32.3 ___
___ 08:14PM BLOOD Glucose-123* UreaN-15 Creat-1.0 Na-140
K-5.1 Cl-101 HCO3-25 AnGap-14
___ 08:14PM BLOOD ALT-12 AST-34 AlkPhos-64 TotBili-0.3
___ 08:14PM BLOOD Lipase-114*
___ 03:58AM BLOOD Lipase-51
___ 08:14PM BLOOD cTropnT-<0.01
___ 03:58AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:14PM BLOOD Albumin-4.1 Calcium-9.2 Phos-3.3 Mg-1.9
___ 08:20PM BLOOD Lactate-1.8
___ 04:34PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:34PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:34PM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:34PM URINE CastHy-1*
IMAGING:
===================
CHEST XRAY ___
No acute cardiopulmonary process.
RUQ ULTRASOUND ___. No evidence of acute cholecystitis. Again seen gallbladder
sludge and
gallbladder neck stone without distension or gallbladder wall
thickening.
2. Multiple hepatic cysts, largest measuring up to 2.6 cm in the
left hepatic lobe.
ABDOMINAL XRAY ___
No radiographic evidence of mechanical obstruction or
pneumoperitoneum, within the limitations of a single supine
radiograph. Small and large bowel are normal in caliber.
MICROBIOLOGY:
===================
___ 4:34 pm URINE Source: ___.
URINE CULTURE (Pending):
DISCHARGE LABS:
===================
___ 06:30AM BLOOD WBC-11.3* RBC-3.78* Hgb-12.3* Hct-37.2*
MCV-98 MCH-32.5* MCHC-33.1 RDW-13.4 RDWSD-48.5* Plt ___
___ 06:30AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-141
K-4.5 Cl-101 HCO3-27 AnGap-13
___ 06:30AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ year-old man with history of CAD, CVA with L
sided paralysis, atrial fibrillation on apixaban, history of
abdominal pain, constipation, hypertension, hyperlipidemia, and
mild cognitive impairment who was admitted with abdominal pain
likely secondary to constipation and possibly passed gallstone.
ACUTE ISSUES:
==============
# Abdominal pain
# Constipation:
Admitted with diffuse abdominal pain, worst in right upper
quadrant. This was felt secondary to constipation, given
abdominal pain improved status post bowel movement and more
aggressive bowel regimen. Pain may also have been secondary to a
passed gallstone, given his history of gallstones, slightly
elevated lipase (that subsequently normalized) suggestive of
transient pancreatic insult, and RUQ ultrasound with gallbladder
sludge. Recent CT abdomen/pelvis on ___ showed no concerning
findings. Very low suspicion that abdominal pain is a
manifestation of angina, given troponin was negative x2 and
recent stress test ___ showed no anginal type symptoms or
significant ST segment changes. Patient was started on Ursodiol
300 mg PO BID for medical management of gallstones. His home
bowel regimen was increased at discharge.
# Hypertension:
Blood pressures were elevated during admission. He was continued
on losartan 25mg daily
and her metoprolol XL was increased to 50mg daily. His blood
pressures should be closely monitored as an outpatient.
CHRONIC/RESOLVED ISSUES:
===========================
#Dementia: At his baseline, he has preserved executive function
and relatively good short-term recall. He was continued on
memantine and delirium precautions.
#Afib: Continued home apixaban and metoprolol XL was increased
to 50mg as above
#CAD: Continued home asa 81, home pravastatin.
#Depression: Continued home Sertraline 50 mg PO DAILY.
#Insomnia: Continue home Mirtazapine 30 mg PO QHS.
#Lumbar spondylosis
#Bilateral shoulder pain
#OA: Continued home Acetaminophen 500 mg PO Q8H as PRN
#GERD: Increased omeprazole to 40mg daily given abdominal pain
may be due in part to GERD.
#Vitamin deficiencies/supplements: Vitamin D 1000 UNIT PO DAILY,
Cyanocobalamin 1000 mcg PO DAILY, Biotin 2 mg oral DAILY
#BPH: Continued home Tamsulosin 0.4 mg PO QHS
#BULLOUS PEMPHIGOID: Now off azathioprine given intolerable
nausea. Started on aquaphor.
#H/O CVA: Residual L sided deficits; continue home asa 81, home
pravastatin. Could consider dose-reduction of pravastatin as
this could be contributing to GI symptoms
TRANSITIONAL ISSUES:
============================
[] Patient previously had MOLST stating his wish to be DNR/DNI.
On this admission, he expressed a wish to be full code. His
MOLST was updated to reflect this but consider ongoing
discussion.
[] Patient was started on Ursodiol 300 mg PO BID for medical
management of gallstones.
[] Increased omeprazole to 40mg daily, given GERD may contribute
to abdominal pain
[] Metoprolol XL was increased to 50mg daily, given hypertension
during admission. Please closely monitor blood pressure as
outpatient and adjust medications as needed.
[] Patient's bowel regimen was increased, discharged with plan
for bisacodyl suppository prn with goal for bowel movement at
least every other day.
[] Consider decreasing dose of pravastatin as this may
contribute to abdominal discomfort.
#CODE: Full code (MOLST updated)
#CONTACT: ___ wife ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Vitamin D 1000 UNIT PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. biotin 2 mg oral DAILY
4. Sertraline 50 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Pravastatin 80 mg PO QPM
8. Apixaban 5 mg PO BID
9. Memantine 10 mg PO BID
10. Senna 8.6 mg PO BID
11. Psyllium Powder 1 PKT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN wheezing
15. Mirtazapine 30 mg PO QHS
16. Losartan Potassium 25 mg PO DAILY
17. Acetaminophen 500 mg PO Q8H
18. econazole 1 % topical BID
19. flunisolide 25 mcg (0.025 %) nasal BID
20. Lidocaine 5% Patch 1 PTCH TD QPM back pain
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heart burn, abdominal pain
2. Aquaphor Ointment 1 Appl TP BID bullous lesions, itch
3. Bisacodyl 10 mg PR QHS:PRN constipation, no bowel movement
in 2 days
RX *bisacodyl 10 mg 1 suppository(s) rectally At night Disp #*50
Suppository Refills:*0
4. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Twice
a day Disp #*100 Packet Refills:*0
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth Every 6
hours Disp #*12 Tablet Refills:*0
6. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth Twice a day Disp #*60
Capsule Refills:*0
7. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
9. Senna 17.2 mg PO BID
10. Acetaminophen 500 mg PO Q8H
11. Apixaban 5 mg PO BID
12. biotin 2 mg oral DAILY
13. Cyanocobalamin 1000 mcg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. econazole 1 % topical BID
16. flunisolide 25 mcg (0.025 %) nasal BID
17. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN wheezing
18. Lidocaine 5% Patch 1 PTCH TD QPM back pain
19. Losartan Potassium 25 mg PO DAILY
20. Memantine 10 mg PO BID
21. Mirtazapine 30 mg PO QHS
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. Pravastatin 80 mg PO QPM
24. Psyllium Powder 1 PKT PO DAILY
25. Sertraline 50 mg PO DAILY
26. Tamsulosin 0.4 mg PO QHS
27. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
# Abdominal pain
# Constipation
# Hypertension
SECONDARY
# Dementia
# Atrial fibrillation
# Coronary artery disease
# Depression
# Insomnia
# Lumbar spondylosis
# Bilateral shoulder pain, osteoarthritis
# GERD
# Benign prostatic hyperplasia
# Bullous pemphigoid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
abdominal pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had an xray and an ultrasound of your abdomen. Your
abdominal pain was probably caused by a combination of
constipation and a gallstone.
- You were given stool softeners and your abdominal pain
improved after you had a bowel movement.
- You were started on a medicine called Ursodiol to help treat
your gallstones.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all your medicines as described in this paperwork.
- Please keep all your follow up appointments as listed below.
- You are being discharged with a suppository. Please use this
if you haven't had a bowel movement in 2 days.
WHEN SHOULD I COME BACK TO THE HOSPITAL?
- If you have fevers/chills, severe abdominal pain that doesn't
get better, or any other symptoms that concern you.
It was a pleasure to participate in your care, and we wish you
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10734900-DS-5
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DS
| 5 |
2114-09-13 00:00:00
|
2114-09-13 13:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Superficial surgical site infection of left upper extremity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ left hand SCC s/p ___ ray amputation and tumor
resection with axillary sentinel LNB (negative margins) now s/p
free flap to hand (super thin ALT) & ___ web space ex-fix
(___). He has been followed in clinic for wound evaluation
since discharge to rehab on ___. Wicks were placed in his
wound
on ___, and during follow-up today, he was noted to have
serous
drainage from the wound and was referred to the ___ ED for
evaluation by the Hand Surgery team for concern of wound
infection. Overall, he notes that he feels fine without
fevers/chills or other signs of infection. He has been dressing
his flap with DSD, a splint and ACE wrap. He was initially on PO
antibiotics but has been on IV vancomycin at rehab.
Past Medical History:
None
Social History:
___
Family History:
Positive for colon cancer, but no known skin
cancers.
Physical Exam:
On discharge: packing in place, erythema resolving to LUE.
Incisions clean, dry and intact.
Pertinent Results:
___ 11:00AM CRP-17.6*
___ 11:00AM WBC-7.8 RBC-2.79* HGB-8.9* HCT-27.5* MCV-99*
MCH-31.9 MCHC-32.4 RDW-14.9 RDWSD-54.7*
___ 11:00AM NEUTS-80* BANDS-1 LYMPHS-9* MONOS-6 EOS-2
BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-6.32* AbsLymp-0.70*
AbsMono-0.47 AbsEos-0.16 AbsBaso-0.00*
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ and had a ?local wound care for a superficial soft
tissue infection of his left upper extremity flap. The patient
tolerated the procedure well.
Neuro: The patient received oral pain medications with good
effect.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: He was maintained on a regular diet. He continued to void
spontaneously. Intake and output were closely monitored.
ID: His antibiotic coverage was broadened on admission to
vancomycin and cefepime. A wound culture was obtained which was
growing mixed bacterial flora including sparse GNR (thought to
be P. aeruginosa based on prior cultures). He was transitioned
to PO ciprofloxacin and doxycycline on discharge.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. He was
discharged back to rehab for assistance with ___ and wound care.
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 121.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. HydrOXYzine 25 mg PO DAILY:PRN itching
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H: PRN
Disp #*30 Tablet Refills:*0
7. Senna 17.2 mg PO HS
8. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 21 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*84 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left upper extremity surgical site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You should keep your left arm elevated when you are not walking
(you may use pillows) to help with swelling and drainage.
-You should continue to walk around with assistance.
-Your left lower extremity incision should be left open to air
and assessed for any signs of infection and/or breakdown on a
daily basis.
-Your left arm dressing should be changed daily, packing changes
daily.
-You may shower but cover your left arm splint/dressing with
plastic wrap/bag to shield from moisture. You may leave your
lower extremity incision site open to let warm water run over
it. Pat dry with soft towel. No tub baths until directed by your
doctor.
.
Diet/Activity:
1. You may resume your regular diet.
2. Avoid heavy lifting and do not engage in strenuous activity
until instructed by your doctor.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
6. Take all your antibiotics as written
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern
Followup Instructions:
___
|
10735843-DS-16
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2194-10-12 00:00:00
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2194-10-12 18:05:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Quinidine
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
___: Angiogram, embolization of distal middle meningeal
artery
___: Right-sided image guided craniotomy for tumor resection
History of Present Illness:
___ is a ___ year old male who has had intermittent
confusion since ___. Early ___ morning, he
had an episode where he was looking for his wife, although she
was in bed next to him. He presented to his PCP office later
that
day and a NCHCT was ordered and completed ___. He presents
to the ED for further evaluation. His family states that he has
been 'off' over the past six to nine months including balance
problems, falls, personality changes, and exhaustion. Patient
denies feeling confused today. He also denies dizziness, and
nausea.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. OTHER PAST MEDICAL HISTORY:
- Paroxysmal Atrial fibrillation - on amiodarone per Dr.
___. Has had PAF since his ___ and undergone DCCV three
times, although one time he spontaneously converted prior to
shock. Last DCCV was ___.
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- s/p lap CCY in ___
Social History:
___
Family History:
Father died of MI at ___, ___ family history of A-fib, no DM.
Paternal uncle with ___ Disease. Denies family history of
brain aneurysms or brain tumor.
Physical Exam:
==============
ON ADMISSION
==============
O: T: 99.2 BP: 124/72 HR: 62 R: 18 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRL 3-->2 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
==============
ON DISCHARGE
==============
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRL 3-->2 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. R periorbital edema.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Skin: R craniotomy incision well-approximated with staples, open
to air without erythema. Mild post-operative periorbital edema.
Pertinent Results:
============
IMAGING
============
___ CT BRAIN WITHOUT CONTRAST
1. Right frontal lobe mass demonstrating curvilinear
calcifications resulting in underlying right frontal and
temporal
lobe parenchymal edema pattern and 1.6 cm leftward midline
shift.
This may be potentially centered in the
sylvian fissure.
2. There is subfalcine and right uncal herniation. Effacement
of
the right lateral and third ventricle, without definitive
evidence for contralateral ventricular entrapment.
3. If extra-axial, the lesion likely represents a meningioma,
although there is no adjacent osseous hyperostosis. However, if
intra-axial, differential considerations include lesions such as
oligodendroglioma. Further evaluation with MRI, if there no
contraindications is recommended.
___ MR HEAD W & W/O CONTRAST:
IMPRESSION:
Large lobulated extra-axial mass in the right middle cranial
fossa and along the floor of the right anterior cranial fossa
has characteristics highly suggestive of a meningioma. There is
extensive associated vasogenic edema with substantial leftward
shift of midline structures, right to left subfalcine
herniation, right uncal herniation, and severe effacement of the
right lateral and third ventricles , as seen on the preceding
CT.
___ CEREBRAL EMBO
Right common carotid artery: Carotid bifurcations
well-visualized. There is no significant atherosclerosis or
carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal
and distal MCA and ACA branches are well-visualized. Vessel
caliber smooth and tapering. Normal arterial, capillary, and
venous phase . No vascular abnormalities identified .
External carotid artery: branches well-visualized, tumor blush
was identified with main feeders from the middle meningeal
artery.
Right common femoral artery: Well-visualized with a good caliber
size for
closure device.
___: CT HEAD W/O CONTRAST
IMPRESSION:
Expected postsurgical changes after frontotemporal craniotomy
and resection of an extra-axial right frontal mass. Improved
midline shift and effacement of the right lateral ventricle.
___ MR HEAD W & W/O CONTRAST
IMPRESSION:
1. Appropriate postoperative changes status post right fronto
temporal
craniotomy and resection of an right extra-axial mass with
residual extensive surrounding vasogenic edema. Interval
improvement of midline shift, with residual leftward shift of
approximately 8 mm, compared to the preoperative exam from ___.
============
LABS
============
___ 04:50AM BLOOD WBC-14.6* RBC-3.34* Hgb-10.3* Hct-31.4*
MCV-94 MCH-30.8 MCHC-32.8 RDW-13.2 RDWSD-45.0 Plt ___
___ 04:50AM BLOOD ___ PTT-22.4* ___
___ 04:50AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-137
K-4.2 Cl-104 HCO3-24 AnGap-13
___ 04:50AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.5
___ 04:27PM BLOOD Lactate-1.4
___ 04:27PM BLOOD Hgb-10.9* calcHCT-33
___ 04:27PM BLOOD freeCa-0.95*
Brief Hospital Course:
Mr. ___ presented to the ED on ___ after NCHCT showed
right frontal brain lesion, edema, and midline shift. He was
started on Keppra and Dexamethasone and it was determined he
would be admitted to the ___ for close monitoring and further
work-up.
On ___, the patient was neurologically stable and his imaging
was reviewed to determine if he was a candidate for embolization
of the meningioma prior to resection for improved hemostasis
during resection. It was determined that he was a good
candidate, therefore embolization planned for ___.
On ___, the patient's neurological exam remained stable. He
underwent preoperative workup.
On ___ The patient underwent endovascular embolization of the
distal middle meningeal artery in preparation for resection of
meningioma. He was neurologically intact after the procedure.
On ___ Patient underwent a right craniotomy for resection of
tumor. Procedure was uncomplicated and well tolerated. He
recovered from anesthesia in the PACU and was transferred to the
___ for further care.
On ___ the patient remained neurologically stable and remained
in the NIMU.
On ___ the patients JP drain was removed. A routine post
operative MRI was performed and demonstrated postoperative
changes as well as interval improvement of midline shift. He
remained in the ___ overnight.
On ___ the patient remained hemodynamically and neurologically
stable. He was started on subcutaneous heparin and was called
out to the floor. Physical therapy and occupational therapy
consults were placed in preparation for discharge planning.
On ___, the patient remained neurologically and
hemodynamically stable. He was evaluated by physical and
occupational therapy who recommended discharge home with
physical therapy services. He was started on a tapering schedule
of his dexamethasone and discharged home in stable condition.
Medications on Admission:
Amiodarone, Atenolol, Vitamin D, Levothyroxine, Lisinopril,
Pravastatin, Prochlorperazine maleate, Xarelto
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 4 mg PO Q8H Duration: 9 Doses
This is dose # 4 of 9 tapered doses
3. Dexamethasone 3 mg PO Q8H Duration: 9 Doses
This is dose # 5 of 9 tapered doses
4. Dexamethasone 3 mg PO Q12H Duration: 6 Doses
This is dose # 6 of 9 tapered doses
5. Dexamethasone 2 mg PO Q12H Duration: 6 Doses
This is dose # 7 of 9 tapered doses
6. Dexamethasone 2 mg PO DAILY Duration: 3 Doses
This is dose # 8 of 9 tapered doses
7. Dexamethasone 1 mg PO DAILY Duration: 3 Doses
This is dose # 9 of 9 tapered doses
8. Dexamethasone 4 mg PO Q6H Duration: 2 Doses
This is dose # 1 of 9 tapered doses
RX *dexamethasone 1 mg 1 tablet(s) by mouth As dir Disp #*184
Tablet Refills:*0
9. Dexamethasone 5 mg PO Q6H Duration: 12 Doses
This is dose # 2 of 9 tapered doses
10. Dexamethasone 4 mg PO Q6H Duration: 12 Doses
This is dose # 3 of 9 tapered doses
11. Docusate Sodium 100 mg PO BID
12. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
13. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*0
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H PRN Disp #*24 Tablet
Refills:*0
15. Senna 8.6 mg PO BID:PRN constipation
16. Amiodarone 200 mg PO DAILY
17. Atenolol 25 mg PO DAILY
18. Levothyroxine Sodium 100 mcg PO DAILY
19. Lisinopril 5 mg PO DAILY
20. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right frontal brain lesion
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Tumor
Surgery
You underwent two surgeries to remove a brain lesion from your
brain. The first stage was to decrease blood supply to the tumor
and the second was to remove the tumor.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You may restart Xarelto for atrial fibrillitation on
post-operative day #7 (___)
Please do NOT take any other blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) unless cleared by your
neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10735915-DS-20
| 10,735,915 | 28,571,610 |
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| 20 |
2160-11-03 00:00:00
|
2160-11-03 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of COPD,
remote EtOH abuse, WPW s/p ablation, and AAA followed by Dr.
___ with recent increase in size of his AAA from 3.9cm to
5.1cm over the course of 6 months. He has had persistent
mild-moderate diffuse abdominal pain for the past month centered
above the umbillicus, which is aggrevated by bending. He is
followed by GI at ___, and underwent EGD last week
for GERD, as well as CT scan recently there for f/u of his AAA.
It was noted that his AAA had increased markedly in size to
5.1cm. Given the rapid progression of the AAA and his history of
abdominal pain, he was advised to proceed to the ED for urgent
CTA.
Past Medical History:
PMH: PTSD, lower back pain, GERD, ___ s/p
ablation, significant COPD, history of alcohol abuse in the
past, depression/anxiety, history of ___, paroxysmal
Afib, prostate cancer
PSH:
1. Prostatectomy and LND ___
2. WPW ablation (remote)
3. Open excision of Angio-Seal in R CFA, R CFA endarterectomy
and repair of CFA with bovine pericardial patch ___ at ___
(angio seal placed after cardiac cath the week prior had caused
severe RLE claudication)
Social History:
___
Family History:
Family History: Father may have had AAA.
Physical Exam:
Discharge Exam:
VS: 98.5 HR 61 BP 134/83 RR 18 95% on RA
Gen: NAD, AAOX3
CV: RRR
Resp: CTAB
Abd: Soft, TTP in b/l lower abdominal quadrants, non-distended
Ext: -c/c/e
Neuro: MAE's
Pulses:
___
R: P/D/P/P
L: P/D/P/P
Pertinent Results:
___ 04:10PM LACTATE-1.5
___ 04:05PM GLUCOSE-69* UREA N-9 CREAT-1.1 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
___ 04:05PM WBC-10.6 RBC-4.43* HGB-15.2 HCT-43.2 MCV-98
MCH-34.2* MCHC-35.1* RDW-13.2
___:
1. 5.1 x 4.0 x 5.3 cm saccular infrarenal abdominal aortic
aneurysm without aortic stranding or fluid to suggest rupture.
Patent abdominal
vasculature.
2. Incidental findings of hepatic steatosis, fat-containing
right lumbar
hernia, scattered colonic diverticula without inflammatory
changes, and
bilateral renal cysts.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ with concern for
AAA rupture. He has a known AAA which Dr. ___ has been
following closely. It recently increased in size by 1 cm over
the past 6 months. A stat CTA abdomen/pelvis was ordered upon
his arrival to the ER, and his labs were drawn. They were
significant for a normal hematocrit/hemaglobin and a normal
lactate. The CTA revealed that the aneurysm had not ruptured and
that the aneurysm measured 5.3 cm. The patient was monitored
closely overnight with serial abdominal exams and close
monitoring of his vital signs. He remained stable with no
changes in his exam. Because he takes xarelto daily at home, he
will return to ___ for a planned endovascular AAA repair next
week. He was instructed to stop his xarelto until his surgery.
He will receive a call with the time and date of that
appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Mirtazapine 45 mg PO QHS
3. Montelukast 10 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Prazosin 5 mg PO QHS
6. Rivaroxaban 20 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Sertraline 100 mg PO DAILY
9. Vitamin D 50,000 UNIT PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Mirtazapine 45 mg PO QHS
3. Montelukast 10 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Prazosin 5 mg PO QHS
6. Sertraline 100 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Vitamin D 50,000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___. You were admitted
because you were having abdominal pain in the setting of a known
abdominal aortic aneurysm measuring 5.3cm. We would like to
surgically repair your aneurysm, but this procedure would best
be done when you are off your xarelto blood thinning medication.
We would like you to *******stop taking xarelto********* at this
time and return next week for your surgery. If you develop
severe abdominal pain, back pain, lightheadedness, or if you
pass out or lose consciousness, you need to seek emergency
medical attention IMMEDIATELY and call Dr. ___ office at
___.
Followup Instructions:
___
|
10736049-DS-20
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| 20 |
2116-08-20 00:00:00
|
2116-08-20 17:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - Oral and IV Dye
Attending: ___.
Chief Complaint:
Chest pain/discomfort
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures were performed during
this hospitalization.
History of Present Illness:
___ male past medical history of CAD s/p CABG and 5x
stents, hyperlipidemia, hypertension, stroke, atrial
fibrillation (not on A/C), tissue aortic valve replacement
resenting complaining of chest discomfort. Patient states that
his pain began 2 days ago and felt like gas pain. He states the
pain was constant and associated with nausea. He also endorses a
feeling as though his heart was racing as well as
lightheadedness.
Patient was found to be tachycardic at his primary care
physician's office today and was referred to ___.
Patient found to be in atrial flutter with rates in 130s. Given
concomitant chest pain and elevated troponin I to 0.36, he was
given 50mg IV diltiazem with subsequent improvement in rates to
60-70s. He was also given morphine and nitroglycerin SL with
resolution of his chest pain. He was given a full dose aspirin
and started on heparin gtt, then transferred here for further
evaluation and consideration for LHC.
In the ED, initial vitals were: T 97.5, HR 79, BP 142/71, RR 15,
O2Sat 100%RA
- Exam notable for: CTAB, RRR, abdomen benign
- Labs notable for: TropT 0.03, Cr 1.5, Hgb 10.9, WBC 7.2
- While in the ED, the patient's heart rate increased again to
126bpm sustained so he was given an additional 20mg IV diltiazem
and 30mg PO.
- Vitals prior to transfer: HR 63, 114/59, RR 13, O2Sat 94%RA
On arrival to the floor, the patient denies any ongoing chest
pain. Also denies fevers, chills, cough, shortness of breath,
leg swelling or tenderness or any recent travel.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- CAD s/p CABG and 5x stents
- Hyperlipidemia
- Hypertension
- H/o stroke
- H/o atrial fibrillation (not on anticoagulation)
- S/p aortic valve replacement (tissue)
- PAD
- GERD
Social History:
___
Family History:
-Father died at ___
-Mother died at ___ is unaware of her medical history
-Brothers with coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.5, 98/64 (98-125/64-59), 102 (82-102), 16, 97%
RA
Weight: 94.9 kg
General: Alert, oriented, no acute distress, walking around
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: Supple. JVP flat (visible only with hepatic pressure).
CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, trace to no edema
DISCHARGE PHYSICAL EXAM:
========================
VITALS: afebrile, BP ___, HR ___, RR ___, O2
100% RA
GENERAL: Alert, oriented, no acute distress, walking around
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple. JVP flat (visible only with hepatic pressure).
HEART: Irregularly irregular. Normal S1+S2, soft systolic
murmur.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended
EXT: Warm, well perfused, trace to no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 11:15PM BLOOD WBC-7.2 RBC-3.64* Hgb-10.9* Hct-33.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-14.4 RDWSD-48.5* Plt ___
___ 11:15PM BLOOD Neuts-56.3 ___ Monos-9.8 Eos-3.3
Baso-1.4* Im ___ AbsNeut-4.07 AbsLymp-2.07 AbsMono-0.71
AbsEos-0.24 AbsBaso-0.10*
___ 11:15PM BLOOD ___ PTT-67.6* ___
___ 11:15PM BLOOD Glucose-85 UreaN-19 Creat-1.5* Na-141
K-4.3 Cl-107 HCO3-22 AnGap-16
___ 06:15AM BLOOD CK(CPK)-51
___ 11:15PM BLOOD CK-MB-3
___ 11:15PM BLOOD cTropnT-0.03*
___ 06:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 Cholest-158
___ 06:15AM BLOOD Triglyc-182* HDL-26 CHOL/HD-6.1
LDLcalc-96 LDLmeas-108
MICROBIOLOGY:
=============
NONE
IMAGING:
========
CXR (___):
FINDINGS:
There is dense retrocardiac opacification and mild chronic lung
disease. The remainder of the lungs are clear. No pleural
effusion or pneumothorax. Heart size is normal. Median
sternotomy wires are midline and intact. Surgical clips project
over the mediastinum. A presumed aortic valve replacement is
noted.
IMPRESSION:
1.Dense retrocardiac opacity likely reflecting atelectasis in
the absence of infectious symptoms.
2. Mild chronic lung disease.
LABS ON DISCHARGE:
==================
___ 04:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.4
___ 04:50AM BLOOD ALT-12 AST-16 LD(LDH)-222 AlkPhos-82
TotBili-0.4
___ 04:50AM BLOOD Glucose-87 UreaN-23* Creat-1.7* Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
___ 04:50AM BLOOD ___ PTT-50.8* ___
___ 04:50AM BLOOD WBC-7.2 RBC-3.59* Hgb-10.7* Hct-33.5*
MCV-93 MCH-29.8 MCHC-31.9* RDW-14.3 RDWSD-48.9* Plt ___
Brief Hospital Course:
Mr. ___ is an ___ year old man with CAD s/p CABG, cardiac
stents, HLD, HTN, CVA, and history of A fib who presented with
chest pressure/epigastric pain secondary to Afib/flutter with
RVR. At first there was concern for ACS but his trops trended
down quickly and he had recent normal pharm nuc stress test in
___ at ___. He had on-going chest pain with afib
RVR/aflutter with better response to diltiazem than metoprolol.
Because of this he was switched from metoprolol to diltiazem.
The patient spontaneously converted to normal sinus rhythm in AM
of ___ prior to TEE cardioversion, and patient was discharged
on amiodarone.
#HISTORY OF ATRIAL FIBRILLATION WITH NEW ATRIAL FLUTTER, RVR:
patient presented with rapid rates in ED. Initially controlled
with IV metop and dilt, followed by increased dose of PO metop
(home dose 50XL, given 75mg XL). Broke through with episodes of
RVR, so switched to PO diltiazem with rates decreasing to
___. Of note, the patient is not on anticoagulation prior to
admission because AFib improved after valve replacement and
because of a GI bleed requiring ICU about ___ years ago (while on
warfarin) and smaller amounts of blood in stool since. Patient's
home clopidogrel for ___ PAD/stents was held on admission, and
he was started on a heparin drip which was continued until
apixiban started. Given the patient's persistent Afib/Aflutter,
he was scheduled to undergo a TEE cardioversion in AM of ___.
The patient spontaneously converted to sinus rhythm in AM of
___, and TEE cardioversion was canceled. Patient was started on
amiodarone 200 mg 3 times daily for 1 week, then twice daily for
1 week, then once daily ongoing. Baseline CXR on ___
demonstrated dense retrocardiac opacity, likely reflecting
atelectasis in the absence of infectious symptoms, and mild
chronic lung disease. Baseline LFTs on ___: ALT 12, AST 16. TSH
pending at time of discharge. He was discharged on long-acting
diltiazem 120 mg PO daily, in addition to apixaban 2.5 mg PO BID
for anticoagulation.
#NSTEMI/DEMAND ISCHEMIA: patient has a known history of CAD s/p
CABG and multiple stents. Mild troponin elevation in the setting
of sustained tachycardia (0.03 to 0.02) in setting of CKD
(creatinine 1.4 in ___ in ___ records). Pharm stress
test canceled as patient recently received one in ___. He
was continued on home ASA, home Imdur.
CHRONIC/STABLE ISSUES:
======================
#CKD: Baseline Cr appears to be 1.3-1.7 from ___ records from
___ and the ___. Cr remained at baseline during
hospitalization.
#PVD s/p bilateral lower extremity stents: significant PAD,
symptomatic. Per patient's wife, patient has lower extremity
stents placed many years ago. He was continued on home
pentoxyifylline, and clopidogrel was held at discharge in favor
of continuing ASA and apixaban as above.
#HYPERTENSION: Continued imdur, metop and lisinopril.
#HYPERLIPIDEMIA: Patient has a reported allergy to statins. He
was continued on ezetimibe.
#GERD: Continued home Protonix.
TRANSITIONAL ISSUES:
====================
[] consider repeat CXR as outpatient given dense retrocardiac
opacity noted on CXR on ___
[] f/u TSH pending at discharge
[] follow up on ___ of ___ monitoring (copy of report
requested to be faxed to patient's cardiologist, Dr. ___
___, Phone: ___, Fax: ___
[] consider TTE as an outpatient
[] if evidence of decreased LVEF on TTE, consider switching
diltiazem to higher doses of metoprolol for rate control
[] Of note, the patient was previously on anticoagulation prior
to admission despite history of AFib because of a GI bleed
requiring ICU about ___ years ago (while on warfarin)
[] Amiodarone monitoring (CXR yearly, TFTs/LFTs q 6 months)
[] anticoagulation consult in ___ system ordered for apixiban
(given 1 month supply on discharge)
#CODE STATUS: Full (presumed)
#CONTACT: Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Pentoxifylline 400 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Amiodarone 200 mg PO TID
amiodarone 200 mg TID x1 week (day 1: ___, then 200 mg BID x1
week, then 200 daily ongoing
RX *amiodarone 200 mg 1 tab tablet(s) by mouth AS DIRECTED Disp
#*50 Tablet Refills:*0
2. 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
3. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5 min PRN
Disp #*25 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q 24 hours Disp #*30
Tablet Refills:*0
11. Pentoxifylline 400 mg PO TID
RX *pentoxifylline 400 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Atrial fibrillation and atrial flutter
SECONDARY DIAGNOSES:
====================
NSTEMI/DEMAND ISCHEMIA
CKD
PVD s/p bilateral lower extremity stents
HTN
HLD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why were you admitted to ___?
- You had chest pain and atrial fibrillation
What was done in the hospital?
- Your medications were changed to better treat your atrial
fibrillation
- Your heart rhythm converted to normal sinus rhythm without the
need for an electrical cardioversion to shock your heart back
into a regular rhythm
- You were continued on new medications (including diltiazem,
amiodarone, and apixaban) to maintain your heart in normal sinus
rhythm and for anti-coagulation
What should you do when you leave the hospital?
- Please follow up with all of your doctors ___
- ___ note any medication changes below
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10736987-DS-8
| 10,736,987 | 22,676,775 |
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| 8 |
2148-08-11 00:00:00
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2148-08-11 14:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Hydrocortisone / Codeine
Attending: ___.
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
Left hip intramedullary nail ___, Dr. ___
History of Present Illness:
___ DNR DNI w/ severe depression w/ psychotic features, CHF,
afib not on AC, resident of long term care p/w left hip fracture
after fall this morning. Pt unable to describe why she fell or
if she hit her head. Reportedly uses walker at baseline. ED
spoke to geriatrics who advised against head neck CT as she
would not have any intervention. Daughter would consent to
surgical intervention for hip fracture for pain control.
Past Medical History:
Severe depression w/ psychotic features, CAD, CHF, AF not on AC,
hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
Left lower extremity:
- Skin intact
- LLE shortened and externally rotated
- Soft, non-tender thigh and leg
- Full PROM of hip, knee, and ankle, unable to obey commands
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
XR LEFT HIP: left intertrochanteric femur fracture
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left hip intramedullary nail, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated on the left lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. ARIPiprazole 10 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN agitation
5. Mirtazapine 15 mg PO QHS
6. OLANZapine (Disintegrating Tablet) 15 mg PO QPM
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Venlafaxine 25 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
12. Lorazepam 0.5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10737127-DS-6
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2119-10-15 00:00:00
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2119-10-16 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Exercise stress ECG test
History of Present Illness:
___ w/hx of HTN, obesity, smoking, and family hx of early MI,
presenting with one week of intermittent left-sided dull chest
pressure, non-radiating, lasting minutes. He identifies no
factors that precipitate or relieve his pain; he is not active,
no relationship to food, no cough or URI symptoms lately.
Associated symptoms include two episodes of diaphoresis feeling
"hot all over," one episode of nausea, and shortness of breath.
He has noticed ___ edema increasing over the past few weeks. He
has otherwise been feeling well. Limited activity beyond
walking. He came in as he grew concerned that given his family
history that his symptoms could be cardiac in nature.
In the ED, initial vitals: ___ (pain) 98.1 92 145/97 18 98% RA.
ECG with no ST elevations or depressions at this time. Negative
troponins x2. Cr 0.9. Received ASA 324 mg, SLN, morphine sulfate
2 mg, bupropion 150 mg. Underwent ETT with CP but no ECG
changes. Seen by cards who recommended cardiology admit.
On the floor, patient states he has ___ pain that's been for
the past 20 minutes, later came down to ___.
Past Medical History:
Hypertension
Obesity
Smoking
Social History:
___
Family History:
Father with MI and died at age ___, multiple paternal uncles with
MIs in ___.
Physical Exam:
ADMISSION
VS: 97.8, 148/104, 86, 20, 96 RA
149.4 kg
General: NAD, obese gentleman
HEENT: PERRL, EOMI, anicteric sclera oropharynx clear, MMM
Lungs: clear to auscultation b/l
Heart: JVP not elevated (difficult to assess); RRR, distant, no
murmur.
Abdomen: obese, soft, NT, ND, NABS, no HSM,
Extremities: Trace edema
Skin: Warm and dry. No cyanosis.
Neurologic; Speech intact; Alert; Affect appropriate; No gross
motor abnormalities.
DISCHARGE
VS: 97.7, 119-140/70-81, 73-78, 18, ___ RA
General: NAD, obese gentleman
HEENT: PERRL, EOMI, anicteric sclera oropharynx clear, MMM
Lungs: clear to auscultation b/l
Heart: JVP not elevated (difficult to assess); RRR, distant, no
murmur.
Abdomen: obese, soft, NT, ND, NABS, no HSM,
Extremities: Trace edema
Skin: Warm and dry. No cyanosis.
Neurologic; Speech intact; Alert; Affect appropriate; No gross
motor abnormalities.
Pertinent Results:
___ 11:02AM BLOOD WBC-6.1 RBC-5.05 Hgb-16.9 Hct-47.0 MCV-93
MCH-33.4* MCHC-35.9* RDW-13.4 Plt ___
___ 11:02AM BLOOD Neuts-50.1 ___ Monos-8.0 Eos-3.8
Baso-1.1
___ 07:07AM BLOOD Glucose-104* UreaN-23* Creat-1.0 Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
___ 11:02AM BLOOD Glucose-101* UreaN-18 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-24 AnGap-16
___ 07:07AM BLOOD CK(CPK)-51
___ 08:58PM BLOOD CK(CPK)-55
___ 07:07AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:58PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:02AM BLOOD cTropnT-<0.01
___ 07:07AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
___ 11:02AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.9
Cardiovascular ReportStressStudy Date of ___
EXERCISE RESULTS
RESTING DATA
EKG: SINUS, ERWP, BORDERLINE AV DELAY
HEART RATE: 75BLOOD PRESSURE: 140/104
PROTOCOL MODIFIED ___ - TREADMILL
STAGETIMESPEEDELEVATIONHEARTBLOODRPP
(MIN)(MPH)(%)RATEPRESSURE
___
TOTAL EXERCISE TIME: 7.25% MAX HRT RATE ACHIEVED: 74
SYMPTOMS:ANGINAPEAK ___ LEFT SIDED CHEST PRESSURE
TIMEHRBPRPP
ONSET:___
RESOLUTION:2 ___
ST DEPRESSION:NONE
INTERPRETATION: This ___ year old man with a h/o HTN, smoking and
a
positive family h/o premature CAD was referred to the lab from
the ED
following negative serial cardiac biomarkers for evaluation of
chest
discomfort, shortness of breath and palpitations. The patient
exercised
for 7.25 mintues of a modified ___ protocol and stopped for
fatigue.
The estimated peak MET capacity is 5.2, representing a poor
functional
capacity for his age. At 7 minutes of exercise the patient
reported a
___ left sided chest pressure/discomfort which resolved
completely with
rest by 2 minutes of recovery. There were no significant ST
segment
changes seen with exercise or in recovery. The rhythm was sinus
with one
VPB during exercise. Baseline diastolic hypertension with an
appropriate
BP response to exercise and recovery. Blunted HR response to
exercise.
IMPRESSION: Anginal type symptoms in the absense of ischemic EKG
changes. Baseline diasolic hypertension. Blunted HR response to
exercise. Poor functional capacity.
CXR ___
FINDINGS:
Lung volumes are low but the lungs appear clear. The
cardiomediastinal silhouette, hilar contours, and pleural
surfaces are normal. There is no pleural effusion or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ yo M with multiple risk factors for CAD presents with
intermittent CP during stress test without ECG changes, admitted
for further workup of ACS.
# Chest pain - Symptoms have both typical and atypical features.
No ECG changes, though did not reach 85% predictive heart rate
and low METS. Moderate treadmill risk score given poor
functional status and chest pain. Smoking and family history are
also concerning. Admitted for persantineMIBI given blunted
response to exercise ___ but cannot do it on the weekend and as
patient's chest pain resolved after admission, scheduled an
appointment for him to get the test on ___ as an
outpatient.
CHRONIC:
# Hypertension - continued home hydrochlorothiazide.
# Smoking - used to be 2PPD smoker but quit a few months ago,
now smokes e-cigarettes. Offerred nicotine patch but patient
said he'd rather see how he does without it. Counseled on
smoking cessation (including e-cigarettes.)
Transitional Issues:
- No medication changes
- Outpatient pharmMIBI on ___ (they will
call him ___ morning to make an appointment and he was also
given the information to call in case there is any problem)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Chest pain
SECONDARY:
-Hypertension
-Family history of heart disease
-Smoking
-Obesity
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 to the hospital with chest
pain. Your electrocardiogram (ECG) and blood work was reassuring
and showed no evidence of a heart attack. You had a stress test
which produced chest pain without any findings on the ECG. Your
chest pain improved. You will need to follow up with a
cardiologist and have a nuclear stress test performed as an
outpatient. Please call them on ___ to have both of this
scheduled.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10737233-DS-14
| 10,737,233 | 24,277,750 |
DS
| 14 |
2189-09-21 00:00:00
|
2189-09-21 18:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / lisinopril
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yoF hx of asthma, DM, who presents with increasing
sob since ___. States she recently moved and cannot find
her nebulizer treatment. Felt her asthma acting up on ___ and
took her rescue inhaler but it has not been helping. Endorses
sore throat and nonproductive cough but denies other cold
symptoms. No fevers or chills. Feels like this is her asthma.
Endorses chest tightness. She uses nebulizer treatment
approximately once monthly. She has been intubated once in the
distant past for asthma exacerbations.
Initially this patient was kept for observation, so she was in
the ED for over 24 hours. In the ED, initial vitals were: T98,
HR 91, BP 140/73 RR18-27, Pox 96% RA. Initial labs revealed:
Blood glucose 58->62, UA trace protein trace glucose trace
Ketones few bacteria, lactate 2.9->2.4. otherwise labs were
normal (please see OMR for full labs). In the ED, she received
albuterol nebulizer x8, ipratropium bromide neb x8, prednisone
60 mg x2, and was kept on her metformin as well as an ISS for
her diabetes.
On the floor, the patient reports feeling much better than when
she first presented to the ED, but still endorses dyspnea and
wheezing. She was able to speak in full sentences at this
point. She also c/o headache, lightheadedness. She denies
fevers/chills, abdominal pain, chest pain. On the floor her
vitals ar T99, HR96, RR22, BP 143/76, O297%. After receiving
another albuterol breathing treatment while on the floor, she
reported feeling much better.
Past Medical History:
T2DM
asthma
hyperlipidemia
schizoaffective disorder
arthritis
fibromyalgia
OSA
PSH: rotator cuff surgery
Social History:
___
Family History:
denies hx of ovarian, uterine, colon cancers
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T99, HR96, RR22, BP 143/76, O297%
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Before neb: inspiratory and expiratory wheezing
diffusely. After neb: expiratory wheezing only, diffuse
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3
DISCHARGE PHYSICAL EXAM:
Vitals: T98.1, HR77, RR20, BP 120/79, O2 95% RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: bilateral wheezes on upper lung fields but not lower lung
fields
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3
Pertinent Results:
Admission labs:
___ 05:23PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
___ 05:23PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 04:38PM COMMENTS-GREEN TOP
___ 04:38PM LACTATE-2.4*
___ 10:54AM LACTATE-2.9*
___ 10:43AM GLUCOSE-58* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 10:43AM estGFR-Using this
___ 10:43AM WBC-7.4 RBC-4.10 HGB-11.3 HCT-34.6 MCV-84
MCH-27.6 MCHC-32.7 RDW-12.7 RDWSD-38.8
___ 10:43AM NEUTS-47 BANDS-1 ___ MONOS-7 EOS-7
BASOS-0 ATYPS-3* ___ MYELOS-0 AbsNeut-3.55 AbsLymp-2.81
AbsMono-0.52 AbsEos-0.52 AbsBaso-0.00*
___ 10:43AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
___ 10:43AM PLT SMR-NORMAL PLT COUNT-175
Discharge Labs:
___ 06:02AM BLOOD WBC-13.0* RBC-3.83* Hgb-10.4* Hct-32.6*
MCV-85 MCH-27.2 MCHC-31.9* RDW-13.0 RDWSD-39.9 Plt ___
___ 06:02AM BLOOD Glucose-151* UreaN-22* Creat-0.7 Na-141
K-4.1 Cl-102 HCO3-29 AnGap-14
Imaging: CXR ___: The lungs are minimally hyperexpanded There is
no evidence of focal consolidation, pleural effusion,
pneumothorax, or pulmonary edema. The cardiac silhouette is
top-normal in size. Right acromioclavicular joint degenerative
changes have slightly progressed from the prior examination.
IMPRESSION:
Minimally hyperexpanded lungs without evidence for superimposed
pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with h/o asthma and
Insulin-dependent DM2 with difficult to control hyperglycemia,
who presents with an asthma exacerbation.
#Asthma Exacerbation:
She presented with shortness of breath "that feels like my
asthma", which improved over 4 days after 5 day burst regimin of
60 mg Prednisone, neb treatments, and inhalers. Likely this was
brought on by allergies or a viral URI that precipitated the
exacerbation, and the fact that she did not have a functioning
nebulizer machine at home prevented her from stopping the
progression of the attack. Never had evidence of significant CO2
retention, never required intubation. She had a CXR that showed
only mild hyperinflation. She was sent home with Albuterol
rescue inhaler and Advair was added to her home regimen. She
will follow up with Pulmonology as an outpatient to optimize her
asthma treatment and for formal PFT testing.
#Hyperglycemia/Insulin dependent DM2:
Patient came in on 75 glargine in the AM, 65 at night, plus
Metformin, Glimepiride, and ISS. She received her home regimen
originally but due to a period of hypoglycemia she was given a
lower insulin regimen for 24 hours. She was seen by ___, who
recommended that she stay on Metformin and Glimeperide with
continuation of humalog sliding scale and glargine 60 units in
the morning and 60 units at dinner for simplification of her
regimen. Her blood sugar was elevated while in the hospital
secondary to prednisone use that was completed upon discharge.
We recommend close follow up with ___ for further managmenet
of her diabetes and optimization of her regimen.
#OSA:
Patient placed on CPAP while in the hospital given her history
of sleep apnes. She reported that her CPAP machine at home was
broken and she does not really know how to use it. We were
unable to provide machine or evaluation of her current one in
the setting of her acute hospitalization but recommended close
follow up with her PCP as well as keeping her previosly schedule
sleep study for follow up. Given patient's known OSA benadryl
was discontinued given it is sedating.
#Elevated lactate:
Patient had elevated lactate on admission likely due to
albuteorl use and type B lactic acidosis in setting of metformin
though renal function was normal. Lactate improved with
resolution of asthma exacerbation.
Chronic Issues:
#Insomnia:
Patient continued on clonazepam but diphenhydramine was
discontinued given her history of OSA and risk for oversedation.
#Shoulder pain
- Continude Acetaminophen w/codeine
#HTN
- continued losartan
#Allergic rhinitis
- continued fluticasone nasal spray
TRANSITIONAL ISSUES:
======================
patient started on advair this hospitalization
-lantus dose adjusted to 60 mg in the morning and evening
-sedating medications including benadryl at bedtime were
discontinued given concern for sleep apnea and destauration
-patient noted possible non-functioning CPAP that needed to be
repaired. Unable to arrange this during hospitalization but
recommend she follow up with her PCP for further management and
continue with her sleep study that is scheduled in ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
2. Glargine 75 Units Breakfast
Glargine 65 Units Dinner
Insulin SC Sliding Scale using Humalog Mix Insulin
3. ClonazePAM 1 mg PO QHS
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Losartan Potassium 25 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. DiphenhydrAMINE 50 mg PO QHS:PRN poor sleep
9. RISperidone 2 mg PO QHS
10. Simvastatin 40 mg PO QPM
11. glimepiride 4 mg oral BID
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Omeprazole 20 mg PO BID
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
Discharge Medications:
1. Nebulizer Machine
Diagnosis: Asthma
ICD-9 493
2. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma
RX *albuterol sulfate 90 mcg 1 inhaled every 4 hours Disp #*1
Inhaler Refills:*3
4. ClonazePAM 1 mg PO QHS
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. glimepiride 4 mg oral BID
7. Loratadine 10 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Omeprazole 20 mg PO BID
11. RISperidone 2 mg PO QHS
12. Simvastatin 40 mg PO QPM
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Glargine 60 Units Breakfast
Glargine 60 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 60 Units before
BKFT; 60 Units before DINR; Disp #*1 Vial Refills:*0
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
inhaled twice daily Disp #*1 Disk Refills:*0
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Asthma exacerbation
Hyperglycemia
Secondary diagnoses
OSA
Lactic acidosis
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 ___ due to an asthma exacerbation and
difficulty controlling your blood sugars. For your asthma, you
were given multiple breathing treatments from nebulizers and
inhalers as well as oral steroids. We gave you breathing
treatments and you improved over time. We also adjusted your
insulin and diabetes regimen and recommend that you follow up
with the ___. We also recommend that you
follow up with the lung doctors for further ___ of your
asthma. We also recommend that you follow up with your sleep
study that was already scheduled below for re-evaluation of your
CPAP machine and sleep apnea. The appointments are listed below.
It was a pleasure being involved in your care
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10737258-DS-9
| 10,737,258 | 21,625,825 |
DS
| 9 |
2176-01-09 00:00:00
|
2176-01-09 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Percocet / Latex / Rifampin / Vancomycin /
Levofloxacin / Linezolid
Attending: ___
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman known to our service for prior
lumbar spine surgery for exploration of prior L-Spine surgical
wound. We performed an I and D of her wound in ___. prior to
this she had a fusion with subsequent removal of hardware by
ortho spine. She had been doing well until a few months ago when
she began experiencing increasing lower back pain. She went to
see her PCP who referred her to Dr ___ at ___ for eval. While awaiting her appointment her symptoms
progressed and she noted that she had been febrile at home. She
reports that her temperature was 100.3 while at home. She also
reports increasing headaches and photophobia. She also reports
that she recently began to notice a collection at the inferior
aspect of her prior incision that has increased in size. She
initially went to ___ for eval and was sent here for
further workup. Prior to the consult an MRI of the cervical,
thoracic, and lumbar spines was obtained. Secondary to her
inability to tolerate the imaging only the noncontrasted portion
was completed. She denies bowel or bladder issues, changes in
vision, hearing, or speech, weakness, numbness, or tingling, or
radiation of the pain
Past Medical History:
PMH: Tachycardia, Asthma, Interstitial cystitis, ?MS, celiac
disease
PSHx: Back surgery X 3, Knee Arthroscopy, b/l carpal tunnel
surgery, appendectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
afebrile, AVSS
Gen: WD/WN, anxious, tearful.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
Pertinent Results:
MRI spine:
C-Spine, T-Spine: :
Enhancement of part of the wall of the small fluid collection
superficially at the surgical site. This may represent a
seroma. The
possibility of infection cannot be excluded, but there is no
evidence of fat induration at this level.
Brief Hospital Course:
The patient was admitted to the neurosurgery service due to
lower back pain and concern for infection at the incision site.
The area was aspirated and revealed thick, red-tinged aspirate
that was sent for microbiology. She had an MRI with contrast to
evaluate for discitis which revealed a seroma. Her pain was
controlled with her home dose of MsContin and ___ morphine for
break through pain. The MRI revealed a seroma and infectious
disease was consulted. She remained afebrile with normal vital
signs throughout her hospitilization. The aspirate had no growth
and did not show organisms on gram stain. The seroma was deemed
to be nonoperative. The patient was discharged with oral
doxycycline. All questions were answered and the patient
expressed readiness for discharge.
Medications on Admission:
omeprazole, toprol xl, flexeril, clonidine, alprazolam,
fioricet, reglan, levoxyl, sumatriptan, hydroxyzine, singulair,
nitrofurantoin, ventolin, ambien, morphine, Vit D
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
3. ALPRAZolam 0.5 mg PO TID:PRN anxiety
4. Bisacodyl 10 mg PO/PR DAILY
5. CloniDINE 0.4 mg PO HS
6. Cyclobenzaprine 10 mg PO TID:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Ibuprofen 400 mg PO Q6H:PRN HA
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Montelukast Sodium 10 mg PO DAILY
12. Morphine SR (MS ___ 30 mg PO Q8H
13. Morphine Sulfate ___ 30 mg PO Q6H:PRN pain
RX *morphine 30 mg 1 tablet(s) by mouth q6hr Disp #*60 Tablet
Refills:*0
14. Nitrofurantoin (Macrodantin) 50 mg PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Senna 1 TAB PO BID
17. Sumatriptan Succinate 50 mg PO Q8H:PRN headache
RX *sumatriptan succinate 50 mg 1 tablet(s) by mouth q8hr Disp
#*30 Tablet Refills:*0
18. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
seroma / sterile fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pain and redness around the incision site
on your back. The fluid from this was aspirated and had concern
for infection. You had an MRI of the spine which showed a
seroma. Infectious disease was consulted and they will continue
to follow you as an outpatient.
Followup Instructions:
___
|
10737274-DS-21
| 10,737,274 | 23,439,125 |
DS
| 21 |
2147-03-28 00:00:00
|
2147-03-31 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gabapentin / Cymbalta
Attending: ___.
Chief Complaint:
Fever, Cough
Major Surgical or Invasive Procedure:
___ ___ line
History of Present Illness:
___ PMH RA (on MTX), DVT ___ ago, no longer on A/C), presenting
with cough, generalized weakness, urinary retention, dysuria,
and was admitted to medicine for UTI.
Pt noted that he lives at home by himeself, and began to feel
unwell several days ago, but is overall a poor historian. I was
able to ellicit that he had nausea/vomiting after eating dinner
last night, had no constipation/diarrhea, but has had urinary
hesitancy, likely retention, dysuria, and lower abdominal pain.
He noted that the cough is non-productive. Denied fevers/chills.
Pt's housekeeper saw him today, and felt that he looked ill so
called EMS. EMS noted SpO2 88% in room air en route, up to
low-to-mid ___ on NC. Daughter arrived after workup in ED,
stated that her father has h/o urinary retention with overflow
incontinence; has seen a urologist who told him to self-cath,
but he doesn't want to. She thinks he is always somewhat
dehydrated because he doesn't drink many fluids. States he gets
very anxious about his health and often complains of feeling
weak and malaised. However his O2 sat is usually normal, so this
is a change for him.
In the ED, initial VS were: 98.5 100 146/82 26 97% 4L. Exam
notable for chest with bibasilar coarse rhonchi, abdomen tender
throughout, and heme+ on rectal exam. Labs were significant for
WBC 3.2 (60% PMN, 12% mono), Hgb 15.1, Plt 124, CHEM w/ BUN 21,
Cr 0.8, CK 102, Lactate 1.2, LFTs w/ AST 48, otherwise normal,
Lipase 31, UA w/ 155 WBC, Nitr Positive, spec ___ 1.024. Inr
1.___-Spine w/ no acute fracture or subluxation
but severe multilevel degenerative changes. CT Head w/ no acute
intracranial abnormality. CXR w/ cardiomegaly with mild edema
but no convincing evidence for pneumonia. CTA Torso w/ no
pulmonary embolism, nonspecific prominent mediastinal nodes are
increased in size relative to prior study dated ___,
diffuse small airways disease with bronchiectasis, most
pronounced within the bilateral medial basilar segments, dilated
common extrahepatic duct as well as main pancreatic duct with no
obstructing lesion or mass identified, bilateral simple
appearing renal cysts, markedly distended bladder with
trabecular wall suggestive of chronic obstruction.
Pt was then given 1500cc NS, CTX, and Tylenol. Pt unable to void
and geriatrics fellow requested straight cath which was done. Pt
was then admitted for further w/u and mgmt.
Past Medical History:
PAST MEDICAL HISTORY:
#. Seizure disorder- From head trauma ___ years ago
#. Polyneuropathy
#. Severe degenerative disease in the spine- MRI showed multiple
levels of severe degenerative diseases, cervial spinal canal
stenosis, spinal stenosis, and compression of cauda equina.
#. Depression
#. Urinary retention and incontinence.
#. Osteoporosis.
#. Seronegative rheumatoid arthritis
#. Osteoarthritis.
#. Traumatic amputation of his fingers
#. Transurethral resection of prostate twice
#. Right eye cataract in ___
Social History:
___
Family History:
FAMILY HISTORY: No FH of blood clots
Physical Exam:
ADMISSION:
===========
Vitals - 97.9, BP120/53, ___, R20, O295RA, Wt62.9
GENERAL: NAD, pleasant, lying in bed
HEENT: MMM, R pupil 3mm, Left 1mm disconjugate gaze, both
reactive to light, no LAD
CV: rrr, no m/r/g, normal S1/S2
LUNGS: Crackles b/l in all lung fields, no accessory muscle use,
unlabored breathing
ABD: Soft, NT, ND, normoactive Bs, no rebound/guarding
EXT: warm, well perfused no edema
NEURO: R pupil 3mm, Left 1mm disconjugate gaze, both reactive to
light, AOx3, CNII-XII intact w/ exception of pupillary
abnormalities as described.
DISCHARGE:
==========
Vitals: 98.1, 139/74, 65, 18, 96%RA
General: AAOx3, hard of hearing, comfortable appearing, in NAD
HEENT: NCAT, EOMI, Sclera anicteric, conjunctiva pink. MM dry.
OP clear.
Neck: supple, no JVD
Lungs: Wheezy throughout without accessory muscle use
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: moves all extremities with purpose
Pertinent Results:
ADMISSION:
=========
___ 11:03PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE UHOLD-HOLD
___ 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:00PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 05:00PM URINE RBC-2 WBC-155* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 05:00PM URINE HYALINE-3*
___ 05:00PM URINE MUCOUS-RARE
___ 01:50PM ___ COMMENTS-GREEN TOP
___ 01:50PM LACTATE-1.2
___ 01:30PM GLUCOSE-88 UREA N-21* CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
___ 01:30PM estGFR-Using this
___ 01:30PM ALT(SGPT)-36 AST(SGOT)-48* CK(CPK)-102 ALK
PHOS-64 TOT BILI-0.3
___ 01:30PM LIPASE-31
___ 01:30PM ALBUMIN-3.8 CALCIUM-8.4 PHOSPHATE-3.6
MAGNESIUM-2.0
___ 01:30PM WBC-3.2* RBC-4.65 HGB-15.1 HCT-43.6 MCV-94
MCH-32.4* MCHC-34.6 RDW-15.6*
___ 01:30PM NEUTS-60.1 ___ MONOS-12.7* EOS-1.0
BASOS-0.6
___ 01:30PM PLT COUNT-124*
___ 01:30PM ___ PTT-36.1 ___
DISCHARGE:
==========
___ 05:07AM BLOOD WBC-3.2* RBC-4.56* Hgb-14.2 Hct-42.8
MCV-94 MCH-31.2 MCHC-33.3 RDW-16.0* Plt ___
___ 05:07AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-140
K-3.9 Cl-102 HCO3-30 AnGap-12
___ 05:07AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
IMAGING:
========
CT C-Spine w/ no acute fracture or subluxation but severe
multilevel degenerative changes.
CT Head w/ no acute intracranial abnormality.
CXR w/ cardiomegaly with mild edema but no convincing evidence
for pneumonia.
CTA Torso w/ no pulmonary embolism, nonspecific prominent
mediastinal nodes are increased in size relative to prior study
dated ___, diffuse small airways disease with
bronchiectasis, most pronounced within the bilateral medial
basilar segments, dilated common extrahepatic duct as well as
main pancreatic duct with no obstructing lesion or mass
identified, bilateral simple appearing renal cysts, markedly
distended bladder with trabecular wall suggestive of chronic
obstruction.
___ CXR:
IMPRESSION:
In comparison with the study of ___, the patient has taken
a slightly better inspiration. Enlargement of the cardiac
silhouette process, possibly with continued mild elevation in
pulmonary venous pressure. No evidence of pleural effusion or
acute focal pneumonia at this time.
MICROBIOLOGY:
=============
___ 5:00 pm URINE
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ 23:03
Report Comment:
Source: Nasopharyngeal swab
VIRAL, MOLECULAR
Influenza A by PCR POSITIVE *
Reported to and read back by
___ AT 0110 ___
PERFORMED AT ___ LAB
Influenza B by PCR NEGATIVE
PERFORMED AT ___ LAB
Brief Hospital Course:
___ PMH RA (on MTX), DVT ___ ago, no longer on A/C), presenting
with cough, generalized weakness, urinary retention, dysuria,
found to have UTI and Influenza.
# Influenza: Flu positive, CXR without bacterial PNA,
respiratory status stable. Likely explains his generalized
feelings of malaise and myalgias. He was treated with Tamiflu at
renal dosing for ___ to finish ___. Chest xray repeated on ___
due to wheezing was negative for any infiltrate. Due to
wheezing, he was started on 5 days of prednisone on ___ and
standing nebulizers.
# UTI: Hx of urinary retention, has declined to initiate
self-caths at home previously. Pt currently w/ dysuria and +UA.
Ceftriaxone in ED. Has hx of pseudomonal UTI resistant to Cipro.
Urine culture again grew ciprofloxacin resistant pseudomonas so
he was started on cefepime on ___ for a 7 day course. PICC
line was placed on ___.
# ___: Baseline creatinine 0.7-0.9, 1.2 on admission, likely in
setting of UTI and obstructive uropathy for which patient was
self-cathing in the past. Creatinine improved with treatment and
was 0.7 on discharge.
# Biliary ductal dilitation: Clinically pt w/o abdominal pain,
jaundic. Found on imaging after fall at home. LFTs were within
normal limits.
# Fall: Unwitnessed, per patient did not fall. Most likely ___
generalized deconditioning and in setting of acute viral
infection superimposed on UTI. Trauma series was negative.
# Thrombocytopenia/Leukopenia: Likely in setting of bone marrow
suppression from influenza viral infection and UTI. No signs of
active bleeding.
# Multiple joint issues/RA: Continue Lyrica, lidocaine patch,
tylenol for pain/symptom control
TRANSITIONAL ISSUES:
-Nonspecific prominent mediastinal nodes are increased in size
relative to
prior study dated ___.
-Dilated common extrahepatic duct as well as main pancreatic
duct with no
obstructing lesion or mass identified. Correlation with lab
values is
advised. MRCP if clinically indicated may be helpful for
further evaluation.
-Tamiflu to finish ___
-cefepime to finish ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Alendronate Sodium 70 mg PO QMON
2. Escitalopram Oxalate 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. LeVETiracetam 250 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Methotrexate 17.5 mg PO 1X/WEEK (MO)
7. Omeprazole 40 mg PO DAILY
8. Pregabalin 50 mg PO BID
9. Acetaminophen 1000 mg PO Q12H
10. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral
Q12H
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Senna 17.2 mg PO QHS:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H
2. Escitalopram Oxalate 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. LeVETiracetam 250 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Omeprazole 40 mg PO DAILY
7. Pregabalin 50 mg PO BID
8. Senna 17.2 mg PO QHS:PRN constipation
9. CefePIME 1 g IV Q24H
10. OSELTAMivir 75 mg PO Q24H
finish ___. Guaifenesin ___ mL PO Q6H:PRN cough
12. Docusate Sodium 100 mg PO BID
13. Alendronate Sodium 70 mg PO QMON
14. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral
Q12H
15. Fish Oil (Omega 3) 1000 mg PO DAILY
16. Methotrexate 17.5 mg PO 1X/WEEK (MO)
17. Ipratropium Bromide Neb 1 NEB IH Q6H
18. PredniSONE 40 mg PO DAILY Duration: 5 Days
19. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
-urinary tract infection
-influenza A
Secondary:
-Seronegative nonerosive rheumatoid arthritis - previously on
plaquenil/sulsalazine, now dc'ed on MTX
-Right shoulder adhesive capsulitis
-Bilateral knee osteoarthritis
-Lumbar spondylosis and left radiculopathy on lyrica
-C4 mass (schwannoma versus a migrated disc) no intervention by
___
-Sicca on evoxac
-DVT ___ ago, no longer on A/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 taking care of you during your
hospitalization. You were admitted after falling at home and
feeling unwell. You were found to have a urine infection and the
flu. You were given Tamiflu and antibiotics. You also worked
with physical therapy to make sure you are safe to go home. In
addition, your kidney function was below normal, likely related
to your infection. It improved during your hospitalization.
You will be on antibiotics through ___ and Tamiflu through
___. You were also started on prednisone and nebulizers to help
with your cough. The prednisone will finish after 5 days.
No other changes were made to your medications.
Your ___ Care Team
Followup Instructions:
___
|
10737550-DS-16
| 10,737,550 | 26,070,730 |
DS
| 16 |
2188-07-30 00:00:00
|
2188-08-01 19:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Reglan / Erythromycin Base / Milk Containing Products
/ ACE Inhibitors / ___ Receptor Antagonist /
Beta-Blockers (Beta-Adrenergic Blocking Agts) / Lipitor /
Vytorin ___ / spironolactone / Edecrin / pravastatin / Lescol
/ Crestor / amlodipine / lovastatin / aspirin / levothyroxine
sodium / pitavastatin / red yeast rice / contrast dye
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Pt is a ___ PMHx T1DM, HTN, HLD, CKD and CAD s/p CABG in ___
(LIMA to LAD, reverse SVG to posterior L ventricular branch
artery, ___ obtuse marginal artery and diagonal artery) who
presents with CP.
Regarding her cardiac history, she first underwent LHC in ___
for unstable angina which demosntrated 70% mid LAD stenosis.
She was medically treated without PCI. She developed
progression of her anginal symptoms and decreased exercise
tolerance in ___. A stress test in ___ was
positive for inferolateral ST depression. Urgent LHC at that
time demonstrated 80% stenosis of the mid-LAD, serial 90% and
99% stenoses in the diagonal branch., 90% LCx stenosis in OM1
branch and 80% stenosis of the dominant RCA in a small PDA
branch. She underwent subsequent CABG for her multivessel CAD.
Since her CABG, she had done relatively well without recurrent
chest pain or dyspnea up until recently. She reports increasing
fatigue over the past several months. 6 weeks ago, she began
having typical substernal chest pain again similar in character
to her prior episodes. She has no nitroglycerin at home
currently. She reports chest pain which developed yesterday
evening not relieved with Tylenol. She took her home aspirin
this morning but in clinic, reported ongoing chest pain ___
in severity associated with some dyspnea. She reported that her
chest pain was exertional and nonpleuritic. She also reports
increased bilateral leg swelling (L>R) and progressive orthopnea
(now uses 3 pillows). She has had 12 pound weight gain over the
past 3 months total. She denies any fever, chills, cough. She
was seen by Dr. ___ today in ___ Clinic who referred
her to the ED for stress vs cardiac catheterization to assess
for ischemia.
In the ED, initial VS 97.7 62 164/80 14 100% 1L NC. Initial
labs notable for K 5.2, Cr 1.7 (baseline Cr 1.4 in ___, proBNP
822, CBC wnl, INR 1.0, trop-T < 0.01. Rectal exam showed guaiac
negative stool. EKG showed NSR, HR 63 with LAD and TWI in aVL.
CXR was wnl. The patient continued to endorse ___ chest pain
and was hypertensive to the systolics 170s; she received NTG x 1
after which her chest pain resolved and her systolic BPs
improved. Upon further discussion with Dr. ___ patient
was started on a heparin gtt and brought to the cath lab for
LHC.
LHC showed occlusion of her SVG to the diag and the OM. SVG to
the obtuse marginal was patent and her LIMA was patent as well.
Her most concerning lesion was in her native diag branch so she
received DES to the native diag branch since her graft was
already down. She received Plavix 600 mg and full dose aspirin
prior to catheterization. Access was R femoral.
Upon arrival to the floor was asymptomatic, VS afebrile 162/74,
63, 18, 98% on RA. Patient denies any SOB, orthopnea, chest
pain/pressure. She says her substernal chest pressure is
completely resolve and she feels that she can breathe
comfortably without issue now after the PCI.
Cardiac review of systems is otherwise negative.
Past Medical History:
Coronary Artery Disease
Insulin Dependent Diabetes Mellitus/T1DM (last known HbA1c 7.5%
in ___
Hypertension
Hyperlipidemia
Chronic Kidney Disease (baseline creatinine 1.5)
Legal blindness
Gastroparesis
Social History:
___
Family History:
Father died at age of ___ due to coronary thrombosis, mother
alive, 1 brother with HTN, 13 half brothers and sisters several
of whom have kidney disease. multiple second degree relatives on
her father's side who have early heart disease and DM-II.
Physical Exam:
ADMISSION EXAM
Vitals: afebrile, 162/74, 63, 18, 98% on RA
General: well-appearing middle-aged female lying flat in bed in
NAD
HEENT: MMM, NCAT, anicteric sclera
Neck: supple, no LAD, JVP flat
CV: regular, nml S1 and S2, ___ systolic murmur best heard at
the RUSB
Lungs: CTAB on anterior exam, no labored respirations
Abdomen: soft, obese, NTND, normoactive bowel sounds
GU: R groin site w/o hematoma, no active bleeding, no femoral
bruit
Extr: wwp, trace to 1+ pitting edema of LLE (stable), no
pitting edema of RLE
Neuro: AOx3, decreased sensation of BLE to knees, spontaneously
moving all extremities
Skin: no rash or lesions, no livedo rash
DISCHARGE EXAM
VS: T=98.4 BP=135-172/53-74 ___ RR=18 O2 sat= 97-99% Ra
I/O: not strict
Wt: not taken
General: anxious appearing, middle-aged female, sitting up in
bed, no acute distress
HEENT: MMM, NCAT, anicteric sclera
Neck: supple, no LAD, JVP flat
CV: regular, nml S1 and S2, no murmur/rub/gallop appreciated
Lungs: CTAB, unlabored respirations on room air
Abdomen: soft, obese, NTND, normoactive bowel sounds
GU: R groin site w/o hematoma, no active bleeding, no femoral
bruit
Extr: warm and well perfused, trace LLE pitting edema, no edema
of RLE
Neuro: AOx3, decreased sensation of BLE to knees (chronic),
spontaneously moving all extremities
Skin: no livedo rash, no other rash or lesions
Pertinent Results:
LABS ON ADMISSION
___ 11:50AM BLOOD WBC-6.6 RBC-4.03# Hgb-11.8# Hct-36.3#
MCV-90 MCH-29.3 MCHC-32.5 RDW-12.4 RDWSD-40.5 Plt ___
___ 11:50AM BLOOD ___ PTT-30.2 ___
___ 11:50AM BLOOD Glucose-254* UreaN-26* Creat-1.7* Na-135
K-5.2* Cl-96 HCO3-30 AnGap-14
___ 07:20AM BLOOD ALT-24 AST-23 AlkPhos-96 TotBili-0.3
___ 07:20AM BLOOD Albumin-3.6 Calcium-9.5 Phos-4.1 Mg-2.2
Cholest-165
LABS ON DISCHARGE
___ 07:20AM BLOOD WBC-12.1*# RBC-4.05 Hgb-12.0 Hct-37.5
MCV-93 MCH-29.6 MCHC-32.0 RDW-12.4 RDWSD-42.2 Plt ___
___ 01:15PM BLOOD Glucose-295* UreaN-30* Creat-1.7* Na-130*
K-4.2 Cl-93* HCO3-24 AnGap-17
___ 09:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:00AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD cTropnT-<0.01
___ 01:15PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.2
___ 07:20AM BLOOD Triglyc-83 HDL-46 CHOL/HD-3.6 LDLcalc-102
___ 01:34PM BLOOD ___ pO2-59* pCO2-55* pH-7.30*
calTCO2-28 Base XS-0
___ 01:34PM BLOOD Lactate-1.7
IMAGING
CARDIAC CATHETERIZATION ___:
Coronary Anatomy:
Right dominant anatomy.
The LMCA is without significant disease.
The LAD is occluded in the mid segment.
There is a 95% stenosis in the ___ diagonal at the origin with
mild-moderate diffusse disease beyond into bifurcating vessel.
The lesion has a TIMI flow of 3 and has moderate calcification
noted. This lesion is further described as diffusely diseased.
An intervention was performed on the ___ diagonal with a final
stenosis of 0%. There were no lesion complications.
The circumflex is with mild diffuse disease.
The ___ marginal is diffusely diseased and then occluded mid
vessel.
The RCA tapers distally with diffuse disease into PDA.
The PL branch demonstrates competitive flow.
LIMA-LAD wide patent providing L-to-L collaterals.
SVG-PLV: ectatic graft with tandem mid ___ stenosis and
distal contrast recirculation at site of prominant ectasia
before bifurcation with marked size mismatch into smaller RPL
that has diffuse disease in the retrograde limb.
SVG-OM1 occluded.
SVG-diagonal occluded.
Impression: 1) Multivessel native coronary disease. 2) Patent
LIMA-LAD and SVG-RPL. 3) Occluded SVG-OM and SVG-diagonal. 4)
Successful PCI of the native diagonal with drug-eluting stent.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. No
clinically significant valvular regurgitation or stenosis.
Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
mild tricuspid regurgitation is no longer appreciated and
borderline pulmonary artery systolic hypertension is not seen.
CXR ___: No acute cardiopulmonary process
Brief Hospital Course:
___ PMHx T1DM, HTN, HLD, CKD and CAD s/p CABG in ___ (LIMA to
LAD, reverse SVG to posterior L ventricular branch artery, ___
obtuse marginal artery and diagonal artery) presenting with
unstable angina.
ACTIVE ISSUES
# Unstable angina: Presentation initially concerning for
possible graft occlusion. ___ showed concerning lesion in native
vessel diag which was stented with a drug eluting stent, and
also showed occluded SVG-OM and SVG-diagonal. Patient has CAD,
is high risk for future events, and unfortunately is unable to
tolerate b-blockers, statins, ACEi/ARBs, and multiple
antihypertensives. The patient was continued on Aspirin 81mg
daily, and was started on Plavix daily due to the drug-eluting
stent being placed. She was also written for PRN Nitroglycerin
to be used when she develops chest pain. Of note, the morning
after the catheterization she had an episode of anterior chest
pain and nausea; EKG was unchanged, cardiac enzymes were
negative, and symptoms improved. She declined starting
Isosorbide for afterload reduction and BP control, and will
follow up with Dr. ___ as an outpatient.
# T1DM: Very brittle DM. On levemir and HISS at home, levemir
not on formulary here. Patient refused Lantus, and preferred to
use own levemir which she brought with her. This was started the
morning after admission. A1C 7.5%. Bicarb 18, Gap 16, Glucose
200's this morning. ___ was consulted, and they did not
recommend any changes to her insulin regimen. She was kept on a
very gentle insulin sliding scale. She manages her diabetes very
diligently at home, checking her blood sugars often over 10
times daily.
# HTN: Takes Bumex 0.5mg every other day at home. Intolerant to
Amlodipine, ACEI, ___, Beta blocker. Bumex was held during this
admission, but will be resumed on discharged. She declined
starting isosorbide during this admission.
# CKD. Baseline Cr 1.5. Cr was at baseline both on admission
and the morning after the catheterization. Electrolytes were
trended throughout the hospital stay.
CHRONIC ISSUES
# HLD: Patient unable to tolerate statin, red yeast rice also
listed as an allergy, and has tried Coenzyme Q10 with and
without statins and could not tolerate this either. Takes plant
sterols, and says this has helped her bring her cholesterol down
as an outpatient. A lipid panel was checked, with Total Chol
165, LDL 102, HDL 46, ___ 83.
TRANSITIONAL ISSUES
- pt will follow up with Dr. ___ in clinic
- Patient intolerant of Beta blockers, ACE inhibitors, Statins,
and Calcium channel blockers
- should consider addition of ranolazine as anti-anginal as an
outpatient
- patient discharged with nitroglycerin SL in case of chest pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bumetanide 0.5 mg PO 4X/WEEK (___)
2. Vitamin D 50,000 UNIT PO DAILY
3. levemir 5 Units Breakfast
levemir 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Potassium Chloride 20 mEq PO DAILY
5. Aspirin 81 mg PO DAILY
6. flaxseed 1,000 mg oral DAILY
7. garlic 500 mg oral DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin B Complex 1 CAP PO DAILY
3. Vitamin D 50,000 UNIT PO DAILY
4. Vitamin E 400 UNIT PO DAILY
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
every 5 minutes Disp #*100 Tablet Refills:*0
7. Bumetanide 0.5 mg PO 4X/WEEK (___)
8. flaxseed 1,000 mg oral DAILY
9. garlic 500 mg oral DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. levemir 5 Units Breakfast
levemir 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Unstable angina
Coronary artery disease
Diabetes mellitus Type 1
Secondary diagnoses:
Hypertension
Hyperlipidemia
Chronic Kidney Disease
Gastroparesis
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 participating in your care at ___. You were
admitted to our hospital after developing chest pain that was
similar to your previous heart-related pain. You had a procedure
called a cardiac catheterization, and a blockage was found in
one of the arteries of your heart. A stent was placed to fix
this blockage. Because of this, you will need to be on the
medication Plavix for at least one year, in addition to the baby
aspirin you already take. You may continue to have chest pain
when you return home. If you have chest pain, you should take
nitroglycerin. During your hospital stay, you were also seen
by the ___ Diabetes team, who did not recommend any changes
to your insulin dosages.
You will follow up with Dr. ___ in his clinic. You will
continue to take plavix and the baby aspirin.
It was a pleasure participating in your care. We wish you the
best.
___ Medicine Team
Followup Instructions:
___
|
10737771-DS-13
| 10,737,771 | 23,775,230 |
DS
| 13 |
2167-09-12 00:00:00
|
2167-09-15 15:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle infection
Major Surgical or Invasive Procedure:
___ - I&D, VAC Right ankle wound
History of Present Illness:
___ hx of poorly controlled diabetes, tobacco use who
underwent right open reduction tib/fib with Dr. ___ ___ year
ago and removal of lateral end plate 2 weeks ago for
osteomyelitis and nonunion who presented to ___ today
with increased bleeding from the site. Noted to have fever to
101.3 there. ___ who spoke w/ Dr. ___, given
vanc/unasyn and sent for further evaluation. Plain film
concerning for osteo of ankle.
Pt states he woke up this morning and noticed bleeding from the
lateral aspect of his ankle. Has had increased pain. Swelling at
baseline. Felt sweaty overnight but denies documented fever at
home. Has baseline neuropathy but no acute changes in sensation.
Has difficulty ambulating ___ pain/bleeding.
Past Medical History:
-DM type 2, diabetic neuropathy, nephropathy
-Diverticulitis s/p hemicolectomy, s/p colostomy take-down
-Hypertension
-Hyperlipidemia
-Ankle surgeries stated in HPI
Social History:
___
Family History:
non contributory
Physical Exam:
Gen: NAD
RLE: chronic vascular changes, decreased sensation and pulses at
baseline, vac in place holding suction, weakly fires ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R ankle infection and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for I&D, VAC Right ankle wound, 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 services was
appropriate.
ID was consulted for MSSA both in the blood and from his OR
tissue culture. He was initially started on vancomycin initially
but narrowed to Nafcillin 2gm q4h at discharge. He will continue
on this regimen at discharge. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB on the RLE, and will be discharged on ASA 325mg for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
lantus 50U SC bid
novolog per sliding scale
Tylenol ___ mg q8h
aspirin 325mg daily
gabapentin 300 mg tid
oxycodone 5mg ___ tablets q4h prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
6. Nicotine Patch 14 mg TD DAILY
7. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every
four (4) hours Disp #*252 Intravenous Bag Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
10. Heparin 5000 UNIT SC TID
RX *heparin, porcine (PF) 5,000 unit/0.5 mL 5000 units SC three
times a day Disp #*84 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R ankle infection
Discharge Condition:
Stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing R lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- You have a vac dressing in place. This should be changed every
3 days and as needed if it leaks.
Physical Therapy:
NWB RLE
Treatments Frequency:
Wound monitoring
Wound care - vac change every 3 days and as needed, next change
___
Wound VAC @ 125mmHg
IV antibiotics: Nafcillin 2g q4h
Weekly monitoring labs: CBC w/ diff, BUN/Cr, LFTs
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Followup Instructions:
___
|
10737771-DS-14
| 10,737,771 | 22,412,802 |
DS
| 14 |
2167-10-15 00:00:00
|
2167-10-15 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Opiate overdose - Found unresponsive, responded to narcan
Major Surgical or Invasive Procedure:
Renal ultrasound
TTE
History of Present Illness:
___ with history of recent MSSA bacteremia/osteomyelitis,
chronic RLE wound, IDDM2 who was found unresponsive ___ at 10am
by his partner and revived with Narcan by EMS. Pt states he was
in his usual state of health yesterday going through his normal
daily routine. He went to bed last night as normal. He faintly
remembers drinking coffee in the morning prior to being found
down. He states he's been out of his oxycodone for the past 2
weeks and "isn't sure" if he might have taken anything else to
___. He has a car but appears unclear what antifreeze
is, and denies memory of drinking any liquids. He denies
depression / SI. He has also been out of his insulin for the
past 90 days. He says he can't drive to the pharmacy to refill
his insulin.
He recalls waking yesterday morning, drinking coffee and taking
his ___ medication but does not recall anything
else. Per EMS, he was found unresponsive ~10AM and revived with
2g Narcan. Transferred here from outside hospital given past
management of RLE wound here.
___ emesis x1 today in ED.
REVIEW OF SYSTEMS:
No fevers, chills, night sweats. No changes in vision or
hearing. No chest pain or palpitations. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits. No SI/HI
+ for cough, SOB, headache, 5lb weight loss, problems with
balance over past 2 weeks
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
- ___ DM2, diabetic neuropathy, nephropathy
- MSSA bacteremia ___
- Diverticulitis s/p hemicolectomy, s/p colostomy ___
- Hypertension
- Hyperlipidemia
- right ankle ORIF ___
- right ankle hardware removal ___
- right hand surgery ___ years ago)
- hemicolectomy
- expressive language disability
Social History:
___
Family History:
DM (father)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.4F 124 / 69 90 24 98 RA
GENERAL - Obese man, interacting and in no acute distress, lying
in bed and answering most questions appropriately.
HEENT: PERRLA with 3mm->2mm b/l. EOMI.
Cor: Nl S1/2. LLSB ___ systolic murmur. JVD ~12cm
Pulm: CTAB b/l.
Abd: Soft, protuberant, NTND
Extr: RLE: Wound vac in place to lateral right foot draining
malodorous fluid. Multiple open chronic skin wounds without
erythema / pus. WWP bilaterally. Skin tight over RLE. No
sensation distal to upper shin on R. Decreased sensation to
posterior toes on L foot. Slight pitting edema to upper shins
bilaterally, R>L.
Neuro: AOAx2, to self and place. MMS 18. ___ backwards intact
(attention).
Alert and oriented to person, place, time. CNs ___ tested in
detail and intact. Motor exam grossly intact in upper / lower
extremities. UE sensation normal bl, ___ sensation as above.
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 161 / 83 67 18 99 RA
PMN UOP: UOP 1.3 cc/kg/hr
___ fluid balance -1090cc
___ fluid balance -462cc
___ fluid balance -458cc
___ fluid balance -156.5cc
Exam:
GENERAL - Obese man, lying in bed and answering questions
appropriately. No apparent distress.
HEENT: PERRLA with 3mm->2mm b/l. No jaundice. No
submandibular/cervical LAD.
Cor: Nl S1/2. LLSB and apex ___ systolic murmur. Bilateral
carotid bruits.
Pulm: CTAB b/l.
Abd: BS+ Soft, protuberant, nontender.
Extr: RLE: Wound vac in place to lateral right foot draining
scant blood. Multiple open chronic skin wounds without erythema
/ pus. WWP bilaterally. Skin tight over RLE with pitting edema.
Trace pitting LLE edema to knee.
Neuro: Awake and alert, appropriate.
Pertinent Results:
====================
LAB ADMISSION LABS:
====================
WBC 22 Hb 7.4 Hct 25.5 Plat 505
Bicarb 11, Cr 4.8 BUN 42 AGap 23 Lactate 1.1
Ca: 8.3 Mg: 2.1 P: 9.2
pH 7.15 pCO2 45 pO2 42 HCO3 17 BaseXS -14
UA 600prot 300gluc no ketones
CK 416
Lip: 173
AP: 138 Tbili <0.2
UTox +for opiates
======================
PERTIENT LABS
======================
___ ___
==========================
BLOOD GASES AND LACTATE:
==========================
Lactate:
___ 1.1 (on admission)
___ 0.8
___ 1.1
___ 1.1
___ 0.7
___ 0.9 (on discharge)
___
___ ___ pO2 42 pCO2 45 pH 7.15* (on admission)
___ ___ pO2 42 pCO2 45 pH 7.15*
___ ___ pO2 42 ___
___ ___ pO2 47 ___
___ ART pO2 87 ___
___ ___ pO2 192 ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
======================
STUDIES
======================
___ TTE
Left Ventricle - Ejection Fraction: >= 55%
55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure PCWP>18mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets 3) appear structurally normal
with good leaflet excursion and no aortic enosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. No mass or vegetation is seen on the mitral valve. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension. Increased PCWP.
___ ECG
Sinus rhythm. Early R wave transition. ___ ST segment
changes.
Compared to the previous tracing of ___ the suggestion of a
prior anteroseptal myocardial infarction is less pronounced.
Rate PR QRS QT QTc (___) P QRS T
81 146 74 416 452 58 30 32
___ DX Right Ankle XRays
There are several partially image lucencies in the tibial shaft
of the sites of prior external fixation pin tracts, grossly
unchanged. There has been resection of the distal fibula.
Residual hardware is seen in the distal tibia. There is
fragmentation of the tibial plafond, overall, not largely
changed given differences in technique. Bones of the foot are
diffusely demineralized. There soft tissue swelling over the
dorsum. No acute fracture is seen.
___ CXR PICC Line
Right PICC ends in the low SVC. Compared to prior lung volumes
are low
without focal consolidation. Cardiomediastinal silhouette is
unchanged. There is no pleural effusion or pneumothorax.
___ Renal Ultrasound
The right kidney measures 10.2 cm. The left kidney measures 11.2
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is moderately well distended and normal in
appearance. No
postvoid residual was obtained.
Brief Hospital Course:
___ is a ___ year old male with IDDM, CKD, chronic RLE
osteomyelitis and recent MSSA bacteremia (with nafcillin, PICC)
who presented from an OSH after being found unresponsive by his
partner at home. He responded to narcan in the field and was
found to have a profound ___ (Cr 2.3) and metabolic acidosis
(with elevated anion gap) as well as a new heart murmur.
___ on CKD with metabolic acidosis: Baseline Cr 2.3 / BUN 23 on
___, 2 days prior to presentation; Cr was 4.3 / BUN 39 on
admission with a peak of 5.3. His admission VBG pH was 7.15 (7.2
corrected); serum bicarb was 14, lactate 1.1, urine without
ketones. He received a bicarb drip (1.5L 150mEq/L D5W) with
improvement of his metabolic acidosis. Renal was consulted to
evaluate causes for ___. A urine sediment was unremarkable, with
few (3) RBCs per ___ field(isomorphic), few white blood
cells (<1) per ___ field, no granular casts, and no
crystals. He had massive proteinuria with a urine protein:Cr
ratio of 8.8 (repeat 14.3)(although measurement of nephrotic
range proteinuria is complicated during ___, per the renal
team). Urine tox was notable only for opiates; serum tox was
negative. He had no serum Osm gap, with little concern for
ingestion of an ___ metabolite that would be missed on
toxicology. He maintained good urine output, ranging 0.8 - 1.4
cc/kg/hr, during this hospitalization.
#Chronic osteomyelitis with recent MSSA bacteremia:
The patient received continued management of his chronic
osteomyelitis, receiving nafcillin 2g IV q4h. There was no
change to his home OPAT nafcillin regimen. On admission his WBC
22K but this trended down within 24 hours, and he remained
afebrile throughout this hospitalization. His R foot was
evaluated by orthopedics and the wound vac remained in place
changed according to schedule. The Infectious Disease team
recommended continuation of his nafcillin regimen until
amputation. Early on in his course there was concern for
possible acute interstitial nephritis secondary to the
nafcillin, but this was thought to be unlikely given his
duration of use and acute presentation. Per the infectious
disease team, Mr. ___ likely require ongoing nafcillin
treatment as an outpatient until eventual amputation of his RLE.
#Anemia
The patient was noted to have a worsening of his baseline
anemia. His hemoglobin on admission was 7.4, but this trended
down to 6.4 after 24 hours (likely dilutional, after receiving
IV fluids). During his recent admission in ___, his Hb
ranged from 5.0 - 8.2. His baseline Hb in ___ appears to be 10.
During this admission, the patient received 2 unit PRBC and
maintained a stable hemoglobin around 7.5. The etiology of his
anemia was thought to be anemia of chronic disease, in the
context of chronic inflammation (chronic osteomyelitis, recent
MSSA bacteremia) with low serum iron and high ferritin. His
reticulocyte index was inappropriately low at <1 given his
degree of anemia.
#New systolic murmur, elevated troponin and ___
On presentation, the patient was noted to have murmurs that do
not appear to have been previously reported. He also had
elevated troponin and ___, both which trended down. He
consistently denied chest pain, and his troponin elevation was
thought to be type 2 / demand ischemia with retention in the
setting of CKD. He was noted to have a left lower sternal border
and an apical systolic murmur. He also had bilateral carotid
bruits. With his edematous RLE (with chronic wound), TTE was
obtained, which was unchanged from his previous ECHO, showing
mild mitral regurgitation with normal valve morphology,
preserved systolic function, and mild pulmonary artery systolic
hypertension. His LLE edema resolved during this admission.
#Nausea and vomiting
Mr. ___ had recurrent episodes of nausea and vomiting, with
one day of abdominal pain. The abdominal pain resolved after a
meal. The nausea and vomiting occurred when he ordered meals,
but he maintained a good appetite and his nausea resolved with
meals. He received Zofran PRN, as well. Possible etiology for
his nausea includes uremia and electrolyte shifts and is most
likely given resolution with improvement in kidney function;
antibiotic use was considered, however he says he doesn't get
nauseous at home.
#Opiate overdose
The patient's initial presentation (unresponsiveness, responsive
to Narcan) was consistent with opiate overdose, with a possible
element of gabapentin overdose. Although the patient stated he
ran out of his oxycodone (prescribed for his RLE pain) 2 weeks
prior to admission, he admitted that he wasn't sure whether he
might have taken other medications. He consistently denied
heroin use or any IVDU. We learned that the patient's fiance as
well as another individual living at the patient's home both
take Vicodin for chronic pain; unintentional diversion from
these sources in the setting of acute pain could have
precipitated the overdose. The patient was encouraged to use and
teach family members how to use Narcan to prevent opioid
overdose mortality in the future.
#Diabetes mellitus, type 2, insulin dependent
The patient has a history of poorly controlled ___
type 2 diabetes mellitus. However, he reports that he hasn't
taken any of his insulin for the past 3 months, because the
insulin he has at home is expired. He reported difficulty
driving to the pharmacy, given his chronic RLE wound, and was
hesitant to take expired medications. He also reports
drastically cutting down on sweets and sugars, and eating more
healthfully at home. Here, his blood sugar control was very
good. He was placed on a diabetic diet and received sliding
scale insulin control, but his typical daily values ranged from
___ without insulin. It is likely that progression of his
chronic kidney disease has led to increased renal retention of
insulin. Hgb A1C on admission was 6.6%, previously reported at
10% in ___, likely secondary to worsening renal function.
=======================
Transitional:
=======================
- Increased amlodipine from 5 to 10 mg ___ stage II hypertension
- TTE with moderate pulm hypertension, elevated wedge likely ___
OSA. Refused CPAP in hospital and at home
- Will follow up with nephrology in ___ to trend
proteinuria, consider renal duplex ultrasound
- AHA Risk calculator >7.5%, start statin; consider duplex
carotid ultrasound
- Once Cr stable for 1 wk consider starting ___
- Continue to monitor hypertension and consider adding or
increasing antihypertensive medications if persistently
hypertensive
- Administer Nafcillin antibiotics for MSSA osteomyleolitis as
prescribed by OPAT
- Assess vitals: call physician if SBP<100, Temp ___, HR>100
- Administer medications as prescribed
***************Lab draw M, W, F********************
CBC: WBC, RBC, Hgb, Hct, MCV, RDW
Chem10: Na+/K+/Cl-/HCO3-/BUN/Cr/Mg++/Ca++/Phos
- Call Physician to transfuse for Hgb/Hct ___
- Please ensure family is aware of narcan use.
- Consider iron supplementation with PCP
- contact: full code
- discharge weight: 191.2lbs
- Contact: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Nafcillin 2 g IV Q4H
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 325 mg PO DAILY
5. Gabapentin 300 mg PO TID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
You should have one bowel movement daily
3. Nafcillin 2 g IV Q4H
4. OxyCODONE (Immediate Release) ___ mg PO DAILY dressing
change only
Please administer prior to dressing change only. Hold for RR
>18, sedation.
RX *oxycodone 5 mg ___ tablet(s) by mouth daily prior to
dressing change Disp #*7 Tablet Refills:*0
5. Senna 17.2 mg PO BID:PRN constipation
You should have one bowel movement daily
6. Sodium Bicarbonate 650 mg PO TID
7. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Metabolic acidosis with elevated anion gap
Chronic osteomyelitis
Diabetes mellitus
Chronic kidney disease
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 serving you during your recent admission to
the ___.
You were in the hospital because you were found unresponsive at
home. It appears that you accidentally overdosed on opioid pain
killers (likely oxycodone). At the hospital, we learned that the
acid level in your blood was too high, and that your kidneys
were not working well.
While you were here, you had ultrasound imaging of your kidneys
and heart. Both appear normal. You also had tests to measure
your kidney function. You received medicines to improve the acid
and mineral levels in your blood, and we measured your urine.
You were also seen by the Renal, Orthopedics, Infectious
Disease, and Physical Therapy teams.
When you go home, you should continue to drink plenty of water
and other liquids. You will need more blood tests with your
primary care doctor to measure your kidney function. You will
need to be seen by the kidney doctors as ___. You will also
need to continue taking the nafcillin (antibiotic through the
___ line in your arm) at this time.
Changes to your medications:
-Continue taking nafcillin every 4 hours through your PICC
-Increase your amlodipine (blood pressure medication) from 5mg
to 10mg every day
-Take sodium bicarbonate 650mg three times per day with meals
Thank you for allowing us to participate in your care!
___ Care Team
Followup Instructions:
___
|
10737771-DS-16
| 10,737,771 | 23,785,334 |
DS
| 16 |
2168-08-15 00:00:00
|
2168-08-15 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Protonix
Attending: ___.
Chief Complaint:
R leg infection
Major Surgical or Invasive Procedure:
R leg guillotine BKA ___, ___
R BKA I&D ___, ___
R BKA I&D & closure ___, ___
History of Present Illness:
Mr. ___ is a ___ with DM and R
leg chronic osteomyelitis, p/w R leg purulence. Patient has a
history of R ankle fracture requiring revision fixation and ring
external fixator, complicated by infection, necessitating
removal
of hardware and multiple prior debridements. He has chronically
draining ulcers on his R ankle. From his last OR procedure, the
wound grew MSSA and was on nafcillin, now transitioned to
chronic
PO doxycycline. Mr. ___ has been evaluated and scheduled for
R BKA ___ the recent months, but last not been able to have
surgery due to electrolyte abnormalities on preoperative workup.
___ the last week, his ___ has had concerns for increasing edema
as well as a piece of hardware falling out of his wound. He
presents today to Dr. ___. He is not had any known
fevers, but does complain of foul-smelling drainage.
Past Medical History:
- Insulin-dependent DM2, diabetic neuropathy, nephropathy
- MSSA bacteremia ___ ___
- Diverticulitis s/p hemicolectomy, s/p colostomy take-down
- Hypertension
- Hyperlipidemia
- Expressive language disability
Social History:
___
Family History:
DM (father)
Physical Exam:
Ortho Admission exam:
GENERAL: Patient appears comfortable, ___ NAD
EXTREMITIES:
Dressing c/d/i
KI ___ place
Discharge exam:
VITALS: 98.3
PO 156 / 80 85 18 94 RA
GEN: Lying ___ bed, comfortable
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: Regular rate and normal rhythm, no m/r/g
Abd: Soft, NT, ND +BS
Skin: Multiple tattoos
Ext: S/P R BKA with stump wrapped ___ ACE bandage, brace
Neuro: AAOx3
Psych: Normal affect
Skin: Warm, dry no rashes
Pertinent Results:
On Admission:
___ 06:47PM BLOOD WBC-31.1*# RBC-1.95*# Hgb-5.3*#
Hct-17.8*# MCV-91 MCH-27.2 MCHC-29.8* RDW-16.7* RDWSD-55.8* Plt
___
___ 06:47PM BLOOD Glucose-215* UreaN-56* Creat-4.2*#
Na-131* K-5.2* Cl-98 HCO3-17* AnGap-21*
Pertinent Interval:
___ 06:28AM BLOOD Ret Aut-3.2* Abs Ret-0.08
___ 02:42PM BLOOD calTIBC-237* Hapto-351* Ferritn-281
TRF-182*
___ 05:41AM BLOOD Hapto-362*
___ 06:47PM BLOOD CRP-GREATER TH
___ 05:41AM BLOOD C3-168 C4-44*
___ 07:12AM BLOOD Vanco-22.0*
___ 06:01AM BLOOD Vanco-14.1
___ 02:42PM BLOOD Vanco-39.4*
___ 05:15AM BLOOD Vanco-33.4*
___ 09:16AM BLOOD Vanco-23.6*
___ 03:00PM BLOOD Vanco-17.1
___ 06:40AM BLOOD Vanco-15.7
___ 06:36AM BLOOD Vanco-12.1
___ 05:48AM BLOOD Vanco-16.5
___ 12:10PM BLOOD Vanco-13.7
Micro:
SWAB RIGHT ___ MARGIN.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). RARE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
Time Taken Not Noted ___ Date/Time: ___ 6:36 pm
TISSUE Site: LEG RIGHT LEG SWAB 3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Daptomycin Sensitivity testing per ___
___.
Daptomycin MIC 0.094 MCG/ML Sensitivity testing
performed by
Etest.
MINOCYCLINE Sensitivity testing per ___ (___)
___.
MINOCYCLINE = INTERMEDIATE.
MINOCYCLINE sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Time Taken Not Noted ___ Date/Time: ___ 6:39 pm
SWAB Site: LEG RIGHT LEG SWAB 1.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringenes, and C.septicum.
None of
these species was found.
___ Pathology: findings consistent with osteomyelitis
Imaging: renal US ___
Normal renal ultrasound. No evidence of hydronephrosis.
On discharge:
___ 09:44AM BLOOD WBC-13.7* RBC-3.10* Hgb-8.5* Hct-27.6*
MCV-89 MCH-27.4 MCHC-30.8* RDW-17.0* RDWSD-55.1* Plt ___
___ 09:44AM BLOOD Glucose-214* UreaN-___* Creat-3.4* Na-140
K-5.1 Cl-105 HCO3-23 AnGap-17
___ 05:14AM BLOOD ALT-8 AST-8 LD(LDH)-172 AlkPhos-209*
TotBili-<0.2
___ 02:42PM BLOOD Calcium-8.4 Phos-5.8* Mg-1.9 Iron-40*
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with PMH of poorly
controlled DM2, chronic osteomyelitis of right leg ___ hardware
infection, and CKD stage IV, who presents with frank purulence
of his right leg s/p R BKA course complicated by ___,
hyperkalemia, metabolic acidosis, anemia.
# Right leg osteomyelitis
# R BKA: Patient underwent BKA on ___ with I+D on ___ and ___.
BKA site now healing well. No plans for additional surgical
intervention at this time. Wound culture grew MRSA. He was seen
by ID- plan for 6 week course of IV antibiotics throug ___ via
PICC. During his hospitalization his vancomycin level was
carefully monitored, particularly ___ light of his renal
dysfunction. He is discharged on Vancomycin 1g Q48 hours with
recommendations by pharmacy to dose vanc by level
- Next due to check Vancomycin trough on ___ prior to next
dose, goal trough ___
- OPAT follow up arranged
- Pain control with standing tylenol, oxycontin with oxycodone
for breakthrough, gabapentin (renally dosed).
- Please consider weaning down on opiate therapy at rehab
- Follow up with orthopedics arranged.
# ___ on CKD stage IV complicated by proteinuria
# Hyperkalemia
# Metabolic acidosis: Patient's post operative course
complicated by acute on chronic renal failure, metabolic
acidosis, and hyperkalemia. Renal was consulted. Etiology of
worsening renal function likely secondary to fluid shifts ___ the
setting of significant surgery. However, renal function
continues to remain within his recent baseline based on his
___ records. Renal failure complicated by long standing
history of proteinuria. CKD likely secondary to longstanding DM.
Proteinuria secondary to diabetic nephropathy. He developed a
persistent hyperkalemia, thought secondary to DM and CKD, which
can lead to type IV RTA. Acidosis was treated with bicarbonate.
Lasix 40mg BID was added for ongoing managemeng of hyperkalemia.
Hydralazine was held to avoid hypotension and worsening renal
failure. He is discharged with close renal follow up. He will
likely need RRT ___ the near future.
- Started on bicarb 1300mg BID
- Nepro TID with meals
- Low phos, low K diet
- Sevalamet 1600mg TID with meals
- Lasix 40 mg BID
- Dose medications for GFR <15, avoid nephrotoxins
# Anemia: Patient with chronic anemia secondary to renal
dysfunction. Patient had worsening anemia during his
hospitalization, likely multifactorial from blood loss from
surgery, renal failure and anemia of inflammation. There was no
ongoing blood loss from ___ site, he was guiaic negative on
serial checks. Hemolysis labs
negative. Iron studies difficult to interpret ___ the setting of
multiple pRBC transfusions post-operatively. H/H remains stable
on discharge.
# HTN
# HL: Blood pressure elevated earlier ___ the hospitalization,
subsequently borderline low likely due to worsening anemia and
possible volume depletion. Now stable.
- Hydralazine 25 mg TID has been discontinued to avoid relative
hypotension and renal hypoperfusion
- PRN clonidine order discontinued (was not receiving)
- Continue Toprol 100 mg daily
- Continue amlodipine 10 mg daily
- Holding parameters for all antihypertensives
- Initiated on statin this admission
# DM II complicated by neuropathy, nephropathy. Overall sugars
well controlled on current regimen 100s-180.
-Continue Lantus 8 units qHS, sliding scale
Transitional:
OPAT Diagnosis: RLE osteomyelitis s/p BKA
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: Vancomycin 1250 mg IV Q 24H <-- may be adjusted
based on trough monitoring (CURRENTLY AT 1000MG Q48HR), NEXT
TROUGH ___, GOAL TROUGH ___
Start Date: ___
Projected End Date: ___ (6 weeks, to be determined by ID
f/u)
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed ___ the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
*PLEASE OBTAIN WEEKLY ESR/CRP for patients with bone/joint
infections and endocarditis or endovascular infections
- Please wean down narcotic therapy prior to discharge from
rehab
- Please discharge with narcan script if discharging on opiate
medication at rehab
- Please check Vanc trough on ___ prior to dosing vancomycin
Medications on Admission:
Oxycodone 2.5-5mg PO Q4H prn pain
Insulin sliding scale
Acetaminophen 100mg PO Q8H
Amlodipine 10mg PO QD
Clonidine 0.2mg PO BID prn HR>140
Docusate sodium 100mg PO BID prn constipation
Doxycycline 100mg PO Q12H
Gabapentin 600mg PO TID
Hydralazine 25mg PO Q8H
Metoprolol tartrate 25mg PO TID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Furosemide 40 mg PO BID
4. Metoprolol Succinate XL 100 mg PO DAILY
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice daily
Disp #*20 Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Sodium Bicarbonate 1300 mg PO BID
9. Vancomycin 1000 mg IV Q48H
10. Gabapentin 300 mg PO BID
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
12. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*20
Tablet Refills:*0
13. Acetaminophen 1000 mg PO Q8H
14. amLODIPine 10 mg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R leg osteomyelitis
S/P BKA
Acute on chronic renal failure
Hyperkalemia
Metabolic acidosis
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a leg amputation. This was
performed successfully. However, after the procedure you
developed worsening anemia and kidney function. You were seen by
the kidney team and your kidney function stabilized.
You are safe to be discharged to rehab at this time. Please
follow up with the appointments listed below.
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
10738019-DS-21
| 10,738,019 | 21,286,198 |
DS
| 21 |
2135-11-08 00:00:00
|
2135-11-08 14:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEURO___
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical aka ___ is a ___ male transferred
from OSH to ___ on ___ with a mild TBI. He had
an un-witnessed
fall off a ladder this morning around 6am while working. +LOC.
CT
head at ___ showed small SDH along the R tentorium and anterior
falx, as well as scattered small SAH and frontal contusions. He
was transferred to ___ for further evaluation.
On arrival he is neurologically intact. Hypertensive to SBP 200.
C/o mild headache, prior nausea resolved, no vomiting
Past Medical History:
- hypertension
- type 2 diabetes
Social History:
___
Family History:
non-contributory
Physical Exam:
--------------
on admission:
--------------
O: BP: 191/82 HR: 75 RR: 18 O2 Sat: 98% RA
GCS at the scene: 15
GCS upon Neurosurgery Evaluation: 15
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Gen: WD/WN, comfortable, NAD.
HEENT: dried blood in left ear
Neck: c collar
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
--------------
at discharge:
--------------
alert, oriented to self, date, hospital
PERRL. EOMI. ___. TML
Strength ___ BUE/BLE
No pronator drift
sensation intact
Pertinent Results:
please see OMR for pertinent results
Brief Hospital Course:
Mr. ___ was admitted to neurosurgery step down unit with TBI
after a fall off a ladder.
#TBI
He was started on keppra for seizure prophylaxis x 7 days.
Repeat head CT showed increase in frontal contusions. He was
monitored clinically and his neurologic exam remained
neurologically intact throughout his hospitalization, therefore
repeat CT was deferred. He was started on 3% NaCl with serial
sodium checks and then transitioned to PO salt tabs for
discharge. Sodium goal high normal, instructed to follow up with
PCP for sodium check in the next week. He will follow up with
___ clinic in 8 weeks with repeat head CT.
#Leukocytosis
WBC elevated to 19 on admission. He remained afebrile. CXR
negative for consolidation. UA was negative. WBC was normal at
9.5 at discharge.
#Hypertension
Patient takes lisinopril for HTN. BP was intermittently slightly
elevated to 160s during hospitalization requiring
hydralazine/labetalol with good effect. He was discharged on his
home antihypertensive with instructions to follow up with PCP
for further monitoring.
#Dispo
He was evaluated by ___, who recommended discharge to home. On
day of discharge, his pain was well controlled with oral
medications. He was tolerating a diet and ambulating
independently. His vital signs were stable and he was afebrile.
He was discharged to home in a stable condition.
Medications on Admission:
lisinopril 10, metformin 1g bid
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*10 Tablet Refills:*0
3. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*0
4. Lisinopril 10 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
traumatic brain injury with cerebral compression
subarachnoid hemorrhage, subdural hematoma, frontal contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
10738077-DS-10
| 10,738,077 | 23,553,316 |
DS
| 10 |
2170-10-23 00:00:00
|
2170-10-23 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral foot ulcers
Major Surgical or Invasive Procedure:
___: Debridement of osteomyelitis bilateral ___
metatarsal bases.
___ RLE SFA to DP bypass with L NRGSV
History of Present Illness:
___ w h/o PVD and PTA to both ___ over the past year who now
presents with worsening ___ ulcers on left and right. He has
been followed by podiatry for these lesions as well as vascular.
Dr. ___ has been talking with the patient about a bypass
being
necessary at some point. He denies any fever, chills, malodor.
He
has a PICC in place for long term antibiotics but has been off
Abx for some time. He had vein mapping done in ___ in
preparation for a possible bypass.
Past Medical History:
PMH: IDDM, HTN, HL, PVD
PSH: ___: R foot debridement and angiogram. ___: RLE
angio, PTA AT/Pop. LLE angio and PTA AT, R ___ toe amp ___, R
GSV stripping for varicose veins
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Examination:
98.1 HR 76 BP 108/54 RR 20 98RA
NAD
RRR
CTAB
abd soft, NT, ND
bilateral lateral foot wounds with left sided wound not probing
to bone but concern on right side for probing to bone
Pulse: Fem pop DP ___
R p p d d
L p p d d
DISCHARGE PHYSICAL EXAMINATION:
.........................
98.6 86 106/55 20 97RA
NAD, AOx3
RRR
CTAB
abd soft, NT, ND
b/l wound vacs in place. granular base. no drainage, erythema or
streaking noted.
Pulse: Fem pop DP ___
R p p p d
L p p d d
It should be noted, at the time of discharge Mr. ___ had a
palpable graft and DP pulse RLE.
Pertinent Results:
___ 07:39PM LACTATE-1.8
___ 11:21AM GLUCOSE-335* UREA N-29* CREAT-1.7* SODIUM-134
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-26 ANION GAP-16
___ 11:21AM estGFR-Using this
___ 11:21AM WBC-7.4 RBC-4.42* HGB-11.5* HCT-35.9* MCV-81*
MCH-26.0* MCHC-32.0 RDW-13.9
___ 11:21AM NEUTS-81.2* LYMPHS-13.6* MONOS-4.4 EOS-0.3
BASOS-0.5
___ 11:21AM PLT COUNT-287
___ 05:45AM BLOOD WBC-3.9* RBC-2.92* Hgb-7.8* Hct-24.3*
MCV-83 MCH-26.7* MCHC-32.1 RDW-15.8* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-123* UreaN-16 Creat-1.3* Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
___ 05:45AM BLOOD Calcium-7.4* Phos-3.7 Mg-1.8
___ 04:13AM BLOOD %HbA1c-7.0* eAG-154*
___ 05:45AM BLOOD Vanco-14.5
___ 5:35 ___
FOOT AP,LAT & OBL BILAT Clip # ___
Reason: Please evaluate for osteo B/L ___ met bases
Final Report
INDICATION: Bilateral fifth metatarsal base ulcerations,
evaluate for
osteomyelitis.
TECHNIQUE: Three views left foot, three views right foot.
COMPARISON: Bilateral foot radiograph, ___.
RIGHT FOOT:
There is a VAC dressing over the area of ulceration along the
base of the
fifth metatarsal. There is irregularity to the cortex of the
fifth metatarsal underlying this ulcer with areas of cortical
loss noted distally. The appearances are more extensive than on
the prior study, but this may be related to surgical
debridement. No new areas of bony involvement. Extensive
vascular calcifications. There has been a prior amputation at
the level of the second toe proximal phalanx. Diffuse soft
tissue swelling.
LEFT FOOT:
There is a VAC pump projected over the fifth metatarsal base.
There has been apparent interval resection of the lateral margin
of the base of the fifth metatarsal, there is certainly bony
loss in this region. Mild adjacent periostitis is similar to
prior. No new areas of bony involvement seen. No fracture or
dislocation. Diffuse soft tissue swelling.
CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN ___ #
___ Reason: r dl picc 41cm iv ping ___
Final Report
HISTORY: ___ male with PIICC.
COMPARISON: Chest radiograph dated same day 15 hours prior.
FINDINGS:
AP portable chest x-ray crash demonstrates new right PICC
terminating in the mid SVC. Lungs are essentially unchanged in
appearance when compared to chest radiograph 15 hours prior.
There is minimal bibasilar atelectasis with no new focal
consolidation. Cardiomediastinal and hilar contours are stable.
No pneumothorax or appreciable pleural effusion.
IMPRESSION:
Right PICC terminating in the mid SVC.
ART EXT (REST ONLY) Clip # ___
Reason: evluate PVD bilateral
Final Report
HISTORY: ___ male with bilateral foot ulcers.
COMPARISON: Lower extremity ultrasound ___ and ABI
___
TECHNIQUE: Bilateral lower extremity blood pressure, pulse
volume recording, and arterial doppler tracing at rest.
FINDINGS:
Right ABI is 1.33. Left ABI is 1.33. Triphasic waveforms are
noted in the bilateral common femoral and popliteal arteries.
The posterior tibial and dorsal pedis arteries demonstrate
monophasic waveforms bilaterally.
IMPRESSION:
Significant bilateral arterial disease below the knees
bilaterally, similar to previous examinations.
___ 12:22 AM
CHEST (PORTABLE AP) Clip # ___
Reason: evaluate PICC line
Final Report
HISTORY: ___ male with bilateral foot infections.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The AP portable chest radiograph demonstrates right PICC which
terminates in the axilla. There is no focal consolidation.
There is bibasilar atelectasis. Heart size is top-normal.
Mediastinal and hilar contours are within normal limits. There
is no pneumothorax or appreciable pleural effusion.
IMPRESSION:
Right PICC with tip terminating in right axilla. These findings
were
communicated to surgical house staff officer ___ by
Dr. ___ telephone at 10:00 on ___.
Brief Hospital Course:
___ is a ___ year old male with bilateral diabetic foot
ulcers who initally presented to ___ on ___ with with
concern for infection after being seen in ___ clinic. He
denied any fevers at that time, but had been experiencing some
ongoing drainage from the wounds.
He was admitted to the vascular surgery service and started on
vancomycin, ciprofloxacin, and flagyl. He was also started in
intravenous fluids. A podiatry consult was placed and xrays
were completed on his feet. They demonstrated an erosion on the
right and an irregularity on the left, both concerning for
osteomyelitis. He went to the OR with podiatry on ___ for
debridement of osteomyelitis on bilateral ___ metatarsal bases,
and bilateral wound vac placement.
Noninvasive testing was also done on his bilateral lower
extremities, which demonstrated right and left ABIs of 1.33, and
toe pressures of 21 on the right and 38 on the left. A medicine
consult was placed for preoperative clearance, and noted the
patient to have a 3.6% risk of perioperative major cardiac
complications.
He went to the OR on ___ for right lower extremity SFA to DP
bypass with L NRGSV. For full operative details, please see the
operative report dated ___. He tolerated the procedure
well, and was extubated at the end of the case. He was in the
PACU for a brief stay, and was subsequently transferred to the
surgical floor hemodynamically stable.
On ___, his flagyl was discontinued, but he remained on
ciprofloxacin and vancomycin. His bilateral foot vacs were put
back on by podiatrty. He was advanced to some po intake, but
he had nausea and vomiting. His diet was returned to returned
to NPO, and he was treated with antiemetics. His arterial line
was also removed. Throughout the day, he had high glucose
levels, and his insulin was adjusted, per ___
recommendations. On ___, he denied any continued nausea or
vomiting. His diet was advanced to clears, which he tolerated
well. He was able to get out of bed to the chair. His foley
was removed, and he voided without difficulty. Physical therapy
was consulted. On ___ Physical therapy worked with Mr.
___. They determined that they needed 1 more seesion to
evaluate if he needs to go to rehab. The wound vac paper work
was filled out and sent to the appropriate parties. On ___
the wound vacs were change by the Podiatry Team. His discharge
was held for one more day because he had an elevated creatine.
In addition he was given 1u PRBC because of a low hematocrit. On
___ he was discharged from the hospital with a prescription
for bactrim and a wet to dry dressing and ___ set up to change
the wound vacs every third day.
Medications on Admission:
ASA 81', Plavix 75', levothyroxine 125', lisinopril 10',
metformin 1000'', simvastatin 40', lantus 44', metoprolol 12.5''
MALGH:Meropenem 1'
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain/headache
DO NOT TAKE MORE THAN 4 GRAMS IN A 24 HOUR PERIOD.
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth q6h;prn Disp #*24 Tablet Refills:*0
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet,delayed release (___) by mouth
daily;prn Disp #*20 Tablet Refills:*0
9. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h;prn Disp #*40
Tablet Refills:*0
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
OSTEOMYELITIS
PERIPHERAL VASCUALAR DISEASE
DM type II
HTN
HYPERLIPIDEMIA
NON HEALING FOOT ULCERS BILATERALLY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
Mr. ___ you were admitted to the hospital for care of your
peripheral vascular disease. You underwent Superficial Femorial
Artery to Dorsalis Pedis Bypass with non reversed Left Greater
Saphenous Vein on your Right leg. You also underwent
Debridement of osteomyelitis bilateral ___ metatarsal bases by
podiatry. For treatment of this infection you were placed on
intravenous antibiotics.
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:
Take aspirin as instructed
Follow your discharge medication instructions
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
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10738077-DS-13
| 10,738,077 | 25,914,334 |
DS
| 13 |
2171-05-19 00:00:00
|
2171-05-20 20:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R foot swelling
Major Surgical or Invasive Procedure:
___: PICC placement with repositioning by interventional
radiology
History of Present Illness:
Mr. ___ is a ___ y/o M with h/o DM2 c/b neuropathy, HL, PVD,
recent admission for RLE osteomyelitis ___ (with tissue cx
positive for MRSA) who presents for evaluation of his right
foot.
Yesterday at midnight, the patient started having sharp burning
___ heel/ankle pain radiating to toes. He was unable to sleep
and took oxycodone 10 mg x 1 and 5 mg x 1 and tylenol in the
morning. Wife took temperature, which was 100.1 on tylenol. He
has noticed increased pain and swelling in foot. He called
podiatrist and was given bactrim (took one dose). He continued
to have chills and increasing pain so came to ED for evaluation.
Denies nausea/vomiting, sweats, palpitations, lightheadedness.
Of note, on his last labs with OPAT, his ESR was down to 53 and
CRP to 18 on ___. He had completed a 6-week course of
vancomycin and his PICC line was removed. He was evaluated by
podiatry on ___, who noted that there was still some persistent
swelling and mild warmth across the midfoot, with no crepitus.
In the ED, initial vs were: T 99.0 HR 95 BP 136/61 RR 18 SaO2
98% RA. Labs were remarkable for elevated CRP of 80, stable ESR
of 56, WBC of 7.2 with left shift. UCx and Blood Cx x 2 were
sent. ___ US was negative for DVT bilaterally. Foot Xrays showed
no change since prior in ___ but showed regions of osteolysis
and periosteal reaction of proximal aspect of the ___ and ___
metatarsals and lateral cuneiform. He received 4 mg morphine IV
x 2, tylenol 1g x 1, vanc 1g x 1, cefepime 2g x 1, and 1L NS
bolus.
Podiatry was consulted. They were concerned about septic
arthritis of his R ankle joint. A joint tap was attempted and
was unsuccessful due to obscured landmarks ___ swelling. Concern
for septic arthritis of R ankle joint. Attempted ankle joint tap
but failed due to obscured landmarks secondary to swelling. They
recommended 3-view ankle Xrays.
On the floor, vs were: T 98.2 P 91 BP 102/68 R 18 O2 sat 100%
Past Medical History:
# DM2 (A1C 7.0% ___
# HTN
# HL
# PVD
PSH: RLE SFA-DP bypass (___), R ___ digit amputation (___),
multiple b/l foot debridements, RLE angio (___), PTA AT/pop
(___), R foot debridement (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 98.2 P 91 BP 102/68 R 18 O2 sat 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, scar from
previous appendectomy
Ext: Warm, well perfused, no clubbing, cyanosis; significant
swelling in R ankle with poor ROM; lateral forefoot healed
ulcers bilaterally 0.5 x 1 cm; minimal erythema over medial R
ankle but mildly warm; difficulty appreciating DP pulses bil;
sensation preserved
Skin: long scar on left leg from prior bypass surgery,
Neuro: moves all extremities well but limited ROM in R ankle
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tmax 98.0 BP 118/60 P 86 R 16 SaO2 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, scar from
previous appendectomy
Ext: Warm, well perfused, no clubbing, cyanosis; swelling in R
ankle with minimal ROM; lateral forefoot healed ulcers
bilaterally 0.5 x 1 cm; minimal erythema over medial R ankle but
mildly warm; difficulty appreciating DP pulses bil; sensation
preserved; s/p ___ metatarsal amputation on R foot
Skin: long scar on left leg from prior bypass surgery,
Neuro: moves all extremities well but limited ROM in R ankle
Pertinent Results:
ADMISSION LABS
==============
___ 03:40PM BLOOD WBC-7.2 RBC-4.43* Hgb-11.2* Hct-35.2*
MCV-80* MCH-25.3* MCHC-31.8 RDW-16.1* Plt ___
___ 03:40PM BLOOD Neuts-81.3* Lymphs-11.0* Monos-6.4
Eos-1.0 Baso-0.2
___ 03:40PM BLOOD ESR-56*
___ 03:40PM BLOOD Glucose-147* UreaN-17 Creat-1.2 Na-134
K-4.1 Cl-97 HCO3-27 AnGap-14
___ 03:40PM BLOOD CRP-80.0*
___ 03:40PM BLOOD Lactate-1.8
PERTINENT LABS
==============
___ 06:10AM BLOOD ESR-97*
___ 06:30AM BLOOD ESR-120*
___ 06:00AM BLOOD ESR-126*
___ 05:10AM BLOOD ESR-109*
___ 05:22AM BLOOD ESR-115*
___ 06:10AM BLOOD CRP-291.7*
___ 06:30AM BLOOD CRP-210.8*
___ 06:00AM BLOOD CRP-156.1*
___ 05:10AM BLOOD CRP-146.2*
___ 05:22AM BLOOD CRP-131.1*
___ 06:08AM BLOOD Glucose-185* UreaN-15 Creat-1.3* Na-133
K-4.6 Cl-97 HCO3-25 AnGap-16
___ 06:10AM BLOOD Glucose-182* UreaN-16 Creat-1.4* Na-134
K-4.6 Cl-98 HCO3-29 AnGap-12
___ 06:30AM BLOOD Glucose-169* UreaN-18 Creat-1.2 Na-137
K-4.3 Cl-97 HCO3-28 AnGap-16
___ 06:00AM BLOOD Glucose-149* UreaN-17 Creat-1.1 Na-135
K-4.3 Cl-98 HCO3-26 AnGap-15
___ 04:40PM URINE Hours-RANDOM UreaN-730 Creat-109 Na-113
K-36 Cl-102
DISCHARGE LABS
==============
___ 05:22AM BLOOD WBC-4.8 RBC-4.03* Hgb-10.0* Hct-31.4*
MCV-78* MCH-24.8* MCHC-31.7 RDW-15.9* Plt ___
___ 05:22AM BLOOD Glucose-190* UreaN-19 Creat-1.1 Na-135
K-4.6 Cl-98 HCO3-26 AnGap-16
___ 05:22AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
MICRO
=====
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) 2:05AM
___.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
LINEZOLID & Daptomycin Sensitivity testing per
___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 2230,
___.
GRAM POSITIVE COCCI IN CLUSTERS.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ ___
3:20PM.
GRAM POSITIVE COCCUS(COCCI). IN PAIRS. GROWING IN
BROTH ONLY.
___ 3:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 5:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=======
___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ XRAY foot:
No definite change since ___ with regions of osteolysis
and periosteal reaction centered at the proximal aspect of the
third and fourth
metatarsals and lateral cuneiform. Irregularity of the base of
the fifth metatarsal which is relatively well corticated.
___ ankle:
Soft tissue swelling without focal osseous abnormality.
___ ___ ankle aspiration:
1. Imaging Findings - small tibiotalar joint effusion focal
ectasia of distal tibialis anterior artery. 2. Procedure -
successful ultrasound guided aspiration of the right tibiotalar
joint, yielding 3 cc of slightly cloudy yellow joint fluid. A
sample was sent to the laboratory for Gram stain/culture as well
as cell count/differential and crystal analysis.
___ MRI ankle w/o contrast:
IMPRESSION: Diffuse marrow signal abnormality within the
navicular, cuboid, cuneiforms and metatarsal bases with sparing
of the hindfoot. Although these findings can be seen in in the
setting of osteomyelitis, overlying neuropathic arthropathy
confounds the picture. Clinical correlation is recommended
___ MRI foot w/o contrast:
IMPRESSION: Diffuse marrow signal abnormality and erosive
changes involving the cuboid, navicular, cuneiforms and bases of
the metatarsals. Although these findings can be seen in the
setting of osteomyelitis, overlying neuropathic arthropathy
complicates assessment. More focal areas of cystic change
involving the navicular and the base of the fifth metatarsal
where there is an overlying soft tissue ulceration are more
suspicious for osteomyelitis. Limited evaluation for abscess.
Status post amputation at the proximal phalanx of the second
toe.
___ TTE:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality. No
mitral regurgitation is seen. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: No 2D echocardiographic evidence of endocarditis.
Given poor image quality this would be best excluded with TEE if
clinically indicated.
Compared with the prior study (images reviewed) of ___
left ventricular systolic function appears slightly less
vigorous, but this may be due to technical differences (echo
contrast not used on the current study). Other findings are
similar.
___ TEE:
No mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage. No mass or thrombus is seen in the right
atrium or right atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. 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 (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No valvular vegetations seen. Borderline low left
ventricular systolic function. Mild mitral regurgitation.
Complex, non-mobile atheroma of the descending aorta.
___ EKG:
Normal sinus rhythm, rate 83. Normal ECG. Compared to the
previous tracing
of ___ no diagnostic change.
___ CXR:
New right-sided PICC line is coiled within the right axillary
vein. This needs to be repositioned.
___ ___ guided PICC placement:
Successful repositioning of existing right arm approach single
lumen PICC with tip in the distal SVC. The line is ready to use.
___ MRI foot w/ contrast:
IMPRESSION: 1. Focal signal abnormality with rim enhancement
in the navicular with a tiny adjacent soft tissue fluid
collection is most consistent with osteomyelitis with an small
adjacent intraosseous abscess. 2. Heterogeneous signal
abnormality and enhancement in the base of the fifth metatarsal
with an overlying skin ulcer is equivocal for osteomyelitis.
These signal changes may either be due to osteomyelitis or
related to his the underlying Charcot arthropathy. 3. Diffuse
heterogeneous signal abnormality and enhancement throughout the
bones of the midfoot, as described above, is similar to prior
exams and most likely due to Charcot arthropathy. Superimposed
osteomyelitis cannot be completely excluded, but no other areas
of pronounced focal signal abnormality are identified. 4.
Diffuse soft tissue edema and enhancement, most likely related
to phlegmonous changes.
Brief Hospital Course:
BRIEF SUMMARY
=============
Mr. ___ is a ___ y/o M with h/o DM2 c/b neuropathy, HL, PVD,
recent admission for RLE osteomyelitis ___ with tissue cx
positive for MRSA) s/p 6-weeks of vancomycin who presents for
with right foot pain and swelling, consistent with RLE
osteomyelitis, also found to have MRSA bacteremia.
ACTIVE ISSUES
=============
# Right lower extremity osteomyelitis - The patient has a
history of recent right lower extremity osteomyelitis and
completed 6 weeks of vancomycin on ___. One day prior to his
presentation to the emergency room, the patient was found to
have sharp pain in his right foot and increased swelling and
erythema. There was no evidence of active ulcers. In the
emergency room, labs were significant for an elevated CRP of 80.
The patient was afebrile. An ultrasound of his extremity was
performed and negative for DVT. Foot Xrays showed no change
since prior in ___ but showed regions of osteolysis and
periosteal reaction of proximal aspect of the ___ and ___
metatarsals and lateral cuneiform. Podiatry was consulted and
attempted a joint aspiration but was not successful. They
recommended additional ankle imaging, which only showed soft
tissue swelling. The patient was admitted to the general
medicine floor, received blood cultures, and was started on
vancomycin. Infectious disease was consulted on ___, and
recommended MRI to rule out osteomyelitis. The patient received
arthrocentesis via interventional radiology on ___, which
showed no crystals, WBC 1700 with 79% polys, and negative gram
stain. Podiatry saw the patient on ___ and did not feel there
is a need for wash-out at the time. At this point, the patient
was found to have MRSA bacteremia in ___ bottles from his
original blood culture (see below). The patient received an MRI
of his ankle and foot but unfortunately declined IV contrast.
Upon further discussion with podiatry and infectious disease,
the patient underwent an MRI with contrast of his foot on ___,
which revealed rim enhancement in the navicular with a tiny
adjacent soft tissue fluid collection most consistent with
osteomyelitis with an small intraosseous abscess. Podiatry
ultimately determined that the patient can receive outpatient
drainage of the fluid collection and will contact the patient to
set up an appointment. Per infectious disease, the patient will
require an additional 6 weeks of vancomycin as an outpatient
(last dose ___ and possibly additional suppression therapy. He
received a PICC placement on ___, which required repositioning
by interventional radiology, but was discharged on ___ with
follow-up with outpatient antibiotic therapy. Of note, the
patient had joint fluid from ___ aspiration that revealed
gram-positive cocci growing in pairs in the broth only on ___
awaiting speciation.
# Methicillin-resistant Staphylococcus aureus bacteremia - The
patient had blood cultures from his admission, of which ___
bottles were positive for MRSA. The patient was started on
vancomycin. He received surveillance blood cultures daily, but
no subsequent cultures were positive. He received a TTE on ___,
which was inconclusive, and then received TEE, which was
negative for endocarditis. Of note, the patient was found to
have a complex, non-mobile atheroma of the descending aorta. He
was discharged on a 6-week total antibiotic course of vancomycin
per above).
# Type 2 diabetes - Patient is on metformin and insulin at home.
His metformin was held in the setting of his hospitalization to
avoid lactic acidosis. His insulin regimen is 44 units glargine
and sliding scale. He reports that his blood sugars have been
well-controlled at home. However, in the setting of infection,
the patient had elevated blood glucoses in low 200's. His
insulin was uptitrated to 46 units glargine at night and his
lunchtime correction scale was increased by 2 units. He was
discharged on this regimen and his home metformin. He has a
follow-up appointment at ___ on ___.
# Acute kidney injury - Patient had elevation of Cr to 1.3 from
1.1-1.2 baseline. He received intravenous fluids with improved
to 1.2 on ___, suggesting likely prerenal etiology. It was back
to his baseline on ___.
CHRONIC ISSUES
==============
# Peripheral vascular disease - Patient has a history of SFA-DP
bypass recently in ___. He was continued on home aspirin
and Plavix.
# HTN - The patient's metoprolol was held in the setting of soft
systolic blood pressures on admission. He was discharged on his
home medication.
# HL - Stable. He was continued on home simvastatin 40 mg daily.
# Hypothyroidism - Stable. He was continued on home
levothyroxine.
TRANSITIONAL ISSUES
===================
# Podiatry followup re: osteomyelitis and abscess of R navicular
bone. Please follow-up on joint fluid from ___, which showed
gram-positive cocci in pairs on ___ growing in broth only.
# Continue vancomycin to complete 6 week course (last day
___. Will likely need PO suppressive antibiotics following
this
# Blood sugars have been poorly controlled. Follow up with
___ re: diabetes management
# Weekly CBC with diff, chem 7, ALT/AST, Tbili, ESR/CRP and
vancomycin trough to be faxed to the ___ R.N.s at
___. All questions regarding outpatient parenteral
antibiotics should be directed to the ___ R.N.s
at ___ or to the on-call ID fellow when the clinic is
closed.
# CODE: Full, confirmed
# CONTACT: ___, wife ___ (H), ___ (Cell)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
8. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 500 mg 1500 mg IV every twelve (12) hours Disp
#*222 Vial Refills:*0
7. Glargine 46 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Tartrate 12.5 mg PO BID
10. Outpatient Lab Work
ICD-9 code: ___
Please draw the following labs weekly:
CBC with differential, Chem 7, AST/ALT, Alk Phos, Total bili,
ESR/CRP.
Please fax lab results to ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=================
# Right leg osteomyelitis
# MRSA bacteremia
SECONDARY DIAGNOSIS
===================
# Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted to the hospital with increased foot
swelling and were found to have a blood infection as well as
continued infection of the bone in your right foot. There was no
evidence of infection on the valves of your heart or in the
right ankle joint. There is a small pocket of fluid in one of
your foot bones which the podiatrists will drain as an
outpatient, but they do not recommend surgery at this point in
time. You were restarted on IV antibiotics for an additional 6
weeks, and it is also important for you to follow up with
podiatry and infectious disease following discharge.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
10738109-DS-3
| 10,738,109 | 29,483,799 |
DS
| 3 |
2136-09-21 00:00:00
|
2136-09-21 20:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / morphine
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___: cardiac catheterization
History of Present Illness:
Ms. ___ is a ___ y/o woman with
history of aortic stenosis, HTN, HLD who presents with dyspnea
on
exertion.
The patient reports that she felt completely well and in her
usual state of health until 3 days prior to admission. She awoke
on ___, walked 10 steps to the bathroom, and felt short of
breath. No other symptoms at the time, specifically no chest
pain, palpitations, lightheadedness, nausea, diaphoresis. She
returned to bed. When she awoke again, she continued to find
that
she was short of breath with minimal exertion, such as walking
on
flat ground. She reports that prior to 3 days ago she could
comfortably climb several flights of stairs without shortness of
breath or chest pain. She denies any cough, fevers, chills. She
does note that on the day of presentation she had some nausea.
She presented to ___ where labs were notable for
BNP 216 and Trop-I 0.15. Echocardiogram performed in the
emergency department there revealed an inferior wall motion
abnormality and now severe aortic stenosis. She was given
aspirin
and started on a heparin gtt and transferred to ___ ED.
In the ED, initial VS were: 98.0 84 160/83 18 94% RA
Exam notable for: ___ Systolic murmur; lungs CTA; mild bilateral
lower extremity pitting edema.
ECG: NSR at 80 bpm, NA/NI, T-wave flattening in V1, no acute
ST-T
wave changes
Labs showed: K 3.4, BMP otherwise wnl; H/H 9.4/30.9, plt 135;
Trop-T<0.01; INR 59
Imaging showed: CXR from outside hospital. Overexposed study but
no significant pulmonary edema per my read.
Consults: None
Patient received: Heparin gtt
Transfer VS were: 81 144/74 18 97% RA
On arrival to the floor, patient recounts the above history and
reports that she feels perfectly well at rest. She continues to
feel dyspneic with exertion. She also notes that her legs feel
heavy with exertion. Denies any other symptoms at present. No
syncope. No chest pain. No changes in weight recently. No
orthopnea. No PND. No peripheral edema.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Aortic stenosis
Seronegative Rheumatoid Arthritis
HTN
HLD
Prior provoked DVT/PE while on OCPs
Breast cancer s/p left mastectomy, in remission
Asthma
Social History:
___
Family History:
- Father: ___ stenosis
- No known family history of CAD or heart failure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 130 / 57 80 18 97 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, III/VI systolic murmur at LUSB with radiation
to carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace pedal edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: ___ 1111 Temp: 98.7 PO BP: 132/85 HR: 65 RR: 18 O2 sat:
96% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD appreciated although difficult to
examine
HEART: RRR, S1/S2, III/VI systolic murmur at ___ with radiation
to carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ pedal edema bilaterally, Right groin site c/d/I
no hematoma
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, ___
strength
in all 4 extremities bilaterally, intact sensation to light
touch
Pertinent Results:
ADMISSION LABS:
___ 09:13PM BLOOD WBC-5.4 RBC-4.34 Hgb-9.4* Hct-30.9*
MCV-71* MCH-21.7* MCHC-30.4* RDW-17.4* RDWSD-43.8 Plt ___
___ 09:13PM BLOOD Neuts-60.6 ___ Monos-7.2 Eos-1.5
Baso-0.4 Im ___ AbsNeut-3.26 AbsLymp-1.61 AbsMono-0.39
AbsEos-0.08 AbsBaso-0.02
___ 09:13PM BLOOD Plt ___
___ 09:28PM BLOOD ___ PTT-59.1* ___
___ 09:13PM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-146
K-3.4* Cl-107 HCO3-26 AnGap-13
___ 09:13PM BLOOD CK(CPK)-47
___ 09:13PM BLOOD CK-MB-3
___ 09:13PM BLOOD cTropnT-<0.01
___ 09:13PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8
PERTINENT LABS:
___ 03:15PM BLOOD CK-MB-6 cTropnT-0.03___ 05:00PM BLOOD CK-MB-7 cTropnT-0.02*
___ 10:40AM BLOOD CK-MB-7 cTropnT-0.03*
___ 06:25AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:13PM BLOOD cTropnT-<0.01
___ 09:13PM BLOOD CK-MB-3
___ 03:15PM BLOOD calTIBC-380 Ferritn-16 TRF-292
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-5.0 RBC-4.27 Hgb-9.2* Hct-31.1*
MCV-73* MCH-21.5* MCHC-29.6* RDW-17.7* RDWSD-45.8 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-28.7 ___
___ 06:15AM BLOOD Glucose-114* UreaN-20 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-28 AnGap-11
___ 06:15AM BLOOD CK(CPK)-93
___ 06:15AM BLOOD CK-MB-5 cTropnT-0.03*
___ 06:15AM BLOOD Calcium-9.2 Phos-5.1* Mg-2.0
MICRO:
NONE
IMAGING:
TTE ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with akinesis of the inferior
and inferolateral walls. The remaining segments contract
normally (LVEF = 45-50 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. The aortic valve VTI = 76 cm. There is
moderate (borderline severe) aortic valve stenosis (valve area
1.0 cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size, and mild regional systolic dysfunction c/w
CAD in an RCA/LCx distribution. Moderate (borderline severe)
calcific aortic valve stenosis. Mild aortic regurgitation. Mild
mitral regurgitation.
Cardiac Catheterization ___:
Impressions:
Pulmonary hypertension in the setting of elevated bi-ventricular
pressures. Single vessel epicardial coronary artery disease with
70% mid LCx succesfully treated with 1 Xience DES.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with history of aortic stenosis,
HTN, HLD who presents with dyspnea on exertion who was found to
have an inferior wall motion abnormality of ECHO who underwent
cardiac catheterization with DES to 70% stenosed left circumflex
lesion. She did well post-cath with one instance of IV diuresis
and then was started on maintenance Lasix, lisinopril, and
metoprolol. Her home atorvastatin was increased to 80 mg daily.
=============
ACUTE ISSUES:
=============
# Dyspnea on exertion:
Patient presented with acute onset of dyspnea on exertion 3 days
prior to admission. Given elevated troponin I and inferior wall
motion abnormality on TTE, patient had cardiac cath ___ with
DES to LCx (70% stenosis of OM1) via groin access. Angioseal did
not work well post procedure so C clamp placed to right groin.
No further bleeding from groin site. Cardiac catheterization
also showed elevated filling pressures (PCW 22, PA 36).
Therefore, shortness of breath likely due to missed ACS with
HFpEF. Patient was actively diuresed then placed on 20mg PO
furosemide for maintenance as well as cloidogrel and lisinopril.
While aortic stenosis appeared mildly worse on TTE, can consider
outpatient TAVR workup. Patient continued to endorse
intermittent shortness of breath but repeat chest X rays,
cardiac enzymes, and EKGs unchanged from prior so likely
musculoskeletal/anxiety component as well.
# Diarrhea:
Patient with limited episodes of diarrhea. Likely etiology was
from gut edema from volume overload. Less likely c diff as no
WBC or fevers.
# ___ weakness with ambulation:
Patient with pain with ambulation in ___. She appeared
deconditioned as she sits for most of the day. However, in order
to properly risk stratify, can consider ABI as outpatient. Neuro
exam nonfocal and not concerning.
# HTN: Well-controlled, not on any home medications. Patient
started on metoprolol and lisinopril as above. Blood pressures
at discharge within normal range.
# HLD: Last lipids well-controlled. Home atorvastatin was
increased to 80mg PO daily.
# Thrombocytopenia: Last known platelets 171, 135 on admission
so platelets were monitored without intervention.
================
CHRONIC ISSUES:
================
# Hypothyroidism: Continued home levothyroxine.
# Microcytic Anemia:
Unclear baseline but no notable areas of bleeding. Iron studies
showed borderline iron deficiency with serum iron=34,
ferritin=16, and transferrin=292.
# GERD: Continued home omeprazole.
# Seronegative rheumatoid arthritis: Tylenol as needed for pain.
Counseled to discontinue home ibuprofen and avoid all NSAIDs
pending further discussion with her cardiologist.
====================
TRANSITIONAL ISSUES:
====================
Changed medications:
- increased Atorvastatin to 80mg PO qhs
New medications:
- Lasix 20g PO with pm lytes check
- lisinopril 5 mg PO daily later this afternoon
- Clopidogrel 75 mg PO/NG daily for at least 6 months
- Metoprolol succinate 50mg PO daily
Stopped:
- Ibuprofen
Additional follow-up issues:
[ ] monitor volume status and adjust furosemide as needed
[ ] consider ABI as outpatient to evaluate patient's lower
extremity weakness with walking
[ ] Borderline iron deficiency anemia with possible component of
anemia of chronic disease: please consider supplementation as
outpatient
[ ] discharge weight: 99.3 kg/218.92 lb, discharge
creatinine=0.8.
#CODE: Full (presumed)
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily at night Disp
#*30 Tablet Refills:*1
6. Aspirin 81 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Non-ST Elevation Myocardial Infarction
Heart Failure with preserved Ejection Fraction
Secondary Diagnosis:
Aortic Stenosis
Hypertension
Hyperlipidemia
Hypothyroidism
Anemia
Gastroesophageal Reflux Disease
Seronegative rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Why was I admitted?
-You were admitted because you were having shortness of breath
with exerting yourself.
What was done while I was here?
We performed an ultrasound of your heart which showed it was not
pumping properly. Therefore, we performed a cardiac
catheterization where we looked at the blood vessels supplying
your heart. One of your blood vessels supplying your heart was
blocked so we placed a stent. The stent requires you to be on a
blood thinner so we started you on Aspirin and Clopidogrel
(Plavix). You should continue on this medication until your
doctor tells you otherwise.
What should I do now?
You should take your medications as instructed. You should go
to your doctor's appointments as below.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10738773-DS-21
| 10,738,773 | 25,584,800 |
DS
| 21 |
2130-11-30 00:00:00
|
2130-11-30 18:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, anorexia
Major Surgical or Invasive Procedure:
___ I&D of abscess with drain placed
___ washout and wound vac placement
___ wound vac exchange, right above knee pop to TP trunk
bypass with ipsilateral great saphenous vein
___ popliteal abscess washout with wound vac placement
___ popliteal wound washout, debridement, wound vac change
___ right medial calf incision washout, debridement, wound
vac placement
History of Present Illness:
Ms. ___ is a pleasant ___ year old woman with PMHx
significant for a thoracic aortic aneurysm s/p repair with
aortic
arch debranching and TEVAR (___) c/b
penetrating aortic ulcer distal to the TEVAR s/p TEVAR extension
(___), most recently s/p endovascular stenting of a ruptured
right popliteal aneurysm on ___, with wound vac placement
over the evacuated popliteal hematoma
She was last seen in clinic 2 weeks and is now presenting from
rehab with 2 days of fever and leukocytosis (29 on ___ and 27
on ___, as well as gram positive cocci in 1 out of 2 blood
cultures. Per report she was started on vancomycin and zosyn at
rehab and CXR/UA were normal.
Of note, she was last seen in clinic on ___. Upon taking down
the wound vac, approximately ___ of brown fluid was drained
and sent for culture. It grew coag + staph. It is unclear if she
was placed on abx at the time. An ultrasound was done at the
time
demonstrated patent popliteal stents and an ABI of 1.05 on the
right. She was scheduled to see Dr. ___ to get a CTA to
evaluate her TAAA.
Currently she reports ongoing issues with fevers, chills and
weakness. She also endorses anorexia. Per the patient and the
daughter this has worsened over the past week and they are
worried she has not been making as much progress at rehab. She
denies nausea, vomiting, headache, vision changes, confusion or
leg pain beyond her incision at this time. She has not been
ambulatory for the past couple of days.
Past Medical History:
Past Medical History:
-thoracic aortic aneurysm s/p repair (TEVAR)
-penetrating aortic ulcer distal to TEVAR stent graft w
associated intramural hematoma & aneurysmal dilatation of this
aortic segment s/p repair (TEVAR extension)
-LUE DVT (s/p 3 months of lovenox therapy)
-left vocal cord paralysis s/p voice gel injection (___),
calcium hydroxyapatite injfection (___)
-Asthma
-Cataracts
-Hypertension
-Lung Adenocarcinoma s/p resection
-Meningioma
-Osteoarthritis
-Saddle Pulmonary Embolus, ___
-Subdural Hematoma, ___
-Thyroid Nodule
Past Surgical History:
-extension of previous TEVAR (___)
-aortic arch debranching and TEVAR (___)
-VATS LUL lobectomy (___)
-Cataract surgery
Social History:
___
Family History:
Noncontributory. She denies h/o of cancer, early MIs, CVAs.
Physical Exam:
Admission Physical Exam
Vitals:
T98.8 HR88 115/66 30RR 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist. AxOx3, not
somnolent, not confused
CV: RRR
PULM: Equal symmetric chest rise, no gross chest wall
deformities
ABD: Soft, nondistended, nontender, no rebound or guarding, no
palpable masses
Ext: RLE edema extending to knee, R popliteal fossa
wound(3cmx2cm) taken down with bed of granulation tissue but
some
minor foul smelling purulent discharge noted, no fluctuance
appreciated with no erythema (refer to picture in WebOMR). No
exposed stent noted.
R: p//d/d L: p/p/d/d
Discharge Physical Exam
VS: T 99.5, BP 121/74, HR 82, RR 19, O2 sat 98% (RA)
GENERAL: Awake, alert, resting comfortably in bed
CV: +RRR
PULM: No respiratory distress on RA
ABD: Soft, non-distended, non-TTP
WOUND: RLE in ACE wrap from foot to above knee, black sponge vac
to popliteal fossa on 125 mmHg, black sponge vac to medial
bypass incision on low suction 50 mmHg
EXTREMITIES: Edema to the right lower extremity below the knee
PULSE EXAM: R ___ dopplerable, triphasic
Pertinent Results:
Admission Labs
___ 08:48PM BLOOD WBC-26.7* RBC-3.12* Hgb-8.5* Hct-26.9*
MCV-86 MCH-27.2 MCHC-31.6* RDW-26.8* RDWSD-83.1* Plt ___
___ 08:48PM BLOOD Neuts-83.3* Lymphs-3.7* Monos-11.2
Eos-0.6* Baso-0.2 Im ___ AbsNeut-22.24* AbsLymp-0.98*
AbsMono-2.99* AbsEos-0.15 AbsBaso-0.06
___ 08:48PM BLOOD Plt Smr-NORMAL Plt ___
___ 08:48PM BLOOD Glucose-113* UreaN-49* Creat-1.4* Na-134*
K-4.3 Cl-99 HCO3-21* AnGap-14
___ 08:48PM BLOOD Albumin-2.4*
___ 08:48PM BLOOD ALT-34 AST-55* AlkPhos-123* TotBili-0.4
___ 08:52PM BLOOD Lactate-1.0
Discharge Labs
___ 04:51AM BLOOD WBC-7.1 RBC-3.21* Hgb-9.1* Hct-30.4*
MCV-95 MCH-28.3 MCHC-29.9* RDW-16.4* RDWSD-57.1* Plt ___
___ 04:51AM BLOOD Glucose-83 UreaN-19 Creat-0.8 Na-138
K-4.5 Cl-100 HCO3-27 AnGap-11
___ 04:51AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
___ CTA AORTA/BIFEM/ILIAC R
1. 8.3 x 5.5 cm collection primarily posterior to the right
popliteal artery
contains gas, with questionable peripheral rim enhancement
posteriorly (series
301:319), concerning for abscess.
2. The right popliteal artery is patent with stent in situ.
3. Nondisplaced subacute fractures of the right lateral tenth
and eleventh
ribs (series 301:77).
4. Status post endovascular repair of the ascending thoracic
aortic aneurysm
with patent stent graft. The aneurysmal sac at the aortic arch
is not
significantly changed.
5. Unchanged thickened endometrium measuring up to 12 mm, also
seen on prior
studies. This could be further evaluated with nonemergent
pelvic ultrasound
as an outpatient.
6. 5 mm right upper lobe nodule is unchanged (series 301:45).
Please see
below.
___ CXR
1. Opacities at the right lung base are similar to prior and
likely reflect
atelectasis, however difficult to exclude aspiration or
pneumonia in the
appropriate clinical setting.
2. Right upper extremity PICC line with tip projecting near the
cavoatrial
junction. Otherwise, little change from prior studies.
Venous Duplex (___)
Patent bilateral greater and small saphenous veins as described
above.
CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND ___
IMPRESSION:
1. Interval placement of a drain in the fluid collection in the
right
popliteal fossa, considerably smaller since prior study, with no
clear pockets of fluid identified, only persistent phlegmonous
changes.
2. Right popliteal arterial stent in situ remains patent.
3. Incompletely characterized arterially enhancing subcentimeter
lesion in the hepatic dome, possibly a hemangioma.
4. 11 mm hypodense lesion in the uncinate process, is more
conspicuous than on prior study, and likely corresponds to a
side branch IPMN, but warrants an outpatient evaluation with
MRCP following resolution of acute issues.
5. Incompletely characterized right adnexal hypodense 1.5 cm
structure with punctate calcification. This is likely the right
ovary, but further
evaluation with outpatient followup pelvic ultrasound could be
considered.
Transthoracic Echo (___)
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function. Mildly dilated ascending aorta. Mild-moderate
pulmonary artery systolic hypertension.
Transesophageal Echo (___)
Left Atrium ___ Veins: No spontaneous echo contrast
is seen in the ___.
Left Ventricle (LV): Normal cavity size. Normal regional &
global systolic function
Right Ventricle (RV): Normal free wall motion.
Aorta: Tube graft in ascending and descending aorta. Ascending
aorta aneurysmal.
Aortic Valve: Thin/mobile (3) leaflets. Minimal leaflet
calcification. No mass/vegetation. No stenosis. Mild
regurgitation. Central jet.
Mitral Valve: Normal leaflets. No systolic prolapse. No
mass/vegetation. Mild regurgitation.
Pulmonic Valve: Normal leaflets. No regurgitation.
Tricuspid Valve: Normal leaflets. No mass or vegetation seen.
Trace regurgitation.
Pericardium: No effusion.
RUE Venous Ultrasound (___)
IMPRESSION: No evidence of deep vein thrombosis in the right
upper extremity.
CXR Line Placement (___)
IMPRESSION:
The tip of the right internal jugular central venous catheter
projects over the distal SVC. The tip of the endotracheal tube
projects over the
midthoracic trachea. The tip of the enteric tube projects near
the EG junction and further advancement is recommended. Small
bilateral pleural effusions and bibasilar atelectasis.
Transthoracic Echo (___)
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild pulmonary artery systolic hypertension. Mild
mitral regurgitation with normal valve morphology. Mildly
dilated aortic arch and descending thoracic aorta.
CTA LOWER EXT W/&W/O C & RECON (___)
IMPRESSION:
1. Interval repair of right popliteal aneurysm rupture, with
patent
femoropopliteal bypass graft extending into the right posterior
tibial trunk, with patent tibial anterior and posterior and
popliteal arteries.
2. There is a medial inguinal through distal thigh subcutaneous
hyperdense
fluid collection, most consistent with hematoma. There is no
discrete
evidence of extravasation, however close clinical attention to
this area is advised.
3. Right popliteal fossa fluid collections, the largest
measuring 3.4 x 3.7 x 6 cm with surgical drain in place,
communicates with a more inferior smaller 2.8 x 3.4 x 3.3 cm
collection.
4. Subcutaneous elongated 2.3 x 0.9 x 6 cm fluid collection
extending from the popliteal fossa along the medial calf.
5. Markedly edematous right lower extremity extending from the
right inguinal region into the foot.
RUE Venous Ultrasound (___)
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Soft tissue swelling overlying the right antecubital fossa.
CXR PICC Placement (___)
FINDINGS:
1. Existing left arm approach PICC with tip in the axillary vein
replaced with a new single lumen PIC line with tip in the
cavoatrial junction.
IMPRESSION:
Successful placement of a 53 cm left arm approach single lumen
PowerPICC with tip in the cavoatrial junction. The line is ready
to use.
CXR PICC Placement (___)
IMPRESSION:
In comparison with the study of ___, there has been
placement of a left subclavian PICC line that is extremely
difficult to follow due to the
overlying aortic stent. It does not appear to extend beyond the
brachiocephalic vein. Oblique views would be necessary to
precisely document the position of the tip of the PICC line. The
patient has taken a better inspiration. Cardiomediastinal
silhouette is stable, as is the overall appearance of the heart
and lungs.
Brief Hospital Course:
Ms. ___ is a pleasant ___ year old woman with PMHx
significant for a thoracic aortic aneurysm s/p repair with
aortic arch debranching and TEVAR (___) c/b penetrating
aortic ulcer distal to the TEVAR s/p TEVAR extension (___),
most recently s/p endovascular stenting of a ruptured right
popliteal aneurysm on ___, with wound vac placement over
the evacuated popliteal hematoma, who was recovering at rehab.
She now presents with popliteal abscess, likely surgical site
infection. On arrival she had fever to 102 and had positive
blood culture from rehab, thus she was started on broad spectrum
antibiotic, fluid resuscitated, and subsequently underwent
incision and drainage of the abscess with drain placement in the
operating room. See operative report on the same date for
further details. She tolerated the procedure well and was
transferred to the recovery unit without issue.
After a brief stay in the recovery unit she continued to recover
on the surgical floor. She remained afebrile and hemodynamically
stable, but had positive blood cultures until ___. She was
taken back to the ___ for a wound vac placement on ___, which
she tolerated well, and then brought back to the ___ on ___
for a wound vac exchange.
This operation was complicated by disruption of the popliteal
graft likely secondary to infected graft, resulting in massive
hemorrhage and tourniquet placement. She underwent massive
transfusion protocol and an emergent above knee to below knee
bypass using ipsilateral great saphenous vein. Her EBL during
this procedure was 5 L, and she received blood products
appropriately. She had three JP drains placed. She was
transferred to the SICU intubated and on pressors. She did well
postoperatively in the ICU and was able to be extubated on POD
1, with pressors weaned off. She was transfused as necessary
with continually decreased requirements. She was transferred to
the VICU on POD 3 (___) in stable condition.
She continued to do well on the floor, and all three JPs were
removed. She underwent CTA of the right lower extremity showing
a new hematoma in her groin as well as persistent loculated
fluid collection in her popliteal fossa. She underwent washout
on ___. A Veraflo Cleanse Choice dressing wound vac was then
placed to the popliteal fossa, with improved granulation tissue
and decreased depth of the wound with serial vac changes. She
did require one additional debridement of the right popliteal
fossa in the OR on ___, which she tolerated well, with
replacement of the Veraflo Cleanse choice dressing vac. On
___, she was transitioned back to a black sponge wound vac
on 125 mmHg suction, and this has been changed every 2 days. Her
popliteal wound was evaluated by Plastic Surgery on ___,
who recommended continuing the wound vac and follow up in ___
weeks in clinic for evaluation of a possible split-thickness
skin graft.
On ___, the medial bypass incision on her right calf was
found to be draining bloody, purulent material. A bedside
culture was collected on ___, and the patient went to the
OR for a washout, debridement, and low suction (50 mmHg) black
sponge wound vac placement to this medial calf incision on
___. OR swab and tissue cultures were obtained. She
tolerated the procedure well, and this vac has been changed
every two days. The two wound vacs should not be changed on the
same day to prevent cross-contamination of the two wounds.
Cultures from her medial calf incision have grown Enterococcus
and E coli, which are sensitive to daptomycin and meropenem.
Infectious Disease followed her and helped determine antibiotics
course. Of note, wound cultures from ___ from clinic revealed
MSRA. OR cultures of her popliteal wound revealed a
polymicrobial infection with MDR E.coli, two morphologies of
enterococcus, and MRSA. The patient was subsequently narrowed to
Meropenem and Daptomycin for MDR E.coli and VRE, respectively.
For the medial calf bypass incision, bedside superficial swab
and intraoperative tissue cultures grew E.coli and Enterococcus,
with susceptibility profiles similar to previously isolated
E.coli and enterococcus. She has continued on the daptomycin and
meropenem, and should continue these for at least 4 weeks from
her last washout on ___, so until at least ___. Final
duration of antibiotics to be determined upon follow up with
Infectious Disease at ___, with likely transition to
life-long oral antibiotic suppressive therapy.
On ___, the staples were removed from her right leg
incisions, and steristrips were placed with mastisol, with no
signs or symptoms of infection at these sites. Throughout the
wound vac changes, the patient maintained a dopplerable right
posterior tibial artery signal. She has had persistent swelling
of the right lower extremity, for which she should elevate her
leg on pillows at rest and have an ACE bandage placed from the
foot to the knee once daily. She should also wear a knee brace
when resting in bed, with the right leg in full extension, to
prevent joint contracture. Weekly nutrition labs were obtained,
which demonstrated a low albumin and prealbumin. The patient was
started on Ensure supplements TID with meals, with slow
improvement in her albumin and prealbumin. She also complained
of neuropathic pain to her right lower extremity, and was
started on gabapentin with good effect.
Throughout her stay, the patient received IV antibiotics via a
left PICC line that had been placed at her acute ___
rehab. On ___, the patient accidentally removed her PICC
line in the early morning. The venous access team attempted to
replace the PICC line on ___, but were unable to do so at
the bedside. On ___, the patient had the left PICC line
replaced with Interventional Radiology, with the tip in the
cavoatrial junction. Upon return to the floor, the ___ RN
noticed the site was bleeding and was concerned the PICC may
have been pulled out a few centimeters. Pressure was held at the
site, the bleeding resolved, and the sterile dressing was
replaced. An urgent CXR was obtained to assess the position of
the tip of the PICC. Radiology could not verify the position of
the tip, given the ___ aortic arch graft. Interventional
Radiology was paged, they reviewed the repeat imaging, and
confirmed the PICC was in the appropriate position and safe to
use. PICC was flushing without issue per RN.
During her inpatient stay, the patient worked with Physical
Therapy, who recommended discharge to acute ___ rehab.
Given the improved appearance of her wounds, no longer requiring
washouts in the operating room, and successful replacement of
her PICC line, she was deemed ready for discharge to acute
___ rehab on ___. On the day of discharge, the
patient was doing well, afebrile with stable vital signs. She
was tolerating a regular diet, voiding with a PureWick, and
passing flatus. Her pain was well controlled with PO tramadol,
gabapentin, and acetaminophen, including during her wound vac
change. She was cooperative and motivated to work with physical
therapy. She will follow up with Dr. ___ in about 2
weeks for a post-operative check, with ABIs and Duplex
ultrasound of her right leg. She will also follow up with
Plastic and Reconstructive Surgery in clinic in about 2 weeks
for evaluation of a split thickness skin graft to the right
popliteal fossa. The patient should receive weekly labs for
antibiotic monitoring, with results faxed to Infectious Disease
at ___ clinic. ___ clinic will schedule a follow up
appointment for the patient as well, to determine final course
of IV antibiotics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. Ramelteon 8 mg PO QPM:PRN insomnia
7. Simvastatin 40 mg PO QPM
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
10. Aspirin EC 81 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
12. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Daptomycin 600 mg IV Q24H
Continue at least through ___, final course pending
outpatient follow up in ___ clinic
2. Famotidine 20 mg PO Q12H
3. Gabapentin 200 mg PO TID
4. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
5. Meropenem 500 mg IV Q6H
Continue at least through ___, final course pending
outpatient follow up in ___ clinic
6. Sarna Lotion 1 Appl TP BID:PRN Itching
7. TraMADol 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
10. Aspirin EC 81 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone Propionate 110mcg 1 PUFF IH BID
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Montelukast 10 mg PO DAILY
16. Ramelteon 8 mg PO QPM:PRN insomnia
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
18. Simvastatin 40 mg PO QPM
19. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
20. HELD- Milk of Magnesia 30 mL PO Q12H:PRN Constipation -
First Line This medication was held. Do not restart Milk of
Magnesia until discharge from rehab
21.Outpatient Lab Work
Please draw weekly CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CPK, and CRP.
ICD 9 code: ___ (septicemia)
Responsible Provider: Dr. ___, phone # ___
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Ruptured infected popliteal aneurysm
- Hemorrhagic shock requiring transfusion protocol
intra-operatively and post operative anemia requiring
transfusion
- Right popliteal fossa infection
- Right medial calf surgical site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Working with ___.
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:
Take aspirin as instructed
Follow your discharge medication instructions
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
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10738974-DS-16
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DS
| 16 |
2166-04-01 00:00:00
|
2166-04-01 13:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right tibial plateau fracture
Major Surgical or Invasive Procedure:
ORIF of right tibial plateau fracture
History of Present Illness:
HPI: ___ M presents with R tibial plateau fracture s/p mechanical
fall at work. He drives a delivery truck and fell out of his
truck earlier today, with immediate pain about the right knee
and
inability to ambulate. He denies numbness or tingling. His
last
meal was at 5am this morning.
PMH/PSH: None.
Social History:
Occasional alcohol. Denies tobacco or illicit drug use.
Independently employed, works as a ___.
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of right tibial plateau
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. 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
NVI distally in the right lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. <<<>>> per 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #*28 Syringe
Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right tibial plateau fracture status post surgical fixation
Discharge Condition:
Mental status: AOX3
Ambulatory status: Touch down weight bearing in ___ brace
and assistance
Overall: Stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing right lower extremity
- Range of motion as tolerated at right knee in ___ brace
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10739621-DS-13
| 10,739,621 | 24,603,001 |
DS
| 13 |
2161-09-13 00:00:00
|
2161-09-13 10:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sternal Wound Infection
Major Surgical or Invasive Procedure:
bedside sternal debridement
History of Present Illness:
___ with history of AVR with ___ mechanical valve on
___ who presents with 5 days of chest and neck pain, low
grade temperature, and WBC 20 at ___ emergency department. The
patient was last seen as outpatient on ___ at which time
she was noted to be doing well without any evidence of infection
at her sternal wound site.
Past Medical History:
Aortic Coarctation s/p repair
Aortic Stenosis
Bicuspid Aortic Valve
Hiatal Hernia
Hyperlipidemia
Hypertension
Obesity
Past Surgical History:
Open repair of aortic coarctation via left thoracotomy ___ @
___
Cesarean Sections x 3
Prior D&C
Social History:
___
Family History:
Father - myocardial infarction at age ___
Physical Exam:
Admission PE:
VS: 98.8 110 172/84 18 97%
Gen: Well appearing, no acute distress
Cardiac: RRR [x] Irregular [] Murmur - crisp click
Chest: Lungs clear bilaterally [x]
Abdomen: Soft [x] Nontender [x] Nondistended [x]
Extremities: Warm [x] Well perfused [x]
Edema: trace
Sternal incision:
erythema no[] yes[x]
drainage no[x] yes[]
well approximated yes [x] no []
sternal click no[x] yes[]
Pertinent Results:
MICRO:
___ 3:46 pm SWAB Site: STERNUM Source: sternal.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
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
___ 05:43AM BLOOD WBC-9.3 RBC-3.32* Hgb-9.8* Hct-30.0*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.1 Plt ___
___ 05:59AM BLOOD WBC-13.1* RBC-3.37* Hgb-9.9* Hct-30.6*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.2 Plt ___
___ 05:43AM BLOOD ___
___ 05:59AM BLOOD ___ PTT-34.3 ___
___ 05:30AM BLOOD ___
___ 02:25AM BLOOD ___ PTT-32.8 ___
___ 01:40PM BLOOD ___
___ 12:15AM BLOOD ___ PTT-46.1* ___
___ 05:43AM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-140 K-3.6
Cl-100 HCO3-32 AnGap-12
___ 05:59AM BLOOD Albumin-2.9* Calcium-8.6 Phos-4.1 Mg-1.9
___ 05:43AM BLOOD Mg-2.2
Brief Hospital Course:
The patient was admitted for further evaluation of her sternal
wound. She was started on IV antibiotics. The wound was opened
and debrided at the bedside. Chest CT could not definitively
exclude sternal bone involvement, and transthoracic echo was
performed and did not reveal any valvular vegetations. Lab and
study findings were reviewed with Dr. ___ Dr. ___,
___ covering) and plan is for comprehensive medical management
with VAC dressing and IV antibiotics. Should she fail this
course of treatment, then more aggressive sternal investigation
will be pursued in the operating room. Her wound culture grew
MSSA and per ID team recommendations she was transitioned to
Nafcillin IV for a 6 week course. Her blood cultures remained
negative to date at time of discharge home. Her leukocytosis
improved from 20K/uL at OSH to 9K/uL on day of discharge home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. valsartan-hydrochlorothiazide 80-12.5 mg oral daily
3. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
4. Multivitamins 1 TAB PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Diltiazem 60 mg PO QID
7. Metoprolol Tartrate 100 mg PO TID
8. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Diltiazem 60 mg PO QID
RX *diltiazem HCl 60 mg 1 tablet(s) by mouth four times a day
Disp #*120 Tablet Refills:*0
2. Metoprolol Tartrate 100 mg PO TID
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
3. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Warfarin 2.5 mg PO DAILY16
dose to change daily for goal INR ___ ___
___ *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. valsartan-hydrochlorothiazide 80-12.5 mg oral daily
RX *valsartan-hydrochlorothiazide 80 mg-12.5 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
9. Nafcillin 2 g IV Q4H Duration: 6 Weeks
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every
four (4) hours Disp #*24 Intravenous Bag Refills:*0
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*40 Tablet
Refills:*0
12. Senna 17.2 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 2 tabs by mouth bid prn Disp #*40
Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17g powder(s) by mouth
daily prn Disp #*1 Bottle Refills:*0
14. Acetaminophen 650 mg PO Q6H:PRN pain/fever
15. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. DiphenhydrAMINE 25 mg PO Q6H:PRN puritis/insomnia
RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth q6h prn Disp
#*40 Capsule Refills:*0
17. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Superficial Sternal Wound Infection
PMH:
1. Aortic Coarctation s/p repair
2. Aortic Stenosis
3. Bicuspid Aortic Valve
4. Hiatal Hernia
5. Hyperlipidemia
6. Hypertension
7. Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - wound vac, wound edges with erythema- open
7.5cm x 5cm
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:
___
|
10739621-DS-14
| 10,739,621 | 23,584,982 |
DS
| 14 |
2161-10-02 00:00:00
|
2161-10-02 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
2 days of fever/chills, L shoulder pain and
increased erythema around sternal incision
Major Surgical or Invasive Procedure:
IV access: PICC, non-heparin dependent
Location: Left Basilic, Date inserted: ___
History of Present Illness:
Mrs. ___ is ___ ___ yo who
underwent an AVR ___ with Dr. ___. Her initial post op
course
was uncomplicated and she was discharged home. About a month
after surgery she developed fevers, sternal erythema, pain over
chest and back and L shoulder. She was seen in the ED and had an
elevated WBC to 20. A CT scan showed a fluid collection anterior
to the sternum and she underwent a bedside superficial
debridement. Wound cultures at the time grew MSSA and she was
started on nafcillin, a VAC dressing was eventually placed and
she was discharged home. She has been doing well until 2 days
ago
she developed chills and temps to 101. She felt that there was
increasing erythema at the superficial portion of the incision.
She was seen at an outside hospital and was transfered for
further evaluation. Her temp at the outside hospital was 101.
Past Medical History:
superficial sternal wound infection
Aortic Coarctation s/p repair
Aortic Stenosis
Bicuspid Aortic Valve
Hiatal Hernia
Hyperlipidemia
Hypertension
Obesity
Past Surgical History:
Open repair of aortic coarctation via left thoracotomy ___ @
___
Cesarean Sections x 3
Prior D&C
Social History:
___
Family History:
Father - myocardial infarction at age ___
Physical Exam:
Pulse:80 regular Resp:16 O2 sat:97% on RA
B/P Right: Left:
Height: Weight:
General:well appearing in no distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur, sharp valve click [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
sternal incision with erythema around the superior portion,
blanchable, no fluctuance noted
VAC dressing removed, no drainage noted in canister or in wound,
no odor. Wound about 5cmx3cmx1.5cm deep. Wound bed with good
granulation tissue, beefy red without eschar or drainage. The
most superior pole of the opening has some grey fibrinous
tissue,
a cotton tipped swab can be inserted with minimal pressure about
1 cm. No drainage noted upon withdrawl of swab.
Pertinent Results:
___ TTE
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bileaflet aortic valve prosthesis
is present. The aortic valve prosthesis appears well seated,
with normal leaflet/disc motion and transvalvular gradients. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
clear change.
.
Chest CT ___ preliminary report:
Wet Read: ___ FRI ___ 5:26 AM
1. Improved presternal abscess post drainage with open chest
wall wound
2. Phlegmonous changes superior to the manubrium, at the level
of bilateral
sternoclavicular joints, but less compared to prior. No focal
rim enhancing
drainable abscess.
3. Improved inflammatory changes in the mediastionum
.
Blood Culture, Routine (Preliminary):
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.
ENTEROBACTER CLOACAE COMPLEX. SECOND MORPHOLOGY.
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.
Piperacillin/Tazobactam sensitivity testing confirmed
by ___
___.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. FINAL
SENSITIVITIES.
MINOCYCLINE AND Levofloxacin Susceptibility testing
requested by
___ ___ (___) ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROBACTER CLOACAE
COMPLEX
| |
STENOTROPHOMONAS (XANTHOMON
| | |
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ @
11:07 AM.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 07:20AM BLOOD WBC-7.2 RBC-4.21 Hgb-12.2 Hct-37.3 MCV-89
MCH-29.0 MCHC-32.7 RDW-14.7 Plt ___
___ 06:15AM BLOOD WBC-5.3 RBC-3.74* Hgb-10.6* Hct-33.3*
MCV-89 MCH-28.4 MCHC-31.9 RDW-14.7 Plt ___
___ 07:20AM BLOOD ___
___ 08:45AM BLOOD ___
___ 06:15AM BLOOD ___
___ 06:25AM BLOOD ___
___ 05:30AM BLOOD ___
___ 01:45AM BLOOD ___ PTT-32.8 ___
___ 05:05AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-139
K-3.7 Cl-102 HCO3-27 AnGap-14
Brief Hospital Course:
The patient is admitted for further management of her wound and
fevers. Blood cultures would return positive for ENTEROBACTER
CLOACAE and STENOTROPHOMONAS. ID continued to follow. PICC was
discontinued. Vac dressing was discontinued and the patient
will continue wet to dry dressing changes. PICC was replaced
following 48h of negative blood cultures. Antibiotics were
adjusted according to sensitivities. The patient will be
discharged on IV Ertapenem and PO Levaquin.
She will follow up with ID and Cardiac Surgery as advised. ___
and infusion services have been arranged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 60 mg PO QID
2. Metoprolol Tartrate 100 mg PO TID
3. Simvastatin 20 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. valsartan-hydrochlorothiazide 80-12.5 mg oral daily
9. Nafcillin 2 g IV Q4H
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Senna 17.2 mg PO BID:PRN constipation
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Acetaminophen 650 mg PO Q6H:PRN pain/fever
15. Amiodarone 200 mg PO DAILY
16. DiphenhydrAMINE 25 mg PO Q6H:PRN puritis/insomnia
17. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Diltiazem 60 mg PO QID
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 100 mg PO TID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 17.2 mg PO BID:PRN constipation
6. Simvastatin 20 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth q4h prn Disp
#*60 Tablet Refills:*0
8. Warfarin 5 mg PO DAILY16
dose to change daily per Dr. ___ goal INR ___
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
10. DiphenhydrAMINE 25 mg PO Q6H:PRN puritis/insomnia
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. valsartan-hydrochlorothiazide 80-12.5 mg oral daily
14. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
15. ertapenem 1 gram injection Q 24 Duration: 4 Weeks
16. Levofloxacin 750 mg PO Q24H Duration: 14 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
17. Nystatin Cream 1 Appl TP BID
RX *nystatin 100,000 unit/gram apply to affected area twice a
day Refills:*0
18. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to
affected area tid prn Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Superficial Sternal Wound Infection
PMH:
1. Aortic Coarctation s/p repair
2. Aortic Stenosis
3. Bicuspid Aortic Valve
4. Hiatal Hernia
5. Hyperlipidemia
6. Hypertension
7. Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - superficial opening without erythema 5x3x1cm
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
No driving while taking narcotics
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:
___
|
10739898-DS-5
| 10,739,898 | 28,482,147 |
DS
| 5 |
2172-10-01 00:00:00
|
2172-10-01 17:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a recurrent metastatic GIST s/p
neoadjuvant imatinib and partial gastrectomy, on palliative oral
chemotherapy with Sutent until ___ (when review of scan from
___ revealed progression of disease including large hepatic
metastases) presents with acute RUQ pain X 1 day. Ms. ___
reports that about 24 hours ago she developed sudden RUQ pain
such that she had difficulty even moving about. In ___
she underwent an ultrasound of the RUQ which showed liver
metastases but no obstructive process. She was transferred to
___ ED where she underwent a CT of the abdomen/pelvis
which was notable for
significant enlargement of the left hepatic lobe metastases
since
___, with increased surrounding stranding and
persistent probable invasion into the gastric antrum.
Past Medical History:
Past Medical History:
GASTRIC INTESTINAL STROMAL OF THE STOMACH
GASTRITIS
HYPERLIPIDEMIA
.
Past Surgical History:
LEFT VOLAR GANGLION REMOVAL
Social History:
___
Family History:
She has several cancers in her family. Her father had prostate
cancer. Her grandmother had colon cancer. She has two sisters
who have breast cancer, both of whom have tested negative for
BRCA and another sister who has had an adenoid cystic carcinoma
of the salivary glands as well as cervical cancer. She has two
children, both of whom are alive and well. There is no family
history of gastrointestinal stromal tumors.
Physical Exam:
D/C VS: 98.1 100/60 79 18 93%RA
General: Well-appearing, pleasant woman in NAD lying in bed
HEENT: NC/AT, PERRL, MMM, no OP lesions, no ulcers, no
cervical,
supraclavicular, or axillary adenopathy
CV: RR, NL S1S2 no S3S4
PULM: mild crackles at the right base with decreased breath
sounds bilateral
ABD: soft, nontender inc over RUQ, +hepatomegaly, BS active
LIMBS: No edema, clubbing, wwp
SKIN: No rashes or skin breakdown
NEURO: A&OX3, strength is ___ X 4 extremities and sensation is
grossly intact
Pertinent Results:
___
59 AP: 478 Tbili: 0.4 Alb: 3.1
AST: 38
HCT 31
CT abdomen ___
1. Left hepatic lobe metastases has significantly enlarged since
___, with increased surrounding stranding and persistent
probable invasion into the gastric antrum. Multiple additional
large hepatic metastases are overall stable since ___.
2. Metastatic omental, gastric, and perisplenic implants, a few
which are enlarged and others of which are stable.
3. Interval increase in superiorly located 6.7 x 4.3 cm
mesenteric metastatic lesion. Stable size of more inferior 11.6
x 8.3 cm mesenteric metastatic lesion.
4. Slight interval increase in small amount of complex free
pelvic fluid.
UGI series ___ -
1. There is no extraluminal leak of contrast.
2. Filling defect immediately beyond the gastroesophageal
junction,
consistent with invasive mass seen on recent CT.
Brief Hospital Course:
Hospital Course by Problem:
# Metastatic GIST, now rapidly progressive
- on Sutent as an outpatient, but now with rapidly PD on CT scan
___ inc increased hepatic and mesenteric metastases and gastric
antrum invasion. Regorafenib was prescribed just prior to
admission but held due to elevated LFTs. Will now start on
discharge as liver fxn has improved, see below.
# Acute hepatitis - likely ___ sunitinib as now improved during
her stay while off
drug. No tylenol use. No obstruction on imaging. Also
underlying hepatic mets contributing.
# RUQ abdominal pain
- likely secondary to growth of hepatic mets with capsular
stretching +/- gastric invasion. Upper GI without evidence of
leak at anastomosis site, no evidence of GI bleeding thus far.
Pt was evaluated by surgyer in the ED,
no intervention planned at this time has nonresectable dz.
- Good control with MS contin + ___ discharge on this
regimen
- colace 100 mg tid for bowel regimen
#GERD - exacerbated by tumor invasion, on PPI,added carafate
#Hx HTN - stopped lisinopril, BP overall low
# Elevated INR - likely ___ hepatic dysfxn, had slight
imrpovement with vitK
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
4. Ferrous Sulfate 325 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Lisinopril 5 mg PO DAILY
7. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*120 Tablet Refills:*1
4. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*1
5. Sucralfate 1 gm PO TID
RX *sucralfate 1 gram 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
6. Atorvastatin 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
10. Senna 8.6 mg PO BID:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Stromal Tumor
Hepatic metastases
Esophageal reflux
Hepatitis
Discharge Condition:
Condition: Stable
Mental status: Alert and coherent
Ambulatory status: Independent
Discharge Instructions:
It was a pleasure to care for you during your stay here at
___. You were admitted here with abdominal pain and CT scan
showed the tumors in the liver have enlarged and are also
involving the stomach. Your pain improved with IV pain meds and
now long acting morphine. Your liver enzymes improved after
stopping sutent thus it was likely due to the drug and not
another cause such as inflamed gall bladder.
Followup Instructions:
___
|
10740507-DS-11
| 10,740,507 | 29,990,375 |
DS
| 11 |
2196-05-17 00:00:00
|
2196-05-17 19:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
sulfur dioxide
Attending: ___.
Chief Complaint:
Post stroke seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ woman with a past medical
history significant for prior thalamic hemorrhage (seen here at
___, CEA ___, cataracts, crohn's disease, recent embolic
appearing infarct (treated at ___ in ___ ___ R mca, and
possible further embolic infarct in ___, who presents
as
a transfer from ___ for Left arm and face shaking.
Briefly the patient states that for the past month she has
intermittently noticed that she will have rhythmic jerking of
her
L arm and mouth and eye that will last a few minutes. She did
not
know what this was. In early ___ she was admitted to ___ for groin pain and was noted to have a right gluteal
tear.
At that time she was noted to have rhythmic jerking which
prompted team to perform an MRI brain. The MRI brain revealed
the
prior R sided stroke that occurred in ___ as well as one
small area of diffusion restriction. The shaking was thought to
be seizure but she was not given any medication or started on an
AED but was told to schedule an outpatient EEG at ___
which unfortunately has not yet happened. After this she saw her
caridologist who then was convinced that her strokes appeared
embolic though no afib was ever captured on tele or ekg. She was
started on eliquis 5mg BID two weeks ago. On ___ a loop
recorder was implanted to monitor for afib.
Today, the patient was at a cafe with her daugther around lunch
time. According to her daugther the patietn suddenly started to
have L facial twitching, L eye twitching and rhythmic jerking of
her L arm. The patient tried to hold down the arm to stop it
from
shaking but it would not. EMS was called and the patient was
brought to ___. Versed and Keppra stopped the twitching
activity and she has not had further activity since. Of note,
the
patient has also been having intermittent dysarthria for the
past
few months that seems to randomly get worse. Today her
dysarthria
has been quite significant and has persisted throughout the day.
Of note, the patient has also been complaining of increased
urinary incontinence and neck tightness and pain. Patient takes
care of her own medications etc. but there is concern she may
not
be taking the correct meds.
Past Medical History:
Hypertension, per patient and husband was normal on last check
at
___ office
___ (since early ___
HLD
TIA ___ years ago, consisted of words coming out jumbled
(expressive aphasia)
Anemia - Diagnosed ___ years ago, had a bone marrow biopsy which
ruled out leukemia, she is not sure of definite diagnosis. She
gets intermittent procrit injections.
Crohn's disease. s/p partial bowel resection ___ years ago. On
pentasa.
Social History:
___
Family History:
No family history of bleeding or clotting
problems. No family history of vascular malformations.
Physical Exam:
Admission exam:
Vitals: Temperature 97.5, HR 62, BP 121-150/55-80, HR 62
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx many bruises
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: large growths basal cell cancer, Actinic keratosis,
bruising on arms, venous stasis changes
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.. Able to follow both midline and
appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: Slight L NLFF , labial dysarthria , slower to activate on
L
with smile
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild L pronation
.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4 ___ 5 4+ ___ 5 5
R 4 ___ 5 4+ 4** ___ 5
**pain limited, R gluteal muscle tear
-Sensory: No deficits to light touch No extinction to DSS.
-DTRs:
___ Tri ___ Pat Ach
L ___ 3 2 *5 beats of ankle clonus on L
R ___ 2 2
Plantar response was upgoing
-Coordination: bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: deferred
==============================================
Discharge Exam:
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx many bruises
Neck: supple, no nuchal rigidity
Extremities: warm, well perfused
Skin: Actinic keratosis, bruising on arms, venous stasis
changes
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.
There was no evidence of apraxia or neglect. Mild dysarthria.
-Cranial Nerves:
II, III, IV, VI: EOMI without nystagmus. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: labial dysarthria , slower to activate on L with smile
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild L pronation
.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5- ___ ___ ___- 5 5
R 5 ___ ___ 4** ___ 5
**pain limited, R gluteal muscle tear
-Sensory: No deficits to light touch No extinction to DSS.
-Coordination: bilateral intention tremor. No dysmetria on FNF
bilaterally.
-Gait: deferred
Pertinent Results:
___ 01:00PM BLOOD WBC-8.1 RBC-2.90* Hgb-8.2* Hct-28.5*
MCV-98 MCH-28.3 MCHC-28.8* RDW-18.3* RDWSD-66.5* Plt ___
___ 06:30AM BLOOD WBC-6.3 RBC-2.74* Hgb-7.7* Hct-26.8*
MCV-98 MCH-28.1 MCHC-28.7* RDW-18.4* RDWSD-64.9* Plt ___
___ 07:12AM BLOOD WBC-7.5 RBC-2.79* Hgb-8.0* Hct-27.5*
MCV-99* MCH-28.7 MCHC-29.1* RDW-18.3* RDWSD-66.1* Plt ___
___ 06:28AM BLOOD WBC-7.8 RBC-2.88* Hgb-8.1* Hct-28.0*
MCV-97 MCH-28.1 MCHC-28.9* RDW-18.6* RDWSD-66.4* Plt ___
___ 06:20AM BLOOD WBC-7.6 RBC-2.85* Hgb-7.9* Hct-27.3*
MCV-96 MCH-27.7 MCHC-28.9* RDW-18.6* RDWSD-65.2* Plt ___
___ 02:50PM BLOOD WBC-5.9 RBC-2.86* Hgb-8.1* Hct-27.9*
MCV-98 MCH-28.3 MCHC-29.0* RDW-18.6* RDWSD-66.4* Plt ___
___ 05:15AM BLOOD WBC-7.3 RBC-2.81* Hgb-7.9* Hct-27.5*
MCV-98 MCH-28.1 MCHC-28.7* RDW-18.7* RDWSD-66.8* Plt ___
___ 04:15PM BLOOD WBC-6.1 RBC-3.04* Hgb-8.6* Hct-29.3*
MCV-96 MCH-28.3 MCHC-29.4* RDW-18.7* RDWSD-65.5* Plt ___
___ 06:30AM BLOOD Valproa-47*
___ 06:30AM BLOOD Glucose-84 UreaN-63* Creat-3.0* Na-143
K-4.5 Cl-118* HCO3-13* AnGap-12
___ 04:55PM BLOOD Na-145
___ 07:12AM BLOOD Glucose-85 UreaN-62* Creat-3.2* Na-150*
K-4.9 Cl-126* HCO3-12* AnGap-12
___ 09:15PM BLOOD Glucose-97 UreaN-62* Creat-3.3* Na-146
K-4.5 Cl-122* HCO3-15* AnGap-10
___ 02:50PM BLOOD Glucose-139* UreaN-48* Creat-3.4* Na-148*
K-4.8 Cl-126* HCO3-15* AnGap-12
___ 05:15AM BLOOD Glucose-72 UreaN-66* Creat-3.5* Na-150*
K-4.8 Cl-124* HCO3-14* AnGap-12
___ 04:15PM BLOOD Glucose-148* UreaN-66* Creat-3.2*# Na-145
K-4.7 Cl-122* HCO3-12* AnGap-11
Brief Hospital Course:
___ is an ___ woman with a past medical
history significant for CKD (baseline Cr ~3), prior thalamic
hemorrhage (seen here at ___, CEA ___, cataracts,
crohn's disease, recent embolic
appearing infarct (treated at ___ in ___ ___ R mca, and
possible further embolic infarct in ___, recently
started on
eliquis for high suspicion of afib, s/p loop recorder
implantation on ___
presenting with at least one month of rhythmic jerking of her L
arm and mouth/eye thought to be consistent with focal motor
seizure.
EEG did not show any seizures, but she was thought to have
surface negative focal motor seizures. She was started on keppra
without improvement. She was then switched to Divalproex
(DELayed Release) 500 mg BID with improvement.
Of note she did have some new urinary urgency in setting of UTI.
However, given chronic neck pain, MRI c spine was recommended.
However, she had a recent loop recorder placed and thus can't
undergo MRI for another 6 weeks.
For her UTI she was treated with ceftriaxone x 3 days.
Of note she was also hypernatremic on admission for which renal
was consulted. She was given D5W with improvement of
hypernatremia. She was also found to have low bicarb and after
discussion with renal fellow was started on sodium bicarbonate
supplement on discharge. Per renal fellow this does not require
her to stay in the hospital and she should follow up with her
outpatient nephrologist.
She was seen by ___ who recommended home ___ with family
supervision, per family request. Of note, patient felt mildly
nauseous during ___ session, but patient and family insisted on
taking patient home.
Of note, given patient's renal failure NOAC was not thought to
be an ideal medication since patient's with severe renal disease
were not included in trails. We discussed with family that there
is no evidence for NOAC in severe renal disease. However,
patient decided to stay on this medication and will follow up
with PCP.
=========================
Transitional issues:
-Follow up with nephrology in ___ weeks
-Follow up with PCP ___ 1 week
-Monitor chemistry, including sodium and bicarb
-Monitor platelets, while on Divalproex, as is can affect
platelets.
-Follow up with neurology ( patient states she has follow up
with Dr. ___
___.
-Consider outpatient MRI c-spine when able
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 25 mg PO TID
2. amLODIPine 10 mg PO DAILY
3. Apixaban 2.5 mg PO ONCE
4. Mesalamine 1000 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Citalopram 20 mg PO DAILY
7. Labetalol 200 mg PO BID
8. Ferrous GLUCONATE 324 mg PO BID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. Mirtazapine 15 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Cyanocobalamin ___ mcg PO DAILY
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Divalproex (DELayed Release) 500 mg PO BID
RX *divalproex [Depakote] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*5
2. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
3. amLODIPine 10 mg PO DAILY
4. Apixaban 2.5 mg PO ONCE
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Citalopram 20 mg PO DAILY
8. Cyanocobalamin ___ mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. HydrALAZINE 25 mg PO TID
11. Labetalol 200 mg PO BID
12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
13. Mesalamine 1000 mg PO BID
14. Mirtazapine 15 mg PO QHS
15. Vitamin D ___ UNIT PO DAILY
16.___
Name: ___
___
Prognosis: Good
Length: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
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 for left sided shaking which
is thought to be consistent with focal motor seizures. Your EEG
did not show any seizures. However, this does not mean these are
not seizures as EEG can be negative if seizure focus is close to
the surface.
You were started on Divalproex (DELayed Release) 500 mg twice a
day with improvement.
You were seen by our kidney doctors for ___ which
improved with some fluids.
You were seen by physical therapy who recommended home ___.
Please take your medication as prescribed and follow up with
your PCP, nephrologist and neurology.
Please have your PCP monitor your platelets while on Divalproex
as is can affect platelets.
Followup Instructions:
___
|
10740800-DS-17
| 10,740,800 | 29,615,808 |
DS
| 17 |
2127-09-02 00:00:00
|
2127-09-02 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with HTN, HLD, presumed
mesenteric vasculitis, presenting with right leg pain, dyspnea,
and tachycardia. found to have new multivessel RLE DVT and
bilateral pulmonary emboli.
Patient first noted the right leg pain ___ night. The pain
initially started as cramps, but then despite resting the leg
began to worsen. It began in his calf, but then progressed to
his
foot. He could not tolerate placing any weight on it. He woke up
___ morning, and continued to have significant pain with
inability to tolerate weight. Despite using OTC analgesic
medications, he found no relief. On ___ his pain had improved
slightly, but was still severe, prompting him to reach out to
his
PCP. An ultrasound was scheduled for today, which noted acute
DVTs found in 2 gastroc veins, 2 peroneal veins, and posterior
tibial vein. He was instructed to take apixaban this morning. On
further discussion with the patient, he noted significant
fatigue, malaise, and shortness of breath with exertion. On
review of records at his last clinic appointment, he was also
noted to be tachycardic. Given this, there was significant
concern for PE, prompting him to be referred to the ED for
further evaluation.
Of note, the patient completed a 6 month course of apixaban 1
month ago for his SMA thrombus that was diagnosed in ___.
- ED Course notable for:
- Patient underwent CTA, and was found to have pulmonary
emboli. He was started on heparin IV.
- Initial Vitals in the ED:
- T 98.6, HR 88, BP 127/80, RR 19, SpO2 100% on RA
- Exam notable for:
-Bilateral lower extremities - intact distal pulses,
compartments soft, no cyanosis
- Relevant labs/imaging:
====LABS====
Troponin < 0.01
proBNP 31
CRP 90.3
___ 17.5, PTT 31.8, INR 1.6
====IMAGING====
CTA Chest: Multilobar segmental and subsegmental pulmonary
emboli
most pronounced in the bilateral lower lobes. Scattered areas of
opacity likely represent areas of infarction. No evidence of
right heart strain.
- Consults: None
- Patient Received:
- IV Heparin
Upon arrival to the floor, patient reiterates story as above. He
states he continues to have lower extremity pain. His shortness
of breath is only present with activity, and at rest he feels
fine. He denies any chest pain, cough, hemoptysis, or change in
his baseline abdominal pain.
Past Medical History:
- Hypercholesterolemia
- Supraventricular tachycardia
- Ventricular tachycardia
- Premature ventricular contractions
- Osteopenia
- Adrenal abnormality
- Colonic adenoma
- Meibomian gland dysfunction
Social History:
___
Family History:
No family history of vasculitidies. Mother had blood clots of
unclear etiology.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 2238)
Temp: 98.2 (Tm 98.2), BP: 115/75, HR: 92, RR: 18, O2 sat:
95%, O2 delivery: Ra, Wt: 248.5 lb/112.72 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: MMM
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: soft, non distended, tender to palpitation throughout,
but worst in left abdomen
EXTREMITIES: Tenderness to palpation along right calf and foot.
No erythema or edema noted bilaterally. 2+ pulses and equal
bilaterally.
NEUROLOGIC: CN2-12 grossly intact. Normal strength and sensation
throughout.
DISCHARGE PHYSICAL EXAM
VITAL SIGNS: 98.5, 116 / 72, 76, 16, 97 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: MMM
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: soft, non distended, diffuse TTP
EXTREMITIES: TTP along right calf and foot. No erythema or
pitting edema noted bilaterally, though right calf larger in
size
than left calf, Homans sign+. 2+ pulses and equal bilaterally.
NEUROLOGIC: Alert, oriented, moves all extremities
Pertinent Results:
___ 03:35PM BLOOD WBC-8.8 RBC-4.20* Hgb-13.4* Hct-39.6*
MCV-94 MCH-31.9 MCHC-33.8 RDW-12.1 RDWSD-42.3 Plt ___
___ 07:10AM BLOOD WBC-5.6 RBC-3.69* Hgb-11.9* Hct-36.0*
MCV-98 MCH-32.2* MCHC-33.1 RDW-12.4 RDWSD-43.8 Plt ___
___ 06:57AM BLOOD WBC-5.7 RBC-3.74* Hgb-12.0* Hct-35.6*
MCV-95 MCH-32.1* MCHC-33.7 RDW-12.2 RDWSD-42.6 Plt ___
___ 03:35PM BLOOD Neuts-80.6* Lymphs-7.6* Monos-10.1
Eos-0.5* Baso-0.2 Im ___ AbsNeut-7.07* AbsLymp-0.67*
AbsMono-0.89* AbsEos-0.04 AbsBaso-0.02
___ 03:35PM BLOOD ___ PTT-31.8 ___
___ 03:35PM BLOOD Glucose-118* UreaN-26* Creat-1.2 Na-141
K-4.0 Cl-98 HCO3-25 AnGap-18
___ 07:10AM BLOOD Glucose-103* UreaN-25* Creat-1.0 Na-140
K-3.4* Cl-100 HCO3-23 AnGap-17
___ 06:57AM BLOOD Glucose-104* UreaN-19 Creat-1.0 Na-143
K-3.4* Cl-102 HCO3-22 AnGap-19*
___ 03:35PM BLOOD ALT-32 AST-20 CK(CPK)-38* AlkPhos-54
TotBili-0.6
___ 03:35PM BLOOD Lipase-41
___ 03:35PM BLOOD cTropnT-<0.01 proBNP-31
___ 03:35PM BLOOD Albumin-4.7
___ 07:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9
___ 06:57AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9
___ 03:35PM BLOOD CRP-90.3*
IMAGING:
========
VENOUS DUP EXT UNI (MAP/DVT) RIGHT Study Date of ___ 9:05
AM
1. Acute venous thrombosis of the right calf veins including
gastrocnemius
veins, peroneal veins and a single posterior tibial vein.
CTA CHEST Study Date of ___ 6:21 ___
1. Multilobar segmental and subsegmental pulmonary emboli most
pronounced in the bilateral lower lobes. Scattered peripheral
opacities are most consistent with sites of pulmonary
infarction.
2. No evidence of right heart strain, though the main pulmonary
artery
measures upper limits of normal which could reflect pulmonary
arterial
hypertension.
CTA ABD & PELVIS Study Date of ___ 4:31 ___
1. Unchanged fat stranding around the SMA with mild posterior
wall
thickening/plaque (303, 64). There is minimal stranding seen
around the
celiac trunk, which is nonspecific, as there is no vascular
luminal or mural abnormality.
2. Unchanged left adrenal adenoma measuring 1.9 cm.
3. Multiple bilateral pulmonary emboli with focal areas of
infarct or
hemorrhage, better assessed on prior CT of the chest on ___.
___ (___)
CONCLUSION: The left atrial volume index is normal. There is no
evidence for an atrial septal defect
by 2D/color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional
left ventricular function. The visually estimated left
ventricular ejection fraction is >=70%. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. 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. There is no evidence
for an aortic arch coarctation. 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 trivial tricuspid regurgitation.
The pulmonary artery systolic pressure could
not be estimated. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and global
biventricular systolic function.
Compared with the prior ___ (images not available for review) of
___, the findings are
similar.
Brief Hospital Course:
SUMMARY
========
___ with HTN, HLD, suspected mesenteric vasculitis, presented
dyspnea and RLE pain, found to have new multivessel RLE DVT and
bilateral pulmonary emboli.
HOSPITAL COURSE
===============
# DVT with Bilateral PEs:
Venous duplex showed acute venous thrombosis of the right calf
veins including gastrocnemius veins, peroneal veins and a single
posterior tibial vein. CTA Chest showed multilobar segmental and
subsegmental pulmonary emboli most pronounced in the bilateral
lower lobes, scattered peripheral opacities c/w sites of
pulmonary infarction, no evidence of right heart strain, though
main pulmonary artery measures upper limits of normal which
could reflect pulmonary arterial hypertension. PEs likely ___
emboli from RLE thrombus. Has multiple risk factors, including
suspected vasculitis and prolonged glucocorticoid use. Patient
discontinued apixaban approximately 1 month prior to admission.
No recent trauma or IVDU though he did travel to ___ by train
approx 3 wks prior to admission. Previous antiphospholipid
work-up negative. Received heparin gtt transitioned to apixiban
with loading dose. Repeat CTA abd/pelvis showed unchanged fat
stranding around SMA with mild posterior wall thickening or
plaque, minimal nonspecific stranding seen around the celiac
trunk, no vascular luminal or mural abnormality. ___ unrevealing
and patient's dyspnea improved during hospitalization while on
Apixaban BID. Ambulatory sats were 95-98%, HRs 115-125. Pt
should continue life long anticoagulation as he seems to have a
hypercoagulable state that may be related to his
undifferentiated mesenteric vasculitis.
# Undifferentiated mesenteric vasculitis:
Patient has a history of SMA thrombus and is currently being
treated for presumed mesenteric vasculitis (diagnosed ___. Followed outpatient by Rheumatology. Most recent notes
indicate improvement in underlying disease process prompting
de-escalation of medication regimen. Patient has been on a long
prednisone taper and will continue for several more weeks.
Cyclophosphamide 125mg was held on admission and at time of
discharge. Repeat TPMT pending at time of discharge, and patient
scheduled to follow-up with outpatient rheumatology on ___,
at which time he will likely be transitioned to azathioprine.
Continued Bactrim SS 1 tab PO daily, which patient will need to
take for 1 month after discontinuation of cyclophosphamide. Also
continued home omeprazole.
Additionally, patient continued home chlorthalidone and
amlodipine, home nortiptyline, tamsulosin, and vitamin D
Transitional issues:
=====================
[] Patient resumed apixaban during admission and on discharge.
Was discharged on a loading dose, last day ___. Transition to
regular dosing on ___. Will need to take apixaban
indefinitely.
[] Patient needs hematology follow-up for any additional
hypercoagulable workup not obtained during hospitalization.
Appointment details pending at time of discharge.
[] Cyclophosphamide was held on admission and at discharge.
Final thiopurine methyltransferase pending at time of discharge.
Patient has close follow-up with rheumatology and likely will be
switched to azathioprine at that time.
[] Patient will need to continue taking Bactrim 1 month past
discontinuation of cyclophosphamide.
[] Patient to receive age-appropriate cancer screening including
colonoscopy. Last colonoscopy in ___ for history of polyps,
with follow-up recommended in ___.
[] CT Chest findings showing main pulmonary artery measuring
upper limits of normal which could reflect pulmonary arterial
hypertension. Pulmonary artery systolic pressure could not be
estimated on ___ need further evaluation on future chest
imaging.
#CODE: Full (presumed)
#CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Calcium Carbonate 500 mg PO QID:PRN reflux
3. CycloPHOSPHAMIDE 125 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Nortriptyline 10 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID
Take Eliquis 10mg twice a day through ___
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
2. Apixaban 5 mg PO BID
From ___ onward, only take Eliquis 5mg twice a day
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
3. amLODIPine 5 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN reflux
5. Chlorthalidone 25 mg PO DAILY
6. Nortriptyline 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 10 mg PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- CycloPHOSPHAMIDE 125 mg PO DAILY This medication was
held. Do not restart CycloPHOSPHAMIDE until you discuss with
your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Bilateral Segmental and Subsegmental Pulmonary emboli
Multivessel right lower extremity deep vein thrombosis
SECONDARY DIAGNOSIS:
====================
History of SMA thrombus
Possible mesenteric vasculitis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had worsening shortness of breath and pain in your right
leg.
What did you receive in the hospital?
- You received blood thinning medications through an IV, which
was later switched to Eliquis.
- A CAT scan of your abdomen was performed.
What should you do once you leave the hospital?
- Please continue taking your medications as prescribed. Please
continue taking Eliquis as directed. You will need to take
Eliquis 10mg twice a day until ___. From ___ onward, you
should take Eliquis 5mg twice a day.
- Please do not take cyclophosphamide after discharge. You only
need to take Bactrim for 1 month after discontinuing
cyclophosphamide (discuss with Dr. ___ at your appointment
about discontinuing Bactrim around ___.
- Please attend any upcoming outpatient appointments you have.
Please remember to attend your appointment with Dr. ___ on
___ at 4 ___.
- If you feel worsening shortness of breath, palpitations,
lightheadedness to the point you feel you may pass out, please
call ___ or go to the nearest emergency room to be evaluated.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10740800-DS-18
| 10,740,800 | 24,463,587 |
DS
| 18 |
2127-09-14 00:00:00
|
2127-09-15 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
Pharmacologic nuclear stress test ___
History of Present Illness:
___ with a PMH of SMA thrombus, possible mesenteric vasculitis,
recently diagnosed RLE DVT and bilateral PE on apixaban, history
of SVT who p/w palpitations, SOB and heartburn.
Around 6 ___ ___ pt developed palpitations, dyspnea and
heartburn.
He was seated at rest, had just eaten dinner (salad) and
shoveled
his driveway earlier today. He endorses a dry cough for several
weeks, some chills the last ___ days, stable shortness of breath
since PE diagnosis, he has had ongoing nausea since ___. No
pain radiating to arms or necks. He had stopped omperaozle
several months ago and has been having three weeks of worsening
sternal/epigastric chest pain, worse at night when laying down
and associated with sore taste in throat. At home checked
vitals
HR: 103 BP:154/84. Was referred by At___ to ED for evaluation.
He also has nausea that gets progressively worse as the day goes
on and has a metallic taste in his mouth. He denies fevers,
abdominal pain, vomiting, sick contacts.
Patient was admitted ___ and diagnosed with right calf
gastrocnemius, peroneal vein, posterior tibial vein DVTs and
multilobal segmental/subsegmental PEs w/o e/o RH strain. This
was
thought to be precipitated by possible vasculitis and had been
off apixaban for 1 month. Previous APL work up negative. Reports
taking his apixaban as prescribed. Symptoms feel different than
original presentation w/ PE.
He has a history of palpitation and underwent TTE
(unremarkable),
EKG stress test (no ischemic changes) and 24hr holter (most
notable for symptomatic premature atrial beats.
In the ED, initial vitals: 98.4 81 173/92 19 99% RA
Exam notable for:
General: Comfortable, lying in bed, awake and alert
Head/eyes: Normocephalic/atraumatic. Pupils equal round and
reactive to light.
ENT/neck: Mucous membranes slightly dry. Neck supple.
Chest/Resp: Breathing comfortably on room air. Lungs clear to
auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
Radial
pulses intact and symmetric
GI/abdominal: Soft, nontender, nondistended
GU/flank: No CVA tenderness
Musc/Extr/Back: Radial and DP pulses intact. Pitting edema of
right lower extremity with tenderness to palpation. Warm and
well-perfused.
Skin: Warm and dry
Psych: Normal mood, normal mentation
Labs notable for:
1) BMP: Na 139, K 4.1, Cl 101, HCO3 24, BUN 19, Cr 0.9
2) Trop 0.01
3) CBC: Hb 5.3, Hb 11.2, plt 242
4) BNP 54
Imaging notable for:
1) RLE US: DVT of R peroneal vein unchanged. Resolution of R
posterior tibial/gastrocnemius
2) CXR: Increased opacification of right hilus, LLL c/f
developing PNA
3) EKG: SR, normal axis, no ischemic changes
Pt given: cefepime and 1L LR
Vitals prior to transfer: T: 98.2 HR: 74 BP: 124/75 RR: 14 SO2:
95% RA.
Upon arrival to the floor, the patient reports no chest pain, no
more palpitations.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
- Hypercholesterolemia
- Supraventricular tachycardia
- Ventricular tachycardia
- Premature ventricular contractions
- Osteopenia
- Adrenal abnormality
- Colonic adenoma
- Meibomian gland dysfunction
Social History:
___
Family History:
No family history of vasculitidies. Mother had blood clots of
unclear etiology, does have coronary disease among other
relatives.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: none yet documented
General: Alert, oriented, no acute distress
HEENT: JVP flat, mucosa moist
CV: Regular rate and some premature beats rhythm, normal S1 +
S2,
no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, resonant to percussion, no egophany
Abdomen: Soft, mild epigastric tenderness, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 851)
Temp: 98.6 (Tm 98.6), BP: 123/78 (120-142/74-81), HR: 75
(61-75), RR: 18, O2 sat: 97% (95-97), O2 delivery: Ra, Wt: 254.6
lb/115.49 kg
General: Alert, oriented, no acute distress
HEENT: JVP flat, mucosa moist
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, mild epigastric tenderness, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS
___ 11:38PM BLOOD WBC-5.3 RBC-3.52* Hgb-11.2* Hct-33.7*
MCV-96 MCH-31.8 MCHC-33.2 RDW-12.5 RDWSD-43.6 Plt ___
___ 11:38PM BLOOD Neuts-65.5 Lymphs-14.7* Monos-11.7
Eos-4.7 Baso-0.8 Im ___ AbsNeut-3.49 AbsLymp-0.78*
AbsMono-0.62 AbsEos-0.25 AbsBaso-0.04
___ 11:38PM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-139
K-4.1 Cl-101 HCO3-24 AnGap-14
___ 11:38PM BLOOD Lipase-41
___ 11:38PM BLOOD proBNP-54
___ 11:38PM BLOOD cTropnT-<0.01
___ 01:34PM BLOOD cTropnT-<0.01
___ 11:38PM BLOOD CRP-3.1
PERTINENT STUDIES
___
CHEST XRAY
FINDINGS:
Lungs are mildly well aerated. There is increased opacification
at the right
hilum and left lower lobe. No large pleural effusion or
pneumothorax. The
cardiomediastinal silhouette appears within normal limits.
IMPRESSION:
Increased opacification of the right hilus and left lower lobe
are concerning
for developing pneumonia.
___
RLE DOPPLER
FINDINGS:
There is normal compressibility, color flow, and spectral
doppler of the right
common femoral, femoral, and popliteal veins. There is now
normal color flow
and compressibility of the posterior tibial veins. The peroneal
veins remain
noncompressible with no internal color flow.
The visualized gastrocnemius vein demonstrates normal
compressibility and
color flow.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep venous thrombosis of the right peroneal veins, unchanged
compared to prior exam.
2. Interval resolution of deep venous thrombosis of the right
posterior tibial
and gastrocnemius veins.
___
STRESS TEST
INTERPRETATION: This ___ year old man with a PMH of HLD, HTN,
NSVT,
NSPSVT, recent DVT/PE was referred to the lab for evaluation of
chest
discomfort and shortness of breath. The patient was infused with
0.4mg/5ml of regadenoson over 20 seconds followed immediately by
isotope
infusion. No arm, neck, back or chest discomfort was reported by
the
patient throughout the study. There were no significant ST
segment
changes during the infusion or in recovery. The rhythm was sinus
with no
ectopy. Appropriate hemodynamic response to the infusion and
recovery.
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
CARDIAC PERFUSION PHARM STRESS TEST
FINDINGS:
The image quality is adequate but limited due to soft tissue
attenuation.
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 64% with an
EDV of 100 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
DISCHARGE LABS
___ 06:34AM BLOOD WBC-4.9 RBC-3.46* Hgb-10.9* Hct-33.2*
MCV-96 MCH-31.5 MCHC-32.8 RDW-12.7 RDWSD-43.7 Plt ___
___ 06:34AM BLOOD Glucose-87 UreaN-15 Creat-0.8 Na-144
K-4.0 Cl-102 HCO3-28 AnGap-14
___ 06:34AM BLOOD Calcium-9.5 Phos-4.7* Mg-1.9
Brief Hospital Course:
SUMMARY STATEMENT:
====================
___ male with past medical history of SMA thrombus
status post 9 months of apixaban ending ___ who developed RLE
DVT and bilateral PE ___, history of concern for possible
mesenteric vasculitis, history of SVT presenting with
palpitations, shortness of breath and chest pain. Initial EKG
and troponins were normal, chest x-ray showed possible new
opacities in the right hilum and left lower lobe and given
immunosuppression patient was initiated on treatment for
community acquired pneumonia. On the floor, antibiotics were
discontinued due to low concern for pneumonia. Chest pain was
thought possibly due to pleuritic chest pain from prior
pulmonary infarct due to PE vs GERD based on history. To rule
out cardiac cause, stress test was performed on ___.
Metoprolol dose was increased. The patient was discharged home
with rheumatology, hematology oncology, and primary care
physician ___.
ACTIVE ISSUES:
==============
# Chest pain
Evaluation was reassuring for ruling out ACS. 2 troponins were
negative 14 hours apart. EKG showed no ischemic changes. Chest
x-ray in the ED showed possible right hilar opacity as well as
left lower lobe opacity. Upon review, right hilar opacity seen
stable from prior x-rays. Patient was initiated on treatment for
pneumonia in the emergency department based on this finding and
a dry cough. Upon presentation of the floor, antibiotics were
discontinued as patient did not have fever, leukocytosis,
productive cough. Patient reported 1 out of 10 chest pain on the
floor which was thought due to possibly pleuritic pain from
prior pulmonary infarct from PEs for gastroesophageal reflux
disease, as the history suggested possible GERD as etiology of
chest pain. Also on the differential was a large vessel
involvement of his possible vasculitis, although with negative
imaging 2 weeks ago and a CRP of 3 this seems less likely. Due
to the description of his chest pain sounding like typical
angina, he underwent pharmacological nuclear stress test on
___ which showed no perfusion defects.
# Palpitations
Patient presented complaining of palpitations. On admission, EKG
was consistent with normal sinus rhythm. Overnight telemetry had
some episodes of tachycardia consistent with sinus tachycardia
versus SVT. Patient was asymptomatic during these episodes. This
is consistent with his history of paroxysmal SVT. Given his
history of symptomatic SVT, his dose of metoprolol succinate was
increased from 25 mg daily to 50 mg daily.
#Gastroesophageal reflux disease
Patient history suspicious for GERD. Had taken 1 month of PPIs
___, but he did not recall. Initiated on omeprazole 20
daily.
CHRONIC ISSUES:
===============
# Right lower extremity DVT
Right lower extremity LENIs showed ongoing DVT of the right
peroneal vein with resolution of prior posterior tibial
gastrocnemius vein DVTs.
# Mesenteric vasculitis
Continued prednisone 7.5 mg daily.
TRANSITIONAL ISSUES:
====================
[] Consider referral to neurology as outpatient for tremor
[] Annual ___ for adrenal incidentaloma (last CT ___
[] Metoprolol dose was increased due to symptomatic SVT.
CONTACT:
No proxy. Patient would like ___ to be emergency
contact, ___.
CODE STATUS: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Calcium Carbonate 1000 mg PO QHS:PRN reflux
3. Chlorthalidone 12.5 mg PO DAILY
4. Nortriptyline 10 mg PO DAILY
5. PredniSONE 7.5 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Apixaban 5 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Calcium Carbonate 1000 mg PO QHS:PRN reflux
6. Chlorthalidone 12.5 mg PO DAILY
7. Nortriptyline 10 mg PO DAILY
8. PredniSONE 7.5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Pulmonary embolism
Deep vein thrombosis
Supraventricular tachycardia
Supraventricular artery thrombosis/vasculitis
SECONDARY DIAGNOSES:
Hypertension
Headache
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 was feeling
palpitations.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, tests were performed to rule out any
emergency causes of your chest pain. You had a chest x-ray
which showed possible pneumonia so you were given antibiotics,
however your symptoms were not consistent with this, so your
antibiotics were stopped.
- Your heart rhythm was monitored overnight.
- To rule out your heart as the cause of her chest pain, a
nuclear stress test was performed. This showed a normal result,
indicating that blood flow to your heart was normal.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your ___ appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Two week history of short term memory loss
Major Surgical or Invasive Procedure:
___ Right EVD placement
___ R frontal VPS
History of Present Illness:
This is a ___ y/o ___ female brought to the ED by
her husband for a two week history of percieved short therm
memory loss. Patient was driving
to church in the past day or two and had to have her daughter
tell her how to get there and when taken to see her PCP she did
not remmber being in his office in the past.
Past Medical History:
HTN, Hospitalized last year at ___ for w/u
hysterectomy for fibroids
Social History:
___
Family History:
NC
Physical Exam:
On Admssion:
PHYSICAL EXAM:
O: T: 98.2 BP: 148/103 HR:71 R 17 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, but not date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
AT DISCHARGE:
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT, dressing over R scalp c/d/i
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Gait: narrow based, good arm swing, independent
Pertinent Results:
CT head ___
1. Severe hydrocephalus with transependymal flow of CSF and
associated
effacement of the sulci.
2. No evidence of hemorrhage or obstructing mass.
MRI Brain ___ -
1. Moderate dilatation of all the ventricles with associated
transependymal CSF flow. The etiology of hydrocephalus is not
identified on this study.
2. No evidence of acute infarct or intracranial hemorrhage.
3. No abnormal leptomeningeal or parenchymal enhancement
CXR ___
The lung volumes are normal. No pleural effusions. Normal size
of
the cardiac silhouette. Normal hilar and mediastinal structures.
No evidence of pneumonia or other acute lung changes.
CT head ___
Interval decrease in ventricular size status post external
ventricular drain placement.
CSF:
___ 09:36AM CEREBROSPINAL FLUID (CSF) WBC-85 RBC-1650*
Polys-PND Lymphs-PND Monos-PND
___ 09:36AM CEREBROSPINAL FLUID (CSF) TotProt-156*
Glucose-57 LD(LDH)-72
___ 10:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-19* Polys-1
___ Monos-24
CSF culture ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
MRI Head CSF study ___. Incomplete study as CSF flow study could not be performed.
Consider
performing when the patient is cooperative.
2. Moderate dilation of the lateral and the third ventricles
with narrowing of the superior portion of cerebral
aqueduct/near-total occlusion.
3. Ventricular catheter appears to be outside the confines of
the lateral
ventricle. To correlate with catheter function and the position
if necessary.
CT Chest ___. No evidence of sarcoid.
2. Sub 4 mm pulmonary nodule in the left lower lobe. If there is
no history of smoking or other lung cancer risk factors, this
does not need followup. Otherwise, 12 month followup is
recommended.
3. Fatty liver and cholelithiasis.
CTA Chest ___. No pulmonary embolus or acute intrathoracic process.
2. Cholelithiasis.
___ CT head postop: Interval decrease in ventricular size
status post placement of right frontal external ventricular
drain with the catheter tip located in the frontal horn of the
right lateral ventricle.
ADMISSION LABS:
___ 12:12PM BLOOD WBC-5.9 RBC-4.87 Hgb-13.2 Hct-43.0 MCV-88
MCH-27.0 MCHC-30.6* RDW-12.9 Plt ___
___ 12:12PM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
___ 12:12PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.3
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-7.3 RBC-4.10* Hgb-11.2* Hct-35.6*
MCV-87 MCH-27.3 MCHC-31.4 RDW-13.2 Plt ___
___ 06:00AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-135
K-3.9 Cl-102 HCO3-24 AnGap-13
___ 06:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
___ 03:25AM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
Ms. ___ underwent a head CT in the Emergency room which
revealed enlargement of her ventricular system with
transependymal flow. She was admitted to the Neurosurgery
service in the ICU for close monitoring. Her exam remained
stable, but to prevent progression of hydrocephalus, patient was
taken to OR on ___ for placement of R EVD. She was made NPO and
was consented for the procedure. On ___, patient was taken to
the OR for placement of R EVD. There were no complications and
patient was transferred back to SICU for monitoring. CSF was
sent in OR for evaluation. She remained intact on exam
throughout the day, overnight she was seen to have religious
delusions. For concern of worsening hydrocephalus, a head CT was
done which was stable. On ___, patient was back to baseline.
CSF was sent for further evaluation and MRI CSF study was
ordered to help determine etiology of hydrocephalus and this was
inconclusive.
She had a CT head on ___ and this showed decompression of the
ventricular system. Repeat CSF studies were sent. On ___ she
was transferred to the SDU in stable condition. Her EVD
continued at 10cm above the tragus. She remained stable until
___ when she became tachycardic and tachypneic and a CTA chest
was obtained. This showed no evidence of pulmonary embolus. She
was kept NPO on the morning of ___ in preparation for a Right
frontal VPS. She tolerated the procedure well with no
complications and post operatively she was transferred back to
the floor. She has a programmable valve set at 1.5.
On ___ Patient was deemed fit for discharge. She was given
instructions for followup and prescriptions for required
medications.
TRANSITIONAL CARE ISSUES:
Pt will need a repeat chest CT in 12 months to follow up the
lung nodule found incidentally on our scan here. She will need
one in 6 months if she has any tobacco or cancer hx we are
unaware of.
Medications on Admission:
Labetalol PO
Discharge Medications:
1. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q4H PRN ()
as needed for nausea.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hydrocephalus
aqueductal stenosis
delerium
tachycardia
cholelithiasis
pulmonary nodule
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.
Dressing may be removed on Day 2 after surgery.
You have dissolvable sutures so you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
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.
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° F.
We made the following changes to your medications:
1) We STARTED you on DOCUSATE 100mg twice a day to prevent
constipation while taking opiate pain medications.
2) We STARTED you on SENNA 8.6mg twice a day as needed for
constipation.
3) We STARTED you on PERCOCET ___ tabs every 4 hours as needed
for pain. Each tablet has 325mg of tylenol in it. Do not exceed
4,000mg of tylenol in a 24 hour period as this can cause fatal
liver damage. In addition, do not drive, operate heavy
machinery, drink alcohol or take other sedating medications
while taking this medication until you know how it will effect
you, as it can make you dangerously sleepy.
4) We STARTED you on ZOFRAN 4mg every 4 hours as needed for
nausea.
Please continue to take your other medications as previously
prescribed.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
___
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2156-11-02 13:57:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left open elbow dislocation
Major Surgical or Invasive Procedure:
___: Left Elbow I&D
History of Present Illness:
___ year old right hand dominant male presents with left elbow
pain after being struck by a car going ___ while on a
bicycle. He flipped over the hood of the car and landed on his
elbow. No HS or LOC. Denies any other extremity pain, back pain,
neck pain, hip/pelvis pain. He had immediate onset of elbow pain
with sensation that elbow was dislocated. Patients reports that
last tetanus shot was definitely within last ___ years although
does not recall exactly when.
Past Medical History:
Past Medical History:
None
Past Surgical History:
None
Social History:
___
Family History:
n/c
Physical Exam:
General: Well appearing male in no acute distress.
Neck:
No midline tenderness
Full ROM in rotation from side to side with no pain or
paresthesias
Left upper extremity:
Sensation intact in axillary, median, ulnar and radial
distributions
Palpable radial pulse
Firing wrist flexors/extensors, finger flexors/extensors,
EPL/FPL/FDI
Dressing intact
Pertinent Results:
___ 04:08PM BLOOD WBC-11.7* RBC-5.27 Hgb-14.9 Hct-43.3
MCV-82 MCH-28.3 MCHC-34.4 RDW-13.1 RDWSD-38.6 Plt ___
___ 04:08PM BLOOD Neuts-67.2 ___ Monos-6.1 Eos-1.2
Baso-0.7 Im ___ AbsNeut-7.86* AbsLymp-2.86 AbsMono-0.72
AbsEos-0.14 AbsBaso-0.08
___ 04:08PM BLOOD ___ PTT-25.7 ___
___ 04:08PM BLOOD Plt ___
___ 04:08PM BLOOD Glucose-166* UreaN-12 Creat-1.0 Na-139
K-3.5 Cl-102 HCO___ AnGap-18
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 open elbow dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left Elbow I&D, 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. He received 48 hours
of postoperative antibiotics. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in ___ locked at 90 in the Left upper extremity, and
will be discharged on Aspirin 325mg daily for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
2. 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
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours
as needed for pain Disp #*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
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
Discharge Disposition:
Home
Discharge Diagnosis:
left open elbow dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - independent
Discharge Instructions:
Mr. ___,
- ___ 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 left upper extremity in locked ___ brace
at 90 degrees
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 ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325 daily for 2 weeks
WOUND CARE:
- ___ 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 ___ 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. ___
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:
___
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2199-07-02 12:13:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: repair of incisional hernia, lysis of adhesions and
repair enterotomy
History of Present Illness:
___ with HTN, HLD who presents with incisional hernia. She
was supposed to undergo a right knee replacement today however
last night after drinking some ensure she developed acute onset
abdominal pain at the side of her known incisional hernia
radiating to the umbilicus. She then developed bilious
nausea/vomiting which lasted through the night. She then
presented to pre-op holding this AM the decision was made to
send
her to the ED and cancel the knee surgery. She denies any
fevers/chills, chest pain, or shortness of breath. She denies
any
changes in urinary symptoms. She reports she has known about the
hernia for ___ years and has always been able to reduce it. In
the
ED, the hernia was noted to be out and was reduced prior to
going
to CT scan.
Past Medical History:
anxiety, colon polyps, compression fractures, hyperlipidemia,
HTN, OA, osteoporosis, and obesity
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
97.9 62 146/62 16 100% 2L NC
GEN: A&Ox3, NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: no respiratory distress, unlabored respirations
ABD: soft, non-distended, non-tender, no rebound or guarding,
there is palpable reducible hernia at the superior portion of
the
prior midline hysterectomy incision, no overlying skin changes
PELVIS: deferred
EXT: WWP, no edema
NEURO: A&Ox3, no focal neurologic deficits
Discharge Physical Exam:
VS: 98.2, 126/73, 82, 18, 89
Gen: A&O x3, sitting up in chair, dressed, in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND. Incision CDI closed with dermabond
Ext: No edema
Pertinent Results:
___ 04:25PM BLOOD WBC-4.3 RBC-3.72* Hgb-10.6* Hct-33.7*
MCV-91 MCH-28.5 MCHC-31.5* RDW-15.1 RDWSD-49.9* Plt ___
___ 08:20AM BLOOD WBC-6.4 RBC-4.56 Hgb-12.9 Hct-39.7 MCV-87
MCH-28.3 MCHC-32.5 RDW-14.6 RDWSD-46.5* Plt ___
___ 07:16AM BLOOD Glucose-111* UreaN-13 Creat-1.1 Na-141
K-3.9 Cl-101 HCO3-30 AnGap-10
___ 04:25PM BLOOD Glucose-110* UreaN-14 Creat-0.9 Na-138
K-3.1* Cl-99 HCO3-25 AnGap-14
___ 07:16AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.6
___ 04:25PM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7
CT Abdomen Pelvis:
1. Fat containing supraumbilical hernia with haziness of the fat
may represent
incarcerated fat and could cause acute pain at this site.
Correlate with site
of point tenderness.
2. No bowel obstruction. No CT findings to suggest acute
cholecystitis.
3. 2.2 cm heterogeneous left adrenal nodule is incompletely
characterized.
Possible right-sided heterogeneous adrenal nodule is less
distinct.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain, nausea
and vomiting. Admission abdominal/pelvic CT revealed an
incisional hernia. The patient opted for surgical repair, and
underwent repair of incisional hernia, lysis of adhesions, and
repair of enterotomy, which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating sips, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
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 may be inaccurate and requires
futher investigation.
1. Atenolol 50 mg PO DAILY
2. Fluticasone Propionate NASAL ___ SPRY NU DAILY Sinus
allergies
3. Atorvastatin 10 mg PO QPM
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Naproxen 500 mg PO Q12H:PRN Pain - Mild
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 500 500
oral DAILY
7. Aspirin 81 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once a
day Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 500 500
oral DAILY
9. Fluticasone Propionate NASAL ___ SPRY NU DAILY Sinus
allergies
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Naproxen 500 mg PO Q12H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Incisional hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with an incisional hernia that
required surgical repair. You tolerated the operation well and
are now ready for discharge home to continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10741016-DS-5
| 10,741,016 | 21,257,676 |
DS
| 5 |
2188-06-10 00:00:00
|
2188-06-10 17:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, fevers, dyspnea on exertion
Major Surgical or Invasive Procedure:
None performed.
History of Present Illness:
Ms. ___ is a ___ y/o F w/ CKD ___ single kidney and HLD,
presenting now for evaluation of fatigues, fevers, and DOE.
Patient was seen by her PCP on ___ after noting a tick
bite
by an "engorged" deer tick 1.5 weeks prior. But had mild
symptoms
of fatigue, headache, and joint pain, and thus tick testing
(lyme/Babesia/anaplasma titers) were ordered. Given that the
patient was planning on traveling to ___ on ___, she was
given a prescription for doxycycline incase any testing came
back
positive. All testing came back negative. On ___, prior to her
flight, patient developed worsening symptoms of joint pain,
fatigue, and headache, as well as fevers and DOE, prompting her
to begin taking the Doxycycline. Her symptoms improved slightly
with this medication, however again began to worsen over the
last
week, thus she presented to urgent care at ___
today. Labs drawn there showed Hb: 8.5, WBC: 4.7, no L shift.
TSH
5.31, free T4 0.68, ALT: 38, AST 39, Na: 133, BUN: 34, Cr: 2.0
(was 1.07 on ___. She also had a negative CXR. Given her
lab
abnormalities, she was transferred to ___ for further management.
In the ED here, patient's labs were fairly consistent with those
from the urgent care, except her Hgb was noted to be down to
7.2.
Repeat tick-borne disease panel was obtained, as well as a
parasite smear, which was concerning for Babesia upon review by
pathology. She was given IVF, and started on Atovaquone and
Acyclovir.
On arrival to the floor, patient reports feeling slightly
better.
She reiterates story as above.
Past Medical History:
Single kidney ___ removal of right due to congenital blockage
Social History:
___
Family History:
Reviewed and non-contributory
Physical Exam:
Exam on Admission:
VITALS: Reviewed in OMR
GENERAL: Alert and interactive. In no acute distress.
HEENT: Mucus membranes dry
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Exam on Discharge:
___ 0729 Temp: 98.3 PO BP: 164/87 HR: 61 RR: 20 O2 sat: 95%
O2 delivery: Ra
GEN: NAD, face appears to have more color
HEENT: moist mucous membranes. improving conjunctival pallor.
CV: RRR. no rubs, murmurs, or gallops. normal S1 S2.
PULM: faint crackles at base of R lung, L lung clear to
auscultation
ABD: soft, non distended, nontender. normal bowel sounds. no HSM
EXT: well perfused, warm to touch.
Pertinent Results:
LABS
=====
Admission Labs:
___ 01:49PM BLOOD WBC-3.9* RBC-2.40* Hgb-7.2* Hct-22.2*
MCV-93 MCH-30.0 MCHC-32.4 RDW-17.0* RDWSD-56.3* Plt ___
___ 01:49PM BLOOD Neuts-47 Bands-1 ___ Monos-15*
Eos-1 Baso-0 Plasma-6* AbsNeut-1.87 AbsLymp-1.17* AbsMono-0.59
AbsEos-0.04 AbsBaso-0.00*
___ 01:49PM BLOOD Anisocy-1+* Poiklo-1+* Polychr-1+*
Ovalocy-1+* RBC Mor-SLIDE REVI
___ 01:49PM BLOOD Plt Smr-LOW* Plt ___
___ 04:15PM BLOOD Parst S-POSITIVE*
___ 04:15PM BLOOD Ret Aut-9.8* Abs Ret-0.23*
___ 01:49PM BLOOD Glucose-128* UreaN-38* Creat-2.1* Na-130*
K-4.6 Cl-99 HCO3-18* AnGap-13
___ 01:49PM BLOOD ALT-40 AST-41* LD(LDH)-538* AlkPhos-70
TotBili-1.0
___ 01:49PM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.4 Mg-2.0
Iron-51
___ 01:49PM BLOOD calTIBC-228* Hapto-<10* Ferritn-963*
TRF-175*
___ 02:10PM BLOOD Lactate-1.8
Interval Labs:
___ 11:10PM BLOOD WBC-5.2 RBC-2.31* Hgb-7.1* Hct-21.4*
MCV-93 MCH-30.7 MCHC-33.2 RDW-17.0* RDWSD-55.4* Plt ___
___ 10:25AM BLOOD Neuts-47.7 ___ Monos-21.9*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-1.91 AbsLymp-1.15*
AbsMono-0.88* AbsEos-0.02* AbsBaso-0.01
___ 11:10PM BLOOD Plt ___
___ 08:05AM BLOOD ___ 07:40PM BLOOD Parst S-POSITIVE*
___ 11:10PM BLOOD Glucose-107* UreaN-55* Creat-2.6* Na-129*
K-5.6* Cl-97 HCO3-20* AnGap-12
___ 11:10PM BLOOD LD(___)-499* CK(CPK)-60 TotBili-0.9
___ 11:10PM BLOOD TotProt-5.5*
Discharge Labs:
___ 06:53AM BLOOD WBC-4.3 RBC-2.37* Hgb-7.2* Hct-22.4*
MCV-95 MCH-30.4 MCHC-32.1 RDW-17.8* RDWSD-58.6* Plt ___
___ 06:38AM BLOOD Neuts-49.6 ___ Monos-16.6*
Eos-1.1 Baso-0.3 Im ___ AbsNeut-1.83 AbsLymp-1.14*
AbsMono-0.61 AbsEos-0.04 AbsBaso-0.01
___ 06:53AM BLOOD Plt ___
___ 06:53AM BLOOD Ret Aut-10.6* Abs Ret-0.25*
___ 06:53AM BLOOD Glucose-103* UreaN-21* Creat-1.2* Na-133*
K-5.1 Cl-105 HCO3-20* AnGap-8*
___ 06:53AM BLOOD LD(LDH)-426*
___ 06:53AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.3
MICROBIOLOGY
==============
___ 1:49 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 1:49 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
POSITIVE by Latex Agglutination.
(Reference Range-Negative).
BABESIA MICROTI DNA PCR
Test Result Reference
Range/Units
BABESIA MICROTI DNA, REAL Detected A Not Detected
TIME PCR
Test Result Reference
Range/Units
ANAPLASMA PHAGOCYTOPHILUM Not Detected Not Detected
DNA, QL REAL TIME PCR
___ 05:40PM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV
IgG-PND EBNA-PND EBV IgM-PND EBVI-PND
___ 11:10PM BLOOD HCV Ab-NEG
___ 11:10PM BLOOD HIV Ab-NEG
___ 11:10PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
___ 05:40PM BLOOD IgM HAV-NEG
___ 06:28AM BLOOD Parst S-POSITIVE*
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of CKD
secondary to solitary kidney and HLD, presenting now for
evaluation of fatigues, fevers, and dyspnea on exertion. She
initially presented to her primary care provider following ___
tick bite 1 month prior with symptoms of joint aches, headache,
and fatigue. She was started presumptively on doxycycline at the
time and completed a 1 week course, with only mild improvements
in symptoms prior to her presentation. She was found to have
hemolytic anemia requiring 1U PRBC transfusion and worsening
renal function with Cr peak at 2.6. Her initial outpatient
babesia PCR returned positive and lyme Ab preliminarily was
positive. Her confirmatory western blot was still pending. She
was treated in consultation with ID and Heme/Onc with
azithromycin, atovaquone and continued doxycycline. Her renal
function down-trended with additional IVF. Plan to continue with
azithromycin and atovaquone through ___.
ACUTE/ACTIVE ISSUES
======================
#Babesiosis - Patient initially presented with worsening
headache, arthralgias, cyclical fevers and dyspnea on exertion.
She was also found to have hemolytic anemia and given her
history of tick bite 1 month ago she was empirically treated for
babesiosis and possible lyme co-infection. She was started on
azithromycin 500mg x1 followed by 250mg QD and atovaquone 750mg
BID. She was also treated presumptively for lyme as well and
continued on doxycycline 100mg PO BID and completed a ___ peripheral blood smears were obtained which
returned positive for parasitemia however with low burden <0.1%.
Her anaplasmia, babesia PCR and lyme Ab titers were re-sent. Her
outpatient PCP lab results per review of Atrius records
ultimately did return positive for acute babesia with IgM
positive at 1:320. Also her outpatient preliminary lyme Ab
titers were positive with confirmatory Westernblot pending at
time of discharge. Although with hemolytic anemia requiring
blood transfusions and worsening renal disease, per renal and ID
was felt to have low severity infection given the relatively low
parasitemia burden. She will continue with azithromycin and
atovaquone for a 10 day total course through ___. She
completed a 10 day course of doxycycline 100mg BID on ___. Her
monospot test returned positive however per ID you can have a
false positive monospot with babesia and lyme. She was arranged
for ID ___ per above however per ID, if she is feeling
better with stable labs at PCP ___ she can cancel this
appointment.
#Hemolytic Anemia - Patient was found to have hemolytic anemia
with haptoglobin < 10 and Hb nadir at 6.2 requiring 1U PRBC. She
ultimately did not require any additional transfusions during
her hospitalization with discharge Hb 7.2. Hematology-oncology
team followed her during admission. There was no indication for
exchange transfusion. Will make transitional issue for repeat Hb
at PCP ___.
#Acute on Chronic Kidney Disease - Ms. ___ has a solitary
kidney due to congenital malformation and experienced acute
kidney injury (Cr 2.6 on admission) likely secondary to her
hemolytic anemia. She also reported recent history of increased
ibuprofen use given her symptoms of fever and arthralgias. Urine
sedimentation showed granular sedimentation casts, most likely
secondary to hypovolemia. Kidney function was followed via urine
studies. Urine sodium initially <20 supporting a component of
pre-renal ___. She received 3L IVF total. Her discharge Cr was
1.2.
#Monoclonal Ab - SPEP was measured as part of her ___ and
hemolytic anemia work-up. She was found to have Free Kappa 45.8
and Free Lambda 42.7 with a positive monoclonal IgG lambda
antibody detected on immunofixation. Also was found to have
elevated ___ with titer 1:320. ___ Heme-Onc, this could
represent MGUS. In an infectious setting per Heme-Onc, a
polyclonal gammopathy would be expected. As a transitional issue
per Heme-Onc she should have a skeletal survey and repeat SPEP
and ___ at PCP ___.
#Hypoxemia - Ms. ___ experienced a desaturation to 89% with
symptoms of orthopnea requiring 2L NC during her
hospitalization, however promptly normalized and saturated well
on room air. She had received 2L IVF and blood products since
admission, so may have been experiencing fluid overload. Chest
x-ray demonstrated possible focal consolidation in the RLL,
concerning for pneumonia, however patient remained afebrile
without cough or sputum production during her hospitalization.
TRANSITIONAL ISSUES
=======================
New Or Changed Medications:
- started atovaquone 750mg twice a day for 10 days total - last
day ___
- started azithromycin 250mg daily for 10 days total - last day
___
- finished a 10 day course of doxycycline 100mg twice per day -
last dose on ___
[ ] Repeat CBC, electrolytes with renal function and hemolysis
labs at PCP ___
[ ] Positive ___ 1:320. Should be repeated after completion of
antibiotics and resolution of above infection
[ ] Found to have positive monoclonal IgG lambda antibody
detected on immunofixation on SPEP. She should undergo
outpatient skeletal survey and repeat SPEP at ___. If
persistently abnormal consider referral to Heme-Onc
[ ] Patient planning on traveling to ___. Per ID here there is
no contraindication to her going despite some ongoing low level
hemolysis. She should receive malaria prophylaxis to be
coordinated by her PCP prior to going
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Atovaquone Suspension 750 mg PO BID
RX *atovaquone 750 mg/5 mL 5 ml by mouth twice a day Disp #*210
Milliliter Milliliter Refills:*0
2. Azithromycin 250 mg PO/NG Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Babesiosis Infection
Lyme Co-infection
Acute Hemolytic Anemia
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
Why did you come to the hospital?
You came to the hospital initially because you were having
fevers and feeling fatigued.
What happened during your hospitalization?
During your stay, you received one unit of red blood cells,
which led to an increase in your hemoglobin. A smear of your
blood cells showed that you were infected with a parasite called
Babesia, which are transmitted through tickbites. You were
treated with three antibiotics which you will continue when you
leave the hospital. Your kidney function improved with fluids.
You were able to breathe better as your condition improved.
What should you do when you leave the hospital?
You should follow up with your primary care doctor and
infectious disease team. You should complete your antibiotic
regimen.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10741092-DS-20
| 10,741,092 | 22,083,884 |
DS
| 20 |
2172-06-15 00:00:00
|
2172-06-15 13:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
sulfa
Attending: ___.
Chief Complaint:
back pain s/p fall
Major Surgical or Invasive Procedure:
bracing
History of Present Illness:
___ M with history of diabetes, hypertension, complains of
lower back pain. The patient fell from ___ feet yesterday,
landing on his back. He has had worsening lower back pain since.
He was able to walk yesterday. The pain is localized to his
lower
back. It is worse while bearing weight. He was seen at ___ today and was found to have compression fractures
from
L1-L3 with an unstable, 2 column fracture of L3 with 50% spinal
canal stenosis due to retropulsion of this fracture, as well as
an L2 left lateral spinous process fracture. He denies any
history of spine surgery. He is not on anticoagulation. Denies
numbness/tingling, focal weakness, upper back pain, neck pain,
urinary incontinence or retention, stool incontinence, saddle
anesthesia.
___ M with history of diabetes, hypertension, complains of
lower back pain. The patient fell from ___ feet yesterday,
landing on his back. He has had worsening lower back pain since.
He was able to walk yesterday. The pain is localized to his
lower
back. It is worse while bearing weight. He was seen at ___ today and was found to have compression fractures
from
L1-L3 with an unstable, 2 column fracture of L3 with 50% spinal
canal stenosis due to retropulsion of this fracture, as well as
an L2 left lateral spinous process fracture. He denies any
history of spine surgery. He is not on anticoagulation. Denies
numbness/tingling, focal weakness, upper back pain, neck pain,
urinary incontinence or retention, stool incontinence, saddle
anesthesia.
Past Medical History:
PMH/PSH: DM, HTN, mutliple orthopedic surgeries excluding the
spine
MEDS: reviewed in med rec. Not on anticoagulation of
antiplatelets
ALL: sulfa
Social History:
___
Family History:
NC
Physical Exam:
SPINE EXAM:
Sensory: UE C5 C6 C7C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
Rintact intact intact intact intact intact
Lintact intact intact intact intact intact
Trunk/Lower Extremities: intact
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 5 5 5 5 ___
L 5 5 5 5 ___
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ Per(S1) ___
R 5 ___ 5 5 5
L 5 ___ 5 5 5
Rectal tone: normal
perianal sensation: normal
Babinkski: Downgoing
Brief Hospital Course:
Patient admitted form ___ in a stable condition. TEDs/pnemoboots
were used for postoperative DVT prophylaxis. Pain was
controlled with oral pills. Brace was applied by NOPCO.
Physical therapy was consulted for mobilization OOB to ambulate.
1 episode of tachycardia after working with ___ with decreased
sats. CT negative for PE. DVT ppx had already been initiated
with SQH and ASA. Med consult suggested cardiac enzymes which
were negative. No further issues On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 60 mg PO DAILY
8. fesoterodine *NF* 4 mg Oral QAM
9. fesoterodine *NF* 4 mg Oral QAM
10. Fleet Enema ___AILY:PRN constipation
11. Gabapentin 600 mg PO Q6H
12. GlipiZIDE 5 mg PO BID
13. Heparin 5000 UNIT SC TID
14. Lantus - ___ 38 Units Breakfast
Lantus - ___ 26 Units Dinner
Insulin SC Sliding Scale using REG Insulin
15. Lisinopril 10 mg PO DAILY
16. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. Omeprazole 20 mg PO DAILY
19. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
20. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
21. Senna 1 TAB PO BID
22. Simvastatin 80 mg PO DAILY
23. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
L3 burst fracture
L1 and L2 compression fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have undergone the following treatment:
Brace for lumbar fractures
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
-Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when lying in
bed.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks if
this has not been done already.
Please call the office if you have a fever>101.5 degrees
Fahrenheit.
Physical Therapy:
activity as tolerated
TLSO for OOB activity
walker for safety
Treatment Frequency:
no incision
Followup Instructions:
___
|
10741136-DS-8
| 10,741,136 | 29,718,012 |
DS
| 8 |
2133-07-06 00:00:00
|
2133-07-06 21:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Abilify
Attending: ___.
Chief Complaint:
Pleuritic chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with past medical history
notable for OUD on methadone c/b methadone-induced
gastroparesis,
s/p hemicolectomy at ___ c/b anastomotic leak s/p ex-lap
for washout and repair and diverting loop ileostomy (___),
bipolar disorder, and prior RUE DVT who initially presented to
___ with left arm pain.
She reports that the pain began 5 days ago, and was located just
past the elbow. IT radiated up her arm over the next few days.
For the past 4 days, she has experienced chest pain worsened by
inspiration and shortness of breath. Her dyspnea feels different
from how she feels from her asthma.
At ___, she has a LUE US that showed L brachial vein
thrombus. She subsequently underwent CTA that showed bilateral
pulmonary emboli and area of pulmonary infarct vs. cavitary
lesion. She was started on a heparin gtt, vancomycin/cefepime
and
was then transferred to ___ for further evaluation.
Past Medical History:
- OUD on methadone c/b methadone-induced gastroparesis and
constipation, s/p hemicolectomy at ___ c/b anastomotic
leak s/p ex-lap for washout and repair and diverting loop
ileostomy (___)
- Bipolar disorder
- RUE DVT (provoked iso abdominal surgery)
- ADHD
- PTSD
- Anxiety
- Depression
Social History:
___
Family History:
Mother - IBS
No family history of blood clots or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.6 BP 104/68 HR 97 RR 18 O2 100 RA
GENERAL: Well-appearing woman, in NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM, tongue
piercing
in place
NECK: Supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Non-distended, Ileostomy in place, soft brown stool in bag,
active bowel sounds, mild TTP around ileostomy and in RLQ
without
rebound/guarding
EXTREMITIES: No cyanosis, clubbing, or edema. Small area of
erythema above L elbow that is warm to touch and TTP
SKIN: Warm, well-perfused, no rashes
PULSES: 2+ radial and pedal pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
========================
___ 1854 Temp: 98.6 PO BP: 102/71 R Lying HR: 103 RR: 18
O2 sat: 96% O2 delivery: Ra
GENERAL: Well-appearing woman, in NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM, tongue
piercing
in place
NECK: Supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Non-distended, Ileostomy in place, soft brown stool in bag,
active bowel sounds, mild TTP around ileostomy and in RLQ
without
rebound/guarding
EXTREMITIES: No cyanosis, clubbing, or edema. Small area of
erythema above L elbow that is warm to touch and TTP
SKIN: Warm, well-perfused, no rashes
PULSES: 2+ radial and pedal pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 11:32PM BLOOD WBC-7.0 RBC-3.02* Hgb-9.2* Hct-30.0*
MCV-99* MCH-30.5 MCHC-30.7* RDW-14.4 RDWSD-51.6* Plt ___
___ 11:32PM BLOOD Neuts-49.4 ___ Monos-8.0 Eos-2.9
Baso-0.1 Im ___ AbsNeut-3.44 AbsLymp-2.72 AbsMono-0.56
AbsEos-0.20 AbsBaso-0.01
___ 12:15AM BLOOD ___ PTT-62.2* ___
___ 11:32PM BLOOD Glucose-105* UreaN-3* Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-25 AnGap-15
___ 06:50AM BLOOD ALT-<5 AST-8 LD(LDH)-182 AlkPhos-78
TotBili-<0.2
___ 11:32PM BLOOD proBNP-59
___ 11:32PM BLOOD cTropnT-<0.01
___ 11:32PM BLOOD Calcium-8.6 Phos-4.6* Mg-1.9
___ 06:40AM BLOOD Calcium-8.4 Phos-4.8* Mg-1.9 Iron-23*
___ 06:40AM BLOOD calTIBC-198* Ferritn-120 TRF-152*
___ 06:50AM BLOOD VitB12-577 Folate-5
___ 08:35AM URINE Color-Straw Appear-Clear Sp ___
___ 08:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
DISCHARGE LABS:
===============
___ 05:57AM BLOOD WBC-6.0 RBC-2.47* Hgb-7.5* Hct-24.2*
MCV-98 MCH-30.4 MCHC-31.0* RDW-14.3 RDWSD-51.6* Plt ___
___ 05:57AM BLOOD Glucose-96 UreaN-3* Creat-0.6 Na-138
K-4.3 Cl-99 HCO3-25 AnGap-14
___ 05:57AM BLOOD Calcium-8.6 Phos-5.0* Mg-1.8
IMAGING:
========
CTA CHEST ___ read):
1. Bilateral lower lobe segmental and subsegmental pulmonary
emboli. Two
peripheral left lower lobe wedge-shaped airspace opacities,
without
cavitation, most consistent with pulmonary infarcts.
2. Left upper quadrant fat stranding with the appearance of fat
necrosis;
correlate with recent surgical history.
CT ABD/PELVIS:
1. Thrombosis of the posterior branch of the right portal vein.
2. Partially occlusive thrombus in the left renal vein.
3. Small partially occlusive left femoral common vein.
4. Status post subtotal colectomy with a small air containing
fluid collection
around the anastomosis sutures concerning for a small
anastomotic leak
although no rectal contrast extravasation was seen.
MICROBIOLOGY:
=============
__________________________________________________________
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:20 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:05 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
LABS PENDING AT DISCHARGE:
==========================
B2 microglobulin
Cardiolipin antibodies
Brief Hospital Course:
SUMMARY:
========
Ms. ___ is a ___ female with past medical history
notable for OUD and chronic pain on methadone c/b
methadone-induced gastroparesis and constipation, s/p
hemicolectomy at ___ c/b anastomotic leak s/p ex-lap for
washout and repair and diverting loop ileostomy (___),
bipolar disorder, and prior RUE DVT who initially presented to
___ with left arm pain, found to have superficial left
brachial vein thrombus as well as bilateral pulmonary emboli.
ACUTE ISSUES:
===============
# Multiple bilateral pulmonary emboli
# L brachial vein thrombus
# Renal vein, portal vein, femoral vein thrombi
Presenting with LUE superficial thrombus and multiple bilateral
pulmonary emboli, likely provoked iso recent surgeries.
Otherwise hemodynamically stable with no evidence of right heart
strain on bedside ultrasound. ECG, trops, and BNP unremarkable.
___. Lukes CT read as concern for cavitary lesion/abscess raising
concern for septic emboli, though review of imaging and second
opinion read by radiology here more consistent with pulmonary
infarction. Started on heparin gtt prior to transfer, now
transitioned to PO Apixaban prior to discharge. Of note, she was
also incidentally found to have renal vein, portal vein, and
femoral common vein thrombi on CT abdomen pelvis. Hematology was
consulted given significant clot burden in atypical locations.
Hematology recommending treatment with apixaban and follow up as
an outpatient for further hypercoagulability workup. B2
macroglobulin and cardiolipin antibodies pending at discharge.
# Normocytic anemia
Hgb 9.2 on arrival from 8.5 at ___. Notably, has ranged
from 7.8-10.4 over the past month. No e/o active bleeding. Iron
studies consistent with anemia of chronic disease. B12, folate
within normal limits. Will follow up with hematology as an
outpatient as above for further workup.
# Severe constipation s/p hemicolectomy c/b anastomotic leak s/p
ex-lap for washout and repair and diverting loop ileostomy
(___)
Patient has continued to have abdominal pain since admission,
prompting repeat CT abdomen/pelvis to rule out organic etiology
given complicated surgical history. CT was notable for small air
containing
fluid collection around the anastomosis sutures. Her abdominal
exam is otherwise reassuring in that her tenderness is limited
only to her stoma site without diffuse or lower abdominal pain
in the region of this collection. Colorectal surgery was
consulted for further evaluation. Per surgery, likely that the
collection represents resolving abscess related to her index
operation rather than an ongoing anastomotic leak, given no
active rectal contrast extravasation on imaging. Recommended
conservative treatment with cipro/flagyl PO for resolving
abscess. Patient will plan to follow up with her colorectal
surgeons to discuss timing of repeat imaging to ensure
resolution of abscess as well as duration of antibiotics. Will
otherwise continue antibiotics until follow up. Continued home
reglan TID.
#Ostomy care
Seen by wound ostomy nurse during admission and colorectal
surgery. Prescribed loperamide and psyllium wafer PRN. Will
discharge with ___ for further assistance at home regarding
ostomy care.
Wound care and ostomy care recommendations as below:
*Peristomal skin care:
-cleanse with water, gently pat dry.
-Sprinkle stoma powder to pink skin. Rub in then dust off
excess.
-Then, seal in with NO sting barrier & allow to dry.
-Firmly place ___ Seal on back of measured wafer.
-Place over stoma. ___ use warm cloth to help wafer mold into
skin.
Surgical Midline dressing:
-Cleanse wound with wound cleanser, pat dry with dry gauze
-Loosely fill with ___ AMD packing strip
-Cover with gauze, then ___ ABD pad. Secure with medipore tape.
-Change daily.
# Chronic pain
# History of IVDU
Continue home methadone 74mg daily for chronic pain and history
of IVDU, confirmed with ___ clinic ___
___, ___. She was also discharged on PO
hydromorphone PRN after her hemicolectomy procedure in ___,
which she has since run out of. On admission, she is having
severe abdominal pain and back pain. She is currently being
treated for multiple intra-abdominal thrombosis and presumed
anastomotic abscess as above. Chronic pain service was
consulted, as to optimize pain regimen. Plan for continued home
methadone and oxycodone ___ Q6H PRN for breakthrough pain.
Will prescribe 5 day supply of oxycodone with plan for PCP
follow up. ___ also consider dosing home methadone TID as an
outpatient for improved pain control.
#Ear pain
L sided ear pressure over the last ___ days. No ear redness or
drainage. No other sinus congestion, sore throat, viral
symptoms. Otoscopic exam within normal limits. ENT recommended
saline nasal spray PRN, Afrin x 3 days. Ear pain improved prior
to discharge.
CHRONIC ISSUES:
===============
# Asthma: Continue home breo and albuterol inhalers,
# Bipolar disorder: Continue home doxepin, valproic acid liquid.
# ADHD: Continue home atomoxetine.
# Tobacco abuse: Continue home nicotine patch 14mg daily.
TRANSITIONAL ISSUES:
=====================
[] Started on Apixaban daily
[] Please ensure follow up as an outpatient for further
hypercoagulability workup.
[] Follow up B2 macroglobulin and cardiolipin antibodies pending
at discharge.
[] Plan for continued home methadone and oxycodone ___ Q6H
PRN for breakthrough pain. Will prescribe 5 day supply of
oxycodone with plan for PCP follow up and weaning as tolerated.
Would also consider dosing home methadone TID as an outpatient
for improved pain control as an outpatient.
[] Found to have fluid collection at anastomotic sutures on CT
abdomen pelvis. Likely resolving abscess rather than an ongoing
anastomotic leak per surgery. Will treat conservatively with
Cipro/Flagyl PO.
[] Please ensure follow up with her colorectal surgeons to
discuss timing of repeat imaging to ensure resolution of abscess
as well as duration of antibiotics.
#CONTACT: ___
Phone number: ___
>30 minutes spent coordinating discharge home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Pantoprazole 40 mg PO Q24H
3. Montelukast 10 mg PO DAILY
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
5. atomoxetine 25 mg oral DAILY
6. Cetirizine 10 mg PO DAILY
7. Doxepin HCl ___ mg PO QHS
8. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation PRN
9. Methadone 74 mg PO DAILY
10. Metoclopramide 5 mg PO DAILY:PRN abdominal pain
11. Nicotine Patch 14 mg TD DAILY
12. Aspirin 325 mg PO DAILY
13. valproic acid (as sodium salt) 250 mg/5 mL (5 mL) oral QAM
14. valproic acid (as sodium salt) 500 mg/10 mL (10 mL) oral QPM
Discharge Medications:
1. Apixaban 10 mg PO BID
Take 2 tabs by mouth twice daily from ___. On ___ start
taking 1 tablet by mouth twice daily.
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*76 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*28 Tablet Refills:*0
3. LOPERamide 2 mg PO DAILY:PRN stool output > 1500
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth once a day Disp #*30 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
5. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN
RX *naloxone [Narcan] 4 mg/actuation 1 dose once Disp #*1 Bottle
Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
7. Psyllium Wafer 1 WAF PO DAILY
RX *psyllium 1 (s) by mouth once a day Disp #*30 Tablet
Refills:*0
8. Acyclovir 400 mg PO Q12H
9. Aspirin 325 mg PO DAILY
10. atomoxetine 25 mg oral DAILY
11. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation PRN
12. Cetirizine 10 mg PO DAILY
13. Doxepin HCl ___ mg PO QHS
14. Methadone 74 mg PO DAILY
15. Metoclopramide 5 mg PO DAILY:PRN abdominal pain
16. Montelukast 10 mg PO DAILY
17. Nicotine Patch 14 mg TD DAILY
18. Pantoprazole 40 mg PO Q24H
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing
20. valproic acid (as sodium salt) 250 mg/5 mL (5 mL) oral QAM
21. valproic acid (as sodium salt) 500 mg/10 mL (10 mL) oral
QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Chronic pain
#Pulmonary embolism
#Renal vein thrombosis
#Portal vein thrombosis
#Abdominal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a blood clot in your lungs.
What happened while I was in the hospital?
- You were treated with blood thinners, which you should
continue to take at home.
- You were also found to have blood clots in the veins going to
your kidney, liver, and leg. You were seen by hematology, who
recommended blood tests for clotting disorders. You should
follow up with hematology in the clinic after you go home.
- You were also seen by our chronic pain service. They
recommended your home methadone as well as oxycodone as needed
up to 4 times daily. You should follow up with your primary care
doctor as an outpatient for your chronic pain.
- You were also found to have a small area of fluid in your
abdomen, which is likely residual from your prior surgeries. It
is possible that this fluid is infected. You were seen by the
surgeons who recommended antibiotics at home. You should
continue to take antibiotics and follow up with your colorectal
surgeons.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10741954-DS-2
| 10,741,954 | 22,836,993 |
DS
| 2 |
2179-08-30 00:00:00
|
2179-08-30 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Demerol / meperidine
Attending: ___.
Chief Complaint:
Right Flank Pain
Major Surgical or Invasive Procedure:
Uretal Stent Placement And Lithotripsy (___)
History of Present Illness:
Ms ___ is a ___ w/ PMHx anxiety, chronic right sided
hydronephrosis (following ? ureteral obstruction as a child),
breast cancer in remission, nephrolithiasis presenting with
right sided flank pain. Pt has known stones and intermittent
episodes of pain related to these stones which have previously
been managed conservatively. She presented to the ED on this
occasion because her pain was worse than usual. Patient states
that the pain started at 6PM, was R-sided, sudden onset, worse
than normal, sharp and similar to previous kidney stones except
stronger. Last time she had similar pain was a few weeks ago,
and also a few months ago, however these episodes self-resolved
at home. Patient does report a history of urinary tract
infections, last time a few years ago. States that she has
macrobid at home if needed. Denies any fever, chills, nausea or
vomiting at home. No hematuria, dysuria, polyuria. Last BM this
AM, normal.
In the ED, initial vitals were: 8 96.8 96 144/78 20 99% RA. Pt
appeared uncomfortable. Labs were notable for UA with small
leuks, 16 wbcs, tr ketones. LFTs were AST 89, AST 65, AP 149.
CT showed severe hydroureteronephrosis of R kidney seen to the
level just proximal to the R ureterovesicular junction where
there is an 8mm obstructing renal stone. A second smaller stone
was also seen slightly more distally measuring approx. 6 mm.
She was evaluated by urology who recommended admission to
medicine with medical management and consideration of a stent
later today. Pt was given dilaudid, tamsulosin, ceftriaxone,
Zofran, morphine, 4 L NS.
On the floor, pt states that she has had a problem with stones
for the last ___ years, they are known to be calcium oxylate and
she had been followed by urology for this but has not been
followed recently since her urologist retired. She has never
had a procedure to treat her stones and her pain episodes, which
occur ___, although this has been recommended by urology in
the past. She has opted to for conservative management because
of her abnormal anatomy from prior surgery. She notices
worsening of her sxs when she is dehydrated. Her pain has
improved from ___ to ___ with pain meds. It was initially
constant but is now coming in spasms. Also improved with
heating pad. She endorses nausea following pain meds but none
prior to arrival in the ED. She has no sxs currently other than
the pain and generalized weakness which she attributes to her
RA/PMR. She tells me that she does not want any procedures and
would like to manage her sxs conservatively. She tells me she
has chronic constipation which she manages with prune juice
daily.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. 10 pt ros otherwise negative.
Past Medical History:
GERD-not on medication, improved with decreasing pred dosing
RA-atypical presentation with characteristics of PMR
Sjogrens syndrome-endorses dry eye/mouth
Breast Ca, in remission after surgery and radiation
Anxiety
Vit D deficiency
IBS, severe constipation
R Hxydronephrosis -had surgery for this in ___
___ me it was an experimental surgery due to "twisted
ureter"
chronic wrist pain
migraines
Social History:
___
Family History:
Mother with CHF.
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.0 PO129 / 84L Lying___
Constitutional: Alert, oriented, no acute distress, moves slowly
in bed
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, TTP on R side, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
DISCHARGE EXAM
Appears well, comfortable, seated upright in bed in NAD
Lungs CTAB
CV RRR, normal
Abdomen soft, NT, ND
Pertinent Results:
ADMISSION LABS:
___ 12:12AM BLOOD WBC-9.6 RBC-4.82 Hgb-12.4 Hct-39.3 MCV-82
MCH-25.7* MCHC-31.6* RDW-13.0 RDWSD-38.3 Plt ___
___ 12:12AM BLOOD Neuts-62.3 ___ Monos-10.1 Eos-1.4
Baso-0.4 Im ___ AbsNeut-5.96 AbsLymp-2.44 AbsMono-0.97*
AbsEos-0.13 AbsBaso-0.04
___ 12:11AM BLOOD ___ PTT-30.9 ___
___ 12:12AM BLOOD Glucose-114* UreaN-9 Creat-0.8 Na-135
K-4.5 Cl-96 HCO3-25 AnGap-14
___ 12:12AM BLOOD ALT-89* AST-65* AlkPhos-149* TotBili-0.2
___ 12:12AM BLOOD Lipase-35
___ 12:12AM BLOOD Albumin-4.1 Calcium-9.7 Phos-3.0 Mg-1.9
___ 06:54AM BLOOD HCV Ab-NEG
___ 06:54AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 12:18AM BLOOD Lactate-1.2
Discharge Labs:
___ 02:16AM BLOOD WBC-10.0 RBC-3.91 Hgb-10.3* Hct-32.2*
MCV-82 MCH-26.3 MCHC-32.0 RDW-13.2 RDWSD-39.7 Plt ___
___ 02:16AM BLOOD ___ PTT-28.7 ___
___ 06:45AM BLOOD Glucose-98 UreaN-10 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-26 AnGap-12
IMAGING:
- CTAP ___: Severe hydroureteronephrosis of the right kidney
seen to the level just proximal to the right ureterovesicular
junction where there is an 8 mm obstructing renal stone. A
second smaller stone is seen slightly more distally measuring
approximately 6 mm. There is associated perinephric stranding
Brief Hospital Course:
___ is a ___ hx nephrolithiasis admitted with
obstructive stone, hydronpehrosis, and ___, treated with stent
placement and lithotripsy.
# Obstructive Nephrolithiasis
# Hydonephrosis
# Acute Renal Failure:
CTAP on admission with 8mm at UVJ and second 6mm stone in calyx.
No signs of infection and urine culture was negative. Urology
consulted and recommended stent placement, but patient initially
declined operative intervention. Trialed patient on oral pain,
fluid regimen to see if she could safely go home per her wishes,
but she experienced worsened pain and developed an ___. After a
repeat discussion with GU/medical teams, she agreed to stent
placement. Underwent lithotripsy/stent placement of 2 stones
impacted at UVJ on ___. She was treated with supportive care
and discharged on POD#1 after creatinine improved, with
appropriate follow-up.
# RA/PMR/Sjogrens: followed by rheumatology, recommended to
start DMARD however pt has declined due to c/f side effects.
Home prednisone and acetaminophen-codeine were continued.
# Depression/anxiety: stable. Pt was very anxious inpatient in
regard to her procedure. Continued home lorazepam
# Transaminitis: Patient had an RUQUS in ___ to eval for cause,
with no abnormalities, LFTs normalized in ___ and are now
elevated again. Intervally improved. Hep sreologies negative.
- Will need HBV vaccination as TI, given HBsAb negative
TRANSITIONAL ISSUES
- Will need HBV vaccination as TI, given HBsAb negative
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 35 mg PO QTHUR
2. Vitamin D ___ UNIT PO EVERY 2 WEEKS (TH)
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. PredniSONE 4 mg PO DAILY
5. DULoxetine 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Acidophilus (Lactobacillus acidophilus) oral DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Oxybutynin 5 mg PO TID:PRN Bladder spasm
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*30 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID:PRN Dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*10 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
4. Acidophilus (Lactobacillus acidophilus) oral DAILY
5. Alendronate Sodium 35 mg PO QTHUR
6. DULoxetine 20 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. LORazepam 0.5 mg PO DAILY:PRN anxiety
9. Multivitamins 1 TAB PO DAILY
10. PredniSONE 4 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Vitamin D ___ UNIT PO EVERY 2 WEEKS (TH)
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Stones
Obstructive Uropathy
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you in the hospital. You were
admitted to ___ because you had kidney stones causing you
significant pain and injury to your kidney. There was no sign of
an infection. You were treated with pain medications, had a
procedure to break up the stones, and had a stent placed to
relieve your obstruction.
You will now be discharged home to follow-up with urology.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10741985-DS-8
| 10,741,985 | 21,275,583 |
DS
| 8 |
2159-05-23 00:00:00
|
2159-05-23 13:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 morbidly obese (415 lbs) female w/ PMH dysfunctional uterine
bleeding, hypothyroidism, pituitary adenoma, and fibromyalgia,
p/w sudden onset SOB since last night. She reports she had
sudden need to gasp for air. No hx of prior similar symptoms.
Has been on Minipill since ___ for continuous vaginal
bleeding, which finally stopped 3 days ago (endometrial bx done
however she is unaware of results). Was given morphine, asa at
OSH. D-dimer +. Attempted to get CT but due to weight, unable to
CT or V/Q. Transferred for CTA of chest. No hx of dvt/pe in self
of family.
Initial ED vitals 98.7 102 120/88 20 96%. She reported left
sided pleuritic pain ___. EKG with S1Q3T3. Labs notable hct
28.1, negative trops. CTA limited due to body habitus but
appears small cylindrical filling defects in the segmental
branches of the right lower lobar pulmonary artery that are
concerning for pulmonary embolus. Heparin gtt was started at
6am for body weight of 100kg (purposely underdosed given
stability and significant bleeding that just stopped). ED Exam
without current vaginal bleeding or rectal bleeding.
On the floor, patient is resting comfortably in bed. She
reports diffuse chest pressure which she says she has had for
past 1 month. She also reports anterior pain in R thigh since
yesterday without erythema, remains mildly tender. No hx of
trauma/falls. No fevers/chills. Reports sedentary lifestyle.
No recent travel. Denies recent calf pain/swelling/erythema.
For her bleeding hx, patient reports being diagnosed with a
pituitary adenoma ___ prior which was felt to contribute to
uterine bleeding. Recently started on Minipill. Hct has
downtrended from 40 four months ago to 26 three days ago, no
transfusion given at that time. Follows with OB-GYN Dr. ___ at
___. Spoke with Dr. ___ has been working patient
up for this bleeding for some time. Most recent hct in her
records 23 in ___. Believes most likely endometrial
hyperplasia due to obesity and excess unopposed estrogen. s/p
prior D&C to control bleeding, which was unsuccessful. Recent
TVUS showed endometrial stripe thickness of 1.5 mm. Repeat
endometrial biopsy attempted for diagnoses and r/o endometrial
CA, however could not be done due to patient's weight. Dr. ___
was planning for D&C soon for diagnosis and potentially therapy.
Patient reports no bleeding in the past 4days.
Past Medical History:
Dysfunctional Uterine Bleeding
Hypothyroid
Pituitary Adenoma
Fibromyalgia
Back pain
Social History:
___
Family History:
Father with heart disease, ischemic stroke, aneurysm. Mother
with heart disease. Two aunts with breast cancer. No history
of coagulopathies or frequent miscarriages.
Physical Exam:
Admission Exam
==============
GEN: Middle-aged Hispanic female resting comfortably in bed, NAD
HEENT: NCAT, MMM
NECK: cannot assess JVP due to habitus
CV: RR, S1+S2, NMRG
RESP: CTABL, no w/r/r, no accessory muscle use
ABD: Obese, SNTND, normoactive Bs
GU: Deferred given recent ED exam and no bleeding x4days
RECTAL: Deferred
EXT: WWP, trace pitting edema in BLLE, anterior R thigh mildly
tender but without erythema or palpable mass
SKIN: Acanthosis of neck and midline lower back
NEURO: CN II-XII grossly intact, MAE, sensation to light touch
grossly intact
.
Discharge Exam
==============
VS: 98.4/98.2 99 116/67 18 95% RA
HEENT: NCAT, MMM
NECK: cannot assess JVP due to habitus
CV: RR, S1+S2, NMRG
RESP: CTABL, no w/r/r, no accessory muscle use
ABD: Obese, SNTND, normoactive BS. Mild reproducible left flank
tenderness.
EXT: WWP, trace pitting edema in BLLE
SKIN: Acanthosis of neck and midline lower back
NEURO: CN II-XII grossly intact, MAE, sensation to light touch
grossly intact
Pertinent Results:
Admission Labs
==============
___ 06:25AM BLOOD WBC-9.1 RBC-3.44* Hgb-8.8* Hct-28.1*
MCV-82 MCH-25.6* MCHC-31.3 RDW-14.7 Plt ___
___ 06:25AM BLOOD Neuts-79.0* Lymphs-14.3* Monos-4.6
Eos-1.7 Baso-0.4
___ 06:25AM BLOOD ___ PTT-32.0 ___
___ 06:25AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-136
K-4.2 Cl-103 HCO3-26 AnGap-11
___ 06:25AM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 10:26AM BLOOD %HbA1c-6.3* eAG-134*
.
Imaging
=======
The study is limited by body habitus with associated beam
hardening artifact. Heart size is top normal with a trace
physiologic
pericardial fluid. The thoracic aortic arch is normal in
caliber without
aneurysmal segment or dissection. The main pulmonary artery is
normal in
caliber. There are small filling defects in the proximal
segmental branches of the right lower lobar pulmonary artery
which are concerning for pulmonary embolus particularly since
they appear contiguous and serpiginous. There is no evidence of
right heart strain. There is no axillary, mediastinal or hilar
lymphadenopathy by CT size criterion.
While this study is not tailored for subdiaphragmatic diagnosis,
the imaged upper abdomen is grossly unremarkable. Bilateral
dependent atelectasis is small. Lungs are otherwise clear.
Pleural surfaces are clear without effusion or pneumothorax.
OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions
in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Although study is highly limited by body habitus and
contrast timing,
small filling defects are noted in the proximal segmental
branches of the
right lower lobar pulmonary artery which are concerning for
pulmonary embolus particularly since they appear contiguous.
2. No acute aortic abnormality.
.
Micro
=====
None
.
Discharge Labs
==============
___ 07:10AM BLOOD ___ PTT-98.0* ___
Brief Hospital Course:
___ with morbid obesity and heavy vaginal bleeding with sudden
onset dyspnea found to have PE after being started on OCPs.
.
Acute Issues
============
# Pulmonary Embolism: Presumed due to obesity w/ sedentary
lifestyle and recent start of OCPs to manage menorrhagia.
Cabergoline not known to increase PE risk. Hx of pituitary
adenoma but no clear hypercoagualable state, no family history
of hypercoagulability. OCPs were stopped on admission. Pt was
not a candidate for lovenox or oral factor Xa inhibitor given
obesity, started on heparin gtt as bridge to therapeutic
warfarin. Patient expressed desire numerous times to leave
against medical advice however was convinced to stay due to high
risk of stopping heparin drip while coumadin subtherapeutic.
She was discharged when her INR reached a therapeutic level of
2.4, on a dose of 7.5mg daily due to the rapid rise in her INR.
She has follow-up with PCP for coumadin management in two days.
- Will require at least three months anticoagulation
.
# Vaginal bleeding -> blood loss anemia: Per OB/GYN, most likely
___ endometrial hyperplasia due to obesity and unopposed
estrogen. Started OCPs for this recently, however stopped as
above. Had initial withdrawal spotting which resolved
spontaneously. Hematocrit was stable throughout admission.
.
.
Chronic Issues
==============
# Prolactinoma: Continued cabergoline.
.
# Hyperglycemia: BS 140 on presentation, no known hx of
diabetes. Repeat A1Cs were in prediabetic range as above.
- Consider starting metformin and encourage lifestyle changes
for management of prediabetes
.
# Hypothyroid: Continued home Levothyroxine 200mcg
.
# Asthma: Albuterol prn
.
# Back Pain/Fibromyalgia: Pain controlled with standing tylenol
and prn oxycodone.
.
.
Transitional Issues
============
- Will require at least three months anticoagulation
- Consider starting metformin and encourage lifestyle changes
for management of prediabetes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
2. norethindrone (contraceptive) 0.35 mg oral daily
3. Cyanocobalamin 50 mcg PO DAILY
4. cabergoline 0.5 mg oral ___
5. cabergoline .25 oral ___
6. Ferrous Sulfate 325 mg PO TID
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain
Discharge Medications:
1. cabergoline 0.5 mg oral ___
2. cabergoline 0.25 mg ORAL ___
3. Cyanocobalamin 50 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO TID
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain
7. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 3 tablet(s) by mouth daily Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Pulmonary embolism
Secondary Diagnoses:
- Menorrhagia ___ endometrial hyperplasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted with a blood clot in your lungs. We started you on a
medication called coumadin which thins your blood, and stopped
your mini-pill. You were kept in the hospital receiving another
blood thinner until your coumadin could take effect. You will
need to continue taking coumadin for some time, which will be
managed by your primary care provider.
Please be sure to attend the follow-up appointment listed below.
Thank you for allowing us to be part of your care.
Followup Instructions:
___
|
10742136-DS-2
| 10,742,136 | 22,002,679 |
DS
| 2 |
2120-09-20 00:00:00
|
2120-09-20 08:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
confusion, fever, cellulitis
Major Surgical or Invasive Procedure:
LP ___ (failed)
History of Present Illness:
Ms. ___ is a ___ retired elementary school
___ with a PMH pertinent for osteoarthritis s/p bilaterally
TKR's, depression, asthma, HTN, GERD, morbid obesity, gout,
endometrial cancer s/p TAH-BSO (___), bilateral breast cancer
(R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who presented to the ED in the evening
___ for altered mental status, fever, LLE cellulitis. The
limited history was provided by husband/son given patient's
confusion.
Patient was in her usual state of health until ___ when patient
became febrile (Tmax ___ at home) and developed malaise,
weakness, worsening confusion, and was noted to have worsening
lower left leg redness and swelling. She was also noted to have
urinary incontinence. Husband notes that about a week per he was
ill for a few days and his illness involved fevers,
fatigue/malaise, and confusion. Upon arrival to the ED, patient
had some mild nausea that spontaneously resolved but family
denies she had complaints about headache, visions changes, neck
stiffness, chest pain, cough, shortness of breath, abdominal
pain, vomiting, diarrhea, melena, BRBPR, or dysuria.
ROS: Denies pain, headache, neck stiffness, weakness, shortness
of breath, nausea but ROS not reliable given patient's altered
mental status.
ED course:
-VS: Tmax 102.8 (1:23am ___, HR ___, BP 120s-150s/60s-90s, RR
___, 95-99% on RA -> 92% on 2L NC (developed hypoxia).
-Initial exam pertinent for left lower extremity being warm,
tender, and erythematous from ankle to ___ up calf. Also,
patient confused/disordered. No headache, neck stiffness.
-Pertinent labs: WBC 14.2 (92% neutrophils), CMP wnl except Mg
1.4, Phos 0.8. Lactate 2.7->2.2. UA with just trace leuk
esterase, neg nitrate, 3 WBC, few bact. Type & screen sent.
-Pertinent micro: urine culture pending, 2 blood cultures sent.
-Pertinent imaging: CXR showing vascular congestion without
pulmonary edema, no focal consolidation, no effusions, no
pneumothorax.
-Meds administered:
Allopurinol ___, atenolol 50, bupropion 150, fluoxetine 80,
gabapentin 300 (x2), omeprazole 20, vancomycin 1g (3AM), Mag
sulfate 2g, Phos 500mg.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Osteoarthritis s/p bilaterally TKR's (L in ___, R in ___
Depression
Asthma
Hypertension
GERD
Morbid obesity (BMI 77)
Gout
Choledocholithiasis s/p cholecystectomy
Endometrial cancer s/p TAH-BSO (___)
Bilateral breast cancer (R stage 1 ER+ invasive ductal cancer, L
DCIS) s/p lumpectomies (___) & on letrozole,
ONCOLOGY HISTORY:
Patient was diagnosed with endometrial cancer in ___. She had
her surgery with a TAH-BSO at the ___ by Dr ___. This showed a
grade I, well differentiated endometrial cancer, stage IB.
Patient is followed by Dr. ___ Oncology
(Atrius) given her history of bilateral breast cancer (Stage I
invasive ductal cancer of the right breast and DCIS of the left
breast).
___ prior right breast biopsy showed intraductal
hyperplasia
and fibrocystic changes.
___ routine mammograms showed a 7 mm mass in the right
UOQ
and a possible asymmetry in the left breast
___ she had additional mammograms and bilateral
ultrasound. This showed a spiculated mass in the right breast
measuring 0.7 x 0.6 x 0.6 cm is suspicious for malignancy and
ultrasound-guided biopsy is recommended. Hypoechoic mass in the
left breast corresponds to a developing asymmetry on mammography
and while this may represent a deep complicated cyst the walls
are slightly irregular and therefore ultrasound-guided biopsy is
recommended.
___ she had bilateral ultrasound guided biopsies. This
showed:
A. RIGHT BREAST, 10 O'CLOCK, 9 CM FROM NIPPLE, ULTRASOUND-GUIDED
CORE BIOPSY: Invasive ductal carcinoma, well differentiated
___ grade II/III), involving 4 of 5 cores,
measuring approximately 0.7 cm. There is no
ductal carcinoma in situ identified. Lymphatic/vascular invasion
is NOT identified. The cancer was ER positive (>95%), PR
positive
(>95%) and HER 2/neu 1+ negative
B. LEFT BREAST, 2 O'CLOCK, 9 CM FROM NIPPLE, ULTRASOUND-GUIDED
CORE BIOPSY: Atypical ductal hyperplasia present within a
densely
hyalizined stroma. Surgical consultation is advised. Presence of
ADH on the left is incidental as the lesion revolved during
biopsy and felt to represent a cyst
___ she was seen by Dr ___
___ she underwent bilateral lumpectomies and right
sentinel LN mapping at the ___. This showed:
Left breast: DCIS, grade 2, fibroadenoma, biopsy site changes
and
close margins
Right breast: invasive ductal cancer, grade I, measuring 0.7 cm.
There was severe atypical intraductal proliferation bordering on
DCIS. There was ALH/LCIS. There was no LVI. A total of 3 SLNs
were removed and all were negativ. Stage T1bN0, stage I
___ Dr ___ has advised additional excision of the
left
breast.
Interval history ___: Since her initial consult on ___
she is undergone a left breast reexcision by Dr. ___ on
___ at the ___. This showed no residual DCIS. She has noted
no breast masses nor nipple discharge.
Social History:
___
Family History:
Her mother had colon cancer in her late ___. There is no family
history of breast, ovarian or uterine cancer.
Physical Exam:
ADMISSION EXAM
VITALS:
T 97.5, BP 137/71, HR 78, RR 20, 93% on 2L NC
Weight: 344, Height: 56, BMI: 77.1.
GENERAL: Very large woman in hospital bed appearing confused, in
no apparent distress.
EYES: Anicteric, PERRL, slightly injected bilaterally.
ENT: Ears and nose without visible erythema, masses, or trauma.
Poor dentition. Oropharynx without visible lesion, erythema or
exudate.
NECK: Neck supple, no lymphadenopathy.
CV: RRR, no S3 or S4, ___ SEM best heard at RUSB, no JVP
although difficult assessment.
RESP: Breathing comfortably on 2L NC. Bibasilar crackles. No
wheezes.
GI: Normoactive bowel sounds. Obese. Abdomen non-distended,
non-tender to palpation.
GU: Purewick in place. No suprapubic fullness or tenderness to
palpation.
VASCULAR: Palpable pulses in all distal extremities.
SKIN: Left lower extremity with indurated, warm, tender,
erythematous circumferential area beginning at the ankle and
extending over ___ the way up the leg. Marked with pain.
NEURO: Alert. Oriented to person and general situation. Poor
attention. Unable to identify hospital, remember basic facts
like
her prior vocation (___). Able to follow most basic
commands. Face symmetric, gaze conjugate with EOMI. Speech
fluent
but word finding difficulties. Moves all limbs without obvious
limitations.
PSYCH: Cooperative, confused, appropriate affect.
Pertinent Results:
ADMISSION LABS:
___ 01:05AM BLOOD WBC-14.2* RBC-4.52 Hgb-14.5 Hct-43.4
MCV-96 MCH-32.1* MCHC-33.4 RDW-13.6 RDWSD-48.1* Plt ___
___ 07:30PM BLOOD WBC-22.6* RBC-4.20 Hgb-13.5 Hct-39.8
MCV-95 MCH-32.1* MCHC-33.9 RDW-14.3 RDWSD-49.1* Plt ___
___ 01:05AM BLOOD Neuts-92.3* Lymphs-3.0* Monos-3.4*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-13.11* AbsLymp-0.42*
AbsMono-0.48 AbsEos-0.01* AbsBaso-0.05
___ 10:45AM BLOOD ___
___ 01:05AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-136
K-4.2 Cl-100 HCO3-22 AnGap-14
___ 07:30PM BLOOD Glucose-107* UreaN-20 Creat-0.9 Na-134*
K-3.8 Cl-100 HCO3-21* AnGap-13
___ 01:05AM BLOOD ALT-22 AST-30 AlkPhos-92 TotBili-0.9
___ 07:30PM BLOOD ALT-24 AST-40 AlkPhos-65 TotBili-0.7
___ 10:45AM BLOOD LD(LDH)-359*
___ 01:05AM BLOOD Albumin-4.0 Calcium-9.9 Phos-0.8* Mg-1.4*
___ 07:30PM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.6* Mg-1.8
___ 08:40AM BLOOD Vanco-12.7
___ 01:09AM BLOOD Lactate-2.7*
___ 07:54AM BLOOD Lactate-2.2*
___ EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with new hypoxia// eval for PE
r/o
TECHNIQUE: Axial multidetector CT images were obtained through
the thorax
after the uneventful administration of intravenous contrast.
Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal
intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.9 mGy
(Body) DLP = 3.0
mGy-cm.
2) Stationary Acquisition 1.4 s, 0.2 cm; CTDIvol = 37.2 mGy
(Body) DLP =
7.4 mGy-cm.
3) Spiral Acquisition 5.1 s, 33.3 cm; CTDIvol = 25.6 mGy
(Body) DLP = 834.7
mGy-cm.
Total DLP (Body) = 845 mGy-cm.
COMPARISON: No prior chest CT available for direct comparison.
Correlation
with chest radiograph dated ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart is normal in size. Coronary
artery
calcifications are noted. The pericardium, and great vessels
are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Gravity dependent atelectasis is present in both
lower lobes.
Faint ground-glass opacities in the lateral aspect of the right
middle lobe
could be infectious or inflammatory in nature. The airways are
patent to the
level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: The patient is status post cholecystectomy. Included
portion of the
upper abdomen is otherwise unremarkable.
BONES: There are degenerative changes throughout the spine and
in both
shoulders. No suspicious osseous abnormality is seen.? There is
no acute
fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Faint ground-glass opacities in the lateral aspect of the
right middle lobe are nonspecific, and could be infectious or
inflammatory in nature.
___ EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with fever, encephalopathy,
left-sided
weakness, aphasia, and facial droop// please rule-out acute
bleed so we can
proceed with LP.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy
(Head) DLP =
940.0 mGy-cm.
2) Stationary Acquisition 3.0 s, 11.4 cm; CTDIvol = 49.5 mGy
(Head) DLP =
564.0 mGy-cm.
Total DLP (Head) = 1,504 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial
infarction,hemorrhage,edema,
or mass. There is mild prominence of the ventricles and sulci
suggestive of
mild involutional changes. There are bilateral periventricular
and
subcortical white matter hypodensities, nonspecific but
compatible with
sequelae of chronic small vessel ischemic disease. Slight
asymmetry in the
hypodensities of the right frontal lobe could be due to small
vessel disease.
There is no evidence of fracture. There is complete
opacification the right
maxillary sinus and right anterior and middle ethmoid air cells.
There is
partial opacification of the bilateral mastoid air cells.
Otherwise, the
visualized portion of the paranasal sinuses and middle ear
cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality. Basal cisterns
are patent and there is no mass effect seen.
___ EXAMINATION: MRI ___ AND MRA NECK PT13 MR HEAD
INDICATION: ___ year old woman with fever, and per OMR, improved
dysarthria,
aphasia, left facial droop and left-sided weakness// stroke?
TECHNIQUE: Brain imaging was performed with diffusion, T1,
FLAIR, T2,
gradient echo technique, and T1 postcontrast imaging.
Dynamic MRA of the neck was performed during administration
intravenous
contrast.
T1 post contrast imaging was then performed.
Three dimensional maximum intensity projection and segmented
images were
generated. This report is based on interpretation of all of
these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___
FINDINGS:
MRI BRAIN without and with contrast:
There is no evidence of acute infarction, hemorrhage, edema,
masses, mass
effect, or midline shift. There is no abnormal enhancement
after contrast
administration. Mild-to-moderate chronic small-vessel ischemic
disease..
Moderate bilateral parietal lobe atrophy.
The right maxillary sinus is near completely opacified and
contains an
air-fluid level. Additionally, there is partial opacification
of the right
anterior ethmoid air cells with mild mucosal thickening
throughout the
bilateral anterior ethmoid air cells. There is near complete
opacification of
the right mastoid air cells and middle ear cavity. There is
partial
opacification of the left mastoid air cells.
MRA NECK with contrast:
Suboptimally seen bilateral vertebral artery origins secondary
to artifact,
there is probably mild bilateral vertebral artery origin
narrowing.
Otherwise, the origins of the great vessels and subclavian
arteries appear
normal bilaterally. The common, internal and external carotid
arteries appear
normal. There is no evidence of internal carotid artery
stenosis by NASCET
criteria.
3 cm right thyroid nodule, ultrasound recommended according to
guidelines.
Heterogeneous, nodular remainder of the thyroid gland.
IMPRESSION:
1. No acute intracranial abnormality.
2. Suboptimally seen origin of vertebral arteries, probably mild
bilateral
narrowing.
3. Moderate opacification mastoids, may be reactive,
inflammatory, consider
otomastoiditis.
4. Acute paranasal sinusitis, most prominent at the right
maxillary sinus..
5. 3 cm thyroid nodule, guidelines below.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow-up
recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
Brief Hospital Course:
___ woman with a complicated PMH including bilaterally
TKR's, morbid obesity, and recent bilateral breast cancer (R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who is admitted after presenting to the
ED in the evening ___ with fever to 102, encephalopathy, and
leukocytosis
#Acute metabolic encephalopathy
#Severe sepsis with unclear source
#Left-sided weakness, aphasia, dysarthria
There was initially concern for stroke or TIA on the second
hospital day, but these findings were not noted when she was
initially admitted or in the ER. At the time of discovery, she
had dysarthria, aphasia, and left-sided weakness (___), but she
was out of the window for possible tPA. Head CT ___ did not
show any acute process. She received ASA 325mg PO ___
MRI/MRA head and neck ___ showed no acute process either. (She
needed large MRI which caused 1-day delay). LP attempted on
___ AM out of concern for meningitis, but unsuccessful. In
particular, excess soft tissue made this difficult. ___ was then
consulted, but said that after someone has full ASA, they are
ineligible for LP for 5 days. At 5 days, study would be
non-diagnostic, so will not be pursued. Thankfully, towards the
end of the day on ___, the symptoms had largely resolved.
She was placed on Vancomycin and Cipro on ___ out of concern
for possible meningitis. Cellulitis was very notable on her LLE,
and there was possible PNA on CT (not very convincing) and no
evidence of UTI. Blood cultures were drawn and showed no
growth. Her WBC was as high as 22.6, but improved to normal
after receiving antibiotics. Ultimately, the possibility of
bacterial meningitis was low, so after receiving Vancomycin and
Cipro, this was changed to keflex and doxy on discharge for
extended course for cellulitis. Swallow consult for diet safety
had no issues on ___. With thrombocytopenia, viral illness is
also on the differential, but LFTs normal. Flu swab was
negative.
#Acute hypoxemic respiratory failure
She presented requiring 4L of nasal oxygen. CTA negative for PE
but did show atelectasis and possible aspiration or infection.
She received standing Duonebs, which seemed to help. OSA/OHS
and atelectasis were the likely largest culprits. She was able
to wean O2 to RA several days prior to discharge.
#Hx of bilateral breast cancer
Diagnosed late ___ with R stage 1 invasive ductal cancer and L
DCIS), now s/p lumpectomies/partial mastectomy (___) and now
on letrozole given cancer was ER-positive. Per review of
records,
patient was not recommended chemotherapy or radiation therapy.
Followed by Dr. ___ at ___ On___ (___). Last
seen in ___. She continued home letrozole 2.5mg daily
#Hypophosphatemia and hypomagnesemia - replaced
#Hypertension - continue home at atenolol 50mg daily
#Fungal skin rashes - skin care and anti-fungal cream ___
changed to Fluconazole 200mg PO x1 on ___ and then 100mg PO
daily ___.
# Morbid obesity - outpatient exercise program
# Gout - She continued home allopurinol ___ daily
#Outstanding issues
[]changed to keflex and doxy on discharge for extended course
for cellulitis (total duration of treatment ___ days)
[] For fungal rash started Fluconazole 200mg PO x1 on ___ and
then 100mg PO daily ___.
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Letrozole 2.5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Gabapentin 900 mg PO QHS
5. FLUoxetine 80 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H cellulitis Duration: 7
Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*14 Capsule Refills:*0
3. Fluconazole 100 mg PO/NG Q24H Duration: 6 Days
RX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth once
daily Disp #*2 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
5. Allopurinol ___ mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. BuPROPion (Sustained Release) 150 mg PO BID
8. FLUoxetine 80 mg PO DAILY
9. Gabapentin 900 mg PO QHS
10. Letrozole 2.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoxemic respiratory failure
Cellulitis
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - uses walker.
Discharge Instructions:
Your admitted to the hospital with respiratory failure and
cellulitis. Your breathing improved and we are ultimately able
to wean you off of oxygen. We also treated a skin infection
called cellulitis with 2 antibiotics, called cipro and
vancomycin. He received 7 days of antibiotics but we extended
your course after discharge from the hospital.
Followup Instructions:
___
|
10742538-DS-3
| 10,742,538 | 25,316,068 |
DS
| 3 |
2189-12-18 00:00:00
|
2189-12-29 05:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / scented chemicals
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
___ - placement and advancement of an ___ tube
History of Present Illness:
Ms ___ is a ___ year old woman with history of fibromyalgia,
POTS, chronic fatigue, and gastroparesis, who is referred to ED
from her gastroenterologist due to nausea, vomiting, po
intolerance, concern for dehydration, and consideration for
feeding tube placement.
Per patient, over the past few months she has had ongoing
nausea/vomiting and inability to tolerate PO. She vomits approx.
___, she starts burping and then vomits typically 30minutes
- 2 hours after she eats, looks like undigested food or bile.
She had x1 episode of "brown bile" 2 nights ago, otherwise
denies coffee ground/bright red blood. She reports feeling
nauseous all of the time. She has mild abdominal pain that is
sharp, epigastric when she vomits, otherwise denies abdominal
pain. She has regular, daily BMs that she describes as firm. She
recently completed a trial of azithromycin x14 days without
improvement in her symptoms.
She also reports feeling more dehydrated since the weather has
been hotter - she tries to drink fluids but feels this makes her
vomiting worse and so has not had much. She receives IVF weekly
as an outpatient but is worried this isn't enough and thinks she
should have twice weekly fluids. She is concerned about losing
___ of her body weight in the last 4 months and is now 88lbs.
Due to her concern about her worsening symptoms, she spoke with
Dr. ___ recommended admission to the hospital for evaluation
for dehydration, refeeding syndrome, and consideration of tube
feed placement.
In the ED, initial vitals were: 97.4 120 125/89 18 100% RA
- Exam notable for: abdomen soft, minimal RLQ tenderness with
palpation, non-distended, no rebound or guarding
- Labs notable for: Hgb/Hct 11.4/33.8, negative u-hCG, normal
chemistry. UA contaminated.
- No imaging obtained
- Patient was given: NS 1L, Metoclopramide 10mg IV
- Vitals prior to transfer: 98.2 92 114/76 18 100% RA
Upon arrival to the floor, patient reports feeling "okay". She
continues to feel dehydrated.
Of note, she has a long-standing history of food intolerance,
nausea, and vomiting. She is followed by Dr. ___ Dr. ___
___ GI. ___ has had an extensive recent imaging/study work-up of
her symptoms including: 1) gastric emptying study that showed
delay with a 33% retention at four hours, 2) CT scan that showed
the dermoid cyst on the right ovary, that was recently removed,
3) MRI of the brain that showed a pituitary adenoma and was
subsequently evaluated by a neuro-endocrinologist who determined
that the adenoma was not hormonally active and therefore felt
not to be related to her current set of symptoms, 4) EEG that
showed some nonspecific finding that may be related to what is
called ___ syndrome, 5) Upper endoscopy with biopsies
including small bowel biopsies that were normal, 6) CTA that
showed that the SMA angle was 70 degrees, but without dilatation
of the stomach or proximal duodenum and evidence of cystic
teratoma in her right ovary. She has also been trialed on
multiple medications - in the past, has tried Zofran, Reglan,
Phenergan and Compazine and has found that IV Reglan is helpful,
but the oral Reglan, which she took two to three times per day
actually may have increased her symptoms. Most recently she has
been started on azithromycin for its potential prokinetic
effects and amitriptyline was increased from 10 mg up to
recently 20 mg per day.
ROS:
Positive per HPI. Remaining 10 point ROS reviewed and negative
Past Medical History:
PAST MEDICAL HISTORY:
Childhood asthma
GERD
Chronic fatigue syndrome
Gastroparesis
Headache
Chronic orthostatic hypotension/POTS
Constipation
Iron deficiency
Ovarian mass (Dermoid cyst)
Gastritis
Insomnia
PAST SURGICAL HISTORY:
Laparoscopy, right ovarian cystectomy- ___
Laparoscopy, left ovarian cystectomy- ___
Social History:
___
Family History:
Sister with chronic fatigue.
Grandmother with ___ disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.4 119/70 69 16 97%RA
-Weight: 42.2kg
General: thin, resting in bed, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear without lesions,
good dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, mild TTP in right mid-abdomen
without rebound/guarding, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Skin: clear
Neuro: AAOx3
DISCHARGE PHYSICAL EXAM
Vitals: T 98, BP 129/83, HR 94, RR 18, O2Sat 100% RA
General: Thin young woman who appears her stated age, alert,
oriented, in no acute distress, sitting awake in bed.
HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear.
Dobhoff in place. ___ bilaterally with good light reflex, no
bulging/erythema, no external ear canal erythema or discharge.
Cerumen presence appreciated.
Neck: Supple, JVP not elevated, no LAD.
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi.
CV: Tachycardic; regular rhythm, normal S1 + S2; no murmurs,
rubs, gallops.
Abdomen: Soft, non-tender (improved from prior), non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly.
GU: No foley.
Ext: Warm and well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: CNs II-XII intact, motor function grossly normal.
Pertinent Results:
ADMISSION LABS:
___ 12:42PM BLOOD WBC-4.2 RBC-3.56* Hgb-11.4 Hct-33.8*
MCV-95 MCH-32.0 MCHC-33.7 RDW-12.4 RDWSD-43.2 Plt ___
___ 12:42PM BLOOD Neuts-37.4 ___ Monos-9.5 Eos-6.9
Baso-1.2* Im ___ AbsNeut-1.58* AbsLymp-1.89 AbsMono-0.40
AbsEos-0.29 AbsBaso-0.05
___ 12:42PM BLOOD Plt ___
___ 12:42PM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-140
K-4.4 Cl-102 HCO3-28 AnGap-14
___ 07:28AM BLOOD ALT-12 AST-19 AlkPhos-38 TotBili-0.3
___ 12:42PM BLOOD Calcium-10.1 Phos-3.9 Mg-2.3
___ 02:00PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-MOD
___ 02:00PM URINE RBC-11* WBC-25* Bacteri-FEW Yeast-NONE
Epi-24
___ 02:00PM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-4.8 RBC-3.22* Hgb-10.4* Hct-31.0*
MCV-96 MCH-32.3* MCHC-33.5 RDW-12.5 RDWSD-44.0 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-140 K-4.2
Cl-103 HCO3-27 AnGap-14
___ 07:20AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
___ CULTURE-FINAL no growth
Radiology
FINDINGS:
The right nare was anesthetized with lidocaine jelly. Under
intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was
advanced
post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric
placement. Final
fluoroscopic spot images demonstrated the tip of the feeding
tube in the third
portion of the duodenum.
The feeding tube was secured to the patient using a bridle.
IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube.
The tube is
ready to use.
Brief Hospital Course:
Ms. ___ is a ___ woman with fibromyalgia, POTS, chronic
fatigue, and gastroparesis, who presented with a referral from
her gastroenterologist due to acute worsening of several months
of nausea, vomiting, PO intolerance, and weight loss of unclear
etiology, for feeding tube placement.
# Nausea/vomiting
# Gastroparesis
# Malnutrition
Patient presented with several months of nausea, vomiting,
weight loss, and PO intolerance; with an already extensive
out-patient workup which had largely been unrevealing apart from
moderate gastroparesis and some concern for SMA syndrome
(pending out-patient MRE). Due to refractory nausea/vomiting
that did not seem responsive to promotility agents, as well as
concern that patient was not achieving adequate nutrition, an NG
tube was placed with successful post-pylorus advancement on
___. Tube feeds were successfully advanced without nausea or
vomiting. There was low concern for refeeding syndrome with
serial electrolytes WNL to date. She continued thiamine 100mg,
amitriptyline 20mg QHS, and metoclopramide 10mg Q6H. She was set
up with home infusion for continued feeds. She was set to
follow-up with GI.
====================
CHRONIC ISSUES:
====================
# GERD, Gastritis: Continued home sucralfate
# Migraine:not an active issue this hospitalization
# Insomnia: Continued home amitriptyline, trazodone QHS
# Chronic fatigue syndrome, # POTS: continued home propranolol
and fludrocortisone
TRANSITIONAL ISSUES:
- Follow up with outpatient GI for monitoring of nutrition
status, further workup of symptoms
# CODE: Full (confirmed)
# CONTACT: ___, mother. Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 20 mg PO QHS
2. eletriptan HBr 20 mg oral PRN
3. Fludrocortisone Acetate 0.1 mg PO QAM
4. Propranolol 10 mg PO QAM
5. Sucralfate 1 gm PO BID
6. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral Q6H:PRN
7. TraZODone 50 mg PO QHS
Discharge Medications:
1. Metoclopramide 10 mg PO QIDACHS nausea / vomiting
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth four times a
day Disp #*12 Tablet Refills:*0
2. Thiamine 100 mg PO DAILY Duration: 5 Days
3. Amitriptyline 20 mg PO QHS
4. eletriptan HBr 20 mg oral PRN
5. Excedrin Migraine (aspirin-acetaminophen-caffeine)
250-250-65 mg oral Q6H:PRN headache
6. Fludrocortisone Acetate 0.1 mg PO QAM
7. Propranolol 10 mg PO QAM
8. Sucralfate 1 gm PO BID
9. TraZODone 50 mg PO QHS
10.Tube Feeds
Jevity 1.2 @ 100/hr x 12 hours
2 months duration; Refill: 2
with supplies and pump
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===========================
gastroparesis
abnormal weight loss
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 for malnutrition so that a
feeding tube could be placed. We placed the feeding tube and had
it advanced into your small intestine. We then started tube
feeds to make sure that you were able to tolerate them. There
were no complications and you tolerated the tube feeds well.
You will continue to receive tube feeds at home until your
nutrition improves. You should follow-up with your outpatient
gastroenterology team.
Your follow up appointments and medications are attached. A
nurse ___ come to your home to help set up the tube feeds
there.
It was a pleasure taking care of you and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10742621-DS-9
| 10,742,621 | 24,177,087 |
DS
| 9 |
2185-01-07 00:00:00
|
2185-01-10 14:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fecal incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ is a ___ year old female with history of multiple
sclerosis
that has been well controlled on rituximab who presents with
fecal and urinary incontinence. She says that on ___, she had
one episode of fecal incontinence, where she went to urinate and
found stool in her underwear. She states that she did not have
the urge to defecate and did not know that it had happened. This
occurred again on ___ and several times on ___. She says
that the stool was somewhat loose, so she tried some Imodium,
but
that did not help. She had some abdominal pain yesterday, and
today, she had an episode of urinary incontinence. She says that
she had had been feeling the urge to urinate, but that feeling
is
less today. She says that this has happened a few times in the
past, but it has been single episodes. It has never occurred to
this degree for this long before. Given these symptoms, she went
to an urgent care where they performed a urinalysis that was
suggestive of a urinary tract infection.
At age ___, she presented with fever and headache. She was
diagnosed with a viral meningitis, but she had an MRI that
demonstrated multiple lesions concerning for MS. ___ years
later,
she had multiple episodes with leg weakness and falls. She was
started on copaxone and avonex, but had relapses with both of
those medications. She was then on betaseron for several years,
but she had recurrent relapses. In ___, she was switched from
betaseron to Tysabri, but she had frequent, severe attacks. She
was then treated with Cytoxan and methylprednisone for three
cycles, and betaseron was restarted. However, she had multiple
flares, and she was started on Rituximab with the first dose in
___. She has done extremely well since that time without
relapses. Her most recent imaging was an MRI in ___ that did
not demonstrate any new lesions. She says that she has had her
spine imaged before but not for several years.
She denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. Denies difficulty with gait. Her general review of
systems was negative, except for incontinence as described
above.
Past Medical History:
MS
___ of fecal incontinence in the past
Social History:
___
Family History:
sister with ___ disease, many family members with "stomach
problems", mother with h/o cnetral retinal artery occlusion (now
blind in right eye) and trigeminal neuralgia
Father- estranged.
Grandparents- unsure.
Physical Exam:
Physical Exam:
Vitals: 99.1 81 136/58 18 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: No increased WOB
Cardiac: RRR
Abdomen: soft, non-distended
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to current place and time. Able
to relate history without difficulty. Attentive, able to name
days of the week backward without difficulty. Calculations
intact. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. She was able to
name both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI:
EOMI without nystagmus. Normal saccades. V: Facial sensation
intact to light touch. VII: No facial droop, facial musculature
symmetric. VIII: Hearing intact to finger-rub bilaterally. IX,
X:
Palate elevates symmetrically. XI: ___ strength in trapezii and
SCM bilaterally. XII: Tongue protrudes in midline with normal
strength
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5
R 5 ___ ___ 5 5 5
-Sensory: No deficits to light touch
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 Tr
R 2 2 2 2 Tr
Plantar response was mute bilaterally. ___ beats of clonus at
the
right ankle.
-Coordination: No intention tremor. No dysmetria on FNF. Some
ataxia with HKS on the right, normal on the left.
-Gait: Narrow based gait. Able to toe and heel walk. Unstable
with tandem gait. Romberg negative.
DISCHARGE PHYSICAL EXAM
Gen: Not in acute distress or pain
Neuro:
MS- AAOx3, speech is fluent and coherent, answering questions
appropriately, speech is pressured
CN- PERRL, EOMI, no facial droop
Motor- full strength throughout
Coordination- No dysmetria on FNF
Pertinent Results:
___ 10:02AM GLUCOSE-96 UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
___ 10:02AM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.8
___ 10:02AM WBC-15.5* RBC-4.45 HGB-11.5 HCT-36.2 MCV-81*
MCH-25.8* MCHC-31.8* RDW-15.4 RDWSD-44.9
___ 10:02AM PLT COUNT-329
___ 05:50AM ___ COMMENTS-GREEN TOP
___ 12:41AM LACTATE-4.5*
___ 08:50PM GLUCOSE-77 UREA N-13 CREAT-0.8 SODIUM-139
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-26 ANION GAP-19
___ 08:50PM CALCIUM-10.4* PHOSPHATE-3.7 MAGNESIUM-2.3
___ 08:50PM WBC-16.5*# RBC-5.32* HGB-13.8 HCT-42.9
MCV-81* MCH-25.9* MCHC-32.2 RDW-15.5 RDWSD-44.3
___ 08:50PM NEUTS-70.7 ___ MONOS-5.6 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-11.67* AbsLymp-3.71* AbsMono-0.93*
AbsEos-0.09 AbsBaso-0.06
___ 08:50PM PLT COUNT-512*
___ 08:50PM URINE RBC-1 WBC-13* BACTERIA-FEW YEAST-NONE
EPI-0
+IMAGING+
Spine MRI
1. Patchy T2 hyperintensity throughout the cervical spinal cord
on sagittal STIR and axial T2 weighted images, similar to the
___ cervical spine MRI, likely corresponds to chronic
demyelinating disease. No contrast enhancing lesions are seen
in the cervical spinal cord.
2. Patchy T2 hyperintensity within the thoracic spinal cord,
definitively seen on sagittal STIR images only, appears similar
to the ___ thoracic spine MRI and images through the upper
thoracic spine of the ___ cervical spine MRI. This may
represent chronic demyelinating disease versus artifact. No
contrast enhancing lesions are seen in the thoracic spinal cord
or conus medullaris.
3. Previously noted discrete T2 hyperintense lesion in the
thoracic spinal
cord at T11-T12 is no longer conspicuous.
4. Unchanged mild degenerative disease at C5-C6, C6-7, and
L5-S1, without
significant spinal canal narrowing, neural foraminal narrowing,
or neural
impingement.
Brain MRI
1. Stable confluent white matter signal abnormality, consistent
with provided history of multiple sclerosis. No new high-signal
lesions, restricted diffusion or contrast enhancement.
KUB
Nonobstructive bowel gas pattern. Moderate fecal loading
throughout the
colon.
CT abdomine/pelvis
1. No evidence of mesenteric ischemia. Patent vasculature.
2. Distended vagina with air with some thickening of the lower
and anterior vaginal wall. Correlation with gynecological exam
is recommended. MR may be helpful if gynecological exam is
unrevealing.
3. Extensive fecal material throughout the colon with
fecalization of distal ileum, consistent with chronic
constipation.
Brief Hospital Course:
___ is a ___ year old female with refractory multiple
sclerosis on rituximab who presents with fecal and urinary
incontinence possible sensory changes in the groin. The symptoms
are unusual for MS flare given the prominent GI/GU symptoms
without weakness/paresthesia, though there may be sensory change
in the perineum and prior MS flare presented with incontinence.
Spine imaging showed no changes from prior imaging in ___.
OB/GYN was consulted due to concerns for recto-vaginal fistula
and their examination was negative. They recommended outpatient
follow up for repeat Gyn examination. Infectious processes
remain in differential as has she been immunosuppressed (may not
mount fever, WBC elevated due to steroids). Patient was found
to have UTI for which she was treated with 3 day course of
ceftriaxone. Stool studies were sent and are pending. Patient
was complaining of post-pandrial abdominal pain throughout her
admission for which KUB and CT abdomen and pelvis were done.
Both studies were positive for constipation and no other
abnormalities. Patient was stated on stool softeners and had
normal bowel movement prior to discharge. She was also started
on PPI since on exam she had epigastric tenderness. Lab work
came back unremarkable.
Patient was discharged home to follow up with PCP ___ ___
___, urogynecologist and neurology as previously scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Vitamin D3 (cholecalciferol (vitamin D3)) 6000 units oral
DAILY
3. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20
mcg (21)/75 mg (7) oral DAILY
Discharge Medications:
1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20
mcg (21)/___ mg (7) oral DAILY
RX *norethindrone-e.estradiol-iron ___ FE ___ (28)] 1 mg-20
mcg (21)/75 mg (7) 1 tablet(s) by mouth daily Disp #*1 Packet
Refills:*0
2. Vitamin D3 (cholecalciferol (vitamin D3)) 6000 units oral
DAILY
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [GlycoLax] 17 gram/dose 1 powder(s)
by mouth Daily Refills:*0
4. Calcium Carbonate 500 mg PO QID:PRN Abdominal Discomfort
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple sclerosis
Fecal incontinence
Constipation
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 Neurology Service after presenting to ED
for evaluation of fecal incontinence. While you were in the
hospital, you continued to have spotting of fecal material and
had a large bowel movement associated with abdominal pain. An
image from your abdomen showed moderate amount of stool
throughout your whole large intestine which can be due to
constipation. Further images of your abdomen and pelvis were
unremarkable with the exception of constipation. Also, they
noticed thickness of the anterior wall of the vagina for which
we recommend follow up as outpatient with your OB/GYN. We
recommended to use stool softeners or laxatives at home as
needed for regular bowel movements and follow up with your PCP
___ ___ ___. Please follow up with Dr. ___ as
previously scheduled and with Urogynecologist Dr. ___.
Followup Instructions:
___
|
10742865-DS-14
| 10,742,865 | 23,958,640 |
DS
| 14 |
2185-07-23 00:00:00
|
2185-07-23 12:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R FNFx
Major Surgical or Invasive Procedure:
Right hip CRPP ___, ___
History of Present Illness:
ASSESSMENT: ___ female with hypertension and congestive
heart failure otherwise healthy and previously an independent
community ambulator presents after mechanical fall with a
nondisplaced right femoral neck fracture as well as a fracture
of
the right lateral column of the distal humerus
Past Medical History:
Hypertension, congestive heart failure
Social History:
She is an independent minimally active community ambulator who
lives at home with her granddaughter. ___ tobacco, alcohol,
and illicit drug use.
Physical Exam:
Gen: NAD, occasionally delirius
RLE:
dressing c/d/I
wiggles toes
foot WWP
RUE:
skin intact
long arm functional brace in place
hand WWP
Pertinent Results:
___ 09:30AM BLOOD WBC-11.1* RBC-3.99 Hgb-11.1* Hct-34.9
MCV-88 MCH-27.8 MCHC-31.8* RDW-15.9* RDWSD-50.6* Plt ___
___ 09:30AM BLOOD Glucose-106* UreaN-34* Creat-1.0 Na-146
K-3.8 Cl-109* HCO3-23 AnGap-14
___ 09:30AM BLOOD Calcium-8.4 Mg-2.2
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Right femoral neck fracture and a R distal humerus
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for R hip CRPP,
which the patient tolerated well. Her R distal humerus fracture
will be treated non-operatively in a long arm functional brace.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, non
weight bearing right upper extremity in a long arm functional
brace with ROMAT shoulder/wrist/digits, no ROM R elbow 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:
Lisinopril 5 mg daily
Labetalol 300 mg BID
Furosemide 20 mg daily
Prednisone 5 mg BID
Sertraline 50 mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Enoxaparin Sodium 30 mg SC QHS
RX *enoxaparin 30 mg/0.3 mL 30 mg SC Nightly Disp #*28 Syringe
Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four to six
hours Disp #*20 Tablet Refills:*0
RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp
#*40 Capsule Refills:*0
4. Furosemide 20 mg PO DAILY
5. Labetalol 300 mg PO BID
6. Lisinopril 5 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
8. PredniSONE 5 mg PO BID
9. Sertraline 50 mg PO DAILY
10. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femoral neck fracture
Right distal humerus fracture
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:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
-Nonweightbearing right upper extremity and long-arm functional
brace
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 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per 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 Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
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 any new medications/refills.
Physical Therapy:
Weightbearing as tolerated right lower extremity
Nonweightbearing right upper extremity in long-arm functional
brace
Treatment Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
10742874-DS-5
| 10,742,874 | 20,753,389 |
DS
| 5 |
2113-04-27 00:00:00
|
2113-04-27 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
flank/scrotal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with unremarkable medical history
prior to the recent diagnosis one week ago of left renal
infarct, re-presenting with recurrent left sided abdominal pain,
now extending to the left testicle and left flank, and vomiting.
Patient was in his usual state of good health, when he awoke
around 2am on the morning of ___ to use the bathroom, and
noted severe left sided abdominal pain, causing him to double
over. No fevers, vomiting, or hematuria at the time. He tried to
go back to sleep but was unable to, prompting him to present to
___. CT of the badomne demonstrated a
wedge-shape hypodensity in the upper pole of the left kidney,
most likely due to infarct. Work-up there revealed a PFO on TTE.
TEE done and ruled out cardiac thrombus/mass. Venous ultrasound
was negative for DVT. He was treated with heparin drip and then
started on apixaban, with plan to follow-up for event monitor on
discharge to evaluate for a-fib. Hypercoagulable work-up was
pending at the time of discharge, including ___, ANCA,
anti-cardiolipin antibodies, factor 5 Leiden, serum
homocysteine, lupus anticoagulant. By the time of discharge he
felt back to normal, without abdominal pain.
On ___, he developed recurrent, worse left sided abdominal
pain, now radiating to the left flank and left testicle,
associated with many episodes of vomiting. He re-presented to ___
___
No history of fevers, chills, weight loss, IV drug use. No
history of prior thromboembolism or A-fib. Denies chest pain,
dyspnea, headache, cough, sputum production, dysuria, hematuria,
lower extremity pain or swelling, arthralgia/myalgia. He was
recently sick with a light cold for approximately one month,
recovered ___ weeks ago.
Labs from ___ at ___ showed WBC 16.3, HCO3 21, anion
gap 18, glucose 120. CT scan showed worsening left renal
infarct, with involvement of a larger area of the cortex in the
upper and midportion of the left kidney. No evidence of
atherosclerotic disease, aneurysm, or mural thrombus in the
abdominal arterial structures.
He was transferred to ___ for further evaluation
In the ED, initial vitals were: T 98, BP 134/82, HR 86, RR 18,
SPO2 100% on RA.
- Exam notable for:
Uncomfortable
RR, no murmurs
CTAB
Left sided CVA tenderness; TTP along left flank and abdomen
WWP no edema
- Labs notable for: WBC 11.8, Creatinine 0.8, HCO3 19, anion
gap 22, lactate 1.6, UA with trace blood, 12 RBCs, 3 WBCs, no
bacteria, 30 protein, 40 ketones. Coags were normal.
- Imaging was notable for:
Scrotal ultrasound with: 1. No evidence of testicular torsion.
2. Bilateral hydroceles.
- Patient was given: hydromorphone 0.5mg IV twice, normal
saline, Zofran 4mg IV, metoclopramide 10mg IV, lorazepam 1mg IV,
and was started on heparin gtt with 5000U bolus and 1000u/hr
rate.
Upon arrival to the floor, patient reports that he feels more
comfortable after receiving lorazepam.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
-Left renal infarct, dx ___
-Patent foramen ovale
-GERD
-Cyst removal from neck as teenager
Social History:
___
Family History:
Diabetes mellitus
No family history of blood clots or hypercoag disorder
Physical Exam:
Admission
=========
Vital Signs: T 98.0 BP 151 / 94 HR 77 RR 20 SPO2 96 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, moderately tender in left upper and lower
abdomen, and left flank.
GU: mild pain with palpation of left testis
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Discharge
=========
Vital Signs: 98.4 124-158/78-105 85 14 97 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, moderately tender in left flank and lower back
and mild TTP in LLQ.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Admission Labs
==============
___ 11:55PM BLOOD WBC-11.8* RBC-5.10 Hgb-15.0 Hct-43.3
MCV-85 MCH-29.4 MCHC-34.6 RDW-12.6 RDWSD-39.2 Plt ___
___ 11:55PM BLOOD Neuts-72.4* ___ Monos-7.5
Eos-0.4* Baso-0.2 Im ___ AbsNeut-8.56* AbsLymp-2.27
AbsMono-0.89* AbsEos-0.05 AbsBaso-0.02
___ 11:55PM BLOOD Plt ___
___ 11:55PM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-138
K-3.9 Cl-101 HCO3-19* AnGap-22*
___ 11:55PM BLOOD Calcium-9.7 Phos-3.7 Mg-2.0
___ 03:30AM BLOOD Triglyc-125 HDL-40 CHOL/HD-3.7 LDLcalc-81
___ 11:55PM BLOOD LtGrnHD-HOLD
Discharge Labs
==============
___ 07:30AM BLOOD WBC-9.6 RBC-4.75 Hgb-14.1 Hct-40.9 MCV-86
MCH-29.7 MCHC-34.5 RDW-12.8 RDWSD-39.6 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-77 UreaN-9 Creat-1.0 Na-140 K-4.3
Cl-98 HCO3-24 AnGap-22*
___ 07:30AM BLOOD ALT-25 AST-15 LD(LDH)-498* AlkPhos-75
TotBili-0.6
___ 07:30AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.5 Mg-2.2
Pertinent Interval Labs
=======================
___ 10:20AM BLOOD LD(LDH)-525*
___ 03:30AM BLOOD ALT-37 AST-27 LD(LDH)-576* AlkPhos-68
TotBili-0.8
___ 07:05AM BLOOD ALT-29 AST-17 LD(___)-508* AlkPhos-70
TotBili-0.6
___ 07:30AM BLOOD ALT-25 AST-15 LD(LDH)-498* AlkPhos-75
TotBili-0.6
___ 03:30AM BLOOD Triglyc-125 HDL-40 CHOL/HD-3.7 LDLcalc-81
Imaging & Studies
=================
CTA Torso ___
IMPRESSION:
1. No evidence of aortic thrombosis.
2. Stable appearance of left renal infarcts with persistent
thrombosis of left
renal artery branches.
3. Hypervascular lesion in segment VIII of the liver. In a non
oncologic
patient, this could represent a benign etiology such as a
hemangioma.
Ultrasound is suggested for confirmation.
4. Mild splenomegaly.
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
MRA/MRV Pelvis ___
IMPRESSION:
1. No evidence of deep venous thrombosis involving the pelvic
vessels.
2. Intraluminal thrombus involving the mid and distal left renal
artery. No
evidence of luminal beading, mural irregularity or thickening to
suggest
vasculitis or fibromuscular dysplasia.
3. Other than new perinephric fat stranding and edema on the
left, known left
renal infarctions are overall unchanged in appearance.
4. No other solid organ infarctions.
Scrotal u/s ___
FINDINGS:
The right testicle measures: 5.0 x 2.8 x 3.5 cm.
The left testicle measures: 5.3 x 2.9 x 3.5 cm.
There are bilateral small hydroceles.
The testicular echogenicity is normal, without focal
abnormalities.
The epididymides are normal bilaterally.
Vascularity is normal and symmetric in the testes and
epididymides.
IMPRESSION:
-No evidence of testicular torsion.
-Bilateral small hydroceles.
Microbiology
=============
__________________________________________________________
___ 1:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old man with unremarkable medical history presented as a
transfer from ___ with recurrent left abdominal
pain after a second renal infarct in the setting of a recent
renal infarct despite treatment with apixaban.
# Renal infarction ___ thrombus of the left mid and distal renal
artery: Patient initially to ___ on ___ and was found to
have an infarct of the upper pole of the left kidney. He had a
TTE during that hospitalization that showed a PFO, but no
cardiac mass. He was managed on a heparin ggt and transitioned
to apixiban 10mg BID loading dose. Patient developed recurrent
left-sided flank and testicular pain on ___ and was found to
have worsening/second renal infarct involving the upper and
midportion of the left kidney. He was transferred to ___.
At ___, he was anticoagulated with heparin ggt. His pain was
controlled with oxycodone PO PRN. He was seen by the vascular
surgery and nephrology who recommended no acute intervention. He
underwent MRA/MRV of the abdomen and pelvis which demonstrated
intraluminal thrombus of the mid and distal left renal artery.
Patient underwent repeat LENIs which were negative for thrombis
along with CTA of the aorta which was negative for thrombus.
Testicular u/s was negative for etiology. Patient had extensive
hypercoagulability workup at ___ that was negative.
Beta-2-Glycoprotein 1 Antibodies were sent and were pending at
the time of discharge.
Patient was continued on heparin ggt and oxycodone with
improvement in his pain. He was seen by cardiology who did not
recommend PFO closure, but recommended ZioPatch for 2 weeks
monitoring for afib evaluation. Heparin ggt was stopped and
enoxaparin started at 1mg/kg BID along with warfarin 5mg daily.
He will be continued on enoxaparin for at least 5 days and until
therapeutic on warfarin for at least 24 hours. He will follow
with his PCP for management of his INR. He was hypertensive
after the renal infarct and was started on lisinopril 5mg daily.
He should be continued on this medication pending improvement in
his hypertension.
Transitional Issues
====================
[] f/u Beta-2-Glycoprotein 1 Antibodies to complete
hypercoagulability workup.
[] Discharged on lovenox ___ BID daily and warfarin 5mg daily.
He will need INR check on ___ and adjustment of his warfarin
dose accordingly. He should be continued on lovenox for at least
5 days or until he has been therapeutic on warfarin (INR ___
for 24 hours, whichever is longer.
[] Started on lisonopril 5mg daily for hypertension after renal
infarct. This may be titrated off as hypertension improves or
with renal input.
[] Will follow up with nephrology post discharge.
[] Discharged with oxycodone for 3 days after discharge for
acute pain cotnrol. Counseled to avoid NSAIDs given kidney
injury.
[] Patient will get disc of TEE (Trans-esophageal
echocardiography) from ___ and bring this to his
appointment with Dr. ___ evaluation. Per cardiology no role
for PFO closure at this time.
[] Discharged with ZioPatch monitor for 2 weeks to assess for
atrial fibrillation. He will have placement of this monitor
immediately after discharge in ___ 7. He will follow up with
Dr. ___ results.
[] Imaging Requiring Further Followup: Patient was found to have
hypervascular lesion in segment VIII of the liber. Patient
should have outpatient ultrasound for confirmation.
Greater than 30 minutes were spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Apixaban 10 mg PO BID
3. Omeprazole 20 mg PO BID
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC twice a day Disp #*14 Syringe
Refills:*0
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*15 Tablet Refills:*0
4. Warfarin 5 mg PO DAILY16
RX *warfarin [___] 5 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
6. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Left renal infarction ___ arterial thrombosis of renal artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred to ___ because you were found to have
blood clots causing lack of blood flow to your kidney. This was
causing you to have pain in your abdomen.
You had an imaging test called an MRA (magnetic resonance
angiography) that showed a blood clot in the artery supplying
your left kidney. We started you on a blood thinner medication
called heparin. You were also seen by our
You had extensive testing for a cause of these blood clots and
it was all negative. There was no evidence of a genetic or
acquired condition causing increased likelihood of forming
clots. Additionally, there was no evidence of blood clots in
your lower legs or large artery coming off the heart.
We are concerned that you may have an abnormal heart rhythm
called atrial fibrillation which can lead to clots. You had no
evidence of this during your hospital stay, but we would like
you to wear a heart monitor for the next 2 weeks to check. You
can then follow up with Dr. ___ in Clinic to discuss the
results of the testing. You will also follow up with a kidney
doctor after you leave.
We are starting you on a blood thinner called Coumadin. You will
also need to take another blood thinner called lovenox
(enoxaparin) until you reach the proper levels of blood
thinning. You should take this medication for at least 5 days
and then for 24 hours additionally while your INR is between
___. You will follow up with your primary care doctor for
management of this level. We also started you on a blood
pressure medication called lisinopril because you blood pressure
was high after the injury to your kidney. Your primary care
doctor should follow your blood pressure and stop this
medication if your blood pressure improves.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10743111-DS-10
| 10,743,111 | 28,279,722 |
DS
| 10 |
2150-12-18 00:00:00
|
2150-12-18 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP - ___
History of Present Illness:
Mr. ___ is a ___ male PMHx of leukemia (gleevec),
hypertension and hyperlipidemia who is transferred from ___.
___ for evaluation of pancreatitis.
The patient initially presented to ___ with 1 day of
epigastric abdominal pain which had been progressively worsening
and was colicky in nature. He reported radiation of his
abdominal pain in a band-like distribution to both upper
quadrants. He reported chills but no objective fevers. He has
also had nausea with multiple episodes of emesis. He has been
passing gas but has had no BMs x 2 days. At ___, he
was noted to have a mild transaminitis with elevation of his
Tbili to 3.0. OSH US showed obstructing stone in the CBD and
pancreatitis. He was transferred here for concern for gallstone
pancreatitis.
Upon arrival to the ED, initial VS 97.5, 88, 150/68, 16, 96% on
RA. Initial labs here showed wnl Chem 7, ALT 54, AST 38, AP
127, Tbili 2.9, Lip 77. WBC 11.7 with 95% PMNs, Hgb/Hct
12.2/36.7 (unknown baseline), Plt 153. INR 1.2. UA negative.
RUQ US showed extrahepatic biliary dilation with CBD measuring
1.3 cm. The patient was placed on Zosyn, given 1L NS prior to
transfer. ERCP was consulted and agreed with admission for ERCP
intervention.
Upon arrival to the floor, the patient denies any current
abdominal pain or nausea at this time.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
HTN
HLD
GERD
CML on Gleevec
Social History:
___
Family History:
Patient did not know father. Reports mother was in good health,
now deceased.
Physical Exam:
ADMISSION
Vital Signs: 98.0, 149/65, 93, 18, 98% on RA
General: Alert, oriented, no acute distress
HEENT: MMdry, oropharynx clear, anicteric sclera, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
best heard at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, nondistended, mild TTP of RUQ and epigastrium,
bowel sounds present, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, spontaneously moving all extremities, gait deferred
Skin: no jaundice
DISCHARGE
VS: 98.7 138/63 75 16 97%RA
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI, anicteric, PERRL
ENT - OP clear, abrasion of posterior pharynx improved from day
prior
Heart - RRR no mrg
Lungs - moderate ronchi throughout left lung, no wheezes or
crackles;
Abd - soft nontender, normoactive bowel sounds; no
rebound/guarding; no CVA tenderness;
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, ___ strength in upper and lower extremities
Psych - appropriate
Pertinent Results:
OSH Labs
Cr 1.24
WBC 9.2
Plt 172
Lipase 1230
ALT 71
AST 53
Alkaline Phosphatase 148
Tbili 3.7
___ Admission Labs
___ 11:25PM BLOOD WBC-11.7* RBC-3.61* Hgb-12.2* Hct-36.7*
MCV-102* MCH-33.8* MCHC-33.2 RDW-14.6 RDWSD-54.4* Plt ___
___ 11:25PM BLOOD Neuts-85.0* Lymphs-3.3* Monos-10.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.96* AbsLymp-0.39*
AbsMono-1.25* AbsEos-0.00* AbsBaso-0.02
___ 11:25PM BLOOD Glucose-108* UreaN-13 Creat-1.0 Na-138
K-4.3 Cl-106 HCO3-21* AnGap-15
___ 11:25PM BLOOD ALT-54* AST-38 AlkPhos-127 TotBili-2.9*
___ 11:25PM BLOOD Lipase-77*
___ Discharge Labs
___ 05:50AM BLOOD WBC-11.1* RBC-3.30* Hgb-11.4* Hct-33.1*
MCV-100* MCH-34.5* MCHC-34.4 RDW-14.3 RDWSD-52.7* Plt ___
___ 05:50AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-139
K-4.0 Cl-106 HCO3-23 AnGap-14
IMAGING
___ Abd/Pelvis CT Scan - OSH
1 - Findings suggesting obstructing stone at the level of the
ampulla resulting in dilatation of the biliary system. An ERCP
is recommended for further evaluation
2 - Bilateral renal cysts, one of them on the right side with
partial calcified wall.
3 - Minimal fat stranding surrounding the urinary bladder;
correlate with urinalysis
___ GALLBLADDER US
1. Extrahepatic biliary dilation with the common bile duct
measuring 13 mm. Gallbladder sludge or stone within the common
bile duct, and ERCP is
recommended. No intrahepatic biliary dilation.
2. Gallbladder sludge without evidence of cholecystitis.
___ ERCP - The scout film was normal.
A Schatzki's ring was found in the distal esophagus
(non-obstructing)
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree. The CBD was
dilated at 1.2cm in diameter.
Multiple filling defects consistent with stones were identified
in the CBD. The left and right hepatic ducts and all
intrahepatic branches were normal. A biliary sphincterotomy was
made with a sphincterotome. There was no post-sphincterotomy
bleeding. The biliary tree was swept with a 12 - 15 mm balloon
starting at the bifurcation. Multiple stones and sludge were
seen. The CBD and CHD were swept repeatedly until no further
stones/sludge were seen. The final occlusion cholangiogram
showed no evidence of filling defects in the CBD. Excellent bile
and contrast drainage was seen endoscopically and
fluroscopically. Otherwise normal ercp to third part of the
duodenum
___ - CXR
There is extensive opacity in the left lung concerning for
aspiration. Left effusion present. The right lung is clear
although a small opacity at the bases noted. .
___ - CXR
Slight interval improvement in extensive airspace opacity
involving the left lung and medial right lung base, differential
etiologies include aspiration, aspiration pneumonitis, or
pneumonia.
Brief Hospital Course:
This is a ___ year old male with past medical history of CML on
gleevec, hypertension, hyperlipidemia, admitted ___ with
choledocholithiasis with biliary obstruction and gallstone
pancreatitis, status post ERCP with biliary sphincterotomy and
stone extraction, course complicated by periprocedural
aspiration pneumonia, treated with antibiotics and subsequently
improving, tolerating a regular diet
# Choledocholithiasis with obstruction / Gallstone pancreatitis
- Patient presented to ___ with abdominal
pain, found to have CT scan concerning for choledocholithiasis
with obstruction with elevated lipase > 1,000 concerning for
gallstone pancreatitis, prompting transfer to ___. Patient
underwent ERCP with sphincterotomy and balloon extraction of
stones and sludge. Periprocedural period was complicated by
observed aspiration event as below. Patient's abdominal pain
and laboratory abnormalities rapidly improved and patient was
able to have diet advanced to regular diet without pain or
nausea. Patient treated with antibiotics as below (covering
post-ERCP prophylaxis). Patient preferred to see surgeon local
to him to discuss potential cholecystectomy--would benefit from
local referral.
# Acute Bacterial Pneumonia - patient with observed aspiration
event periprocedurally, with subsequent identification of large
area of consolidation at left lung. Patient clinically with
worsening cough, productive of thick yellow/brown sputum,
suggesting this was not just pneumonitis, but was pneumonia.
Patient was treated with PO levofloxacin, and given worsening
cough, was broadened to include anaerobic coverage given
aspiration etiology and underlying immunosuppression due to his
CML. He clinically improved and was able to ambulate
comfortable without dyspnea or coughing. Discharged with
prescription for levofloxacin (last day ___ and clindamycin
(last day ___ and understanding of warning signs that should
prompt additional care.
# Headache - course was complicated by headache without focal
neurologic or meningeal findings. Likely secondary to
dehydration post-procedurally and coughing secondary to above.
Resolved with IV fluids and treatment of pneumonia.
# Sore throat - had mild posterior pharynx abrasion likely
secondary to trauma during ERCP; improved over course of
admission and did not require additional treatment.
# Hypertension - continued home atenolol
# Hyperlipidemia - continued statin
# CML - held gleevec in setting of acute illness. Discussed
with patient to call his oncologist following discharge to
discuss timing of restarting gleevec.
Transitional Issues
- Last day levofloxacin = ___ last day clindamycin =
___
- Would consider outpatient surgical referral for discussion
about cholecystectomy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. IMatinib Mesylate 400 mg PO DAILY
3. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Clindamycin 300 mg PO Q6H
last day = ___
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*26 Capsule Refills:*0
2. Levofloxacin 750 mg PO DAILY
last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
4. Atenolol 50 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. HELD- IMatinib Mesylate 400 mg PO DAILY This medication was
held. Do not restart IMatinib Mesylate until you speak with your
oncologist tomorrow ___
Discharge Disposition:
Home
Discharge Diagnosis:
# Choledocholithiasis with obstruction / Gallstone pancreatitis
# Headache
# Acute Bacterial Pneumonia
# Hypertension
# Sore throat
# Hyperlipidemia
# CML
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 abdominal pain and found to have stones in your bile duct
and inflammation in your pancreas. You underwent an ERCP
("endoscopic retrograde pancreatography") to remove these
stones.
After your procedure you were found to have a pneumonia. You
were treated with antibiotics and improved.
It will be important for you to complete your course of
antibiotics. The last day of levofloxacin is ___. The last
day of clindamycin is ___.
In order to prevent future issues with gallstones, we recommend
speaking with your primary care doctor about ___ referral to a
surgeon to discuss having your gallbladder removed.
Followup Instructions:
___
|
10743310-DS-14
| 10,743,310 | 27,565,936 |
DS
| 14 |
2144-05-26 00:00:00
|
2144-05-26 20:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
___ year old female with periumbilical migrating to RLQ pain
since breakfast
this morning. Was feeling well day prior to presentation. Pain
worsened
throughout the day, she vomitted several times (non-bloody,
non-bilious). Endorses anorexia. Normal bowel movements until
today when she had diarrhea x1. Denies correlation with her
menstrual cycle.
Past Medical History:
Past Medical History: hypothyroidism
Past Surgical History: uterine ablation, minor orthopaedic
surgery
Social History:
___
Family History:
no history of colon CA, but several members with
breast and uterine CA
Physical Exam:
GEN: A&O, No acute distress
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, appropriately tender at incisions, no
rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 10:31PM ___ PTT-35.8* ___
___ 08:05PM GLUCOSE-114* UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
___ 08:05PM WBC-14.8* RBC-4.95 HGB-14.3 HCT-40.9 MCV-83
MCH-28.9 MCHC-35.1* RDW-13.5
___ 08:05PM NEUTS-87.3* LYMPHS-9.1* MONOS-3.1 EOS-0.3
BASOS-0.3
___ 08:05PM PLT COUNT-289
___ 08:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 08:05PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:05PM URINE AMORPH-MOD
CT abd ___
1. Uncomplicated acute appendicitis.
2. Tiny right hepatic and renal hypodensities, too small to
characterize but
likely cysts.
Brief Hospital Course:
Patient was admitted with acute appendicitis. She was taken to
the operating room and was found to have uncomplicated
appendicitis. The operation went well and she was extubated
without issue and brought to the postoperative care area. She
had her diet advanced to regular on POD 0 and was voiding
without issue. She was discharged on POD1 with good pain
control. She was maintained on subcutaneous heparin throughout
this hospitalization.
Medications on Admission:
levothyroxine
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain for 4 days.
Disp:*40 Tablet(s)* Refills:*0*
She was instructed to resume her levothyroxine
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Secondary:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for acute appendicitis, which is
an inlflammation of your appendix. You were taken to the
oeprating room to have your appendix removed. This oepration
went well and you were watched overnight to make sure you had
good pain control and could tolerate food. You were discharge
the next day with prescriptions for your pain.
You may resume your home medications on discharge.
Please make your follow up appointment below.
General Discharge Instructions:
You have had an abdominal operation. This sheet goes over some
questions and concerns you or your family may have. If you have
additional questions, or ___ understand something about your
operation, please call your surgeon.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside. But avoid traveling long distances until you
see your surgeon at your next visit.
___ lift more than ___ pounds for 6 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or washed out for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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, its OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
___ take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as soreness.
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important you take this
medicine as directed. Do not take it more frequently than
prescribed. Do not take more medicine at one time than
prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine.
If you are experiencing no pain, it is OK to skip a dose of pain
medicine.
To reduce pain, remember to exhale with any exertion or when you
change positions.
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.
In some cases, you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10743336-DS-12
| 10,743,336 | 27,996,124 |
DS
| 12 |
2182-02-20 00:00:00
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2182-02-20 16:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemothorax
Major Surgical or Invasive Procedure:
___
US-guided right thoracentesis
History of Present Illness:
___ presenting with hemothorax. While on vacation in ___, he
slipped on a step in the bathroom on ___, and fell from ground
level onto his right side. Did not seek medical attention. Took
___ ibuprofen q4 for pain from presumed broken ribs, but
continued to walk around the city to finish his vacation.
Returned from ___ the night of ___, and came to the ED
morning
of ___. He is breathing well, satting 93% on room air. He does
have pain on his right side, which is currently well controlled
with IV morphine PRN. He denies chest pain, shortness of breath,
and abdominal pain. He denies fever or chills. He is
hemodynamically stable and his hematocrit is stable at 43.9. CT
chest showed a right hemothorax with at least RML atelectasis,
nondisplaced fractures of ribs ___, and a L1 transverse process
fracture. No need for intervention or brace per neurosurg.
Past Medical History:
bilateral inguinal hernias s/p repair; umbilical hernia s/p
repair with mesh; R triceps repair; L knee arthroplasty
Social History:
___
Family History:
Non-contributory
Physical Exam:
Temp 96.8 HR 59 BP 153/96 RR 16 93% RA
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:
RESPIRATORY
[ ] CTA/P [x] Excursion normal [x] pain along right ribcage
[x] decreased breath sounds lower right chest
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
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 [x] Axillary nl
[x] 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:
OTHER:
Pertinent Results:
___ 06:32AM BLOOD WBC-9.5 RBC-4.91 Hgb-15.3 Hct-45.0 MCV-92
MCH-31.2 MCHC-34.0 RDW-12.8 RDWSD-43.0 Plt ___
___ 10:06AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
___ 10:06AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
___ CXR :
Again seen is the moderate right pleural effusion with
associated right lower lobe volume loss. The rib fractures are
better seen on this CT from yesterday. No pneumothorax is
identified. The left lung is clear
___ CXR :
Stable opacity at the right base consistent with pleural
effusion or
hemothorax. No appreciable pneumothorax.
Brief Hospital Course:
Mr. ___ presented to the ED with right sided chest wall
pain. He had fallen in the bathroom 10 days earlier while
vacationing in ___. CT torso was obtained at the outside
hospital, which revealed fractured right ribs ___, fractured
right L1 transverse process, and a large right hemothorax. He
was admitted, and an US-guided thoracentesis was performed on
___ which drained 1300cc of serosanguinous fluid. His post
thoracentesis film was much improved but the right diaphram was
not visible. A chest CT was done which showed a small right
pleural effusion.
His room air saturations were 96% and his pain was controlled
with Tylenol and Dilaudid. His hematocrit has been stable since
admission in the 44 range. As he was progressing well and not
requiring supplemental oxygen he was discharged to home on
___ and will follow up with Dr. ___ in the ___
Pulmonary Clinic in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fexofenadine 60 mg PO DAILY:PRN allergies
Discharge Medications:
1. Fexofenadine 60 mg PO DAILY:PRN allergies
2. Acetaminophen 650 mg PO Q4H:PRN pain
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
5. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospitla with right sided chest pain
following a fall many days before. Fractured ribs were
identified along with a right pleural effusion.
* The Interventional Pulmonary service drained about 1300 cc's
of serosanguinous fluid from your chest. Some fluid remains but
they will evaluate you in ___ weeks with a chest xray to
determine if more fluid needs to be removed or hopefully it has
resolved.
* You will continue to need some pain medication for your
fractured ribs and this can be weaned off as the pain decreases.
* Make sure that you take a stool softener as narcotic
medication can cause constipation. Stay well hydrated as that
will also help to ease any constipation.
* Ibuprofen can cause bleeding therefore is not recommended.
* If you develop any increased shortness of breath, chest pain,
fevers > 101 or any symptoms that concern you call Drs. ___
___ at ___
Followup Instructions:
___
|
10744371-DS-3
| 10,744,371 | 21,058,105 |
DS
| 3 |
2140-09-02 00:00:00
|
2140-09-02 12:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
Examination under anesthesia, closed reduction and casting of
right ankle fracture (___)
History of Present Illness:
___ w/ no significant PMHx p/w ankle fracture after mechanical
fall. She tripped on a rug at home and everted her L ankle. She
fell to the ground and could not get up. She was unable to
ambulate. Denies weakness, numbness in RLE. No other injuries.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is a well appearing woman in NAD.
Vitals stable, afebrile.
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee
R ankle swollen, ecchymotic, TTP. Pain w/ minimal ROM
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 10:20PM GLUCOSE-131* UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
___ 10:20PM estGFR-Using this
___ 10:20PM WBC-7.9 RBC-4.02* HGB-11.9* HCT-37.2 MCV-93
MCH-29.5 MCHC-31.9 RDW-13.2
___ 10:20PM NEUTS-87.8* LYMPHS-7.6* MONOS-3.6 EOS-0.6
BASOS-0.5
___ 10:20PM PLT COUNT-211
___ 10:20PM ___ PTT-34.3 ___
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE UHOLD-HOLD
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:00PM URINE RBC-2 WBC-5 BACTERIA-MOD YEAST-NONE
EPI-<1
___ 07:00PM URINE MUCOUS-RARE
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for EUA, closed reduction and casting,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor.
Musculoskeletal: Prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status remains NWB
RLE, in a short leg cast. Throughout the hospitalization,
patient worked with physical therapy who determined that
discharge to home with services was most appropriate.
Neuro: Post-operatively, patient's pain was controlled by IV
pain medication and was subsequently transitioned to oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused any blood products.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #1, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The extremity was NVI distally throughout.
The patient was given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient will be continued on chemical DVT prophylaxis for 2
weeks post-operatively. All questions were answered prior to
discharge and the patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe
Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
ACTIVITY AND WEIGHT BEARING:
- NWB RLE in short leg cast
Physical Therapy:
- NWB RLE in short leg cast
Treatments Frequency:
- 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.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
Followup Instructions:
___
|
10744539-DS-15
| 10,744,539 | 27,798,727 |
DS
| 15 |
2162-06-25 00:00:00
|
2162-06-26 14:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ambien / codeine
Attending: ___.
Chief Complaint:
headache, malaise
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ y/o man with a PMH of thoracic aortic dilation
syndrome s/p repair with mechanical AVR ___, TIA and Factor V
Leiden, pAfib, venous insufficiency, who presents with headache,
fatigue, and dark stools.
Patient reports that the night prior to admission he had head
"discomfort" which wasn't quite a headache. He thought this was
from eating MSG, but the following morning it was worse. He
states "it's not a headache... but it hurts my head." Described
as fairly severe, worsening throughout the day, and associated
with fatigue. It becomes acute worse when sitting up. He was
worried that it could be a stroke. He then developed dark
stools,
similar to prior when he had a GI bleed. He denies chest pain,
shortness of breath, or palpitation. Also no abdominal pain or
nausea. He notes that he was on warfarin 6mg daily for a long
time, but was having some low INRs. Last week his INR was 2.1,
and his warfarin was increased to 7mg daily. He has not yet
returned for a repeat INR.
On review of records, patient has been undergoing planning for
knee replacement. He was seen by his cardiologist on ___. He
was noted to have a new left bundle branch block from an EKG in
___. He was referred for a vasodilator nuclear perfusion scan
prior to surgery. Also planned to bridge with lovenox.
In the ED:
Initial vital signs were notable for: T 98.1, HR 78, BP 131/69,
RR 16, 99% RA
Exam notable for: Abd: Soft, Nontender, Nondistended
Labs were notable for:
- CBC: WBC 9.4, Hgb 9.0, Plt 208
- Lytes:
139 / 105 / 56
-------------- 83
4.3 \ 21 \ 0.8
- LFTS: AST: 18 ALT: 10 AP: 43 Tbili: 0.4 Alb: 3.8
- Coags: ___: 42.2 PTT: 39.4 INR: 3.9
- trop<0.01 x2
Studies performed include: CXR with no acute cardiopulmonary
process.
Patient was given:
___ 21:30 IV Pantoprazole 40 mg ___
___ 21:30 PO Acetaminophen 1000 mg
___ 21:21 1u pRBCs
Consults: GI was consulted, recommending PPI BID and NPO after
midnight for EGD.
Vitals on transfer: T 98.6, HR 90, BP 109/60, RR 18, 100% RA
Upon arrival to the floor, patient reports that he still is not
feel well after receiving blood. He states that he has a pain
that is not quite a pain, and is having difficulty describing
how
he is not feeling well.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Likely genetic thoracic aortic dilation syndrome s/p Bentall
25mm Mechanical AVR ___ by Dr. ___
- TIA and Factor V Leiden INR goal 2.5-3.
- hypertension
- paroxysmal afib post AVR
- venous insufficiency
- traumatic L SDH, ___
- UGIB, ___
- MCI, diagnosed in cognitive neurology ___
- osteoarthritis
- melanoma s/p excision ___ years ago
- glaucoma
- cataract surgery (bilateral)
Social History:
___
Family History:
- Father - deceased from ___ at age ___
- 3 cousins - deceased from ___ between ages ___
- Mother - ___ CA
- Son - MS
Physical ___:
VITALS: T 97.7, HR 80, BP 111/60, RR 20, 99% Ra
GENERAL: Alert and in no apparent distress, pale and tired
appearing
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, mechanical S2
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. Bilateral legs somewhat
cool to touch with 1+ edema
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
DISCHARGE EXAM
VS: 97.6 110/58 65 18 97/RA
GEN: elderly male, sitting up in bed
HEENT: MMM
CV: RRR with mechanical S2
RESP: CTAB no w.r
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
NEURO: alert, appropriate, calm
Pertinent Results:
ADMISSION LABS
___ 06:55PM BLOOD WBC-9.4 RBC-2.68* Hgb-9.0* Hct-27.5*
MCV-103* MCH-33.6* MCHC-32.7 RDW-13.5 RDWSD-50.6* Plt ___
___ 06:38AM BLOOD WBC-6.3 RBC-2.71* Hgb-9.0* Hct-26.5*
MCV-98 MCH-33.2* MCHC-34.0 RDW-14.9 RDWSD-53.4* Plt ___
___ 07:15AM BLOOD WBC-5.3 RBC-2.55* Hgb-8.5* Hct-25.2*
MCV-99* MCH-33.3* MCHC-33.7 RDW-14.7 RDWSD-53.0* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-139 K-4.0
Cl-104 HCO3-24 AnGap-11
___ 06:55PM BLOOD Glucose-83 UreaN-56* Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-21* AnGap-13
___ 06:55PM BLOOD Albumin-3.8 Calcium-8.9 Phos-2.6* Mg-1.8
___ 06:55PM BLOOD cTropnT-<0.01
___ 08:35PM BLOOD cTropnT-<0.01
IMAGING
- EGD ___: Normal duodenum. Hiatal Hernia. Erythema, edema and
congestion in the pre-pyloric region and antrum comparable with
gastritis. Focal scarring in the antrum.
- CXR ___: Lungs are clear. There is no consolidation,
effusion, or edema. Prosthetic valve and median sternotomy
wires are noted. There is tortuosity of descending thoracic
aorta. Calcified subcarinal lymph nodes are noted. No acute
osseous abnormalities. IMPRESSION: No acute cardiopulmonary
process.
Brief Hospital Course:
Mr ___ is a ___ year old man with a history of thoracic
aortic dilation s/p repair with Bentall and Mechanical AVR, hx
of TIA and Factor V Leiden, pAfib and previous gastric ulcer who
p/w headache, fatigue, and 24hrs of black stools found to have
acute blood loss anemia secondary to gastritis and INR of 3.9.
# Acute blood loss anemia/UGIB secondary to gastritis: Pt was
admitted with HA and black stools. He was found to have a drop
in hgb from 12 -> 9. He required 2 units of prbcs and INR was
partially corrected with Vit K 2.5mg due to ongoing blood loss.
EGD showed diffuse gastritis and H. pylori was sent (pending at
discharge). Hgb stabilized and there were no further signs of
bleeding. Per discussion with prior MD (___) and ___
PCP, patient was to be discharge on lovenox (off warfarin for
several days, with follow-up CBC taken on ___. If blood counts
found to be stable, warfarin to be restarted.
# Mechanical AVR/Hx of DVT and Supratherapeutic INR: Pt
presented with INR of 3.9 and active UGIB. He was given 2.5mg of
Vitamin K and FFP prior to EGD. INR downtrended slowly and hgb
stabilized. Patient was started on lovenox 90mg BID (as this had
previously been discussed with his cardiologist ISO mechanical
MVR for bridging). Warfarin was to be restarted some days after
discharge by PCP pending ___ stability with outpatient labs.
# Hx of TIA: pt was restarted on Aspirin 81mg without any
evidence of re-bleeding.
# HTN: Metoprolol was held during admission due to UGIB and low
BPs, restarted at discharge.
TRANSIONAL ISSUES
- f/u H. Pylori, will need therapy if positive
- continue Lovenox BID until seen by Dr. ___ week, restart
Coumadin as outpt with goal INR ___
- reassess need for metoprolol and dosing at follow-up next
week.
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Warfarin 7 mg PO DAILY16
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
8. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 90 mg subcutaneous twice daily Disp
#*20 Syringe Refills:*0
2. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. HELD- Warfarin 7 mg PO DAILY16 This medication was held. Do
not restart Warfarin until you are seen by your PCP
10.Rolling Walker
Rx: Decondontiioning Px: Good
Length of Need: 13 months.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute blood loss anemia
UGIB from Gastritis
Supratherapeutic INR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You are admitted with malaise, acute blood loss from gastritis
and an elevated INR. You have been treated with blood
transfusions, temporary correction of the INR and EGD with
Gastroenterology (GI). It is important that you continue
taking Omeprazole 20mg twice daily for another 6 weeks and
return for a repeat EGD with GI. We have sent off labs to
test for an infection that can predispose you to this kind of
stomach irritation and we will let you know when those results
are available. For now, you should continue taking lovenox
90mg subcutaneously twice daily until you are seen at ___ on
___. ___ like you to get labs drawn on
___ and those will be reviewed at your appointment
on ___. Please do NOT resume warfarin until you are
instructed to do it by Dr. ___.
Please avoid alcohol and monitor for any signs of malaise, black
or bloody stools, LH or vomiting of black contents as this would
be concerning for recurrent bleeding.
Hope you have a great thanksgiving
Best wishes from your team at ___
Followup Instructions:
___
|
10744539-DS-17
| 10,744,539 | 20,626,846 |
DS
| 17 |
2162-10-08 00:00:00
|
2162-10-08 22:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ambien / codeine / Percocet
Attending: ___.
Chief Complaint:
Left thigh hematoma ___ mechanical fall
Major Surgical or Invasive Procedure:
Left common/profunda femoral arteriogram
History of Present Illness:
___ male with history of mechanical AVR, afib, factor V
Leiden currently on Lovenox being bridged to Coumadin, ocular
migraine, TIA and remote brain hemorrhage.
Patient tripped on a step outside a restaurant yesterday and
fell
down landing on his left arm and leg. He had some bleeding on
his
left arm and a hematoma on his left thigh. He denied headstrike
or loss of consciousness. He was able to mobilize and drove
himself home. His INR check yesterday was 3.5. Later last night
he developed severe pain in his left thigh w/ hematoma
enlarging.
He called his son last night saying he almost passed out. This
morning when patient woke up he was feeling lightheaded. Patient
reported that he took coumadin 7mg this AM. He has worsening
pain
in his left thigh and worsening hematoma. He was not able to
move
his leg due to pain and worsening hematoma. He presented to the
ED for further evaluation and management.
In the ED, vitals were:
T 97.4, HR 77, BP 122/63, RR 20, O2 98% RA
Exam:
Con: In moderateo acute distress due to pain, right leg moving
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Resp: Clear to auscultation, normal work of breathing
CV: Regular rate and rhythm, mechanical click in RUSB and LUSB,
2+ distal pulses. Capillary refill less than 2 seconds.
Abd: Soft, Nontender, Nondistended
GU: No costovertebral angle tenderness
MSK: +tenderness, ecchymosis on left outer thigh, not able to
move due to pain
Skin: wound covered by dressing in left arm.
Neuro: Cranial nerves II Through XII intact, unable to assess
strength due to pain. sensation intact in all extremities
Psych: Normal mood/mentation
Labs:
___: 43.8 PTT: 65.4 INR: 4.0
Na 134, Cl 101, BUN 18
K 4.2, HCO3 18, Cr 0.8
Hgb 8.0
WBC 7.3
Plt 241
Trop <0.01
Lactate 2.4
Studies:
CT TORSO ___
1. Approximately 12.0 x 4.3 x 8.3 cm heterogeneous collection
within the left anterolateral thigh, with asymmetric enlargement
of the left thigh musculature, compatible with known hematoma.
Hematocrit level is seen as well as extravasation of contrast.
2. Otherwise, no evidence of acute intra-abdominal or
intrathoracic
abnormality. No intrathoracic or intra-abdominal injury.
3. Postoperative changes of the ascending thoracic aorta.
Thoracic aorta above the level of repair measures up to 4.5 cm
in
diameter, similar compared to most recent exam.
4. 8 mm ground-glass opacity within the right upper lobe, likely
infectious or inflammatory in etiology.
5. Multiple bilateral chronic appearing rib deformities. No
evidence of acute fracture.
6. Trace bilateral pleural effusions, with associated
atelectasis.
7. Other findings, as described above.
CT HEAD ___
No acute intracranial abnormality.
CT C-SPINE ___. No acute cervical spine fracture or traumatic malalignment.
2. Minimal anterolisthesis of C3 on C4, likely degenerative in
etiology.
Moderate, multilevel degenerative changes of the cervical
spine.
CXR ___
No acute cardiopulmonary process.
He was given:
500cc NS
morphine 2mg IV x3
ondansetron 4 mg IV
Dilaudid 1 mg IV x1
4g Magnesium Sulfate
Fentanyl citrate 25 mcg IV
On the floor, the patient confirms the above history. Tripped
over a step he did not see and fell onto his left arm and leg.
Says he was not feeling dizzy or lightheaded at the time, no
palpitations. Says his skin was very taut and swollen, but that
has improved in the ED. Pain was severe, but has improved with
medications administered in the ED. Denies numbness or tingling
of LEs. Says he was recently restarted on Lovenox just a few
days
ago and his anticoagulation is managed by Dr. ___. No fevers,
CP, SOB, abdominal pain, dysuria, blood in stool, melena.
Past Medical History:
- Likely genetic thoracic aortic dilation syndrome s/p Bentall
25mm Mechanical AVR ___ by Dr. ___
- TIA and Factor V Leiden INR goal 2.5-3.
- hypertension
- paroxysmal afib post AVR
- venous insufficiency
- traumatic L SDH, ___
- UGIB, ___
- MCI, diagnosed in cognitive neurology ___
- osteoarthritis
- melanoma s/p excision ___ years ago
- glaucoma
- cataract surgery (bilateral)
Social History:
___
Family History:
- Father - deceased from ___ at age ___
- 3 cousins - deceased from ___ between ages ___
- Mother - ___ CA
- Son - MS
Physical ___:
ADMISSION EXAM
=================
VITALS: ___ Temp: 98.5 BP: 144/66 L Lying HR: 87 RR:
18
O2 sat: 100% O2 delivery: 2L
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: supple
CARDIAC: RRR. no murmurs, rubs or 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, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 2+ DP pulses bilaterally, left thigh with firm
swelling nontender with compression wrap in place, bruising at
superior left thigh (lovenox injection site), swelling of left
knee, left forearm dressing c/d/i
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Sensation
intact.
DISCHARGE EXAM
==================
Vitals: Temp: 98.2 BP: 133/68 R HR: 67 RR: 18 O2 sat: 98% O2
delivery: Ra
Gen: Comfortable appearing
HEENT: MMM
CV: RRR, mechanical heart sounds
Resp: CTAB, normal WOB
Abd: Soft, NDNT
MSK: Left thigh markedly enlarged compared to right,
+ecchymosis,
+tenderness. Intact peripheral pulses.
Neuro: Alert, oriented x3, intact attention. CN intact. LEs with
intact proprioception bilaterally and symmetric sensation to
light touch.
Pertinent Results:
ADMISSION LABS
====================
___ 01:17PM WBC-7.3 RBC-2.61* HGB-8.0* HCT-25.0* MCV-96
MCH-30.7 MCHC-32.0 RDW-13.6 RDWSD-47.5*
___ 01:17PM NEUTS-70.1 LYMPHS-17.2* MONOS-10.5 EOS-0.8*
BASOS-0.7 IM ___ AbsNeut-5.10 AbsLymp-1.25 AbsMono-0.76
AbsEos-0.06 AbsBaso-0.05
___ 01:17PM PLT COUNT-241
___ 01:17PM ___ PTT-65.4* ___
___ 01:17PM cTropnT-<0.01
___ 01:17PM GLUCOSE-97 UREA N-18 CREAT-0.8 SODIUM-134*
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-18* ANION GAP-15
___ 01:38PM LACTATE-2.4*
DISCHARGE LABS
====================
___ 07:08AM BLOOD WBC-6.9 RBC-2.48* Hgb-7.5* Hct-23.9*
MCV-96 MCH-30.2 MCHC-31.4* RDW-15.5 RDWSD-53.4* Plt ___
___ 07:08AM BLOOD ___ PTT-42.0* ___
___ 07:04AM BLOOD ___ PTT-48.6* ___
___ 09:45AM BLOOD ___ PTT-61.0* ___
___ 07:04AM BLOOD Ret Aut-4.4* Abs Ret-0.11*
___ 07:04AM BLOOD calTIBC-277 Ferritn-339 TRF-213
___ 06:43AM BLOOD VitB12-271
IMAGING & STUDIES
=====================
___ CT SPINE W/O CONTRAST
1. No acute cervical spine fracture or traumatic malalignment.
2. Minimal anterolisthesis of C3 on C4, likely degenerative in
etiology.
Moderate, multilevel degenerative changes of the cervical spine.
___ CT CHEST W/O CONTRAST
1. Approximately 12.0 x 4.3 x 8.3 cm heterogeneous collection
within the left anterolateral thigh, with asymmetric enlargement
of the left thigh musculature, compatible with known hematoma.
Hematocrit level is seen as well as extravasation of contrast.
2. Otherwise, no evidence of acute intra-abdominal or
intrathoracic abnormality. No intrathoracic or intra-abdominal
injury.
3. Postoperative changes of the ascending thoracic aorta.
Thoracic aorta above the level of repair measures up to 4.5 cm
in diameter, similar compared to most recent exam.
4. 8 mm ground-glass opacity within the right upper lobe, likely
infectious or inflammatory in etiology.
5. Multiple bilateral chronic appearing rib deformities. No
evidence of acute fracture.
6. Trace bilateral pleural effusions, with associated
atelectasis.
___ CT HEAD W/O CONTRAST
No acute intracranial abnormality.
___ CT PELVIS
No fracture.
Brief Hospital Course:
BRIEF SUMMARY
================
___ male with history of mechanical AVR, afib, factor V
Leiden currently on Lovenox being bridged to Coumadin, ocular
migraine, TIA and remote brain hemorrhage, admitted for left
thigh hematoma after a mechanical fall. He remained
hemodynamically stable and responded well to transfusions.
Anticoagulation was restarted without issue and he was
discharged to rehab.
ACUTE ISSUES
=================
#Left thigh hematoma
#Mechanical fall
One day prior to admission, the patient tripped on a step
outside a restaurant and fell, landing on his left leg. He
denied headstrike or loss of consciousness. His INR check that
day was 3.5 (target 2.5-3.5 due to valve). Later that night he
developed severe pain in his left thigh w/ hematoma enlarging
causing him to present to the ___ ED. In the ED, he was
hemodynamically stable, and Hgb was found to be 5.0, INR 4.0. He
received 3 units pRBCs. CT angio showed active extravasation
into the hematoma. ___ felt that his INR was too high for
intervention and he received Vitamin K and two additional units
of pRBCs (5 total). He remained neurovascularly intact without
evidence of compartment syndrome. On ___ repeat angiography
found no evidence of active bleeding. Anticoagulation was
restarted without issue. Pain was controlled with oxycodone and
acetaminophen.
#Long Term Use of Anticoagulation:
#Supratherapeutic INR:
#Mechanical Aortic Valve:
#Factor V Leiden:
Patient has a mechanical Bentall 25mm mechanical AVR that was
placed in ___ for which he is on chronic Warfarin. He also has
Factor V Leiden. Because of these two conditions, he has a
target INR 2.5-3.5. Initially, the patient was started on 2.5mg
Vitamin K to reverse his warfarin. Hematology and Cardiology
were consulted, and ultimately the patient was felt to be
relatively stable and was not completely reversed. Following his
___ procedure (see above), the patient was started on a heparin
drip for easy reversal if necessary. He as transitioned on ___
to warfarin with enoxaparin bridge.
# History of TIAs:
Aspirin was discontinued this admission due to recurrent
bleeding (has had prior GI bleeds in addition to hematoma this
admission). Statin was continued.
# Orthostatic Hypotension
Patient had few episodes of orthostatic hypotension when sitting
upright. Sometimes but not always symptomatic. This was thought
to be due to bedrest, without evidence of ongoing bleeding or
hypovolemia. His metoprolol and tamsulosin were held on
discharge with plan to restart in future.
# Paroxysmal Atrial Fibrillation:
Metoprolol was held in setting of bleeding and later
orthostasis. Rates remained controlled.
#Acute blood loss anemia:
After transfusions, iron stores appear to have been repleted.
There is no evidence of ongoing deficiency, and his retic
response was appropriate. B12 was low-normal but patient had no
exam findings to suggest true deficiency so held off on further
testing.
CHRONIC ISSUES:
===============
# HTN: Metoprolol held as above.
# h/o GI bleed
# h/o Gastritis:
No evidence of GI bleeding this admission. Continued omeprazole.
TRANSITIONAL ISSUES:
=======================
- Please adjust warfarin dose daily, goal INR 2.5-3.5 for
mechanical AV replacement (received warfarin 6mg on ___ and ___,
7mg on ___, 7.5mg on ___. Stop enoxaparin 90mg BID once INR
therapeutic.
- Aspirin STOPPED this admission due to recurrent bleeding
(discussed with patient's PCP and cardiologist).
- Holding metoprolol and tamsulosin due to orthostasis. Restart
as able.
- B12 level low-normal but no evidence on exam or CBC of true
deficiency. Monitor and consider replacement if anemia persists.
#CODE STATUS: Full (confirmed)
#HEALTHCARE PROXY:
Proxy name: ___
___: son Phone: ___
Date on form: ___ Filed on date: ___
Proxy form in chart?: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Enoxaparin Sodium 120 mg SC Q12H
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Tamsulosin 0.4 mg PO QHS
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Warfarin ___ mg PO DAILY16
11. ciclopirox 0.77 % topical DAILY:PRN rash
12. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN scalp
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 2.5 mg by mouth every 4 hours as needed Disp
#*12 Tablet Refills:*0
3. Senna 17.2 mg PO BID
4. Acetaminophen 1000 mg PO Q8H
5. Enoxaparin Sodium 90 mg SC Q12H
6. Polyethylene Glycol 17 g PO BID
7. ___ MD to order daily dose PO DAILY16
8. Atorvastatin 10 mg PO QPM
9. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN scalp
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
11. ciclopirox 0.77 % topical DAILY:PRN rash
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Omeprazole 20 mg PO DAILY
14. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you speak with your primary care doctor.
15. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until you speak with your primary care
doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Left thigh hematoma
# Long Term Use of Anticoagulation
# Supratherapeutic INR
# Mechanical AVR (Bentall 25mm mechanical AVR in ___
# Factor V Leiden
# History of TIA
# Mechanical fall
# Paroxysmal Afib
# Acute blood loss anemia
# Constipation
SECONDARY DIAGNOSES:
# HTN
# h/o GI bleed
# h/o Gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED?
You were admitted for bruising in your left leg after your fall.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
You received blood to replace the blood you lost after your
fall. You worked with ___ to improve your strength. We also
stopped your aspirin because of your history of bruising and
your GI bleed.
WHAT SHOULD I DO WHEN I GET TO REHAB?
Your rehab will continue to monitor your INR to choose the right
warfarin dose.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10744724-DS-3
| 10,744,724 | 26,598,192 |
DS
| 3 |
2182-03-15 00:00:00
|
2182-03-15 14:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex / vinyl ether
Attending: ___.
Chief Complaint:
right leg pain
Major Surgical or Invasive Procedure:
___: ORIF Right tibial plateau fracture
History of Present Illness:
___ w/ high functioning cerebral palsy who was at a wedding
earlier today and had several drinks. Was walking home, tripped
and fell and injured her right knee.
Past Medical History:
Asthma
GERD
Cerebral Palsy (w/ truncal motor deficits)
Social History:
___
Family History:
Mother- ___ cancer, lung cancer, esophageal cancer
Father- ___ cancer, lung cancer, esophageal cancer
Physical Exam:
PHYSICAL EXAMINATION:
General: emotional, anxious
Vitals: AVSS
Right lower extremity:
- Skin intact, unlocked ___ in place
- knee TTP, incisions c/d/I with staples in place
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
See OMR for pertinent results
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a bicondylar right tibial plateau fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF of right tibial
plateau fracture, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing with ROM as tolerated in the right 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:
Singulair 10 mg tablet PO QD
Omeprazole 40 mg QD
Zyrtec 10 mg capsule oral QD
Zoloft 150mg tablet(s) Once Daily
Ativan 0.5 mg tablet oral PRN agitation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO DAILY:PRN CONSTIPATION
3. Enoxaparin Sodium 40 mg SC Q24
RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*40 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
5. Cetirizine 10 mg PO DAILY
6. LORazepam 0.5 mg PO Q4H:PRN agitation
please limit benzodiazepine use while taking narcotic
medications.
7. Mirtazapine 7.5 mg PO QHS
8. Montelukast 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Sertraline 150 mg PO DAILY
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bicondylar right tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- to wear unlocked ___ at all times until told otherwise
- touchdown weightbearing and range of motion as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Touchdown weight bearing
Left lower extremity: Full weight bearing
TDWB RLE, okay ROMAT R knee in unlocked ___
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: on AM of POD 2 by ___, then daily bt RN; please
overwrao any dressing bleedthrough with ABD's and ACE
Followup Instructions:
___
|
10745156-DS-20
| 10,745,156 | 27,275,405 |
DS
| 20 |
2181-12-16 00:00:00
|
2181-12-16 09:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Robaxin-750 / Latex / Bactrim
Attending: ___.
Chief Complaint:
Right hip and shoulder pain
Major Surgical or Invasive Procedure:
Right short trochanteric fixation nail
History of Present Illness:
This is a ___ with a history of MS who sustained a
mechanical fall this evening while walking to her car. She fell
onto her R shoulder and hip with immediate pain and inability to
bear weight. Denies headstrike or LOC. She was taken by
ambulance
to ___ where imaging demonstrated a nondisplaced R FNF and R
greater tuberosity fracture. Orthopedics was consulted for
further management. Of note, patient has a history of MS that
causes intermittent instability and increasing frequency of
falls
while walking. She also endorses fatigue of her RLE with long
walking. Denies any prior history of hip pain or trauma.
Past Medical History:
Multiple sclerosis
s/p gastric bypass
h/o bowel/bladder urgency
Fleur de lis abdominoplasty, panniculectomy ___
Social History:
___
Family History:
NC
Physical Exam:
AFVSS
Gen: A&Ox3, No actue distress
Ext: RLE: ___, SILT ___, WWP, incisions
c/d/i with staples in place
RUE: +ain/pin/u, SILT r/u/u, WWP
Pertinent Results:
___ Right hip unilateral 2-views: Findings There is a
nondisplaced intertrochanteric right femoral neck fracture.
There is no dislocation of the right hip. The patient is status
post right knee arthroplasty. There is no evidence of fracture
of the distal femur and the
knee joint appears anatomically aligned. Soft tissue
calcifications are noted in the anterior right thigh, possibly
vascular.
IMPRESSION:
Nondisplaced intertrochanteric right femoral neck fracture.
___ HIP NAILING IN OR W/FILMS: FINDINGS: Images from the
operating suite show steps in a hip nailing procedure. Further
information can be gathered from the operative report
___ 12:20AM ___ PTT-31.7 ___
___ 12:20AM PLT COUNT-168
___ 12:20AM NEUTS-81.0* LYMPHS-13.4* MONOS-3.6 EOS-1.1
BASOS-0.9
___ 12:20AM WBC-7.4# RBC-4.36 HGB-11.7* HCT-35.8* MCV-82
MCH-26.9* MCHC-32.7 RDW-14.3
___ 12:20AM estGFR-Using this
___ 12:20AM GLUCOSE-101* UREA N-24* CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 04:46PM PLT COUNT-125*
___ 04:46PM WBC-5.9 RBC-4.03* HGB-10.6* HCT-33.2* MCV-82
MCH-26.2* MCHC-31.9 RDW-14.1
___ 04:46PM CALCIUM-8.4 MAGNESIUM-1.8
___ 04:46PM GLUCOSE-114* UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have nondisplaced R intertroch fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right short trochanteric femoral nail,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to 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 weight bearing as tolerated in the
right upper and right lower extremity with passive range of
motion as tolerated in the right upper extremity but no active
abduction or adduction of the right upper extremity. Patient
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:
1. Calcium Carbonate 500 mg PO TID
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Multivitamins 1 CAP PO DAILY
5. Oxybutynin 10 mg PO HS
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose:
Next Routine Administration Time
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Milk of Magnesia 30 ml PO BID:PRN Constipation
9. Multivitamins 1 CAP PO DAILY
10. Oxybutynin 10 mg PO HS
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Senna 2 TAB PO HS
13. Vitamin D 400 UNIT PO DAILY
14. TraZODone 50 mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
___ and ___)
Discharge Diagnosis:
___ with a nondisplaced R intertroch fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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:
- Weight bearing as tolerated in right upper and right lower
extremities, passive ROM of right shoulder as tolerated, no
active abduction or adduction of the right upper extremity until
follow up
Physical Therapy:
Weight bearing as tolerated right lower extremity, weight
bearing as tolerated right upper extremity
Treatments Frequency:
Staples will be removed at follow up appointment. Dressings only
needed if any drainage still occurs for wounds or for comfort
reasons.
Followup Instructions:
___
|
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