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10745195-DS-11
| 10,745,195 | 21,789,903 |
DS
| 11 |
2127-04-25 00:00:00
|
2127-04-25 13:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trouble with speech/swallow, right signed weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(Gathered from pt's daughter/HCP)
___ is a ___ woman with PMH significant for dementia
who
presents with 4 days of progressive symptoms of a left MCA
syndrome. The patient lives in an assisted living. Her daughter
saw her on ___ and noticed that she was making some
language errors. Specifically using the incorrect words in
sentences. On ___ She was starting to use nonsense
words in addition to word substitutions. She was noted to be
fluent, singing, and in a great mood. She was also noted to be
more tired than usual over the weekend into ___. The
patient's
daughter asked for the patient to be evaluated by an MD over the
weekend.
On ___ her language had deteriorated to pure
neologisms, she had become clumsy with her right hand, and
developed a right facial droop. She was still able to walk at
that point. She was evaluated by a Dr. ___ said (per the
patient's daughter) she likely had a stroke but that it was not
necessary to bring her to the ED as an MRI wouldn't tell us
much.
___ night she had a good nights sleep but was noted to have
some coughing and sputtering when she tried to eat or drink.
This morning she was noted to be more somnolent and less
interactive, along with the swallowing trouble prompted her
presentation to our ED.
ROS: unable to obtain
Past Medical History:
- Dementia (Dx about ___ years ago. No specific diagnosis given at
that time)
- Hypothyroid
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 100 HR: 65 BP: 139/56 RR: 12 Sat: 97% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: awake but only minimally interactive.
HEENT: Sclera are non-injected. Mucous membranes are dry.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. No
Edema.
Skin: Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Will wake and regard briefly but closes eyes if
not stimulated. Globally aphasic, done not speak or follow any
commands. regards left more than right but no clear neglect.
Cranial Nerves:
BTT bl. Pupils equally round, reactive to light. gaze
preference
to the left, but does cross midline to the right. R lower
facial
droop.
Motor/sensory: Normal muscle bulk, normal to low tone on the
right. subtle spastic catch on the right.
Strength: quick antigravity withdrawal of the left and and leg
to
noxious. Delayed response to noxious on the right but she will
grimace. RUE with some mild extensor posturing to noxious. RLE
triple flexion.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Toes are down going bilaterally.
Coordination/gait: could not test
DISCHARGE PHYSICAL EXAM:
VS: deferred for GOC, respirations 20
Gen: alert, not oriented
Pulm: breathing comfortably
Neuro: on exam she is globally aphasic with right sided weakness
of the face and arm more so than the leg
Pertinent Results:
ADMISSION LABS:
___ 08:20AM BLOOD WBC-8.0 RBC-4.53 Hgb-14.0 Hct-41.2 MCV-91
MCH-30.9 MCHC-34.0 RDW-13.2 RDWSD-43.8 Plt ___
___ 08:20AM BLOOD Neuts-60.5 ___ Monos-10.7
Eos-0.0* Baso-0.5 Im ___ AbsNeut-4.84 AbsLymp-2.25
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.04
___ 08:20AM BLOOD ___ PTT-27.1 ___
___ 08:20AM BLOOD Glucose-113* UreaN-22* Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-22 AnGap-18
___ 08:20AM BLOOD ALT-18 AST-24 AlkPhos-60 TotBili-0.7
___ 08:20AM BLOOD Lipase-11
___ 08:20AM BLOOD cTropnT-<0.01
___ 08:20AM BLOOD Albumin-4.0 Calcium-9.9 Phos-2.8 Mg-1.9
PERTINENT LABS:
___ 05:55AM BLOOD %HbA1c-5.9 eAG-123
___ 05:55AM BLOOD Triglyc-142 HDL-43 CHOL/HD-6.5
LDLcalc-210*
___ 05:55AM BLOOD TSH-5.0*
DISCHARGE LABS:
None
IMAGES:
___ CTA Head
1. Left MCA infarct involving the left temporal, parietal and
frontal lobes with associated edema and effacement of the sulci.
No shift of midline structure or central herniation.
2. Widespread atherosclerotic disease of the intracranial
vessels results in varying degrees of irregularity and moderate
narrowing of most of the circle ___ and ___ branches as
detailed above.
3. Incompletely imaged right parotid lesion.
___ ECHO
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). No masses or thrombi are seen in
the left ventricle. 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. No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. No mass or vegetation is seen on the
mitral valve. No mitral regurgitation is seen. There is no
pericardial effusion.
Brief Hospital Course:
___ is a ___ woman with dementia who presents with 4
days of evolving left MCA symptoms. on exam she is globally
aphasic with right sided weakness of the face and arm more so
than the leg. Her NCHCT shows an evolving left MCA stroke.
Etiology is likely embolic from atherosclerotic disease. She was
started on 300mg aspirin PR for stroke prevention. She is not
diabetic and a non-smoker. Her ability to swallow was assessed
by speech and swallow with recommendation for NPO as diet and
education on aspiration risk if family would like to feed her
for comfort. A family meeting was held with palliative care to
discuss the severity of her imaging and symptoms. The decision
was made to make her CMO. At this time aspirin and IV fluids
were discontinued.
======================
Transitional Issues:
======================
1. Patient was evaluated by speech and swallow with
recommendation of NPO as diet, as patient not responding to food
stimuli in mouth. However, family may feed her for
comfort/pleasure, as risks of aspiration have been discussed.
====================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
====================================================
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - evaluation by speech and swallow () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - SQH, pneumoboots ()
No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - ASA () No
4. LDL documented? (x) Yes (LDL = 210) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: patient NPO]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? () Yes - (x) No - unable to participate
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - evaluation by ___ with recommendation to rehab at ___ ()
No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: unable to swallow pills, per GOC NG tube not
placed]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No - pt CMO
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Vitamin E 1000 UNIT PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 500 mg PO BID:PRN pain
5. Ascorbic Acid ___ mg PO BID
6. TraZODone 12.5 mg PO 11AM DAILY
Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
pain, discomfort
2. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN Aggitation
3. Acetaminophen 650 mg PR Q4H:PRN pain, fever
4. Lorazepam 0.5 mg SL Q4H:PRN aggitation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of trouble with speech and
swallowing resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
Please followup with Neurology and your primary care physician
as listed below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10745225-DS-10
| 10,745,225 | 24,442,957 |
DS
| 10 |
2145-09-10 00:00:00
|
2145-09-11 16:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hand pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a past medical
history of IVDU and two recent admissions for R hand infection
complicated by AMA discharges, who presented with recurrent R
hand pain and swelling.
Per report she had been taking suboxone for more than a year and
had been doing well, but recently relapsed in ___ and began
using
IV heroin again.
She first presented to ___ on ___ with R hand infection
after injecting into the hand. She was transferred to ___ for
hand surgery evaluation. She was underwent right dorsal hand
irrigation and debridement with tenosynovectomy with ___
drain placement with hand surgery on ___. She was treated with
Vanc/Zosyn ___ and ID was consulted but she left AMA prior
to being seen by them.
She then presented again to the ED on ___. She endorsed heroin
use after leaving the hospital AMA. Patient's outpatient
behavioral health provider called and expressed concern about
patient's safety, stating that she appeared depressed and
suicidal. She was seen by psychiatry and placed on a ___,
but eventually the ___ was lifted on ___ after it was
determined that she was not actively suicidal.
During that admission she was initially treated with vanc/zosyn,
which was then transitioned to oral Bactrim and augmentin per ID
recommendations with plans to complete a 14 day course (day ___ =
___. She left the hospital AMA on ___.
Since discharge she has again resumed using heroin. She reports
last use was on ___. She did not take her oral antibiotics. She
is overall quite lethargic and does not provide much history,
but
does report that she presented to the ED after her right hand
again became painful and she noticed drainage from the wound
over
the past ___ days. She says that prior to this the wound
appeared
to be healing.
In the ED, she received one dose of IV zosyn. She was evaluated
by hand surgery who recommended admission to medicine for IV
antibiotics.
On the floor, she is quite lethargic as above but does awaken to
voice. She reports that she is tired because she has not slept
for several days, and that her last heroin use was yesterday.
Past Medical History:
Hepatitis C, untreated
___
Depression
Anxiety
Social History:
___
Family History:
Mother with early breast cancer in ___. Father COPD.
Physical Exam:
Admission Physical Exam:
========================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: incision over R hand with some mild surrounding erythema
and swelling, no drainage noted. Non-tender to palpation
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 Physical Exam:
========================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: incision over R hand with some mild surrounding erythema
and swelling, no drainage noted. Non-tender to palpation
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 Labs:
===============
___ 04:00AM BLOOD WBC-6.9 RBC-4.10 Hgb-13.6 Hct-40.2 MCV-98
MCH-33.2* MCHC-33.8 RDW-13.1 RDWSD-46.7* Plt ___
___ 04:00AM BLOOD Neuts-52.5 ___ Monos-6.8 Eos-2.5
Baso-0.6 Im ___ AbsNeut-3.61 AbsLymp-2.56 AbsMono-0.47
AbsEos-0.17 AbsBaso-0.04
___ 04:00AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-142 K-4.1
Cl-104 HCO3-25 AnGap-13
___ 04:00AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
___ 04:00AM BLOOD CRP-7.3*
___ 10:57AM BLOOD Vanco-12.9
Imaging:
========
Xray Hand:
No radiopaque foreign body or radiographic evidence of
infection.
Discharge Labs:
===============
___ 07:00AM BLOOD WBC-4.9 RBC-3.82* Hgb-12.8 Hct-36.9
MCV-97 MCH-33.5* MCHC-34.7 RDW-13.0 RDWSD-45.7 Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-143 K-4.1
Cl-103 HCO3-25 AnGap-15
___ 07:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ female with a past medical history
of IVDU and two recent admissions for R hand infection
complicated by AMA discharges, who presented with recurrent R
hand pain and swelling and again left AMA.
ACUTE/ACTIVE PROBLEMS:
# Hand infection: secondary to drug use. S/p wash out on ___,
at which time she was found to have necrosis of deep tissues.
Prior to current admission, she had two admissions with AMA
discharges. During prior admissions she was treated with
vanc/zosyn and eventually transitioned to oral antibiotics but
did not complete the course after leaving AMA.
She then presented again with recurrent pain and swelling. She
was seen by hand surgery who did not feel there was any need for
further operative intervention. They recommended admission to
medicine for IV antibiotics. She was restarted on vanc/zosyn and
wound was dressed.
She again left the hospital against medical advice on ___.
She was discharged with a two week prescription for Bactrim and
augmentin.
# Substance Use disorder
Polysubstance abuse. She was sober for 19 months with recent
relapses. She was seen by both psychiatry and addiction
psychiatry. Patient expressed interest in inpatient addiction
treatment following medical hospitalization, and transition back
to suboxone. However she left AMA as above before any
arrangements could be made.
Due to high risk behaviors patient requested STI testing but
this was unable to be completed prior to her leaving the
hospital
# Anxiety: seen by psychiatry who did not find any evidence of
active suicidal ideation (patient on ___ during prior
admission). She expressed feelings of regret about her relapse
but also hope for the future and desire to treat her addiction
and be a mother to her daughter. She adamantly denied any SI.
She was continued on home gabapentin, Adderall, and Xanax prn
# Elevated LFTs: mild, likely secondary to known HCV
Transitional Issues:
====================
- needs ongoing addiction treatment
- discharged on two week course of Bactrim/augmentin
- should have eventual HCV treatment
- needs repeat STI testing
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine 30 mg PO BREAKFAST
2. Amphetamine-Dextroamphetamine 30 mg PO NOON
3. Sulfameth/Trimethoprim DS 2 TAB PO BID
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
5. Amphetamine-Dextroamphetamine 20 mg PO QPM
6. ClonazePAM 1 mg PO BID:PRN anxiety
7. Gabapentin 800 mg PO QID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tab-cap by mouth twice a day Disp #*28 Tablet Refills:*0
2. Amphetamine-Dextroamphetamine 30 mg PO BREAKFAST
3. Amphetamine-Dextroamphetamine 30 mg PO NOON
4. Amphetamine-Dextroamphetamine 20 mg PO QPM
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Gabapentin 800 mg PO QID
7. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tab-cap by mouth twice a day Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hand cellulitis
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 treated for an infection of your hand.
You will be discharged with a course of oral antibiotics. Please
be sure to complete the entire course to make sure that your
infection is treated.
Please return to the hospital if you experience fevers, chills,
worsening redness or swelling or any other symptoms that concern
you. ___ always be happy to care for you if you
change your mind and decided to return.
- Your ___ care team
Followup Instructions:
___
|
10745462-DS-9
| 10,745,462 | 25,327,624 |
DS
| 9 |
2122-01-01 00:00:00
|
2122-01-04 11:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___
___ Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of CAD
(cath at ___ ___ with chronic occlusion of the right coronary
artery and a moderate 50% stenosis in the LAD), GERD, IBS now
presenting with epigastric pain.
Pain is located in upper epigastrium, just beneath xiphoid
process. It does not radiated to the sides or back. It began at
11 am today, approximately one hour after patient ate two
doughnuts and a banana. Pain has been constant, persistently
"dull" in quality, with some episodes of sharper pain, since
this morning. It started when he was at work, seated. Pain does
not worsen or improve with positioning. He took two antacids
this morning, which did not help the pain. Pain is accompanied
by intermittent nausea and an episode of vomiting earlier this
afternoon. He has also developed a headache. He denies any
associated diaphoresis, lightheadedness, palpitations or
dyspnea. He also denies any cough, dysuria, hematuria, change
in color of stool, hematochezia/melena, fevers/chills, diarrhea.
After calling EMS, he was given a spray of nitroglycerin and
aspirin 325 mg PO in the ambulance. On arrival to ___, his
initial vital signs were: 97.5 58 132/81 16 99% 2L NC. Labs
were notable for troponin < 0.01 at 12:45 pm and 5:40 pm. WBC
normal at 6.8 with 6.9% eos. UA showed no evidence of infection
or hematuria. EKG showed: sinus bradycardia at 48 bpm, NA. Low
voltage. Q wave in III and aVR (old). TW flattening in III, aVF
(old). QTc 420 msec. Overall, unchanged from prior. CXR PA/lat
showed no acute cardiopulmonary process. Per patient's wife, a
bedside ___ U/S showed no evidence of cholecystitis.
In the ED, he was given: morphine IV, Dilaudid IV, viscous
lidocaine, donnatol, aluminum-magnesium-simethicone,
ondansetron, viscous lidocaine, several sublignual
nitroglycerins. He notes that pain seemed to decrease somewhat
with the nitros, but did not resolve all the way. Due to
persistent pain, he was started on a nitroglycerin drip, which
was uptitrated to 1.56 mcg/min. He was also started on a
heparin drip. Prior to transfer, patient's vital signs were:
98.1 57 115/56 18 95%.
On arrival to the floor, patient rated abdominal pain as ___.
He had continued nausea and vomited during this interview. He
also reported a headache. He had no other complaints. He was
accompaanied by his wife.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. Hhe denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Coronary artery disease: no MI, but cath in ___ at ___ showed
chronically occluded RCA and 50% narrowing of LAD
- GERD
- C. diff colitis in ___
- allergic rhinitis
- rotator cuff injury
- s/p knee surgery
Social History:
___
Family History:
Father with first MI at age ___, died of MI at ___. Brother with
CAD s/p CABG (in his ___, and another brother with a stroke.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.7 120/56 60 18 98% 3L
General: Uncomfortable, lying with eyes closed.
HEENT: MMM, sclerae anicteric. PERRL, clear oropharynx.
Neck: Brisk carotid upstrokes, no JVD.
CV: I/VI systolic murmur at RUSB, RRR, nl S1/S2
Lungs: CTAB, resp unlabored, no accessory muscle use
Abdomen: Discomfort with palpation of upper epigastrium. No TTP
in ___. NABS. No masses.
GU: No foley.
Ext: WWP, 2+ distal pulses, no peripheral edema
Neuro: Awake, alert and oriented x3. CNs II-XII intact and
symmetric. Moving all extremities.
Skin: No rashes.
DISCHARGE
VS: 97.8 99/49 (99-127/49-65) 62 18 96%RA
General: Comfortable, pleasant, NAD.
HEENT: MMM, sclerae anicteric. PERRL, clear oropharynx.
Neck: Brisk carotid upstrokes, no JVD.
CV: I/VI systolic murmur at RUSB, RRR, nl S1/S2
Lungs: CTAB, resp unlabored, no accessory muscle use
Abdomen: No TTP. NABS. No masses.
GU: No foley.
Ext: WWP, 2+ distal pulses, no peripheral edema
Neuro: Awake, alert and oriented x3. CNs II-XII intact and
symmetric. Moving all extremities.
Skin: No rashes.
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-6.8 RBC-4.82 Hgb-15.2 Hct-44.4 MCV-92
MCH-31.6 MCHC-34.3 RDW-13.2 Plt ___
___ 12:45PM BLOOD Neuts-61.6 ___ Monos-7.0 Eos-6.9*
Baso-1.1
___ 01:53PM BLOOD ___ PTT-30.3 ___
___ 12:45PM BLOOD Glucose-98 UreaN-14 Creat-1.1 Na-140
K-4.1 Cl-104 HCO3-23 AnGap-17
___ 12:45PM BLOOD ALT-25 AST-31 CK(CPK)-86 AlkPhos-72
TotBili-0.6
___ 12:45PM BLOOD CK-MB-2
___ 12:45PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD ALT-25 AST-31 CK(CPK)-86 AlkPhos-72
TotBili-0.6
PERTINENT LABS:
___ 05:40PM BLOOD cTropnT-<0.01
___ 12:28AM BLOOD CK(CPK)-62
___ 12:28AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS:
___ 12:45PM BLOOD WBC-6.8 RBC-4.82 Hgb-15.2 Hct-44.4 MCV-92
MCH-31.6 MCHC-34.3 RDW-13.2 Plt ___
___ 07:10AM BLOOD ___ PTT-28.9 ___
___ 07:10AM BLOOD Glucose-103* UreaN-11 Creat-1.0 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with a PMH of CAD
(cath at ___ with chronic occlusion of the right coronary
artery and a moderate 50% stenosis in the LAD), GERD, IBS,
admitted with epigastric pain, most likely GI in etiology.
ACTIVE ISSUES:
# Epigastric pain: Although patient has a history of CAD along
with strong FH of CVD, description of epigastric pain does not
seem c/w angina, esp given lack of response to increasing
nitroglycerin IV, lack of exertional component, and lack of SOB.
Additionally, EKG without changes and troponins normal x2.
Certainly, an inferior MI could present with N/V/abd pain. Prior
to discharge, patient did note a few episodes of exertional
chest pain in the preceding months, and was subsequently
instructed to schedule an outpatient nuclear stress test for
further evaluation. He will also follow closely with Dr. ___
in clinic.
Given signficant N/V/epigastric pain with this presentation,
there was higher concern for pancreatitis or cholecysitis. Viral
gastroenteritis also on the differential. Interestingly, had
similar presentation to medicine service in ___. Allergic
rhinitis along with elevated eos raises some concern for
eosinophilic gastrointestinal disease. For GI work-up, LFTs and
lipase, as well as ___ U/S, revealed no abnormalities. Given the
patient's history of GERD, he may have some gastritis or peptic
ulcer disease that are contributing to his current presentation.
He may benefit from further exploration with EGD as outpatient.
He has close follow-up with his PCP and his outpatient GI Dr.
___.
# Headache: Reported headache on arrival to the floor. Symptoms
had been worsening over the course of his time in the ED.
Headache without any neurologic deficits. It was most likely
secondary to nitroglycerin therapy. It resolved after nitro drip
was discontinued. Tylenol was used as needed.
# CAD: As noted above, likely not related to current episode. On
ROS, noted exertional CP over the past few months. Not c/w
current symptoms. As noted, he will have an outpatient stress
test, and close cardiology follow-up. He continued his home
atenolol and aspirin. Patient would benefit from restarting
statin, if it is tolerated.
CHRONIC ISSUES:
# GERD: Continued home omeprazole.
# Allergic rhinitis: Continued home fluticasone nasal spray.
# Supplementation: Continued home mulitvitamins.
TRANSITIONAL ISSUES:
# Urine culture (from ___ was pending at the time of
discharge. It returned negative.
# Code status: full (confirmed)
# Patient to undergo nuclear stress test as an outpatient.
# Would consider restarting statin as outpatient.
# ___ benefit from EGD as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: epigastric pain
SECONDARY DIAGNOSES: CAD, GERD, IBS
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 participate in your care at ___
___! You were admitted with upper
abdominal pain, which was thought to be gastrointestinal in
etiology. You had no evidence of damage to your heart.
Additionally, labs and imaging showed no problems with your
pancreas or gallbladder. This is all very reassuring. You
improved with intravenous fluids and anti-nausea medications.
We hope that you will follow up with Dr. ___
further investigation and management of your symptoms. Please
see below for a list of your follow-up appointments.
As you also mentioned some exertional chest pain, we have
ordered an outpatient nuclear stress test for you. You can
schedule this by calling ___. We recommend that you
have this done within the next month. Dr. ___ will follow-up
with you in Cardiology clinic.
We did not change any of your medications.
Wishing you all the best!
Followup Instructions:
___
|
10745469-DS-10
| 10,745,469 | 25,804,080 |
DS
| 10 |
2188-02-11 00:00:00
|
2188-02-22 14:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending: ___.
Chief Complaint:
R lower ext swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/ HTN, HL, OSA, alcohol dependence, severe neuropathy with
chronic right great toe ulcers now s/p amputation and recent
admission from ___ for cellulitis and group A stress
bacteremia who presents with worsening right lower leg redness.
He was discharged 2 days ago on IV ceftriaxone for planned 2
week course for cellulitis. Today he noted worsening erythema
extending beyond markings, blistering, and weeping. Has
neuropathy making sensation to pain less clear. No fevers or
chills. No systemic symptoms. U/S 2 days ago showed no soft
tissue involvement.
In the ED, initial VS were 99.8 99 167/89 18 96%. On exam his
leg was very red, weeping significantly into leg boot,
blistering and tense, extends from foot to knee with milder
erythema extending to groin. CT scan of leg showed possible
osteomyelitis. Podiatry was consulted but deferred the consult
until AM on the floor. He was given clindamycin and cefepime and
admitted to medicine for further management.
On the floor, the patient is sleeping comfortably.
Past Medical History:
- Obstructive sleep apnea on CPAP
- Alcohol abuse
- Hypertension
- Hyperlipidemia
- Obesity
- Gout
- Restless leg syndrome
- Diverticulitis
- UGIB secondary to NSAIDs ___
- RLE foot drop secondary lumbar radiculopathy
- S/P right carotid endarterectomy for amaurosis fugax OD ___
- S/P L3-4/L4-5 lumbar laminectomy/discectomy ___
- S/P right hallux fracture, osteomyelitis, amputation ___.
Social History:
___
Family History:
Suspected MI in dad in his ___
Physical Exam:
Admission:
Vitals: T: 98.8 BP: 142/88 P: 70 R: 18 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds due to body habitus, regular rate and
rhythm, normal S1 + S2, cannot appreciate any murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: right foot missing great to with small ~1cm diameter
shallow based healed ulcer on plantar side of stump. Intense
erythema and 3+ pitting edema of right leg spreads from foot up
to a sharply demarcated line just below the knee. Multiple skin
breaks and weeping from tense edema. Paler pink erythema spreads
up into the thigh but does not involve the scrotum
Neuro: A&O x3, no asterixis, strength ___ for right dosiflexion
otherwise ___ in UE and ___. No sensation in right foot up to
ankle.
Discharge:
Vitals: T: 98.5 BP: ___ P: ___ R: 18 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds due to body habitus, regular rate and
rhythm, normal S1 + S2, cannot appreciate any murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: right foot missing great to with small ~1cm diameter
shallow based healed ulcer on plantar side of stump. Intense
erythema and 3+ pitting edema of right leg spreads from foot up
to a sharply demarcated line just below the knee. Multiple skin
breaks and weeping from tense edema. Paler pink erythema spreads
up into thigh but improved from ___
Neuro: A&O x3, no asterixis, strength ___ for right dosiflexion
otherwise ___ in UE and ___. No sensation in right foot up to
ankle.
Pertinent Results:
Admission:
___ 10:15PM BLOOD WBC-8.2 RBC-4.66 Hgb-14.8 Hct-42.5 MCV-91
MCH-31.7 MCHC-34.8 RDW-13.4 Plt ___
___ 10:15PM BLOOD Glucose-117* UreaN-17 Creat-1.1 Na-132*
K-4.8 Cl-96 HCO3-25 AnGap-16
___ 08:45AM BLOOD ALT-65* AST-52* CK(CPK)-145 AlkPhos-90
TotBili-0.9
Discharge:
___ 06:45AM BLOOD WBC-8.1 RBC-4.79 Hgb-14.9 Hct-43.5 MCV-91
MCH-31.0 MCHC-34.1 RDW-13.3 Plt ___
___ 09:00AM BLOOD Neuts-65 Bands-0 Lymphs-12* Monos-14*
Eos-1 Baso-0 Atyps-1* ___ Myelos-6* Promyel-1*
___ 06:45AM BLOOD Glucose-137* UreaN-14 Creat-1.0 Na-132*
K-4.9 Cl-96 HCO3-28 AnGap-13
CT R lower extremity
IMPRESSION:
1. Increase in size of irregular calcaneal lucent lesion with
gas within the lesion as well as the subtalar articulation and
irregular changes in the talus as well. These findings could
reflect secondary degenerative changes given subchondral
collapse of the calcenus with vacuum phenomenon within the joint
extending into the lesion. Alternatively, this may represent
osteomyelitis and ___ abscess with potential involvement of
the joint. Correlate with lab/exam findings and consider
orthopedic/podiatric evaluation and if necessary, MRI could be
obtained.
2. No soft tissue gas with diffuse skin thickening and edema
throughout the leg, most pronounced laterally in the proximal
leg and more severe and circumferential distally concerning for
cellulitis.
MRI Right foot:
IMPRESSION:
1. Cystic changes in the subtalar joint involving the anterior
calcaneus and sustentaculum tali as well as the inferior aspect
of the talus. Given that these cystic structures have sclerotic
borders and appears similar in size from prior CT scan dating
back to ___, findings are most suggestive of neuropathic
osteoarthropathy as opposed to erosions related to
osteomyelitis.
2. Marked skin thickening, edema and enhancement more prominent
posteromedially, consistent with cellulitis given the patient's
clinical
history. No rim-enhancing collections to suggest a soft tissue
abscess.
3. Sequela of old injury to the anterior talofibular ligament
and
calcaneofibular ligament as evident by ligamentous thickening.
4. Thickening of the Achilles tendon without focal tear.
RLE doppler:
IMPRESSION:
No evidence of DVT in the right lower extremity.
Brief Hospital Course:
# Cellulitis: Patient returned to hospital with worsening of his
previously diagnosed RLE cellulitis. Pt had been discharged on
IV ceftriaxone for cellulitis with blood cultures growing group
a strep. Pt noted increased swelling, weeping, and redness of
leg prompting him to come back in. On admission, he as noted to
have erysipelas with increasing edema of RLE. A CT RLE was
unconcerning for necrotizing fascititis but did raise concern
for ___ abscess in calcaneus. A follow up MRI showed stable
bone cyst with low concern for abscess or osteo. He was
initially started on Vanc/cefepime/clindamycin due to concern
for worsening infection. However, it was deemed his symptoms
were most likely secondary to not elevating leg and progression
of erysipelas. He was transitioned back to ceftriaxone with
continued improvement in cellulitis. He was encouraged to
continue to elevate leg above heart has much as possible.
# Hypertension: Continued to hold amlodipine in setting of leg
swelling. HCTZ was held due to hyponatremia. He was continued on
home lisinopril with good bp control.
# Alcohol dependence: Did not trigger on CIWA, continued
thiamine and folate
# Hyponatremia: chronic, improved since stopping HCTZ on last
admission. Based on repeat urine electrolytes, he does appear to
have a component of reset osmolality most likely secondary to
long term HCTZ use. He remained asymptomatic this admission.
# OSA: continued home CPAP at night
# Hyperlipidemia: continued atorvastatin
# Neuropathy: stable; continued home gabapentin
Transitions of Care:
#Pt will complete remaining 6 days of 14 day course of CTX at
home
#Continue to elevate leg above heart as much has possible
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. CeftriaXONE 2 gm IV Q24H
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. arginine (L-arginine) *NF* 3 g Oral BID
11. cod liver oil *NF* 1 tab ORAL DAILY
12. flaxseed oil *NF* 1 pill ORAL DAILY
13. tadalafil *NF* 5 mg Oral daily PRN sexual activity
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 1 bag IV daily
Disp #*6 Bag Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. arginine (L-arginine) *NF* 3 g Oral BID
11. cod liver oil *NF* 1 tab ORAL DAILY
12. flaxseed oil *NF* 1 pill ORAL DAILY
13. tadalafil *NF* 5 mg Oral daily PRN sexual activity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Right lower extremity cellulitis
Secondary:
Obstructive sleep apnea on CPAP
Hyponatremia
Hypertension
L5 nerve palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You returned after your right lower leg
cellulitis worsened following your previous discharge. We
believe your leg became more swollen and red due to not
elevating your leg in the setting of a bad cellulitis infection.
We continued you on IV antibiotics this admission and elevated
your leg with improvement of your symptoms. You will continue an
additional week of IV antibiotics as an outpatient. Please
continue to elevate your leg as much as possible and avoid
wearing your boot if possible.
Followup Instructions:
___
|
10745469-DS-15
| 10,745,469 | 27,989,670 |
DS
| 15 |
2191-05-14 00:00:00
|
2191-05-14 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
R lower extremity redness and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of OSA, htn, gout, s/p R CEA, R hallux fracture c/b
osteomyelitis and amputation (___), hx of acute pancreatitis,
and recent hospital admission for L medial thigh cellulitis,
presenting with ___ redness and pain x 1 week.
He states that over the past week, he noticed worsening redness
and itchiness in his RLE. He reports that he made an appointment
to see his podiatrist on ___, but was encouraged by his
masseuse and his wife to come to the doctor. He denies fevers,
chills, recent trauma. He has a scab on his right ankle but is
unsure how he got it.
Over the past month, he reports significant weight gain and
worsening lower extremity edema. He reports that his weight has
changed from 133 kilos to 142 kilos. He otherwise denies chest
pain, palpitations, dyspnea, orthopnea.
Of note, the patient was recently admitted at ___ for L
medial cellulitis, was initially treated with vancomcyin and
cefepime and was discharged on 7 days of PO Keflex and Bactrim.
He reports that since his last discharge, he has been doing
well. The L medial thigh cellulitis improved. He still notes
some induration in that area, but denies warmth.
Past Medical History:
Per Dr. ___, dated ___:
- Obstructive sleep apnea on CPAP
- Alcohol abuse
- Hypertension
- Hyperlipidemia
- Obesity
- Gout
- Restless leg syndrome
- Diverticulitis ___ and ___
- Amaurosis fugax OD
- UGIB secondary to NSAIDs ___
- RLE foot drop secondary lumbar radiculopathy
- S/P right carotid endarterectomy for amaurosis fugax OD ___
- S/P L3-4/L4-5 lumbar laminectomy/discectomy ___
- S/P right hallux fracture, osteomyelitis, amputation ___
Dr. ___ - ___
- "stump ulcer" R great toe ___
- ETOH abuse
- hip replacement
- Acute pancreatitis ___ complicated by sepsis/acute
cholecystitis with perforation, percutaneous cholecystotomy
tube/volume overload,/hospital acquired ___ withdrawal
- per chole tube removed ___ ___
- ___ LLE
- R. CEA ___ after TIA
- CTS surgery RUE ___
- partial medial meniscectomy knee LLE ___
- s/p Sesamoidectomy RLE foot ___ per ___ podiatry,
transitioned to ___ podia___
Social History:
___
Family History:
Per OMR:
Suspected MI in dad in his ___, prostate ca
mom with thyroid problems
brother with DM
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.6 147/89 58 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP difficult to appreciate
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur
best appreciated at the RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 1+ DP pulses, Doppler ___ pulses, ___
pitting edema to the knee bilaterally, + erythematous and warm
skin of the RLE wrapping laterally with vertical scar over the
right ankle.
Neuro: CNII-XII grossly intact, speech is fluent, alert and
oriented, moves all extremities
DISCHARGE PHYSICAL EXAM
========================
PHYSICAL EXAM:
Vital Signs: 98.2 130/68 59 20 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no JVP
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present
Torso/Back: flushed diffusely on torso/back. Unchanged.
Ext: Warm, well perfused, non-pitting edema to the knee
bilaterally, + erythematous and warm skin of the RLE with
vertical scar over the right ankle. Erythema is much improved
and receding from marker line made on skin. ___ sign negative.
Patient does not have big toe on R side secondary to previous
amputation.
Neuro: CNII-XII grossly intact, speech is fluent, alert and
oriented, moves all extremities. Strength in right lower
extremity is ___. Dorsiflexion and plantarflexion in left lower
extremity is ___.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 05:12PM BLOOD WBC-5.8 RBC-5.43 Hgb-15.9 Hct-48.8 MCV-90
MCH-29.3 MCHC-32.6 RDW-14.8 RDWSD-49.1* Plt ___
___ 05:12PM BLOOD Neuts-61.3 ___ Monos-8.7 Eos-3.4
Baso-0.7 Im ___ AbsNeut-3.58 AbsLymp-1.46 AbsMono-0.51
AbsEos-0.20 AbsBaso-0.04
___ 05:12PM BLOOD Glucose-113* UreaN-18 Creat-1.2 Na-140
K-4.9 Cl-103 HCO3-26 AnGap-16
___ 06:00AM BLOOD ALT-32 AST-41* AlkPhos-79 TotBili-0.8
___ 06:00AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.5 Mg-1.9
___ 05:21PM BLOOD Lactate-1.8
DISCHARGE LAB REULTS
====================
___ 06:00AM BLOOD WBC-5.5 RBC-5.50 Hgb-16.0 Hct-50.1 MCV-91
MCH-29.1 MCHC-31.9* RDW-15.5 RDWSD-50.4* Plt ___
___ 06:00AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-29 AnGap-14
IMAGING
=======
#XRAY TiB/Fib ___
Bilateral subcutaneous edema without definite evidence of soft
tissue gas. Noradiographic findings to suggest acute
osteomyelitis. If clinical concern is high, consider
cross-sectional imaging for further evaluation.
Linear lucency at the left femoral head is felt to be
artifactual, however,correlate clinically for concern for
nondisplaced fracture.
#Foot AP/Lat ___
Marked right foot soft tissue swelling and subcutaneous edema
without evidence of soft tissue gas or radiographic findings to
suggest acute osteomyelitis.
Brief Hospital Course:
___ with hx of OSA, htn, gout, s/p R CEA, R hallux fracture c/b
osteomyelitis and amputation (___), hx of acute pancreatitis,
and recent hospital admission for left medial thigh cellulitis,
presenting with ___ redness and pain.
# Right lower extremity cellulitis: Patient presented with RLE
swelling, erythema, and warmth concerning for a skin and soft
tissue infection. Plain films significant for right foot soft
tissue swelling and subcutaneous edema. He had no evidence of
systemic infection including normal WBC, normal lactate, normal
hemodynamics. His cellulitis was demarcated with a skin pen, and
he was started on IV vancomycin and transitioned to PO Keflex
and Bactrim. He will be treated for a total of 10 days. Day 1 of
antibiotics = ___. Day 10 = ___
# Bilateral lower extremity edema: Patient presenting with ___
pitting edema to the knees bilaterally, significant 10 kg weight
gain the past month, without evidence of dyspnea or chest pain.
He was diuresed with Lasix 10mg IV two separate times with
minimal resolution of edema. Most likely etiologies for
patient's BLE edema was amlodipine effect vs. lymphedema. Given
normal BNP and lack of pulmonary complaints, there was lower
concern for heart failure as cause of patient's symptoms;
however, could consider TTE as outpatient for further
evaluation.
CHRONIC ISSUES
==============
# HTN: Continued on home amlodipine and metoprolol succinate.
# Hx of CVA s/p CEA: Continued home aspirin and atorvastatin.
# BPH: Continued home tamsulosin.
# GERD: Continue home Omeprazole
# OSA: He was continued on home CPAP.
TRANSITIONAL ISSUES
===================
- It is possible that amlodipine is causing the lower extremity
swelling. Consider changing to a different antihypertensive
medication.
- We did not get an ultrasound of the heart during this
admission, but it would be something to consider pursuing as an
outpatient.
- Please continue Bactrim and Keflex for a total 10 day course
of antibiotic treatment. (Day 1 = ___, Day 10 = ___
- Blood cx x 2 pending at the time of discharge and will need to
be followed up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Gabapentin 200 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. arginine (L-arginine) 3000 mg oral BID
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
12. Cephalexin (cephALEXin) ___ mg ORAL PRIOR TO DENTAL
PROCEDURES
13. flaxseed oil 1,000 mg oral DAILY
14. Naproxen 220 mg PO Q8H:PRN Pain - Mild
15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
16. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal 2 pumps
daily
17. Viagra (sildenafil) 25 mg ORAL PRN sexual intercourse
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
Please take 1 tablet every six hours. Last day of antibiotics is
___
RX *cephalexin 500 mg 1 capsule(s) by mouth every six hours Disp
#*30 Capsule Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please take one tablet twice per day. Last day is ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice per day Disp #*15 Tablet Refills:*0
3. Amlodipine 5 mg PO DAILY
4. arginine (L-arginine) 3000 mg oral BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
8. flaxseed oil 1,000 mg oral DAILY
9. Gabapentin 200 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Naproxen 220 mg PO Q8H:PRN Pain - Mild
14. Omeprazole 20 mg PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
16. Tamsulosin 0.4 mg PO QHS
17. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal 2
pumps daily
18. Viagra (sildenafil) 25 mg ORAL PRN sexual intercourse
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Right lower extremity cellulitis
Secondary diagnosis:
- Bilateral lower extremity edema
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Why were you here?
==================
You were hospitalized at ___ for an skin infection in your
right leg.
What did we do for you?
========================
- we gave you IV antibiotics (vancomycin) to fight the
infection.
- Because you were improving on the IV antibiotics, we changed
you to oral antibiotics (Cephalexin and Bactrim)
- You had swelling in your legs, and got IV diuretic medications
What do you need to do?
======================
- It is important that you continue taking your oral antibiotics
for a total of 10 days, until ___. Take Bactrim two
times per day, and take Keflex (Cephalexin) every 6 hours.
- It is also important that you follow up with your primary care
doctor within one week of discharge to make sure that the oral
antibiotics are working to fight your skin infection.
- You should further workup of your swelling with an
echocardiogram as an outpatient with your PCP.
It was a pleasure caring for you while you were here!
We wish you the best,
Your ___ Medicine Team
Followup Instructions:
___
|
10745469-DS-16
| 10,745,469 | 25,705,724 |
DS
| 16 |
2191-07-30 00:00:00
|
2191-07-30 20:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Bactrim
Attending: ___
Chief Complaint:
Rash
Lower extremity cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with HTN, HL, early ___ s/p CEA, morbid
obesity, OSA on CPAP, RLS, diverticulitis, NSAID-induced GIB,
alcohol abuse, pancreatitis with cholecystitis s/p PCT, gout,
and two bouts of cellulitis this year who presented with
recurrent cellulitis.
He was in his usual state of health until about 1 week ago. He
says he was on a cruise with his wife when he noticed some left
medial ankle redness. He thought it was a contact allergy and
washed the area with some soapy water. The redness got
progressively worse over the ensuing days, with associated
progressive swelling of the left lower extremity. He put some
triamcinolone cream on it to no effect. Today, after going for a
swim while toweling off, he noticed the skin slough. He denies
any f/c/s, and did not have too much pain there initially,
though a mild dull nonradiating ache has developed.
He went to his PCP's office and was referred to the ED for IV
antibiotics. Of note, while there he reported a few weeks of
otherwise asymptomatic truncal rash. PCP thought it was
pityriasis.
In the ED, he was given vancomycin and ceftriaxone, 1L IVF. Labs
were hemolyzed but otherwise unremarkable. Left ___ showed no
DVT. He had a TTE that showed some LVH and pulmonary HTN but was
normal EF. Admission was requested.
Also of note, patient has been seen a few times in recent months
for leg swelling. He was on calcium channel blocker for HTN, but
this was stopped and he was started on HCTZ.
ROS is negative in 10 points except as noted
Past Medical History:
PMH:
- Obstructive sleep apnea on CPAP
- CKD3
- Hypertension
- Hyperlipidemia
- Obesity
- Gout
- Restless leg syndrome
- Alcohol abuse
- Diverticulitis ___ and ___
- Amaurosis fugax OD
- UGIB secondary to NSAIDs ___
- RLE foot drop secondary lumbar radiculopathy
- Meralgia parsethetica LLE
- Acute pancreatitis ___ complicated by sepsis/acute
cholecystitis with perforation, percutaneous cholecystotomy
tube/volume overload,/hospital acquired ___ withdrawal
PSH:
- S/P right carotid endarterectomy for amaurosis fugax OD ___
- S/P L3-4/L4-5 lumbar laminectomy/discectomy ___
- S/P right hallux fracture, osteomyelitis, amputation ___
Dr. ___ - ortho - ___
- "stump ulcer" R great toe ___
- hip replacement
- perc chole tube s/p removal ___ ___
- R. ___ ___ after ___
- CTS surgery RUE ___
- partial medial meniscectomy knee LLE ___
- s/p Sesamoidectomy RLE foot ___ per ___ podiatry,
transitioned to ___ podiatry
Social History:
___
Family History:
Father with likely CAD, also prostate cancer
Mother with thyroid problems
Brother with DM
Physical Exam:
On Admission:
Vitals
Gen NAD, pleasant, talkative
Abd obese, soft, NT, ND, bs+
CV somewhat distant heart sounds, RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin scaly erthythematous papular rash on trunk, left lower
extremity cellulitis, right lower extremity venous stasis
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
Psych normal affect
On Discharge:
VS: 97.7 127/76 51 18 96% RA
General: Well appearing, walking around hospital room
Eyes: PERLL, EOMI, sclera anicteric
ENT: MMM, oropharynx clear without exudate or lesions
Respiratory: CTAB without crackles, wheeze, rhonchi.
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops
Gastrointestinal: Soft, nontender, prominent but nondistended,
+BS, no masses or HSM
Extremities: Warm and well perfused. Bilateral lower extremities
compressed to the upper shin by ACE wraps bilaterally.
Skin: RLE with chronic venous stasis changes, LLE erythematous
and warm to touch from ankle to mid-shin with area of skin
breakdown over medial malleolus surrounded by dried serous
discharge without purulence, mild improvement in erythema from
day prior
Neurological: Alert and oriented x3, motor and sensory exam
grossly intact
Pertinent Results:
Labs on admission:
___ 04:10PM BLOOD WBC-8.5 RBC-5.41 Hgb-15.8 Hct-47.8 MCV-88
MCH-29.2 MCHC-33.1 RDW-14.8 RDWSD-47.3* Plt ___
___ 04:10PM BLOOD Neuts-67.6 Lymphs-17.9* Monos-10.1
Eos-2.5 Baso-0.7 Im ___ AbsNeut-5.74# AbsLymp-1.52
AbsMono-0.86* AbsEos-0.21 AbsBaso-0.06
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-133* UreaN-19 Creat-1.2 Na-131*
K-8.9* Cl-100 HCO3-22 AnGap-18 ** HEMOLYZED **
___ 06:27PM BLOOD K-4.2
___ 04:19PM BLOOD Lactate-2.0
Microbiology on admission:
Blood cultures x2 obtained in ED
Pertinent interval:
___ 6:20 am Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. ___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
___ 6:20 am SEROLOGY/BLOOD
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Imaging on admission:
Plain film left leg
"1. Diffuse soft tissue edema extending distally from the knee.
2. Degenerative disease at the left knee."
Left ___
"No evidence of deep venous thrombosis in the left lower
extremity veins."
TTE
"The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of ___, no clear change."
Labs on Discharge:
___ 07:00AM BLOOD WBC-5.6 RBC-5.86 Hgb-16.9 Hct-52.2*
MCV-89 MCH-28.8 MCHC-32.4 RDW-14.2 RDWSD-45.1 Plt ___
___ 07:40AM BLOOD Glucose-98 UreaN-20 Creat-1.6* Na-134
K-5.5* Cl-98 HCO3-27 AnGap-15
___ 07:40AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ with HTN, HL, early ___ s/p CEA, morbid
obesity, OSA on CPAP, RLS, diverticulitis, NSAID-induced GIB,
alcohol abuse, pancreatitis with cholecystitis s/p PCT, gout,
BPH, and two bouts of cellulitis this year who presented with
recurrent cellulitis in the setting chronic venous ___
edema.
# LLE cellulitis: Patient with multiple episodes of cellulitis
likely related to chronic ___ edema and skin breakdown. No
evidence of systemic infection during his hospital admission. He
was initially treated with IV vancomycin. Given improvement in
clinical exam he was switched to bactrim/keflex with plan for 10
day course through ___. Wound care was consulted with the
following recommendations:
1.Commercial wound cleanser or normal saline to cleanse wounds.
2.Apply Soothe and ___ ointment to bilat LLE.
3.Apply Meglisrob Ag to weeping areas, cover with gauze, wrap
with Kling. Secure with Medipore tape.
He was monitored for 24 hours after transition to PO
antibiotics. His clinical exam improved, though slowly, as his
hospital course progressed. ***On the day prior to his discharge
he was noted to have elevated creatinine. This was 24 hours
after initiation of Bactrim therapy. Bactrim was discontinued as
his cellulitis was nonpurulent and he is discharged only on
Keflex***. He is discharged with close follow up with his PCP
for ongoing monitoring. If there is no significant improvement
despite a 10 day course of antibiotics, he may need
prolongation. He was counseled on leg elevation and ACE wrap
daily.
# Bilateral venous ___ edema: Followed by Dr. ___ in
Podiatry. Evidence of chronic venous stasis changes on exam. No
known hx of CHF though at risk given OSA, HTN, HLD, ___. TTE
shows preserved EF and no clinical hx of heart failure making
this less likely etiology, especially given low BNP of 504. It
does appear, however, that patient has a tendency to retain
fluid which may be partially related to ___. Has been on
amlodipine and had not fully stopped this medication which may
be playing a role. Has been on HCTZ for HTN though switched to
Lasix for better fluid management. He will benefit from ongoing
___ compression stockings. On the day prior to discharge his Cr
noted to rise to 1.5. This was thought secondary to bactrim
therapy rather than overdiuresis, though out of caution his
Lasix has been discontinued pending improvement in renal
function. He will benefit from low dose of Lasix in the future.
Amlodipine remains on hold. Advised to continue compression
stockings/ACE wraps from toes to knees.
# Truncal rash: Patient endorses a 1 month history of rash.
Maculopapular with some areas erythemous and other more
hyperpigmented, worst on LUE but present on top and sides of
back as well as chest. Initially pruritic but now not
bothersome. Pityriasis is a strong possibility as no clear
exposures. Lyme negative, would be somewhat atypical at this
time of year though remains possible. Ddx also includes fungal
infection, syphilis though less likely, especially with
nonreactive RPR. Remained stable and asymptomatic during his
hospital course. Will require outpatient derm follow up.
#Peripheral neuropathy/chronic back pain: Continued gabapentin,
tylenol, oxycodone PRN
# Hx of alcohol abuse/elevated LFTs: Per records patient has not
been an active alcohol abuser recently but patient reports
drinking about 1 bottle of wine 5 days/week. Mild LFT elevation
on admission could be related to ETOH use. Normalized during
admission. Did not score on CIWA during his admission.
# HTN: Patient will need outpatient adjustment of his
antihypertensives as amlodipine has bee discontinued in the
setting ___ edema. HCTZ was initially held in-house in favor
of Lasix for better fluid management. Lasix has been
discontinued as it precipitated ___ as above and he is restarted
on HCTZ on discharge.
# HLD: Continued atorvastatin
# Acute kidney injury
# ___: Patient with Cr 1.2 at baseline. This was thought to play
a role in fluid retention and edema. He was started on Lasix
in-house with significant improvement in ___ edema. On the day
prior to discharge his creatinine rose to 1.5 and did not
improve with IVF. The most likely etiology is secondary to
Bactrim therapy as his creatinine elevation was noted 24 hours
after Bactrim initiation. Bactrim was discontinued. He will need
repeat chemistry panel ___ to ensure stable renal function. If
no improvement or worsening he will require renal follow up.
# OSA: Continued on CPAP
# BPH: Continued on tamsulosin
# Hypogonadism: Held testosterone in-house
# Transitional Issues:
- Amlodipine held given lower extremity edema, will need ongoing
monitoring of HTN and titration of medications
- Keflex through ___ to complete a 10 day course, though
may need prolongation of antibiotic therapy pending ongoing
improvement in exam
- Patient to wear compression stockings/ACE wraps to knees daily
- Please repeat chemistry panel on ___ to ensure ongoing
improvement in ___. If no improvement will require renal follow
up
- Will benefit from low dose Lasix in the future once renal
function stabilizes
- Patient will require dermatology referral for truncal rash
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Gabapentin 200 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. arginine (L-arginine) 3000 mg oral BID
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
10. flaxseed oil 1,000 mg oral DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. Naproxen 220 mg PO Q8H:PRN Pain - Mild
13. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal 2 pumps
daily
14. Viagra (sildenafil) 25 mg ORAL PRN sexual intercourse
15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
16. econazole 1 % topical DAILY
17. Hydrochlorothiazide 12.5 mg PO DAILY
18. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*20 Capsule Refills:*0
2. arginine (L-arginine) 3000 mg oral BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. econazole 1 % topical DAILY
8. flaxseed oil 1,000 mg oral DAILY
9. Gabapentin 200 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4-6H pain
16. Tamsulosin 0.4 mg PO QHS
17. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal 3
pumps daily
18. Viagra (sildenafil) 25 mg ORAL PRN sexual intercourse
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cellulitis
Secondary: Edema, rash, obstructive sleep apnea, hypertension,
alcohol abuse, venous stasis, ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with an infection of the skin in your
left leg. This is likely due to skin damage from your chronic
leg swelling. You were treated with IV antibiotics which were
switched to oral antibiotics, which you should take through
___. Please make sure to wear your leg wraps every day and
to follow up with your PCP and podiatrist regarding your leg
swelling.
During your hospital stay we gave you Lasix to improve the
swelling in your legs. On the day of your discharge, you were
found to be dehydrated, which was reflected in your kidney
function. You were treated with IVF with improvement in your
renal function. You will not be discharged on Lasix at this
time, though a lower dose can be considered by your PCP in the
future.
It was pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
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2187-07-24 00:00:00
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2187-08-08 18:43:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Nafcillin
Attending: ___.
Chief Complaint:
Nausea and unsteady gait with syncopal sensation.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt is a ___ y/o Ambidextrous man with a history of R CEA in
___ and HTN who presented with nausea and unsteady gait with
syncopal sensation. States that symptoms first appeared shortly
after 11 am while sitting at his computer. Sudden onset of
feeling like " Going to loss consciousness", light headed
feeling, that lasted anywhere from 15 sec to 2 min. The symptoms
abated. No vertigo, tinnitus, Diaphoresis or chest pain at that
time. Drove home and then had the sudden onset of the same
symptoms. had to pull over, was able to get home after a short
time stopped, went to go lay down and wife called EMS. Endorses
unsteady gait, not able to describe but maybe boat like feeling
when given this choice. + oscillopsia. No changes to his voice,
no new weakness, diplopia, changes to vision, vomiting,
sensation of being pulled to one side, ear pain, trouble with
swallowing food or liquid. Never had these symptoms before.
Neurology at bedside for evaluation after code stroke activation
within: 10 minutes
Time (and date) the patient was last known well: 11:10 (24h
clock)
___ Stroke Scale Score: -0
t-PA given: No, Reason t-PA was not given or considered: ___
of 0.
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
new focal weakness, numbness, paraesthesia. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever
orchills. 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.
Past Medical History:
Chronic low back pain
Right foot drop
R toe amputation following fracture
Peripheral neuropathy
HTN
Dyslipidemia
carotid atherosclerosis (s/p R CEA ___ prior amaurosis
fugax OD
Obesity
OSA
GERD
UGIB from ___ use ___
prostatitis ___
Gout
s/p L3-4/L4-5 lumbar laminectomy/discectomy ___
Restless leg syndrome
Social History:
___
Family History:
Suspected MI in dad in his ___
Physical Exam:
ADMISSION:
Physical Exam:
Vitals: 97.8 70 181/100 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. clear TM's b/l.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: 2 + edema ___. right toe amputated..
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Normal
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.
There were no paraphasic errors. Pt. was able to name ___
card
items and read ___ card sentences. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt. was
able to register 3 objects and recall ___ at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI, + Nystagmus, fast phase to right, stops with
left gaze, increases with right ward gaze and up gaze.
V: Facial sensation intact to light touch and PP.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. Weber lateralize
to left, but Bone > air conduction b/l.
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.
+ tremor (postural)
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 - -
R Foot drop, has AFO.
-Sensory: Cold sensation decreased to mid shin b/l.
Otherwise no asymmetry with PP in UE/ ___
Vibration from tuning fork not felt until placed on Tibia.
-DTRs:
Bi Tri ___ Pat Ach
L 1 0 1 0 0
R 1 0 1 0 0
Plantar response mute on the left.
-Coordination: + intention tremor b/l.
No clear rebounding or overshoot with mirror movements.
- No sway to one side when sitting with arms crossed
(subjective:
felt like being pulled to the left)
-Gait: Unable to stand him up at this time, would feel really
unsteady just getting up momentarily.
- head thrust to left with VOR lag.
_____________________________________
DISCHAGE:
Physical Exam:
Vitals: 97.9 ___ 129/82 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. clear TM's b/l.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: 2 + edema ___. right toe amputated..
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Normal
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.
There were no paraphasic errors. Pt.able to read and write.
Speech was not dysarthric.Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI, + Nystagmus, fast phase to right, stops with
left gaze, increases with right ward gaze and up gaze. Nystagmus
attenuated since admission physical.
V: Facial sensation intact to light touch and PP.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. Weber midline,
but Bone > air conduction b/l.
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.
+ tremor (postural)
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 - -
R Foot drop, has AFO.
-Sensory: Cold sensation decreased to mid shin b/l.
Otherwise no asymmetry with PP in UE/ ___
Vibration from tuning fork not felt until placed on Tibia.
-DTRs:
Bi Tri ___ Pat Ach
L 1 0 1 0 0
R 1 0 1 0 0
Plantar response mute on the left.
-Coordination: + intention tremor b/l.
No clear rebounding or overshoot with mirror movements.
- No sway to one side when sitting with arms crossed
(subjective:
felt like being pulled to the left)
-Gait: Unable to stand him up at this time, would feel really
unsteady just getting up momentarily.
- head thrust to left with VOR lag.
Pertinent Results:
ADMISSION:
___ 02:02PM BLOOD WBC-7.2 RBC-5.10 Hgb-15.7 Hct-44.8 MCV-88
MCH-30.8 MCHC-35.1* RDW-12.5 Plt ___
___ 02:02PM BLOOD Neuts-77.8* Lymphs-15.1* Monos-5.5
Eos-1.2 Baso-0.4
___ 02:02PM BLOOD ___ PTT-29.2 ___
___ 02:02PM BLOOD Glucose-129* UreaN-17 Creat-1.0 Na-130*
K-3.6 Cl-94* HCO3-25 AnGap-15
___ 02:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
___ 04:55AM BLOOD WBC-5.9 RBC-4.94 Hgb-15.1 Hct-44.2 MCV-90
MCH-30.6 MCHC-34.2 RDW-12.9 Plt ___
___ 12:35PM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-126*
K-3.8 Cl-90* HCO3-29 AnGap-11
___ 07:00AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-134
K-4.3 Cl-98 HCO3-28 AnGap-12
___ 04:55AM BLOOD ALT-47* AST-36
___ 12:35PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.6
___ 07:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
___ 04:55AM BLOOD %HbA1c-5.8 eAG-120
___ 04:55AM BLOOD Triglyc-90 HDL-66 CHOL/HD-2.1 LDLcalc-54
___ 07:00AM BLOOD Osmolal-276
___ 12:35PM BLOOD Osmolal-267*
IMAGING:
CT w/o contrast: No acute intracranial process.
MRI/A w/o contrast:
1. No infarct.
2. Possible high grade stenosis at the origin of the right
vertebral
artery. Either stenosis or artifact at the origin of the left
vertebral artery origin.
3. Possible high-grade stenosis of the left superior cerebellar
artery. There was a possible small aneurysm of the cavernous
segment of the left carotid artery.
CXR: Mild pulmonary vascular congestion.
Brief Hospital Course:
___ y/o man with R CEA, HTN, HLD, heavy ETOH use who presents for
presyncope and unsteady gait.
# Neuro: Exam is significant for R beating nystagmus with
torsional component, worse with R lateral gaze and abnormal head
thrust to the L with ___ saccades back to midline. Weber
midline, Rhinne air > bone b/l. Etiology is most likely a L
vestibular neuronitis. CT negatve and MRI demonstrates no CVA or
other acute process. However, there is narrowing of the right
vertebral artery origin by MRA neck with contrast and possible
narrowing of the left vertebral artery origin versus artifact.
There was possible high-grade stenosis of the left superior
cerebellar artery. There was a possible small aneurysm of the
cavernous segment of the left carotid artery. The patient was
recommended to have repeat MRA brain without contrast and MRA
neck with and without contrast in one year. By discharge,
nystagmus had attenuated though still present. Was feeling much
steadier on his feet. Otherwise, we continued his home
gabapentin 800 mg for neuropathy. ___ evaluated and recommended
walking with cane/walker and outpatient ___ follow-up.
# CV: He remained hemodynamically stable throughout his stay.
His EKG was consistent with prior EKGs with LAD and RBBB. We
continued his home aspirin 81mg. We uptitrated lisinopril from
30mg to 40mg as we stopped the HCTZ 50mg in light of
hyponatremia (see below).
# Renal: Admission labs notable for Na of 130. Given fluids and
allowed to PO; repeat Na was 126. Given volume status, likely a
euvolemic hyponatremia secondary to high-dose HCTZ and some
component of possible SIADH from pramipexole (known side
effect). After holding both these medications, Na was 134. His
final HCTZ dosing was deferred to his PCP but likely patient
will benefit from lower dose. Also, patient's leg cramps have
resolved with correction of Na and the stopping of HCTZ and
pramipexole.
# Endo: A1C 5.8 Total cholesterol 138, HDL 66 and LDL 54.
Maintained normoglycemia during his stay.
# GI: Mild ALT elevation at 47, likely secondary to heavy
chronic alcohol use. We continued his home omeprezole 20mg.
# ID: UA clean and UC with no growth. CXR w/ mild vascular
congestion.
# Tox/met: Serum tox screen negative. Given history of EtOH use,
we initiated CIWA scale. No evidence of withdrawal in the
hospital. We continued his home allopurinol ___ BID.
# FEN: Was put on regular diet and given fluids PRN.
# PPX: Put on subq heparin, bowel regimen, and fall precautions.
Medications on Admission:
-Cialis 5 mg Tab
1 Tablet(s) by mouth once a day
-___ 81 mg tablet,delayed release
1 Tablet(s) by mouth once a day
-allopurinol ___ mg Tab
2 Tablet(s) by mouth once a day
-gabapentin 800 mg tablet
one tablet(s) by mouth three times a day
-hydrochlorothiazide 50 mg Tab
1 Tablet(s) by mouth once a day
-lisinopril 30 mg Tab
1 Tablet(s) by mouth once a day
-naproxen 500 mg Tab
1 Tablet(s) by mouth twice a day as needed for pain
-omeprazole 20 mg Cap, Delayed Release
1 Capsule(s) by mouth once a day
-oxycodone-acetaminophen 5 mg-325 mg tablet
1 (One) tablet by mouth every six
-pramipexole 0.125 mg tablet
1 tablet(s) by mouth once a day before sleep
-tizanidine 2 mg capsule
one tab(s) by mouth at bedtime and increase as tolerated to two
pills qhs and one tab twice during daytime prn pain
-Cialis 5 mg Tab
1 Tablet(s) by mouth once a day
-Arginine (L-Arginine) 500 mg Cap
-AndroGel 1.25 g/Actuation (1%) Transdermal Gel Pump
-triamcinolone acetonide 0.1 % Topical Cream apply to affected
skin twice a day as needed
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Meclizine 25 mg PO Q8H:PRN vertigo
RX *meclizine 25 mg 1 tablet(s) by mouth every 8 hours as needed
for dizziness Disp #*20 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. Tizanidine 2 mg PO QHS
7. Outpatient Physical Therapy
8. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Vestibular dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
admitted for symptoms of lightheadedness and trouble walking. On
exam we found that you have some eye movement abnormalities that
are consistent with a problem with the inner ear or the nerve
that connects the inner ear with the brain. A CT of your head
revealed no abnormalities. An MRI and MRA showed no stroke,
which was our main concern. It did show some narrowing of the
vertebral arteries, and a small aneurysm of your carotid artery,
and both of these things can be followed up in the outpatient
setting; specifically, we recommend another MRI/MRA/MRV of your
brain in ___ year to assess the blood vessels.
Blood tests were sent to evaluate for stroke risk factors and
were normal. Specifically, you had good cholesterol values and
also a normal hemoglobin A1C (a lab test that we use to check
for diabetes). Based on your history, neurological examination,
and testing, your symptoms were due to a vestibular dysfunction.
This is benign and should resolve over ___ weeks.
We continued your home medications of aspirin, atorvastatin,
lisinopril. However, we made some changes. We increased your
lisinopril dose from 30 to 40 mg because we stopped the
hydrochlorothiazide. We stopped this medication and also the
pramipexole because your sodium was low. Your sodium improved
the day after this change. You also told us that your leg cramps
have resolved. It is possible that the low sodium values were
contributing to your leg cramps.
We have set up an appointment with your PCP next week. You also
have an appointment with Dr. ___ attending physician who
took care of you in the hospital. Physical therapy recommended
walking with a cane/walker and following-up with them as an
outpatient.
Followup Instructions:
___
|
10745469-DS-9
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DS
| 9 |
2188-02-05 00:00:00
|
2188-02-09 17:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending: ___.
Chief Complaint:
Right foot rash
Major Surgical or Invasive Procedure:
Mid-line placement
History of Present Illness:
___ M w/ HTN, HL, OSA, alcohol dependence, severe neuropathy with
chronic right great toe ulcers now s/p amputation and recent
course of bactrim for cellulitis of the stump who presents with
worsening right lower leg redness since yesterday. His ulcer had
reportedly been healing well and he finished a long course of
bactrim (?2 months) about 2 weeks ago when he noticed his leg
looking more red today. Checked the skin temp and found his
right leg was 5 degrees warmer than his right. Also having mild
pains in his right groin and erythema on thigh. Sent here from
podiatrist office due to concern for worsening cellulitis. has
been having myalgias xfew days. Tmax at home was 100.6.
In the ED, initial vs were: T 100.5, HR 90, BP 146/73, RR 16, O2
97% RA. Exam notable for erythema of right leg spreading up into
thigh but not reaching scrotum. Labs were remarkable for WBC
12.8 (95% PMNs), Cr 1.3 (baseline 1.0-1.2), Na 128. Patient was
given tylenol and vancomycin for cellulitis and admitted to
medicine for further management.
On the floor, the patient is feeling ok but not as well as a few
days ago. Feeling mildly warm with some muscle aches.
Past Medical History:
- Obstructive sleep apnea on CPAP
- Alcohol abuse
- Hypertension
- Hyperlipidemia
- Obesity
- Gout
- Restless leg syndrome
- Diverticulitis
- UGIB secondary to NSAIDs ___
- RLE foot drop secondary lumbar radiculopathy
- S/P right carotid endarterectomy for amaurosis fugax OD ___
- S/P L3-4/L4-5 lumbar laminectomy/discectomy ___
- S/P right hallux fracture, osteomyelitis, amputation ___.
Social History:
___
Family History:
Suspected MI in dad in his ___
Physical Exam:
Admission:
Vitals: T 100.1 BP: 105/70 P:76 R: 20 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds due to body habitus, regular rate and
rhythm, normal S1 + S2, cannot appreciate any murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: right foot missing great to with small ~1cm diameter
shallow based healed ulcer that appears to be healing on plantar
side of stump. Erythema and 2+ pitting edema of right leg
spreads from foot up to knee, with a second confluent area
spreading up medial thigh and into groin.
Neuro: A&O x3, no asterixis, strength ___ for right dosiflexion
otherwise ___ in UE and ___. No sensation in right foot up to
ankle.
Discharge:
Vitals: Tm 100.0 Tc 99.4 BP: ___ P: ___ R: 20 O2:
100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds due to body habitus, regular rate and
rhythm, normal S1 + S2, cannot appreciate any murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: right foot missing great to with small ~1cm diameter
shallow based healed ulcer that appears to be healing on plantar
side of stump. Erythema and 2+ pitting edema of right leg
spreads from foot up to knee,more red than yesterday. Erythema
up to groin resolving.
Neuro: A&O x3, no asterixis, strength ___ for right dosiflexion
otherwise ___ in UE and ___. No sensation in right foot up to
ankle.
Pertinent Results:
Admission:
___ 06:46PM BLOOD WBC-12.8*# RBC-5.27 Hgb-16.6 Hct-48.2
MCV-91 MCH-31.4 MCHC-34.4 RDW-13.5 Plt ___
___ 06:46PM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-128*
K-4.2 Cl-91* HCO3-25 AnGap-16
___ 08:00AM BLOOD Albumin-4.0 Calcium-9.1 Phos-1.8*# Mg-1.8
___ 07:10AM BLOOD Osmolal-265*
Discharge:
___ 07:20AM BLOOD WBC-9.0 RBC-4.43* Hgb-14.2 Hct-39.9*
MCV-90 MCH-32.0 MCHC-35.6* RDW-13.5 Plt ___
___ 07:20AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-131*
K-3.7 Cl-96 HCO3-23 AnGap-16
___ 07:20AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.7
Imaging:
Foot Xray: No evidence of osteomylitis
RLE ultrasound:
IMPRESSION: Subcutaneous edema without discrete fluid
collection.
Brief Hospital Course:
# Cellulitis: Pt presented with cellulitis of right lower
extremity. Confluent erythema extended from foot to just below
knee with patches of cellulitis spanning up thigh into groin,
sparing scotum. Infection was thought to be secondary to
lymphedema of right leg. There were no ulcerations on foot at
site of previous amputation of right great toe. Previous ulcer
from earlier this year appeared well healed without surrounding
erythema. There were no clinical findings on exam to suggest
osteomyelitis and ankle had full range of motion. A foot xray
had no findings suggestive of osteomyelitis. His history was
discussed with his outpatient podiatrist who noted his previous
ulcer of right great toe 4 months prior was shallow and he had
low concern for osteomyelitis. Pt was initially empirically
started on IV vancomycin. Initial blood cultures grew group a
strep and he was narrowed to ceftriaxone as he has nafcillin
allergy. He has tolerated cephlosporinsin past. He will receive
a total 14 day course of cetriaxone as an outpatient.
# Group A Strep Bacteremia: Most likely secondary to cellulitis.
A PICC line was placed and he will complete a 14 day course of
ceftriaxone as an outpatient.
# Hypertension: BP was below baseline this admission; most
likely secondary to bacteremia. His antihypertensives were
intially held. He was restarted on his home lisinopril. His
amlodipine was held at time of discharge as it is most likely
contributing to lower extremity edema. His HCTZ was held in
setting of hyponatremia.
# Alcohol dependence: Pt promotes drinking over a liter of wine
per night. He was placed on CIWA but did not trigger. He was
started on thiamine and folate.
# Hyponatremia: Appears to have a mixed etiology with HCTZ
contributing. Hypovolemia most likely was also contributing.
Sodium uptrended from 127 by holdng HCTZ and with IV fluids.
However, his urine osmols were >600 which is most frequently
seen with a component of SIADH. During his previous admission he
was also hyponatremic and etiology was thought to be secondary
to both HCTZ and chronic SIADH. He was asymptomatic this
admission.
Chronic Issues Managed:
# OSA: continued CPAP
# Hyperlipidemia: continued atorvastatin
# Neuropathy: continued home gabapentin
Transitions of Care:
#Pt will complete a 2 week course of ceftriaxone as an
outpatient
#Amlodipine and HCTZ are being held at dishcharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
3. Gabapentin 800 mg PO TID
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. arginine (L-arginine) *NF* 3 g Oral BID
7. Amlodipine 5 mg PO DAILY
Hold for SBP <110
8. Multivitamins 1 TAB PO DAILY
9. flaxseed oil *NF* unknown Oral daily
10. tadalafil *NF* 5 mg Oral daily PRN sexual activity
11. Omeprazole 20 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. cod liver oil *NF* unknown Oral daily
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 1 bag IV daily
Disp #*11 Bag Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. arginine (L-arginine) *NF* 3 g Oral BID
11. cod liver oil *NF* 1 tab ORAL DAILY
12. flaxseed oil *NF* 1 pill ORAL DAILY
13. tadalafil *NF* 5 mg Oral daily PRN sexual activity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Celllulitis of right leg
Secondary Diagnosis:
Peripheral neuropathy of right leg with right foot drop
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in with a right leg pain and rash which
we believe is due to cellulitis. You were also found to have
bacteria in your blood which most likely spread from the skin
infection of your leg. We started you on IV antibiotics, which
you will require for 2 weeks. You will follow up at ___ on ___ to monitor further response to treatment.
We stopped your amlodipine this admission as we believe it is
contributing to your leg swelling.
Followup Instructions:
___
|
10745480-DS-19
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DS
| 19 |
2187-11-12 00:00:00
|
2187-11-13 08:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Slurred speech, facial droop, altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ o ___ M with recurrent anaplastic glioma status
post 20 cycles of metronomic temozolomide since ___ with
progression of disease and prior CVA ___ who presents to the ED
with AMS.
.
Per wife patient had acute onset of slurred speech, altered
mental status and left facial droop with ataxia starting at 6pm
on ___ (time when found by wife, last seen normal at 11:30
am). No tongue biting, no witnessed limb shaking. Evaluated by
neurology on presentation to the ED - NIHHS of 7. Head CT was
negative for any acute process, unchanged from ___.
Patient was febrile to 101.2. CXR and urinalysis unremarkable.
Neurology felt this was consistent with post-ictal state vs
worsening edema from tumor. Discussed with Dr. ___
and recommended 4mg iv decadron and omed admission.
.
Of note, patient was admitted ___ after episode of slurred
speech, AMS and facial droop. Interestingly was also febrile to
101 in the ED. Patient thought to be s/p seizure and in a
post-ictal state therefore he received a load of Keppra and his
dose was increased to 1500mg bid. Infectious w/u was negative.
.
Regarding patient's recurrent anaplastic glioma, recent MRI
showed increase in right parietal lesion. Patient recently had
a portacath placed with plan to initiate bevacizumab.
.
ROS: unable to obtain due to AMS - answers every question with
"i'm good"
Past Medical History:
1) Left parietal oligodendroglioma: Diagnosed in ___ by brain
biopsy in ___. Treated with involved-field cranial irradiation
in ___.
- MRI ___ revealed unchananged left parietal mass effect
- status post 20 cycles of metronomic temozolomide since
___
- portacath placed
- awaiting initiation of bevacizumab
2) CVA right internal capsule ___
3) GIB
-in setting of duodenal ulcer ___ yrs ago
- melena in ___, attributed to duodenitis
4) Colon ademoma: cls ___
Social History:
___
Family History:
Mother stroke at age ___, father CAD, paternal aunt with "benign
frontal tumor" and cousin with brain tumor.
Physical Exam:
ADMISSION EXAM:
VS 97.2 133/83 71 20 96%RA
Appearance: disoriented, eyes opened, slow to follow commands
Eyes: injected sclera, eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: + left lower facial droop, + pronator drift on right,
strength and sensation intact, normal finger-to-nose, downgoing
babinskis
Skin: no rashes
Psych: disoriented
Heme: no cervical ___
___ Results:
ADMISSION LABS:
___ 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:49PM LACTATE-1.1
___ 08:45PM GLUCOSE-109* UREA N-14 CREAT-0.7 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 08:45PM WBC-6.6 RBC-4.15* HGB-13.5* HCT-38.0* MCV-92
MCH-32.5* MCHC-35.5* RDW-13.1
___ 08:45PM NEUTS-76.5* LYMPHS-15.1* MONOS-6.9 EOS-0.9
BASOS-0.6
___ 08:45PM PLT COUNT-197
___ 08:45PM ___ PTT-34.1 ___
.
___ CT HEAD: IMPRESSION: No interval change from ___.
Postoperative changes and findings consistent with history of
surgery and radiation for glioma. No acute hemorrhage.
.
___ CXR: IMPRESSION: No acute cardiopulmonary process.
.
___ MRI BRAIN: IMPRESSION: Progressive increase in area of
enhancement in the left parietal region since ___.
Confluent areas of enhancement demonstrate no definite increase
in perfusion or abnormally slow diffusion. These findings may
represent pseudo-progression related to radiation/chemotherapy.
Close attention on followup imaging is recommended.
.
___ MRI BRAIN: IMPRESSION:
1. Essentially unchanged left parietal irregular enhancing
lesion.
2. Confluence of biparietal FLAIR hyperintensity, left greater
than right, unchanged and likely related to radiation and
chemotherapy.
3. No new abnormal restricted diffusion to suggest new ischemia.
No new enhancing focus.
.
___ EEG: PRELIM: IMPRESSION: Abnormal EEG due to the
prominent left posterior quadrant focal delta slowing. This
suggests a focal subcortical dysfunction, likely structural. The
skull defect can account for some of the mildly sharp features,
but the slowing suggests a subcortical and likely structural
defect. There were no definitely epileptiform features.
Brief Hospital Course:
___ man with refractory anaplastic oligodendroglioma with
recent progression while on temazolamide admitted for altered
mental status, slurred speech, and fever.
.
# Altered mental status, slurred speech, ataxia: Due to tumor
progression as seen on MRI ___. Pt had similar
hospitalization ___, EEG then did not show seizure activity.
CT head and repeat MRI now unchanged and EEG showed no seizure
activity. Neuro-oncology was consulted and pt was started on
Dexamethasone. He should continue on 2mg q 6hr for this next
week and this will be adjusted by Dr. ___ on ___.
.
# Fever: Resolved without antibiotics, unclear source. CXR, U/A
and Blood cultures were negative.
.
# Oligodendroglioma: Planning to start bevacizumab and
irinotecan as outpatient on ___.
.
# CVA history: Continued on dipyridamole. MRI brain showed no
acute ischemia.
.
# Hyperlipidemia: Continued outpatient statin.
.
# PPX: PPI and Calcium VitD due to steroid use
.
# ___ needed at discharge. He will be discharged to ___ for this.
Medications on Admission:
DIPYRIDAMOLE 75 mg PO BID
FOLIC ACID 1 mg PO daily
LEVETIRACETAM 1500 mg PO BID
PRAVASTATIN 20 mg PO daily
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] 20 mg PO daily
Discharge Medications:
1. dipyridamole 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Word finding difficulties.
2. Alterede mental status (confusion).
3. Ataxia (difficulty walking).
4. Fever.
5. Anaplastic oligodendroglioma (brain cancer).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for word finding difficulties,
confusion (altered mental status), and fever. The fever
resolved without antibiotics and tests did not find an
infection. The neurologic symptoms (word finding difficulties
and confusion) improved, but are likely due to a tumor in your
brain that is still growing (anaplastic oligodenroglioma). You
will start chemotherapy ___ at 4:30PM.
Physical Therapy and Occupation Therapy felt that you would
benefit from ___ rehab, so you were discharged to a rehab
facility prior to starting chemotherapy.
.
MEDICATION CHANGES:
1. Dexamethasone (Decadron) 4mg every 6 hours.
2. Calcium and vitamin D while on dexamethasone.
Followup Instructions:
___
|
10745480-DS-21
| 10,745,480 | 23,500,589 |
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| 21 |
2188-02-21 00:00:00
|
2188-02-21 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hallucinations.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ ___ speaking man with recurrent
anaplastic glioma admitted for acute onset of hallucinations
described as ants running on the floor and monkeys playing in
the hallway as well as seeing rain but denies any other
complaitns. Wife states that patient has had word finding
difficulties. Last time that happend patients wife was told it
was due to seizure.
In the ER initial vitals were: T 98.7 F, HR 88, BP 122/88, RR
18, and SaO2 96% in room air. Laboratory studies were
unremarkable but wet read of head CT was notable for worsening
right frontoparietal white matter hypodensities, likely edema,
concerning for a new underlying lesion. Patient was admitted to
Oncology service to be seen by Neuro-Oncology.
On arrival to the floor, the patient continued to talk about
hallucinations of monkeys in the hallways, but was otherwise not
complaining of anything. There is no headache, fevers, chills,
vision, problems.
Past Medical History:
Recurrent anaplastic glioma
- CVA right internal capsule ___
- GIB in setting of duodenal ulcer ___ yrs ago; melena in ___,
attributed to duodenitis
- Colon ademoma: cls ___
Social History:
___
Family History:
Patient unable to recall any illnesses.
Physical Exam:
VITAL SIGNS: Temperature 97.7 F, pulse 77, blood pressure
127/72, respiration 18, and oxygen saturation 100% in room air.
GENERAL: NAD, comfortable. Alert, appropriate.
HEENT: PERRL, EOMI, no nystagmus, no oral lesions, conjuctival
erythema L>R. Alopecia noted on left temporal aspect of head.
CHEST: CTAB, no use of accessory muscles
CARDIOVASCULAR: RRR no m/r/g
ABDOMEN: +BS NTND soft
EXTREMITIES: No edema, 2+ pulses, no lesions
PSYCHIATRY: Patient denies visual or auditory hallucinations
NEUROLOGICAL EXAMINATION: His ___ Performance Score is
60. He is awake, alert, and able to follow simple commands.
His language is fluent but he has problems with comprehension.
He has psychomotor slowing. Cranial nerve examination: His
pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally. Extraocular movements are full. Visual fields are
full to
confrontation. His face is symmetric. Facial sensation is
intact bilaterally. Hearing is intact bilaterally. His tongue
is midline. Palate goes up in the midline. Sternocleidomastoids
and upper trapezius are strong. Motor examination: He does not
have a drift. His muscle strengths are ___ at all muscle
groups. His muscle tone is normal. His reflexes are 2- and
symmetric
bilaterally. His ankle jerks are absent. His toes are down
going. Sensory examination is intact to touch and
proprioception. Coordination examination reveals no dysmetria.
Gait and stance are deferred.
Pertinent Results:
Admission Labs:
___ 08:51PM WBC-6.8# RBC-4.07* HGB-12.9* HCT-39.7*#
MCV-97# MCH-31.7 MCHC-32.5 RDW-15.9*
___ 08:51PM NEUTS-79.8* LYMPHS-14.4* MONOS-5.5 EOS-0
BASOS-0.2
___ 08:51PM PLT COUNT-192
___ 08:51PM GLUCOSE-116* UREA N-17 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___
Reports:
CT Head ___:
1. In this patient with known oligodendroglioma status post
treatment, there is stable moderate vasogenic edema in the left
frontoparietal lobes, secondary to the residual lesion in the
left frontal lobe seen in the prior MRI of ___. Lack of
contrast limits evaluation of the residual tumor.
2. Stable to slightly increased right frontoparietal white
matter hypodensities, may represent vasogenic edema and an
underlying lesion cannot be excluded.
3. Stable extensive small vessel ischemic disease and post
treatment changes. An MRI with contrast is recommended for
further assessment of the above findings.
CXR ___: No acute cardiopulmonary pathology.
MRI Head ___: 1. An irregular enhancing lesion in the left
parietal and posterior temporal lobe, with subependymal
infiltration along body and occipital horn of left lateral
ventricle. There is increase in the size of the enhancing
component with increased FLAIR hyperintensity in the left
parietal lobe. These may represent post treatment changes versus
tumor progression. Continued follow up is advised. 2. No
evidence of acute infarct.
EEG ___: PENDING
Brief Hospital Course:
___ is a ___ man with recurrent anaplastic glioma
and history of CVA and seizures who was admitted with acute
onset of hallucinations and word finding difficulties with head
imaging suggestive of worsening neoplastic disease of the brain.
(1) Hallucinations and Aphasia: He was admitted to the
neuro-oncology service and started on dexamethasone for concern
for worsening of his glioma on CT head. He then underwent MRI
which also showed worsening of disease, which was felt to be
underlying his hallucinations and word-finding difficulties.
Workup for other causes of mental status changes (including
infectious and toxic-metabolic workup including B12, RPR, TSH)
was normal. He was given IV thiamine for potential contribution
of Wernicke's but this was considered unlikely. He also had an
EEG which showed no epileptiform activity (per prelim read) but
some continuous left-sided slowing, and his keppra dosing was
changed to TID dosing. He will be discharged to rehab and
return for outpatient Avastin with Dr. ___ next week.
Antipsychotics were not needed during this hospitalization.
(2) Stroke: Continued on pravastatin and dipyridamole
(3) Hypertension: Continued dipyradimole
(4) History of GI Bleed: He had no evidence of bleeding during
this admission and his hematocrit remained stable.
TRANSITIONAL CARE ISSUES:
- Should return to ___ outpatient chemotherapy infusion
unit on ___ at 11:00am to start bevacizumab.
- EEG is still pending although preliminary read was consistent
with encephalopathy and no seizures.
Medications on Admission:
DIPYRIDAMOLE - 75 mg Tablet - 1 Tablet(s) by mouth twice a day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
HYDROCODONE-ACETAMINOPHEN [VICODIN] - 5 mg-500 mg Tablet - ___
Tablet(s) by mouth q 4 hours prn pain ___ substitute with
tylenol, but do not take in place of tylenol. Do not drive while
on this medication.
LEVETIRACETAM - 500 mg Tablet - 3 Tablet(s) by mouth twice daily
PRAVASTATIN - (Prescribed by Other Provider; Dose adjustment -
no new Rx) - 20 mg Tablet - 1 Tablet(s) by mouth daily
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider; 100
bid) - Dosage uncertain
LOPERAMIDE [LO-PERAMIDE] - 2 mg Tablet - 2 Tablet(s) by mouth at
increased bowel movement then 1 tab every 2 hours (no more than
16 mg daily)
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. dipyridamole 75 mg Tablet Sig: One (1) Tablet PO twice a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Anaplastic Glioma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker or cane).
Discharge Instructions:
You were admitted to the hospital due to hallucinations. You
had a repeat MRI of your head which showed worsening of your
glioma. You were placed on higher dose steroids and your
symptoms improved but did not go away completely. You were also
seen by physical therapy who felt that you would benefit from
rehab.
CHANGES to your medications:
ADD dexamethasone 4mg by mouth twice daily
CHANGE keppra to 1000mg by mouth three times daily
Followup Instructions:
___
|
10745480-DS-24
| 10,745,480 | 25,634,538 |
DS
| 24 |
2188-06-29 00:00:00
|
2188-06-30 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
Nasogastric tube placement
Jejunum tube placement
History of Present Illness:
___ is a ___ man with a history of left parietal
oligodendroglioma, s/p cranial irradiation with recurrence of
anaplastic glioma most recently treated with bevacizumab who
presents from his ___ nursing facility with concerns for
evaluation for tachycardia.
The patient's son is accompanying the patient states that his
current mental status and neurological status is at his baseline
which is awake but disoriented. Patient's baseline heart rate
is in the 90's.
In the ED, initial vital signs: T 98.6 F, HR 147, BP 149/108, RR
20, and oxygen saturation 100% in non-rebeather mass. The
patient had a head CT which on preliminary read shows mass in
the left frontoparietal increased since ___, with no new
hemmhorage or mass effect, no herniation, more sulcal
effacement. The patient was noted to be tachycardic at 147 bpm.
Patient was noted to have a lactate of 3.2 on presentation.
The patient's heart rate and lactate improved after 3L of NS.
Vital signs prior to transfer: T 98.2, HR 107, BP 134/88, RR 18,
and SaO2 95% in room air.
Upon arrival to the floor, patient's heart rate was 110.
Patient appeared in no acute distress.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Left parietal oligodendroglioma (there was previously no
confirmatory pathology unfortunately). He had:
(1) a brain biopsy of a mass in the left parietal brain in ___,
(2) s/p involved field cranial irradiation to the left parietal
brain in ___,
(3) hospitalized at ___ Service from
___ to ___ for stroke,
(4) s/p stereotactic brain biopsy for recurrent anaplastic
glioma by ___, M.D., Ph.D. on ___,
(5) status post 22 cycles of metronomic temozolomide from
___ to ___,
(6) status post observation in OMED Service on ___,
(7) status post hospitalization in OMED Service from ___ to
___,
(8) status post 1 cycle of irinotecan from ___ to ___,
(9) status post OMED Hospitalization from ___ to ___
for bright red blood per rectum secondary to hemorroid bleed,
(10) status OMED hospitalization from ___ to ___ after
change in mental status, and
(11) started C1D1 bevacizumab on ___ and had 3 cycles so
far.
PAST MEDICAL HISTORY:
--Lower GI Bleed due to hemorrhoids earlier this year
--S/P Port-a-cath in ___
--CVA right internal capsule in ___
--GIB in setting of duodenal ulcer ___ yrs ago
--Melena in ___, attributed to duodenitis
--Colon adenoma in ___
--Right-sided hemiparesis s/p CVA
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ADMISSION EXAMINATION:
VITAL SIGNS: T:97.7 F, BP:157/92, HR:110, RR:18, and 02
saturation: 96% in room air
GENERAL: NAD
SKIN: Warm and well perfused, scab over right knee, no other
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry muscous membranes, good dentition, nontender
supple neck, no LAD, no JVD
CARDIAC: Soft heart sounds, RRR, S1/S2, no murmers, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEUROLOGICAL EXAMINATION: His Ka___ Performance Score is
50. He is awake, alert, but mute. He has significant
psychomotor slowing. Cranial nerve examination: His pupils are
equal and reactive to light, 4 mm to 2 mm bilaterally.
Extraocular movements are full. Visual fields are full to
confrontation. His face is symmetric. Facial sensation is
intact bilaterally. Hearing is intact bilaterally. His tongue
is midline. Palate
goes up in the midline. Sternocleidomastoids and upper
trapezius are strong. Motor examination: He has right
hemiplegia with flaccidity. does not have a drift. He can move
his left upper and left lower extremities readily. His muscle
tone is decreased on the right side. His reflexes are ___ and
symmetric
bilaterally. His ankle jerks are absent. His right toe is up
while the left is down going. Sensory examination is intact to
touch and proprioception. Coordination examination reveals no
gross appendicular dysmetria. He cannot walk.
DISCHARGE EXAMINATION:
VITAL SIGNS: T:98.9 F, BP:152/100, HR:98, RR:18, O2 saturation
96% in room air
GENERAL: NAD
SKIN: Warm and well perfused, scab over right knee, no other
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry muscous membranes, good dentition, nontender
supple neck, no LAD, no JVD
CARDIAC: Soft heart sounds, RRR, S1/S2, no murmers, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: J-tube is in, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEUROLOGICAL EXAMINATION: His ___ Performance Score is
40. He can open his eyes to voice but cannot follow simple
commands. He is mute. He has significant psychomotor slowing.
Cranial nerve examination: His pupils are equal and reactive to
light, 4 mm to 2 mm bilaterally. He has divergent gaze. Visual
fields appears decreased to threat on the right side but intact
on the left. His face is symmetric. Corneals are intact. His
tongue is midline. He can turn his head from side to side but
not shrug his shoulders. Motor examination: He has right
hemiplegia with flaccidity. He can move his left upper and left
lower extremities readily and the amount of movement has
decreased. His muscle tone is decreased on the right side. His
reflexes are
3+ on the right and 2+ on the left. His ankle jerks are absent.
His right toe is up while the left has triple flexion. Sensory
examination is intact to pinch. Coordination examination
reveals no gross appendicular dysmetria. He cannot walk.
Pertinent Results:
Complete blood count:
___ 12:15PM BLOOD WBC-9.9# RBC-4.36* Hgb-13.9* Hct-41.3
MCV-95 MCH-31.9 MCHC-33.6 RDW-16.2* Plt ___
___ 04:29AM BLOOD WBC-5.5 RBC-3.57* Hgb-11.6* Hct-34.0*
MCV-95 MCH-32.5* MCHC-34.1 RDW-16.1* Plt ___
___ 06:00AM BLOOD WBC-4.6 RBC-3.28* Hgb-10.7* Hct-31.2*
MCV-95 MCH-32.6* MCHC-34.4 RDW-15.9* Plt ___
___ 02:40AM BLOOD WBC-6.0 RBC-3.33* Hgb-10.7* Hct-30.7*
MCV-92 MCH-32.2* MCHC-34.9 RDW-16.7* Plt ___
___ 05:00AM BLOOD WBC-4.3 RBC-3.57* Hgb-11.4* Hct-33.6*
MCV-94 MCH-31.9 MCHC-34.0 RDW-16.3* Plt ___
CHEMISTRIES:
___ 12:15PM BLOOD Glucose-183* UreaN-20 Creat-0.6 Na-141
K-3.4 Cl-104 HCO3-26 AnGap-14
___ 05:00AM BLOOD Glucose-76 UreaN-10 Creat-0.4* Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
___ 05:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
LACTATE
___ 12:16PM BLOOD Lactate-3.2*
___ 02:57PM BLOOD Lactate-1.7
Discharge Labs:
___ 06:00AM BLOOD WBC-5.9 RBC-3.46* Hgb-10.8* Hct-32.5*
MCV-94 MCH-31.3 MCHC-33.3 RDW-17.0* Plt ___
___ 06:00AM BLOOD Glucose-96 UreaN-13 Creat-0.4* Na-142
K-3.6 Cl-104 HCO3-30 AnGap-12
___ 06:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.___
IMPRESSION: Ill-defined density in left parieto-occipital
region with sulcal effacement is increased since ___
and likely increased since ___, suggesting interval
growth of known oligodendroglioma, although MR technique is
better for detection of subtle change. No new hemorrhage or
shift of midline structures.
CHEST X-RAY ___
Extremely low lung volumes. Increased opacity at the left lung
base laterally, potentially due to atelectasis; however,
infiltrate cannot be excluded. Repeat exam with better
inspiratory effort may offer additional detail if patient is
amenable.
MRI HEAD ___
IMPRESSION: Continued interval enlargement of the infiltrative
mass in the left cerebral hemisphere, with new sulcal effacement
and leptomeningeal infiltration superiorly. Increased
surrounding high T2 signal may represent a combination of edema
and tumor infiltration, including in the splenium of the corpus
callosum.
FLUOROSCOPY ___
1. Unsuccessful placement of a percutaneous gastric feeding tube
given
persistent sub costal position of the stomach despite maximal
air
insufflation.
2. Placement of a ___ nasogastric feeding tube
under fluoroscopic guidance.
CXR ___
FINDINGS: As compared to the previous radiograph, a Dobbhoff
catheter has been advanced. The catheter tip now projects over
the lower end of the C-loop. No evidence of complications,
notably no pneumothorax. Otherwise, unchanged low lung volumes,
borderline size of the cardiac silhouette and unchanged left
pectoral Port-A-Cath.
Brief Hospital Course:
___ is a ___ man with a history of left parietal
oligodendroglioma s/p cranial irradiation with recurrence of
anaplastic glioma most recently treated with bevacizumab who
presented from his SNF for evaluation for unexplained
tachycardia.
(1) Tachycardia: Likely secondary to volume depletion, which
was supported by the finding of hyaline casts on urinalysis as
well as the patient's heart rate responding to fluid boluses in
the ED and on the floor. Review of the patient's previous lab
work suggests that the patient may have been hemoconcentrated as
his HCT on admission today is 41.3, whereas on previous checks
the patient's HCT was 34-38. Given the patient has a history of
stroke, there was concern for ACS but troponins were flat. EKG
in ED showed sinus tach and questionable S1Q3T3 finding. PE was
on differential given history of malignancy and EKG showing
S1Q3T3 and CXR showing questionable atelectasis vs infection.
Patient's O2 saturation remained in ___ during his hospital
course and given that his heart rate came down to below 100 with
IV fluids therefore CTA for PE was not done. The patient had
been taking ritalin at ___ which was discontinued during his
hospital stay.
(2) Nutrition: As patient could not tolerate a diet by mouth,
it was attempted to place a PEG tube so pt could receive tube
feeds. This was attempted by interventional radiology and was
unsuccessful given that patient's stomach was located in chest.
An NG tube was placed under sedation on two separate occasions
as pt pulled out first NG tube. Sedation was used as pt was
unlikley to tolerate NG tube placement while on the floor at
bedside. Patient currently has NG tube and has been receiving
tube feeds on the floor for nutrition. Patient received
Isosource 1.5 Cal started at 20ml/hr with goal for 55ml/hr. The
family wanted pt to receive tube feeds as the family has the
goal to keep him alive until other family members can travel
here from ___ to say their goodbyes the end of ___. A
jejunal tube was placed ___. Postoperatively he developed
erythema surrounding the surgical site which was initially
conerning for cellulitis. He received one dose of vancomycin.
His examination was more consistent with small post-operative
hematoma and his vancomycin was stopped.
(3) Altered Mental Status: Patient was reported to be alert and
oriented times zero. Patient would wake up upon being aroused
and would grunt. Pt was not able to follow commands. He would
occasionally grunt or nod his head when asked questions in
___.
(4) Left Parietal Oligodendroglioma: Patient was continued on
his anti-seizure meds through an IV as pt was unable to swallow
pills, IV levetiracetam. And he was continued on IV
dexamethasone to reduce inflammation in the brain given
patient's brain tumor as he could not tolerate PO dexamethasone.
(5) GERD: As patient could not tolerate PO omeprazole patient
was given IV pantoprazole.
(6) History of Stroke: Stain was discontinued as it was no
longer needed and pt could not swallow it.
(7) Goals of Care: After discussion with patient's wife,
patient's code status was changed to DNR/DNI while in hospital.
All non-essential medications were stoppped. His family decided
to transition his care to a goal of comfort. It was decided to
continue tube feeds while he was still able to communicate with
his wife via non-verbal communication. He should be
transitioned to hospice when his mental status worsens.
Transitional Issues:
(1) Transition to hospice when patient becomes less alert and is
no longer to communicate non-verbally with his wife.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from SNF.
1. Acetaminophen 650 mg PO Q4H:PRN pain
No more than 4g in 24 hours
2. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q4H:PRN pain
do not exceed 4g APAP in 24 hours
3. Loperamide 4 mg PO QID:PRN Diarrhea
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Senna 1 TAB PO BID:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Vitamin D 400 UNIT PO BID
8. LeVETiracetam Oral Solution 1000 mg PO TID
9. Omeprazole 20 mg PO DAILY
10. Dexamethasone 4 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Pravastatin 20 mg PO DAILY
14. MethylPHENIDATE (Ritalin) 15 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg NG Q4H:PRN pain No more than 4g in 24
hours
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Senna 1 TAB PO BID:PRN Constipation
5. Dexamethasone 4 mg IV DAILY
6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
7. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
9. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN pain
10. Pantoprazole 40 mg IV Q24H
11. LeVETiracetam 1000 mg IV TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: sinus tachycardia, volume depletion, left parietal
oligodendroglioma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with elevated heart rate
called tachycardia. This was most likely caused by dehydration
or not having enough to eat or drink. You were given
intravenous fluids and your tachycardia improved. We attempted
to place a feeding tube into your stomach but we were unable to
complete this procedure. An feeding tube was then placed
through your nose and down into your stomach. You were given
tube feeds through this tube. This tube was then removed and a
tube was placed in your intestine, called the jejunum.
Followup Instructions:
___
|
10745635-DS-5
| 10,745,635 | 27,183,970 |
DS
| 5 |
2184-09-08 00:00:00
|
2184-09-08 21:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
worsening Cr; fatigue, dyspnea, pruritis
Major Surgical or Invasive Procedure:
Hemodialysis initiation on ___ and ___
History of Present Illness:
___ female with a history of type 1 diabetes complicated
by nephropathy, followed at ___. Reports she was at a
6 week visit yesterday for routine labs and was called today to
come to the emergency department for a GFR less than 9. The
patient did have a brachiocephalic fistula creation in ___ of
this year, but has not had this evaluated for maturity. Her
symptoms at home included weakness with difficulty breathing
upon walking further than 10 steps at a time, pruritus over the
past one to 2 weeks, and significantly increased bilateral lower
extremit swelling over the past several days. Denies any
confusion, chest pain, decrease in urine output.
In the ED, she was significantly hypertensive to 200/71, and
afebrile. Labs were notable for BUN/creatinine of 105/8.2, and
bicarbonate of 15. Hgb was 9.7. She was given 650mg bicarb.
Transplant surgery has been consulted to evaluate the maturity
of her AV fistula. Nephrology was consulted to plan initiation
of hemodialysis during this admission.
On the floor, she continues to have diffuse puritis. Otherwise,
ROS negative except as noted above.
Past Medical History:
T1DM
Stage V CKD due to diabetic nephropathy
hyperlipidemia
hypertension
dysthymic disorder
orthostatic hypotension
hyperparathyroidism
Social History:
___
Family History:
Per OMR: Her mother died at the age of ___. Father died at the
age of ___. She has two siblings, one sister and one brother,
both are healthy.
Physical Exam:
*Admission Physical*
Vitals: T: 98.3 BP: 134/59 P: 68 R: 18 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, dry cracked
erythematous skin over left eye
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness
Ext: Warm, well perfused, 2+ pulses DP pulses, 2+ pitting edema
to below knees bilaterally
Skin: No rashes or ulcerations over feet, legs, arms, abdomen or
back
Neuro: A&Ox3, grossly intact
*Discharge Physical*
Vitals: Afebrile, SBP ranging 130s-160s, HR ___, RR 18
General: Comfortable, alert, well appearing post-dialysis
HEENT: Sclera anicteric, MMM, OP clear
Lungs: Clear to auscultation bilaterally, good air movement
CV: RRR
Abdomen: Soft, nontender, nondistended
Extremities: 2+ edema to knees bilaterally
Skin: Resolving petechial rash over forearms bilaterally
Neuro: Alert and oriented x3, walking comfortably
Pertinent Results:
*Admission Labs*
___ 05:15PM BLOOD WBC-6.5 RBC-3.27* Hgb-9.7* Hct-31.2*
MCV-95 MCH-29.6 MCHC-31.0 RDW-16.0* Plt ___
___ 05:15PM BLOOD Neuts-71.4* ___ Monos-6.2 Eos-3.4
Baso-0.9
___ 05:15PM BLOOD Glucose-252* UreaN-105* Creat-8.2*#
Na-140 K-4.8 Cl-107 HCO3-15* AnGap-23*
___ 05:15PM BLOOD Albumin-3.4* Calcium-6.2* Phos-9.8*#
Mg-2.2
*Calcium trend*
___ 05:15PM BLOOD Albumin-3.4* Calcium-6.2* Phos-9.8*#
Mg-2.2
___ 05:10AM BLOOD Calcium-6.1* Phos-9.5* Mg-2.2
___ 06:20AM BLOOD Calcium-6.1* Phos-7.2*# Mg-2.0
___ 06:42AM BLOOD freeCa-0.81*
___ 06:55AM BLOOD freeCa-0.88*
*Hepatitis Serologies*
___ 11:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 11:32AM BLOOD HCV Ab-NEGATIVE
*Urinalysis/Urine Culture*
___ 05:52PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:52PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:52PM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-7
TransE-<1
___ Urine Culture: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
*Discharge Labs*
___ 08:00AM BLOOD WBC-5.3 RBC-3.04* Hgb-9.0* Hct-28.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-16.0* Plt ___
___ 07:13AM BLOOD Glucose-210* UreaN-42* Creat-5.0*# Na-140
K-4.1 Cl-104 HCO3-27 AnGap-13
___ 07:13AM BLOOD Calcium-7.5* Phos-5.3*# Mg-2.0
*Imaging*
CXR ___ Preliminary Read:
1. Retrocardiac left base opacitiy could represent a small
Bochdalek hernia, which could potentially be confirmed with
comparison with prior studies or CT.
2. Costophrenic angles are indistinct and could represent small
pleural effusions.
LUE AVF Ultrasound with dopplers ___: Pending at discharge
Brief Hospital Course:
___ w/ DM1 and worsening kidney disease now presenting with GFR
and symptoms (pruritis, swelling, SOB) consistent with ESRD here
for initiation of dialyis.
#ESRD: Patient with CKD likely ___ diabetes here with GFR of 9,
leg swelling, dyspnea on exertion and symptoms of pruritis
suggestive of uremia. Patient evaluated by transplant surgery
who gave the ok to use left upper extremity fistula. Patient
started on dialysis on ___ with additional sessions on ___
and ___. Given concern that fistula was difficult to access at
___ session, LUE ultrasound performed on ___ with read
pending at discharge. Hepatitis serologies showed patient was
not hepatitis B immune and patient was given first immunization
in Hep B series on day of discharge and PPD was planted and was
negative. Patient was continued on home sevelamer and started on
nephrocaps as well as 3 days of aluminum hydroxide. Calcitriol
was stopped as patient on doxercalciferon with dialysis.
# Hypocalcemia: Patient admitted with calcium of 6.2 (corrected
to about 6.5 with albumin). Patient was asymptomatic without
Chvostek's sign and with normal Qtc on EKG. Attempted to correct
with HD however without good effect and patient treated with
calcium gluconate with improvement of calcium to 7.5 on ___
(corrected to 7.8). Patient continued on calcitriol during
hospitalization and this was stopped prior to discharge with
plan for correction of calcium and vitamin D via HD.
# Hypertension: Patient hypertensive on arrival to 180s,
improved with home carvedilol, HCTZ, losartan, doxazosin and
lasix. Patient with recurrent hypertension to 203/64 on ___
with improved to systolic pressures of 140s with evening
carvedilol. Patient with recurrent hypertension to SBP of 200s
thought to be due to volume overload and ineffectiveness of HCTZ
with ESRD. HCTZ stopped and doxazosin increased to 4mg BID on
___. With increased doxazosin and 1.5L off at HD on day of
discharge, blood pressures improved to 130s-160s/60s prior to
discharge. Patient may need down titration of blood pressure
meds as fluid status improves with HD.
#Anemia: Patient with hematocrit ranging ___ (just below
previous baseline in ___ of this year. Normocytic anemia likely
related to low erythropoetin in setting of end stage renal
disease. Patient started on epo with HD on ___ along with iron
supplementation through dialysate. Anemia stable during
admission and patient asymptomatic.
#Petechial rash: Patient developed petechial rash over bilateral
arms to just above elbows bilaterally without any itching or
pain. Rash did not spread, and was slowly improving after
initiation of HD. Rash was thought to be due to uremic platelets
in the setting of ESRD.
# Diabetes, Type I: Patient was initially continued on home
lantus with an insulin sliding scale however, sugars poorly
controlled on initial insulin sliding scale with sugars ranging
170s-340s. On hospital day 4, patient returned to ___ counting
with carb ratio 10:1 and lower dose of sliding scale insulin
with improvement in sugars to 150s-250s prior to discharge.
# Hyperlipidemia: Patient continued on home simvastatin while
inpatient.
# Dysthymic Disorder: Continued on home bupropion and sertraline
while admitted.
# Code Status: Full Code
# Health Care Proxy: ___, sister,
--
Transitional Issues:
[] Follow-up final AV fistula ultrasound read.
[] Need PTH drawn as outpatient
[] Will need ongoing dialysis ___ as outpatient
[] Patient will need ___ Hep B vaccine around ___ and ___
Hep B vaccine around ___ (first vaccine received ___.
[] ___ need to down titrate blood pressure meds as more fluid
taken off at HD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. BuPROPion 75 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Furosemide 80 mg PO BID
6. Sertraline 50 mg PO DAILY
7. Calcitriol 0.5 mcg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Doxazosin 2 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Lantus (insulin glargine) 16 units subcutaneous qAM
12. NovoLOG (insulin aspart) sliding scale subcutaneous qAC
Discharge Medications:
1. BuPROPion 75 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Furosemide 80 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Simvastatin 20 mg PO QPM
8. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
9. Doxazosin 4 mg PO BID
RX *doxazosin 4 mg 1 tablet(s) by mouth BID (twice daily) Disp
#*60 Tablet Refills:*0
10. NovoLOG (insulin aspart) 0 units SUBCUTANEOUS QAC
Please take per home dosing
11. Lantus (insulin glargine) 15 units SUBCUTANEOUS QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. End Stage Renal Disease
2. Hypocalcemia
3. Hypertension
Secondary Diagnosis:
1. Diabetes, Type I
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!
You were admitted with poor kidney function and started on
hemodialysis through your left brachiocephalic fistula placed in
___. You tolerated 3 sessions of HD well and will
continue HD as an outpatient at ___ Dialysis ___
beginning ___ at 3pm.
You were also noted to have very low calcium which is likely due
to poor vitamin D absorption because of your kidney disease. You
were given IV calcium with improvement in your calcium level.
You calcium will continue to be corrected at dialysis.
You also had elevated blood pressure during this admission,
likely due to excess fluid prior to hemodialysis. Your doxazosin
was increased during this admission. Your blood pressure
improved with increased doxazosin and hemodialysis. Your HCTZ
(hydrochlorathiazide) was stopped as this is not effective given
your kidney function.
While here, you were noted to lack immunity to hepatitis B. You
were given the first of three vaccines here. You will need to
follow-up with your primary doctor for the second vaccine in 1
month and the third vaccine in 6 months.
Your ___ Team
Followup Instructions:
___
|
10745718-DS-13
| 10,745,718 | 20,997,857 |
DS
| 13 |
2129-06-09 00:00:00
|
2129-06-10 10:19:00
|
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 leg pain
Major Surgical or Invasive Procedure:
ORIF right tibial fracture with IM nail.
History of Present Illness:
___ male otherwise healthy, s/p skating injury w/ a R distal
tib-fib fx w/ a posterior malleolus component. This is a closed
injury and the patient is neurovascularly intact. This injury
will require surgical fixation.
Past Medical History:
No pertinent past medical history
Social History:
___
Family History:
Noncontributory
Physical Exam:
Right lower extremity:
- closed
- minimal swelling
- Fires ___, FHL
- SILT in S/S/DP/SP/T
- 2+ DP pulse
LABS: ___ 06:13PM BLOOD WBC: 15.2* Hgb: 14.8 Hct: 44.___ ___: 1.1
___ 06:13PM BLOOD Glucose: 111* UreaN: 14 Creat: 1.0 Na:
140
K: 4.2 Cl: 103 HCO3: 23 AnGap: 14
Pertinent Results:
___ 06:15AM BLOOD WBC-9.6 RBC-4.40* Hgb-12.8* Hct-39.5*
MCV-90 MCH-29.1 MCHC-32.4 RDW-12.2 RDWSD-40.2 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.8
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 tib-fib fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right tib-fib fracture with
IM 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 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
weightbearing as tolerated in the right lower extremity, and
will be discharged on aspirin 325 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. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*180 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Docuprene] 100 mg 1 tablet(s) by mouth
twice daily as needed Disp #*60 Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4.Crutches
Discharge Disposition:
Home
Discharge Diagnosis:
right tibia fracture with posterior malleolus component
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 Orthopedic Surgery
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take Aspirin 325 once daily for 4 weeks to help prevent
the formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: 50% partial weight
bearing in the leg that was operated on
- keep your dressing in place for ___ days.
Follow up
- Please follow up with your primary care doctor regarding this
hospitalization
- Please follow up with your surgeon in 2 weeks for a wound
check and general post-operative evaluation.
Followup Instructions:
___
|
10745745-DS-23
| 10,745,745 | 28,015,313 |
DS
| 23 |
2183-03-18 00:00:00
|
2183-03-18 15:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Elavil / Toradol / tromethamine / latex / Bactrim
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Entotracheal intubation/extubation
Punch biopsy L thumb ___
History of Present Illness:
___ w/ PMH of lumbar spine discitis/osteomyelitis s/p multiple
rounds of antibiotics, and multiple spine surgeries for
decompression (most recently T12-L1 laminectomy, L L1-L2
facetectomy & discectomy, T11-L3 posterior fusion at
___ ___, OSA on CPAP, recent hypoxemic respiratory
failure requiring intubation ___ ILD consistent with
eosinophilic pneumonia, who was transferred from ___
with back pain and inferior wound dehiscence, requiring MICU
admission for hypoxemic respiratory failure necessitating
intubation, found to have PJP pneumonia treated with Bactrim and
prednisone, additionally treated for P. acnes, VRE, and yeast
osteomyelitis s/p repeat washout. Returning with worsening SOB,
hypoxic to ___ on RA. Febrile tachycardic, hypotensive, CXR and
ventilator settings c/s ARDS. Febrile with elevated WBC so gave
cefepime, Bactrim and dapto. Was given cefepime and dapto at OSH
and then was sent here.
Past Medical History:
-Lumbar spine/psoas abscess w/ vertebral osteo and discitis
-C. difficle enterocolitis
-Asthma - h/o intubation
-OSA - wears CPAP at night but does not feel it helps
-Migraines (daily)
-Depression/Anxiety
-HLD
-Hypothyroidism
-Chronic back pain
-Femur fractures (due to two separate injuries)
-Restless leg syndrome
-L1-2 laminectomry and L2-3 hemilaminectomy ___
-T11-L1 fusion ___
Social History:
___
Family History:
Mother - heart disease
Brothers - kidney disease
HTN
No family history of colon cancer or prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Intubated/paralyzed
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated
LUNGS: diminished breath sounds b/l
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: skin impairment on back
NEURO: intubated/paralyzed
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.5 106/70 78 18 95%RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: 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: foley draining clear pale yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, raised rough skin on sides of all digits, L thumb wound
without surrounding erythema or drainage.
Neuro: CNs3-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
===============
___ 06:33PM BLOOD WBC-15.6* RBC-2.97* Hgb-9.2* Hct-29.6*
MCV-100* MCH-31.0 MCHC-31.1* RDW-19.0* RDWSD-69.6* Plt ___
___ 06:33PM BLOOD Neuts-90.3* Lymphs-2.9* Monos-4.5*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-14.09*# AbsLymp-0.45*
AbsMono-0.70 AbsEos-0.07 AbsBaso-0.02
___ 06:33PM BLOOD ___ PTT-27.0 ___
___ 06:33PM BLOOD Glucose-129* UreaN-23* Creat-0.9 Na-135
K-5.2* Cl-98 HCO3-20* AnGap-17
___ 06:33PM BLOOD ALT-10 AST-50* LD(LDH)-716* AlkPhos-114
TotBili-0.2
___ 06:33PM BLOOD Albumin-3.2*
___ 06:33PM BLOOD GreenHd-HOLD
___ 07:14PM BLOOD ___ pO2-69* pCO2-34* pH-7.39
calTCO2-21 Base XS--3 Comment-GREEN TOP
___ 07:14PM BLOOD Lactate-1.6
___ 02:15PM BLOOD freeCa-1.15
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 02:54AM BLOOD WBC-17.1* RBC-3.45* Hgb-10.4* Hct-34.1*
MCV-99* MCH-30.1 MCHC-30.5* RDW-18.4* RDWSD-65.9* Plt ___
___ 06:30AM BLOOD WBC-11.2* RBC-3.17* Hgb-10.0* Hct-32.0*
MCV-101* MCH-31.5 MCHC-31.3* RDW-18.5* RDWSD-67.6* Plt ___
___ 11:39PM BLOOD ___ PTT-30.2 ___
___ 06:30AM BLOOD Glucose-88 UreaN-31* Creat-0.7 Na-140
K-4.4 Cl-97 HCO3-28 AnGap-15
___ 11:39PM BLOOD ALT-8 AST-19 AlkPhos-94 TotBili-0.2
___ 02:55AM BLOOD LD(LDH)-526* Amylase-91
___ 06:33PM BLOOD Lipase-54
___ 06:33PM BLOOD cTropnT-<0.01 proBNP-615*
___ 06:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.4
___ 02:55AM BLOOD calTIBC-186* Hapto-358* Ferritn-917*
TRF-143*
___ 02:41AM BLOOD Triglyc-196*
___ 05:01PM BLOOD TSH-2.8
___ 05:01PM BLOOD T4-6.1
___ 02:40PM BLOOD ANCA-NEGATIVE B
___ 02:40PM BLOOD ___
___ 06:32AM BLOOD Type-MIX pO2-65* pCO2-48* pH-7.42
calTCO2-32* Base XS-5 Comment-GREEN TOP
___ 06:06AM BLOOD ALDOLASE-PND
___ 07:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:40PM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:40PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 07:40PM URINE CastHy-5*
___ 07:40PM URINE Mucous-OCC*
___ 09:57AM OTHER BODY FLUID Polys-65* Lymphs-3* Monos-0
Macro-11* Other-21*
___ 03:17AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY:
=============
BAL ___ 9:57 am BRONCHIAL WASHINGS
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
___ 9:57 am BRONCHIAL WASHINGS
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
VIRAL SCREEN/CULTURE ___ 9:57 am Rapid Respiratory Viral Screen & Culture
**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 ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ AT
11:55A.
BLOOD CULTURE x2 ___ - NGTD
REPORTS:
========
L Thumb biopsy pathology ___
-PENDING at time of discharge
VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 9:37 AM
Aspiration with thin liquids, and trace aspiration with nectar
thick liquids on subsequent swallow. Penetration with nectar
thick liquids.
CHEST (PORTABLE AP) Study Date of ___ 3:54 AM
Radiology Report CHEST (PORTABLE AP) Study Date of ___
3:54 AM
Comparison to ___. The lung volumes are decreased.
Mild
pulmonary edema and mild cardiomegaly is present. Parenchymal
opacities,
predominating at the left lung base have decreased in extent and
severity. New areas of atelectasis at the right lung bases. No
pleural effusions. Stable monitoring and support devices.
CT CHEST W/O CONTRAST Study Date of ___ 1:35 ___
Organizing and fibrotic stages of ARDS, and concurrent mild
pulmonary edema. Active infection is less likely. Progressive
pulmonary arterial hypertension.
BRONCHIAL WASHINGS Cytology ___
Negative for malignant cells. Pulmonary macrophages, bronchial
epithelial cells, lymphocytes, and neutrophils.
Brief Hospital Course:
___ w/ PMH of lumbar spine discitis/osteomyelitis s/p multiple
rounds of antibiotics, and multiple spine surgeries for
decompression (most recently T12-L1 laminectomy, L L1-L2
facetectomy & discectomy, T11-L3 posterior fusion at
___ ___, OSA on CPAP, recent hypoxemic respiratory
failure requiring intubation ___ ILD consistent with
eosinophilic pneumonia found to have pcp ___
at last admission presented with hypoxic respiratory failure/
ARDS requiring intubation likely secondary to ILD and pneumonia.
Pt was extubated on ___. Pt was treated with steroids,
antibiotics and diuretics with good response. Pt was transferred
to the floors on ___ where his oxygen was weaned and he was
seen by pulmonology and dermatology. PFTs consistent with severe
restrictive lung defect and impaired exchange consistent with a
steroid-responsive lung disease. Dermatology sent punch biopsy
of possible Mechanic's Hands as findings could potentially
support a diagnosis of anti-synthetase syndrome driving ILD,
which would alter his management.
#Hypoxic respiratory failure: The patient presented with
respiratory failure and a chest X-Ray concerning for ARDS. His P
to F ratio was ranging from 90-130 on admission, with moderate
to severe ARDS. This was thought to be likely secondary to
pneumonia and underlying ILD. This improved with low tidal
volume ventilation and treatment of his underlying pneumonia. He
was started on prednisone 60mg daily, Vanc, Cefepime, Bactrim
Q6h for prophylaxis. Notably, the patient had just finished a
course of Bactrim for treatment for PCP pneumonia, thus it was
not felt that this was likely due to PCP ___. ID was
consulted and recommended linezolid, cefepime and micafungin. A
CT chest was obtained which showed Organizing and fibrotic
stages of ARDS, and concurrent mild pulmonary edema. The patient
developed hyperkalemia throughout his stay (discussed below)
which was thought to be due to Bactrim, and thus the patient was
switched to atovaquone for PCP ___. He was evaluated by
pulmonology who recommended continued 60mg prednisone for
steroid-response lung disease and outpatient follow-up. Serum
aldolase was sent and pending at time of discharge. Skin biopsy
sent to help delineate underlying etiology. Full myositis panel
deferred to outpatient pulmonologist. His oxygen requirement was
decreasing and he should continue to be weaned as able.
#Osteomyelitis: The patient had known VRE, P. Acnes and yeast
osteomyelitis and came in on daptomycin, cefepime and
micafungin. Per ID, this regimen was planned to be continued 6
weeks after ___. His Daptomycin was changed to Linezolid for
better pulmonary coverage. Wound vac was in place, and was
changed Q3D. Orthopedics recommended outpatient followup with
mepilex in place for 7 total days. They will address sutures in
outpatient follow-up. Given the risk of daptomycin-induced
pulmonary injury, he will continue on linezolid for the duration
of his osteomyelitis treatment with bi-weekly labs to monitor
for marrow suppression.
#Hyperkalemia: The patient developed a hyperkalemia which seemed
to begin with the initiation of his Bactrim. Resolved upon
discontinuation.
#Anemia: His anemia was possibly secondary to chronic disease,
however hemolysis labs were checked which were unremarkable. His
CT abdomen and pelvis was negative for an acute bleed. His
bronchoscopy did not reveal intrapulmonary hemorrhage. His stool
was guiac was negative. His H/H on discharge was 10.0/32.0
====================
Chronic issues
#Restless leg/tremor
- Discontinued primidone 25mg BID given somnolence during
hospitalization and lack of benefit. Discussed with outpatient
neurologist
- Continue Gabapentin 600mg TID. Decreased from home Lyrica
200/400/200mg to 200/200/200mg given somnolence during
mid-afternoon. ___ require uptitration back to home regimen if
RLS symptoms worsen.
#Depression/Anxiety:
- continue wellbutrin
- Continue sertraline
- Held QHS 0.5 mg clonazepam given somnolence
- anxiety a bit heightened on the steroid
#Hypothyroidism: normal TSH and T4
- continue home 88mcg synthroid
- outpatient followup in ___ weeks
TRANSITIONAL ISSUES:
[] Foley removed prior to discharge, please ensure void by ___
on ___ or replace foley.
[] Please wean O2 as tolerated for goal >92%
[] Patient to complete cefepime, micafungin, and linezolid AT
LEAST through ___. Final duration to be determined by ___
___
[] Patient to continue PO vancomycin for at least 2 weeks AFTER
completion of IV antibiotics
[] LABS TO BE DRAWN WEEKLY: BUN, Cr, CPK, CRP, LFTs
[] LABS TO BE DRAWN TWICE WEEKLY for linezolid monitoring
(marrow suppression): CBC with differential
[] ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
[] Patient to continue 60mg PO prednisone daily until follow-up
with outpatient pulmonologist.
[] Patient started on Calcium and Vitamin D for BMD prophylaxis
given likely long course of steroids
[] Recommend outpatient DEXA scan for assessment of bone mineral
density
[] Recommend repeat outpatient TTE
[] L thumb punch biopsy performed by dermatology who will
communicate results to pulmonology.
[] Consider adding myositis panel, PL7, PL12, OJ, EJ, KS, Zo
antibodies to labs as outpatient (with pulmonology)
[] Patient's pre-gabalin was decreased while inpatient due to
somnolence and difficulty rousing. Primidone was discontinued.
These plans were discussed with patient's outpatient
Neurologist, Dr. ___. ___ consider uptitrating afternoon dose
of pregabalin from 200mg to 400mg if patient's restless leg
symptoms are worsening.
[] Mepliex dressing on back can be left in place for 7 days (day
7 = ___ Patient can shower with the dressing on.
[] Sutures in patient's back wound to be left in until Ortho
Spine follow-up
[] The patient will need a repeat video swallow evaluation prior
to advancing liquids. Recommend this be completed in ___ weeks
from ___.
[] Patient should follow up with Dr. ___ in the sleep
clinic and be encouraged to wear BiPAP at night
[] Please remove sutures from L lateral thumb punch biopsy site
in two weeks (___)
[] DNR/DNI, confirmed
[] HCP/Wife - ___, Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO DAILY:PRN
upset stomach
3. Bisacodyl ___AILY:PRN constipation
4. BuPROPion 75 mg PO BID
5. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
6. ClonazePAM 0.5 mg PO QHS
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Gabapentin 600 mg PO TID
11. Heparin 5000 UNIT SC TID
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Milk of Magnesia 30 mL PO QHS:PRN upset stomach
14. Montelukast 10 mg PO DAILY
15. Polyethylene Glycol 17 g PO QHS
16. Pregabalin 200 mg PO BID
17. Pregabalin 400 mg PO NOON
18. QUEtiapine Fumarate 12.5 mg PO QHS:PRN insomnia
19. Senna 8.6 mg PO BID:PRN constipation
20. Vitamin D 1000 UNIT PO DAILY
21. Alendronate Sodium 70 mg PO QSUN
22. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
23. Lactobacillus combo ___ cap oral daily
24. Lidocaine 5% Patch 1 PTCH TD QAM
25. Psyllium Powder 1 PKT PO BID:PRN constipation
26. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
27. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Wheezing
28. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
29. CefePIME 2 g IV Q12H
30. Daptomycin 750 mg IV Q24H
31. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
32. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety
33. Micafungin 100 mg IV Q24H
34. Omeprazole 40 mg PO DAILY
35. Ondansetron 4 mg IV Q8H:PRN nausea
36. PredniSONE 20 mg PO DAILY
37. PrimiDONE 25 mg PO BID
38. Sertraline 200 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Wheezing
2. Atovaquone Suspension 1500 mg PO DAILY
3. Linezolid ___ mg PO Q12H
last dose ___
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Vancomycin Oral Liquid ___ mg PO Q6H
Continue 2 weeks after discontinuation of other antibiotics
6. Calcium Carbonate 500 mg PO TID
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. PredniSONE 60 mg PO DAILY
9. Pregabalin 200 mg PO NOON
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
12. Alendronate Sodium 70 mg PO QSUN
13. Bisacodyl ___AILY:PRN constipation
14. BuPROPion 75 mg PO BID
15. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
16. CefePIME 2 g IV Q12H
17. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
18. Docusate Sodium 100 mg PO BID:PRN constipation
19. Fluticasone Propionate NASAL 2 SPRY NU DAILY
20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
21. Gabapentin 600 mg PO TID
22. Heparin 5000 UNIT SC TID
23. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
24. Lactobacillus combo ___ cap oral daily
25. Levothyroxine Sodium 88 mcg PO DAILY
26. Lidocaine 5% Patch 1 PTCH TD QAM
27. Micafungin 100 mg IV Q24H
28. Milk of Magnesia 30 mL PO QHS:PRN upset stomach
29. Montelukast 10 mg PO DAILY
30. Omeprazole 40 mg PO DAILY
31. Ondansetron 4 mg IV Q8H:PRN nausea
32. Polyethylene Glycol 17 g PO QHS
33. Pregabalin 200 mg PO BID
34. Psyllium Powder 1 PKT PO BID:PRN constipation
35. Senna 8.6 mg PO BID:PRN constipation
36. Sertraline 200 mg PO DAILY
37. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
hypoxemic respiratory failure
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 caring for you in the ___
___. You were recently hospitalized for shortness of
breath. You required a breathing tube (intubation). You are
being treated with antibiotics for a possible lung infection.
You are also being treated with steroids to treat your
underlying lung disease. You will follow up with the pulmonology
team as an outpatient to continue your treatment, and continue
on steroids in the interim. Your restless leg syndrome
medication regimen was adjusted and discussed with your
outpatient neurologist. You were also seen by the dermatology
team who did a biopsy of your thumb. The results of this will be
discussed with your pulmonology team and you can discuss it with
them in the clinic. You will see the orthopedic surgery team as
an outpatient to address your wound and staples.
You had a speech and swallow evaluation and a video swallow
examination. While you had made some improvements, you are still
recommended a pureed diet and thickened liquids while you are
recovering. You can be reexamined soon, but taking a regular
diet before another video swallow exam will put you at risk for
aspiration and worsening your lungs. We discussed this and you
understood the risks of advancing your diet before reevaluation,
including another pneumonia or death.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10745745-DS-24
| 10,745,745 | 20,908,082 |
DS
| 24 |
2183-05-02 00:00:00
|
2183-05-02 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Elavil / Toradol / tromethamine / latex / Bactrim
Attending: ___
Chief Complaint:
ascending heaviness in legs bilaterally
Major Surgical or Invasive Procedure:
___ guided aspiration of fluid collection
History of Present Illness:
___ is a pleasant ___ man with a complicated
past medical history including lumbar spine
discitis/osteomyelitis s/p multiple rounds of antibiotics, and
multiple spine surgeries for decompression (most recently T12-L1
laminectomy, L L1-L2 facetectomy & discectomy, T11-L3 posterior
fusion at ___ ___, OSA on CPAP, recent hypoxemic
respiratory failure requiring intubation ___ ILD consistent with
eosinophilic pneumonia who was transferred from ___
with back pain and inferior wound dehiscence, requiring MICU
admission for hypoxemic respiratory failure necessitating
intubation, found to have PJP pneumonia treated with Bactrim and
prednisone, additionally treated for P. acnes, VRE, and yeast
osteomyelitis s/p repeat washout, as well as a recent admission
for hypoxic respiratory failure likely secondary to ARDS due to
underlying ILD.
He presents from rehab given ascending heaviness in his feet
bilaterally. This is described as below. He reports that he
had
a sensation of "numbness" that started more than a month ago
while he was admitted to this hospital. He felt it in the toes
bilaterally, where this remained for some time. Since that
time,
he has had the complicated medical course that is described in
his previous hospital notes. For the past ___ weeks, he has
been in ___ rehab, meeting with his spine surgeon and
pulmonology as well as infectious disease for his multiple
medical issues.
On ___ morning, on ___, he felt that the sensation
of
numbness, which he described to be more as a heaviness, began to
involve his whole foot on both sides equally. That evening, he
felt this heaviness to the ankles bilaterally. The next day, we
found that the heaviness was now involving his entire lower legs
up to the kneecaps bilaterally. His symptoms have not
progressed
since then for the past several days. He denies increased work
of breathing and does not feel weak. He reports that he was
able
to walk 60-70 feet with physical therapy, which she reports is a
significant improvement from prior. He denies tripping over his
own feet or foot drop. He denies any back pain or pain in the
spine. He denies any urinary incontinence. He does admit to
occasional seepage from the rectum, which he reports is a
chronic
issue for him. He denies any paresthesias in his upper or lower
extremities. He denies any dysphonia, dysphagia, dysarthria.
Denies any diplopia.
Past Medical History:
-Lumbar spine/psoas abscess w/ vertebral osteo and discitis
-C. difficle enterocolitis
-Asthma - h/o intubation
-OSA - wears CPAP at night but does not feel it helps
-Migraines (daily)
-Depression/Anxiety
-HLD
-Hypothyroidism
-Chronic back pain
-Femur fractures (due to two separate injuries)
-Restless leg syndrome
-L1-2 laminectomry and L2-3 hemilaminectomy ___
-T11-L1 fusion ___
Social History:
___
Family History:
Mother - heart disease
Brothers - kidney disease
HTN
No family history of colon cancer or prostate cancer
Physical Exam:
PHYSICAL EXAMINATION
Vitals:
T 96.3 HR 101 BP 144/88 RR 18 O2 98% 2L NC
Respiratory mechanics: pending
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes. Can count to 19 in one
breath.
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to finger wiggle.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. he has mild to
moderate, coarse postural and intention tremor bilaterally left
perhaps slightly greater than the right
[___]
L 5 5 5 5 ___ 4 4 4- 4- 4-
R 5 5 5 5 ___ 4 4 4- 4- 4-
- Reflexes:
[Bic] [Tri] [___] [Quad] [___]
L 1 1 1 tr -
R 1 1 1 tr -
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: deferred
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 752)
Temp: 97.8 (Tm 98.1), BP: 158/91 (123-158/74-91), HR: 82
(82-110), RR: 17 (___), O2 sat: 98% (93-98)
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: slightly increased WOB especially with exertion
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Back: Upper dressing with purulent saturation, lower
dressing C/D/I
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact comprehension. Able to follow both midline and
appendicular commands.
-Cranial Nerves: EOMI without nystagmus. 5->3 mm b/l. Facial
sensation intact to light touch. Face symmetric at rest and with
activation. Hearing intact to conversation. trap and scm
strength
full
-Motor: No pronator drift bilaterally. Neck extension ___,
flexion ___.
Delt Bic Tri WrE FFl FE IO* IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 4+ 4+ 4-
R 5 ___ ___ 4- 5 5 4- 4+ -
-Sensory: Deferred.
-DTRs: R bic 0, tri 2, patellar 1, ankle ___, bic 1, tri 2, patellar 0, ankle 0
-Coordination: Deferred.
Pertinent Results:
___ 04:40AM BLOOD WBC-10.5* RBC-3.13* Hgb-9.9* Hct-32.8*
MCV-105* MCH-31.6 MCHC-30.2* RDW-19.5* RDWSD-74.8* Plt ___
___ 04:45AM BLOOD ___ PTT-28.7 ___
___ 04:40AM BLOOD Glucose-93 UreaN-22* Creat-0.7 Na-141
K-4.5 Cl-100 HCO3-29 AnGap-12
___ 04:45AM BLOOD ALT-13 AST-17 AlkPhos-62 TotBili-0.2
___ 04:40AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.8
___ 04:50AM BLOOD TotProt-5.4* Albumin-3.5 Globuln-1.9*
Calcium-8.7 Phos-3.6 Mg-1.7
___ 04:50AM BLOOD VitB12-552 Folate-6
___:45AM BLOOD %HbA1c-5.2 eAG-103
___ 09:45AM BLOOD TSH-3.4
___ 04:50AM BLOOD ___
___ 08:10PM BLOOD CRP-12.8*
___ 04:50AM BLOOD IgA-68*
___ 04:50AM BLOOD PEP-HYPOGAMMAG IgG-346* IgA-74 IgM-52
IFE-NO MONOCLO
___ 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:08AM BLOOD Lactate-3.5*
___ 04:29PM BLOOD Lactate-5.3*
___ 07:32PM BLOOD Lactate-3.5*
___ 09:45AM BLOOD GQ1B IGG ANTIBODIES-Test
___ 09:45AM BLOOD SED RATE-Test
___ 09:13PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 2:11 pm ABSCESS
Source: Back fluid collection, superficial.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
MRI Thoracic/lumbar spine
"FINDINGS:
The lumbar spine portion of the study is partially degraded due
to motion
artifact.
THORACIC:
Status post T11 through L3 posterior instrumented fixation with
associated
susceptibility artifact partially limiting assessment of the
spinal canal and neural foramina at these levels. Alignment is
normal. Stable chronic
anterior wedge deformity of the T3 vertebral body results in
about 50% loss of vertebral body height. There is mild chronic
anterior wedging of the T4 vertebral body. Areas of fatty
marrow signal are present within the T6 and T8 vertebral
bodies.The spinal cord appears normal in caliber and
configuration.
There is no evidence of spinal canal or neural foraminal
narrowing. There is no evidence of infection or neoplasm. There
is no abnormal enhancement after contrast administration.
LUMBAR:
Lumbar spine MRI images are compromised by motion.
Status post T11 through L3 posterior instrumented fixation with
associated
susceptibility artifact partially limiting assessment of the
spinal canal and neural foramina at these levels. There are
laminectomies extending from T12 through L1. Patient is also
status post left L1-L2 facetectomy/discectomy.
There is fluid within the laminectomy bed extending from T12
through L2,
likely representing postoperative seroma although superimposed
infection
cannot be entirely excluded. There is a more organized small
fluid collection (1.3 cm AP x 2.0 cm TV x 3.2 cm SI) just
underneath the skin surface overlying the laminectomy site at
the level of L2-L3 demonstrating evidence of peripheral
enhancement more prominent since prior.
A compression deformity of L1 vertebral body appears unchanged.
There is a slight 1-2 mm retrolisthesis at L2-L3, unchanged.The
spinal cord appears normal in caliber and configuration.The
conus medullaris terminates at the level of L1-L2. multilevel
degenerative changes. T2 signal abnormality at the L1-L 2,
L2-L3 disc, similar to prior. Decreased edema of the L1
vertebral
body.
L1-L2: Moderate central, upper left paramedian disc protrusion,
similar.
Stable moderate spinal canal narrowing. Stable moderate to
severe left,
moderate right neural foraminal narrowing.
L2-L3: A 1-2 mm retrolisthesis, symmetric disc bulging,
ligamentum flavum
thickening and facet osteophytes result in stable moderate
spinal canal
narrowing, moderate right and mild left neural foraminal
narrowing.
L3-L4: Mild symmetric disc bulging, ligamentum flavum thickening
and facet
osteophytes. Stable mild spinal canal narrowing and mild
bilateral neural
foraminal narrowing.
L4-L5: Mild symmetric disc bulging, ligamentum flavum thickening
and facet
osteophytes result in stable mild spinal canal narrowing and
mild foraminal narrowing bilaterally.
L5-S1: Uncovering of the disc, symmetric disc bulging,
ligamentum flavum
thickening and facet osteophytes with stable mild spinal canal
narrowing,
severe bilateral foraminal narrowing.
OTHER: There are multiple bilateral renal cysts. Redemonstrated
is a moderate hiatal hernia. Paraspinal muscle atrophy.
IMPRESSION:
1. Partially degraded lumbar spine portion of the study due to
motion
artifact.
2. Degenerative changes thoracic, lumbar spine.
3. Status post T11 through L3 posterior instrumented fusion.
4. Small volume fluid within the laminectomy beds likely
representing
postoperative seroma although superimposed infection cannot be
entirely
excluded.
5. There is a more organized small fluid collection just
underneath the skin surface overlying the laminectomy site at
the level of L2-L3 demonstrating evidence of peripheral
enhancement, new since prior. Again this may represent
postoperative seroma, consider infection if appropriate.
6. Unchanged compression deformity of the L1 vertebral body.
7. Multilevel degenerative changes of the lumbar spine with
multilevel
mild-to-moderate spinal canal narrowing as detailed above. "
FLUID CULTURE (Final ___:
___. RARE GROWTH.
FURTHER IDENTIFICATION AND Susceptibility testing
requested by ___.
___ ___.
Yeast Susceptibility:.
Fluconazole MIC OF 0.5 MCG/ML.
Antifungal agents reported without interpretation lack
established
CLSI guidelines.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
EMG ___
"
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
generalized,
sensorimotor polyneuropathy with both axonal and demyelinating
features of at least moderate severity. The chronicity of this
process is difficult
to ascertain with confidence. Specific electrodiagnostic
findings for acquired demyelination (as expected in acute
inflammatory demyelinating polyneuropathy (AIDP) were not
identified; however, the early timing in relation to symptom
onset as well as the patient's risk for critical illness
polyneuroathy significantly limits the diagnostic sensitivity of
these studies for identify AIDP. In addition, there is evidence
suggesting chronic and ongoing, moderate-to-severe, lumbosacral
polyradiculopathy involving L5-S1 myotomes on the right. "
CT guided aspiration ___
"IMPRESSION:
Technically successful CT-guided aspiration of superficial and
deep fluid
collection in the laminectomy bed. Samples were sent for
microbiology
evaluation. "
Brief Hospital Course:
Mr. ___ is a ___ man with past medical history
notable for multiple spinal surgeries complicated by infections
including discitis and osteomyelitis, eosinophilic PNA, and ILD
on slow steroid taper admitted with ascending BLE "heaviness".
He was found to have a fungal infection and paraspinal fluid
collection and treated with micafungin. He was empirically
treated for GBS with 5 days of IVIG, given ascending sensory
symptoms and weakness, unable to perform lumbar puncture due to
paraspinal fluid collection and concern over infectious
concerns.
#presumptive GBS s/p IVIG treatment -patient admitted with
symptoms of ascending sensory changes, described as
numbness/heaviness of the lower legs. These symptoms remained
stable during the hospital course. His clinical exam was
monitored. He had an EMG which showed sensorimotor
polyneuropathy with both axonal and demyelinating features. And
a R L5-S1 radiculopathy. Not able to rule out GBS, as EMG was
still early in his course. His strength subsequently was noted
to decrease on exam which prompted presumptive treatment for
GBS. A lumbar puncture was not able to be safely performed, due
to his paraspinal fluid collections, and concern for spreading
infection due to their location. Cervical puncture is not
available at this institution. He was treated with 5 days of
IVIG for a total of 2 g/kg, which he tolerated without
difficulty. His respiratory status remained stable. his strength
has improved as of the day of discharge. See discharge exam for
details. At its worst strength was 4 out of 5 in affected
muscles. His workup was negative as follows: GQ1b negative;
neuropathy labs negative (B12 552, folate 6, A1c 5.2%, TSH 3.4,
ANCA negative, ___ negative, SPEP/UPEP (no monoclonal band),
lyme negative, RPR negative)
#elevated lactate -he had elevated lactate of 3 on admission
which peaked at 5, this was fluid responsive and improved to 3,
however did not clear with repeated fluid boluses. Medicine was
consulted, given that he was clinically stable despite elevated
lactate, no further lactates were checked. There did not appear
to be any other causes of elevated lactate like medications on
his medication list. Blood cultures were negative.
#Rim enhancing fluid collection at T12-L2, growing yeast.
-Infectious disease was consulted for this fluid collection.
They recommended ___ aspiration, this was performed under CT
guidance. ___ grew from this fluid collection, the same
species that he had previously grown on another admission as
such this was considered relapsing infection by infectious
diseases he was started on micafungin and his fluconazole
discontinued. Ortho spine did not recommend I&D given patient's
poor wound healing from previous surgeries, and relatively
stable clinical status at the time. He will continue a
micafungin course until ___, at which point he should
start oral fluconazole 400 mg daily again. He has infectious
disease follow-up scheduled. PICC was placed on ___ for IV
abx. He was continued on his doxycycline and atovaquone
prophylaxis.
#depressed mood -he had notably depressed mood during this
admission. Psychiatry was consulted and his sertraline, which
was being tapered previously was increased back to 100 mg daily.
This can be further uptitrated as needed. Hydroxyzine which
she had been on for sleep at rehab was stopped and ramelteon as
needed was started.
#ILD -he continues on his prednisone taper, which is as follows:
40 mg starting ___ to ___, then 30 mg starting ___ to ___,
then 20 mg from ___ to ___, then 10 mg ___ to ___, then off.
Continued Azathioprine uptitration 100 mg starting ___ ending
___, then 150 mg starting ___. Continued protonix,
montelukast, home nebs, glucose monitoring, sliding scale
insulin, Fosamax, and vitamin D. He had no respiratory issues
during this admission and continued on his baseline level of
oxygen.
#RLS
-continued home primidone
#anxiety
- Continue home Xanax 0.5mg TID PRN
#pain
- Continue home gabapentin, Pregabalin
#Hypothyroidism - Continued home levothyroxine 88 mcg
#HTN -increased HCTZ to 25 mg this admission for better BP
control.
TRANSITIONAL ISSUES:
#presumptive GBS - follow up weakness, neurology follow up as
per appointments section
#paraspinal fluid collection
-continue micafungin 100 mg IV daily through ___.
-start fluconazole 400 mg daily PO on ___.
#ILD
-continue prednisone taper as above
-continue azathioprine up titration as above
#HTN
-increased HCTZ to 25 mg daily this admission, f/u BP control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. AzaTHIOprine 100 mg PO DAILY
3. Fluconazole 400 mg PO Q24H
4. Doxycycline Hyclate 100 mg PO Q12H
5. Sertraline 100 mg PO DAILY
6. Gabapentin 600 mg PO BID
7. Gabapentin 1200 mg PO DAILY
8. HydrOXYzine 25 mg PO BID
9. PrimiDONE 50 mg PO BID
10. Atovaquone Suspension 1500 mg PO DAILY
11. Heparin 5000 UNIT SC BID
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Multivitamins 1 TAB PO DAILY
15. Alendronate Sodium 70 mg PO QSUN
16. Vitamin D ___ UNIT PO 1X/WEEK (FR)
17. PredniSONE 50 mg PO DAILY
This is dose # 1 of 5 tapered doses
18. PredniSONE 40 mg PO DAILY
This is dose # 2 of 5 tapered doses
19. PredniSONE 30 mg PO DAILY
This is dose # 3 of 5 tapered doses
20. PredniSONE 20 mg PO DAILY
This is dose # 4 of 5 tapered doses
21. PredniSONE 10 mg PO DAILY
This is dose # 5 of 5 tapered doses
22. Pregabalin 200 mg PO BID
23. Pregabalin 400 mg PO DAILY
24. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
25. ALPRAZolam 0.5 mg PO TID:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Hydrochlorothiazide 25 mg PO DAILY
3. Micafungin 100 mg IV Q24H
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Ramelteon 8 mg PO QHS:PRN insomnia
6. PredniSONE 30 mg PO DAILY
Start: After 40 mg DAILY tapered dose
Start on ___
This is dose # 3 of 5 tapered doses
7. PredniSONE 20 mg PO DAILY
Start: After 30 mg DAILY tapered dose
Start on ___
This is dose # 4 of 5 tapered doses
8. Alendronate Sodium 70 mg PO QSUN
9. ALPRAZolam 0.5 mg PO TID:PRN anxiety
10. Atovaquone Suspension 1500 mg PO DAILY
11. AzaTHIOprine 100 mg PO DAILY
12. Doxycycline Hyclate 100 mg PO Q12H
13. Gabapentin 600 mg PO BID
14. Gabapentin 1200 mg PO DAILY
give at 4pm
15. Heparin 5000 UNIT SC BID
16. Levothyroxine Sodium 88 mcg PO DAILY
17. Montelukast 10 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. PredniSONE 40 mg PO DAILY
This is dose # 2 of 5 tapered doses
21. PredniSONE 10 mg PO DAILY
Start on ___
This is dose # 5 of 5 tapered doses
22. Pregabalin 400 mg PO DAILY
give at 4pm
23. Pregabalin 200 mg PO BID
24. PrimiDONE 50 mg PO BID
25. Sertraline 100 mg PO DAILY
26. Vitamin D ___ UNIT PO 1X/WEEK (FR)
27. HELD- Fluconazole 400 mg PO Q24H This medication was held.
Do not restart Fluconazole until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ syndrome
___ infection in paraspinal fluid collection
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 hospitalized with progressive sensory symptoms of lower
leg heaviness. You had an MRI of the dorsal spine performed
which showed a fluid collection. This fluid collection grew a
yeast called ___, which you had previously been infected
with. You were treated with micafungin, an antifungal agent
with the guidance of our infectious disease colleagues. You will
continue micafungin until ___ at which point you will be
switched to oral fluconazole. We do not feel that the fluid
collection caused your sensory symptoms. You did appear to
become weaker, which is concerning for Guillain-Barré syndrome.
Your EMG/nerve conduction study test did not show any clear
evidence of GBS, but can be normal early in the course of
things. Normally we will perform a lumbar puncture or spinal
tap to assess for this, but this was not felt to be safe from an
infectious standpoint because of the fluid collection, so we
empirically treated you with IVIG (immune globulin). This
medication often takes several weeks to take full effect, but
shortens the duration of the GBS and causes the peak symptoms to
be milder than they would be otherwise. You were followed by
physical therapy to who recommended discharge to rehab to work
on your strength.
Sincerely,
Your ___ neurology team
Followup Instructions:
___
|
10745790-DS-3
| 10,745,790 | 22,401,906 |
DS
| 3 |
2171-11-18 00:00:00
|
2171-11-19 13:42:00
|
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:
right upper quadrant pain and nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo G0 presenting with abd pain/distension x 1 day. She has
noticed some bloating over the last five days, attributed to
overeating. She reports normal BM, last one earlier today, with
no relief of pain after BM. No constipation, no blood in stool.
No dysuria or hematuria. No nausea or vomiting, but has
decreased PO intake secondary to feeling of distension. No f/c.
No recent diet changes. No abnormal vag discharge. No vaginal
bleeding.
Today, she woke up from sleep and when rolling onto side noticed
diffuse abdominal pain and feeling of distension. The pain is
diffuse, hard to characterize, feels most "like gas." Felt worse
on bus when coming to ED. Pain has not localized to any
particular location.
Past Medical History:
OB Hx: G0
Gyn Hx:
- LMP approx 2 weeks ago
cycles regular q27-28 days, lasting 4 days
- denies STIs
- no known history of ovarian cysts/fibroids/endometriosis
- no abn pap smears, last ___
PMH: hypothyroidism, anxiety
PSH: appendectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, right
lower abdominal fullness on palpation
Ext: no TTP
Pertinent Results:
___ 07:04AM WBC-9.6 RBC-3.78* HGB-11.6 HCT-34.2 MCV-91
MCH-30.7 MCHC-33.9 RDW-12.3 RDWSD-40.4
___ 07:04AM NEUTS-84.5* LYMPHS-8.4* MONOS-6.3 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-8.10* AbsLymp-0.80* AbsMono-0.60
AbsEos-0.00* AbsBaso-0.03
___ 07:04AM PLT COUNT-187
___ 05:07PM LACTATE-0.9
___ 05:00PM GLUCOSE-86 UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 05:00PM estGFR-Using this
___ 05:00PM ALT(SGPT)-21 AST(SGOT)-35 ALK PHOS-41 TOT
BILI-0.8
___ 05:00PM LIPASE-20
___ 05:00PM ALBUMIN-4.5
___ 05:00PM CEA-2.4 CA125-196*
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE UCG-NEGATIVE
___ 05:00PM WBC-10.5*# RBC-4.26 HGB-12.9 HCT-38.9 MCV-91
MCH-30.3 MCHC-33.2 RDW-12.7 RDWSD-42.0
___ 05:00PM NEUTS-77.8* LYMPHS-11.9* MONOS-8.0 EOS-1.2
BASOS-0.5 IM ___ AbsNeut-8.20* AbsLymp-1.25 AbsMono-0.84*
AbsEos-0.13 AbsBaso-0.05
___ 05:00PM PLT COUNT-205
___ 05:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 05:00PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-8
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after presentation to the emergency room for abdominal pain,
distension and nausea. Upon GYN evaluation, her pain had
dramatically improved. Ultrasound imaging demonstrated a large
right pelvic mass, appearing cystic. measuring about 10cm with a
1.2cm nodular wall. She was admitted for further evaluation of
the pelvic mass and pain control.
Her admission course was uncomplicated. Tumor lab markers and CT
scan of her abdomen and pelvis were sent for further evaluation
of possible malignancy.
Given her stable appearance, resolution of pain and nausea with
minimal medication and stable appearance of the mass on repeat
imaging, she was discharged to home with specific warning signs
and follow-up at ___ clinic for surgery planning and
scheduling.
Medications on Admission:
levothyroxine 150 mcg daily, ativan 0.5 mg prn
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not take more than 4g per day
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN naseua
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right pelvic mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service for pain management
and further evaluation of your abdominal pain. You were found to
have an ovarian mass, but we do not have any concern for ovarian
torsion (twisting on the ovary). We think you should have
surgery, and thus have scheduled you for outpatient surgery with
one of our GYN colleagues. See appointment below. The surgery
will be arranged in the next couple of weeks, but if other
concerning signs happen, such as pain not controlled with
ibuprofen and tylneol, then we would like you to call us to let
us know and you may need admission for pain control or sooner
surgery. We would like the surgery to be done in a planned
fashion, however, and thus we would recommend you keep your
outpatient appointment so this can be facilitated.
In addition, on your CT scan, there was a renal cyst, for which
a renal ultrasound was recommended. This can be arranged as an
outpatient, and we will communicate these results with the
doctor seeing you in clinic on ___.
Please call our office with any questions or concerns
(___). Please follow the instructions below.
General instructions:
* Schedule and keep your follow-up appointments as instructed
* Take your ibuprofen or Tylenol for pain as needed. If this
does not help the pain, please call us.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10746056-DS-23
| 10,746,056 | 26,663,573 |
DS
| 23 |
2139-11-15 00:00:00
|
2139-11-15 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
___ Tube Placement
History of Present Illness:
___ year old female with history of diabetes, gastroparesis
presenting with abdominal pain. She was recently discharged
from ___ for gastroparesis two days ago. She was initially
doing well but this morning the patient started to have
vomiting, describing NBNB emesis x 12. There is no diarrhea.
She has been having normal BMs at home. There is no fevers or
chills, no chest pain or dyspnea. She feels like this is
consistent with her gastroparesis. She received metoclopramide
at OSH with improvement in nausea but persistent pain.
In the ED, initial vitals were 98.2 102 160/88 16 97% RA. Her
abdomen was soft and non-tender. Labs showed blood sugar 148.
She received 0.5 mg IV hydromorphone x 1 and lorazepam 1 mg IV x
1.
Currently, the patient notes ___ pain in the epigastric and
periumbilical area.
Review of systems:
10 pt ROS negative other than noted
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
Vitals: T: 98.4, 136/81, 98, 18, 98% on RA
GEN: Alert, oriented to name, place and situation, no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, NT, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
___ 05:41AM BLOOD WBC-7.7 RBC-4.60 Hgb-13.1 Hct-40.4 MCV-88
MCH-28.5 MCHC-32.4 RDW-13.4 RDWSD-42.9 Plt ___
___ 06:15AM BLOOD WBC-8.0 RBC-4.52 Hgb-12.8 Hct-39.6 MCV-88
MCH-28.3 MCHC-32.3 RDW-13.3 RDWSD-42.4 Plt ___
___ 06:07AM BLOOD WBC-8.2 RBC-4.46 Hgb-12.5 Hct-39.4 MCV-88
MCH-28.0 MCHC-31.7* RDW-13.3 RDWSD-43.3 Plt ___
___ 05:20AM BLOOD WBC-9.3 RBC-4.78 Hgb-13.5 Hct-42.4 MCV-89
MCH-28.2 MCHC-31.8* RDW-13.4 RDWSD-43.6 Plt ___
___ 05:55AM BLOOD WBC-6.4 RBC-4.55 Hgb-12.7 Hct-40.3 MCV-89
MCH-27.9 MCHC-31.5* RDW-13.4 RDWSD-44.0 Plt ___
___ 05:09AM BLOOD WBC-5.9 RBC-4.44 Hgb-12.5 Hct-39.1 MCV-88
MCH-28.2 MCHC-32.0 RDW-13.6 RDWSD-44.0 Plt ___
___ 05:09AM BLOOD WBC-5.9 RBC-4.44 Hgb-12.5 Hct-39.1 MCV-88
MCH-28.2 MCHC-32.0 RDW-13.6 RDWSD-44.0 Plt ___
___ 07:26AM BLOOD WBC-6.8 RBC-4.68 Hgb-13.3 Hct-41.1 MCV-88
MCH-28.4 MCHC-32.4 RDW-13.7 RDWSD-44.0 Plt ___
___ 07:15AM BLOOD WBC-6.4 RBC-4.84 Hgb-13.7 Hct-42.5 MCV-88
MCH-28.3 MCHC-32.2 RDW-13.7 RDWSD-44.2 Plt ___
___ 06:36AM BLOOD WBC-5.7 RBC-4.28 Hgb-12.3 Hct-37.9 MCV-89
MCH-28.7 MCHC-32.5 RDW-14.5 RDWSD-46.2 Plt ___
___ 06:55PM BLOOD WBC-8.5# RBC-4.39 Hgb-12.4 Hct-38.3
MCV-87 MCH-28.2 MCHC-32.4 RDW-14.5 RDWSD-46.3 Plt ___
___ 06:15AM BLOOD Neuts-69.1 ___ Monos-8.2 Eos-1.6
Baso-0.5 Im ___ AbsNeut-5.53 AbsLymp-1.64 AbsMono-0.66
AbsEos-0.13 AbsBaso-0.04
___ 06:55PM BLOOD Neuts-71.4* ___ Monos-6.2
Eos-0.4* Baso-0.4 Im ___ AbsNeut-6.04 AbsLymp-1.81
AbsMono-0.52 AbsEos-0.03* AbsBaso-0.03
___ 05:41AM BLOOD Glucose-220* UreaN-20 Creat-0.6 Na-137
K-4.5 Cl-97 HCO3-32 AnGap-13
___ 06:15AM BLOOD Glucose-220* UreaN-19 Creat-0.6 Na-137
K-4.2 Cl-97 HCO3-33* AnGap-11
___ 06:07AM BLOOD Glucose-209* UreaN-17 Creat-0.6 Na-135
K-4.5 Cl-97 HCO3-32 AnGap-11
___ 05:20AM BLOOD Glucose-156* UreaN-15 Creat-0.7 Na-136
K-4.6 Cl-97 HCO3-32 AnGap-12
___ 05:55AM BLOOD Glucose-137* UreaN-14 Creat-0.6 Na-136
K-4.2 Cl-100 HCO3-30 AnGap-10
___ 05:13AM BLOOD Glucose-142* UreaN-13 Creat-0.6 Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
___ 05:22AM BLOOD K-4.3
___ 05:09AM BLOOD Glucose-97 UreaN-11 Creat-0.6 Na-140
K-4.2 Cl-101 HCO3-32 AnGap-11
___ 07:26AM BLOOD Glucose-83 UreaN-7 Creat-0.6 Na-139 K-4.0
Cl-102 HCO3-31 AnGap-10
___ 07:15AM BLOOD Glucose-119* UreaN-6 Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
___ 08:45AM BLOOD Glucose-146* UreaN-7 Creat-0.6 Na-139
K-3.9 Cl-103 HCO3-32 AnGap-8
___ 06:36AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-143
K-3.1* Cl-104 HCO3-29 AnGap-13
___ 06:55PM BLOOD Glucose-148* UreaN-15 Creat-0.7 Na-142
K-3.7 Cl-101 HCO3-32 AnGap-13
___ 06:07AM BLOOD ALT-20 AST-30 AlkPhos-71 TotBili-0.2
___ 05:20AM BLOOD ALT-12 AST-12 AlkPhos-60 TotBili-0.3
___ 05:09AM BLOOD ALT-10 AST-11 AlkPhos-51 TotBili-0.3
___ 07:26AM BLOOD ALT-10 AST-11 AlkPhos-53 TotBili-0.4
___ 05:41AM BLOOD Calcium-9.7 Phos-4.5 Mg-1.9
___ 06:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 06:07AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
___ 05:20AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.0
___ 05:55AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
___ 04:15AM BLOOD Calcium-6.6* Phos-3.3 Mg-1.4*
___ 05:22AM BLOOD Mg-1.9
___ 05:09AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.9
___ 07:26AM BLOOD Calcium-9.2 Phos-4.8* Mg-1.8
___ 05:09AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.9
___ 07:26AM BLOOD Calcium-9.2 Phos-4.8* Mg-1.8
___ 07:15AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.8
___ 08:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.7
___ 06:36AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.6
___ 06:07AM BLOOD %HbA1c-7.4* eAG-166*
___ 06:07AM BLOOD C-PEPTIDE-Test
CHEST PORT. LINE PLACEMENT Study Date of ___ 5:14 ___
IMPRESSION:
Right PICC terminates in the region of the cavoatrial junction.
Cardiac
silhouette is upper limits of normal for portable technique.
Lungs are
well-expanded and clear.
ECG Study Date of ___ 11:52:32 AM
Sinus rhythm. Delayed precordial R wave progression. No major
change from
prior.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
87 162 84 370 417 48 -11 32
___ TUBE PLACEMENT (W/FLUORO) Study Date of
___ 1:37 ___
IMPRESSION:
Successful placement of ___ feeding
tube. The
tube is ready to use. If there is difficulty with feeding,
check tube
placement.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1:31 ___
IMPRESSION:
1. No evidence of obstruction. Moderate colonic fecal loading.
2. Moderate extrahepatic and mild intrahepatic biliary ductal
dilatation with a decompressed and normal-appearing gallbladder.
Possible small noncalcified stone in the distal CBD.
3. Small hiatal hernia.
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 1:09 ___
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. 6.9 x 1.7 cm right lateral upper arm hematoma.
Brief Hospital Course:
___ year old female with history of diabetes, gastroparesis
presenting with abdominal pain and nausea and vomiting
concerning for gastroparesis.
# Abdominal pain, nausea, vomiting:
# Gastroparesis:
CT abdomen/pelvis with no evidence of acute obstruction. Biliary
ductal dilation incidentally noted, but normal liver
chemistries.
Given her persistent symptoms, in discussion with patient and
consulting services options for ___ trial vs permanent GJ tube
placement. ACS requested gastric emptying study prior to
placement of GJ tube, and to do this, will need to be off
medications effecting gastric emptying for 48 hours so
erythromycin stopped.
- Patient expressed preference on ___ for temporary NJ tube
placement as trial for GJ tube placement. NJ Dobhoff placed on
___ and tube feeds at goal on ___ and then advanced to cycle
tube
feeds on ___ over 16 hours.
- had improvement with IV erythromycin, but will not be able to
go home with IV Q8H, discussed transition to PO which patient
declines, stopped ___ for trial
- continued dronabinol
- continued lorazepam prn nausea
- continued simethicone for gassy abdominal distension
- home metoclopramide was stopped due to ineffectiveness
- Duration of tube feeds: Likely at least ___ year given severity
of gastroparesis.
- ___ assistance with insulin regimen and tube feeds
- care connected for outpatient PCP, ___, ACS referrals
# Type 1 DM with Retinopathy, Neuropathy, Gastropathy:
- Patient reports being on oral agents in the past. Unclear DM
picture as she also has insulin resistance.
- per ___, obtained A1c 7.4%, c-peptide WNL
- ___ consulting, has outpatient followup
- continued Lantus with HISS
# Biliary ductal dilation:
- Likely secondary to choledocholithiasis. No evidence of
cholecystitis, cholangitis, with normal liver chemistries.
- outpatient MRCP
# Depression, coping:
- Patient followed by ___, NP from palliative care.
Appreciate her input and involvement.
- Duloxetine continued.
# Chronic pain.
- Prescribed home oxycontin with oxycodone PRN but
patient states she uses medical marijuana at home and rarely
uses
the oxycontin
- oxycodone PRN
# Primary Hypertension:
- Stable. Will continue current regimen.
# Right arm swelling
- RUE US Negative for DVT, just hematoma
# Venous access: PICC line placed as she had no IV access; if
she is discharged home and will return for the surgery she
should
go home with PICC and have surgery scheduled as soon as
possible.
# DVT ppx: Heparin SC
# Diet: regular as tolerated, TPN via NJ tube feeds
# GI PPX: omeprazole
# IV access: ___
# Code status: full
# Contact: Husband, ___
======TRANSITIONAL ISSUES======
1. Outpatient MRCP to evaluate biliary dilation
2. ACS follow up as above
3. Glucose monitoring while on tube feeds
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN c
3. Docusate Sodium 100 mg PO BID
4. DULoxetine 60 mg PO DAILY
5. linaclotide 145 mcg oral DAILY
6. Lisinopril 20 mg PO DAILY
7. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
8. Omeprazole 20 mg PO BID
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Metoclopramide 10 mg PO QIDACHS
13. Erythromycin 125 mg PO Q6H
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN c
3. Docusate Sodium 100 mg PO BID
4. DULoxetine 60 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
7. Omeprazole 20 mg PO BID
8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
9. Tube Feeds
Tube Feed: Glucerna 1.5 Cal
Rate: 65 ml/hr for 16 hours 1700 to 0900
Flush w/ 50 ml water q6h
ICD-10: K31.8
10. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
11. Simethicone 40-80 mg PO QID:PRN gassy feeling
RX *simethicone [Bicarsim] 80 mg 1 Capsule by mouth four times a
day Disp #*100 Tablet Refills:*0
12. Glargine 36 Units Dinner
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
NPH 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin NPH human recomb [Novolin N] 100 unit/mL 6 Units
Subcutaneous 6 Units at 1600 Disp #*1 Vial Refills:*3
13. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Diabetes Mellitus
2. Gastroparesis
3. Legally blind
4. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for recurrent symptoms from gastroparesis.
You were seen by the Gi doctors who recommended a feeding tube
given that your symptoms cannot be managed by medication. You
had an NJ tube placed and your symptoms improved. This will be
continued as an outpatient and you should see your PCP, GI and
Surgery as an outpatient to be set up for a GJ tube placed as an
outpatient.
Followup Instructions:
___
|
10746056-DS-24
| 10,746,056 | 29,256,625 |
DS
| 24 |
2139-12-03 00:00:00
|
2139-12-04 09:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ Gastric Emptying Study
Markedly abnormal gastric emptying with only trace activity
leaving
the stomach for the small bowel after 4 hours.
___ PERC G/G-J TUBE PLMT
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum. The gastric port should
not be used for 24 hours.
History of Present Illness:
In brief, this is a ___ female with PMHx significant for
IDDM c/b neuropathy, severe gastroparesis with frequent flares,
macular degeneration with legal blindness, and obesity, who is
presenting with nausea, vomiting, and abdominal pain. She was
admitted two weeks ago for a gastroparesis flare and had a
temporary NJ tube placed for a tube feeding trial with a plan to
have a follow up emptying study. Her feeding cycle was 16hr
continuous/8hr off. 4 days prior to admission and about 9hrs
into her feed, she felt her stomach becoming uncomfortably full,
which triggered her to become nauseated and vomit (NB, bilious)
and displaced her NJ tube. Following this episode, she reports
severe (___) LLQ abdominal pain. She denies fevers, chills,
chest pain, shortness of breath, dysuria, headache.
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
ADMISSION PHYSICAL EXAM
===============================
VS 98.5 155 / 89 91 16 98 RA
GENERAL: Pleasant, obese female, NAD, quite tearful.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, TTP in LLQ, non-distended, no rebound or
guarding.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash on limited exam
NEUROLOGIC: A&Ox3, no focal deficits
DISCHARGE PHYSICAL EXAM
===============================
VS 97.7 | 142/64 | 88 | 18 | 96% RA
GENERAL: Pleasant, obese female, NAD.
HEENT: no conjunctival pallor or scleral icterus, PERRLA, EOMI,
OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, mildly tender around GJ site, dressing c/d/I, no
discharge or erythema.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash on limited exam
NEUROLOGIC: A&Ox3, no focal deficits
Pertinent Results:
ADMISSION LABS
====================
___ 07:25PM BLOOD WBC-9.4 RBC-4.20 Hgb-12.1 Hct-36.7 MCV-87
MCH-28.8 MCHC-33.0 RDW-14.0 RDWSD-44.4 Plt ___
___ 07:25PM BLOOD Neuts-72.5* Lymphs-18.7* Monos-7.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-6.83* AbsLymp-1.76
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.03
___ 07:25PM BLOOD Glucose-256* UreaN-20 Creat-0.9 Na-137
K-4.1 Cl-96 HCO3-29 AnGap-16
___ 07:25PM BLOOD ALT-10 AST-9 AlkPhos-71 TotBili-0.3
___ 07:15AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
___ 07:33PM BLOOD Lactate-1.4
STUDIES
====================
___ Gastric Emptying Study
IMPRESSION: Markedly abnormal gastric emptying with only trace
activity leaving the stomach for the small bowel after 4 hours.
___ GJ tube placement
1. Successful placement of a 16 ___ MIC gastrojejunostomy
tube with its tip in the proximal jejunum.
DISCHARGE LABS
====================
___ 08:00AM BLOOD WBC-7.7 RBC-4.14 Hgb-11.9 Hct-36.3 MCV-88
MCH-28.7 MCHC-32.8 RDW-13.6 RDWSD-43.4 Plt ___
___ 08:35AM BLOOD Glucose-231* UreaN-14 Creat-0.6 Na-138
K-4.0 Cl-97 HCO3-31 AnGap-14
___ 01:23PM BLOOD ALT-12 AST-16 LD(LDH)-145 AlkPhos-66
TotBili-0.5 DirBili-0.1 IndBili-0.4
___ 08:35AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0
Brief Hospital Course:
Summary
======================
___ female with PMHx significant for IDDM c/b
neuropathy, severe gastroparesis with frequent flares, macular
degeneration with legal blindness, and obesity, who is
presenting with nausea, vomiting, and abdominal pain, consistent
with gastroparesis. She underwent GJ tube placement and was
restarted on tube feeds.
ACTIVE ISSUES
=======================
# Nausea/vomiting/abdominal pain with gastroparesis: Patient
presented with two days of symptoms consistent with prior
gastroparesis flares. Patient was recently discharged with NJ
trial (to see whether permanent g tube would be beneficial).
Symptoms were improved with NJ, though temporary tube was
dislodged and prompted nausea/vomiting/abdominal pain, for which
pt was admitted this time. During this hospitalization, she
underwent gastric emptying study which was grossly abnormal and
then GJ tube placement on ___. Nausea, vomiting and abdominal
pain largely resolved on post-op day 2, tolerating tube feeds
and oral pain medication. She was discharged on pre-admission
pain regimen. Nutrition and ___ Diabetes were consulted, and
recommendations regarding tube feed regimen and diabetes
management were made (discussed below).
CHRONIC ISSUES:
=======================
# IDDM with Retinopathy, Neuropathy, Gastropathy: Type 1 vs Type
2 unclear by history, record review. Given glucose control
without need for basal insulin in >72 hours while NPO/no tube
feeds, there is evidence of endogenous insulin production (in
addition to c-peptide level). Most consistent with latent onset
autoimmune diabetes of the adult. Has intact hypoglycemic
awareness at BG ~70. NPH added to regimen (rather than raising
dose of glargine) to minimize risk of hypoglycemia in the event
of clogging during tube feeding overnight. Discharge insulin
regimen:12u ___ at start of TF; 50u lantus qHS; 12u mealtime
Humalog with ISS.
# Depression: Continued duloxetine 60 mg daily
# Chronic pain: continued home oxycodone/oxycontinue
# Primary Hypertension: Stable. Continued Lisinopril 20 mg and
amlodipine 10 mg daily
TRANSITIONAL ISSUES
=======================
# ___ was consulted and recommended new insulin regimen,
arranged PCP ___ (who manages her insulin) for ___.
# New regimen: 12u ___ at start of TF; 50u lantus qHS; 12u
mealtime Humalog with ISS. She was instructed to check her
finger sticks often with this new regimen to avoid hypoglycemia.
She should have this re-assessed at her PCP ___ in 1 week, whom
manages her insulin.
# Biliary ductal dilation: Patient with imaging that showed
biliary ductal dilation, likely secondary to
choledocholithiasis. No evidence of cholecystitis, cholangitis,
with normal liver chemistries. Outpatient MRCP recommended.
# Cushingoid appearance, may benefit from endocrine workup as
outpatient however no other signs of hyper-cortisol during this
admission.
# CODE STATUS: full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN c
3. Docusate Sodium 100 mg PO BID
4. DULoxetine 60 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
7. Omeprazole 20 mg PO BID
8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
9. Dronabinol 2.5 mg PO BID
10. Simethicone 40-80 mg PO QID:PRN gassy feeling
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Glargine 60 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 65 ml/hr
oral DAILY
65cc/hr for 16 hours per day
RX *nut.tx.gluc.intol,lac-free,soy [Glucerna 1.5 Cal] 65 cc/hr
by mouth daily Disp #*1000 Milliliter Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN c
4. Docusate Sodium 100 mg PO BID
5. Dronabinol 2.5 mg PO BID
6. DULoxetine 60 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
9. Omeprazole 20 mg PO BID
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Simethicone 40-80 mg PO QID:PRN gassy feeling
13. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
50 Units at bedtime Disp #*1 Syringe Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 12 units
at mealtimes Disp #*1 Syringe Refills:*0
14. ___ 12 Units Q24H
RX *insulin NPH and regular human [Humulin ___ KwikPen] 100
unit/mL (70-30) AS DIR 12 Units at start of tube feed every
night Disp #*3 Syringe Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
Gastroparesis flare, with nausea/vomiting/abdominal pain
SECONDARY DIAGNOSES
======================
IDDM with Retinopathy, Neuropathy, Gastropathy
Biliary ductal dilation
Depression
Chronic pain
Primary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you were experiencing nausea, vomiting, and diarrhea due
to a condition called gastroparesis -- this is a condition where
your stomach does not process food correctly, which causes all
of the symptoms you were experiencing.
Your care team offered you medications to help control the pain
and nausea, and preformed a procedure that placed a tube in your
small intestine to allow for food to bypass the stomach so you
do not experience the symptoms you were experiencing before you
came to the hospital.
When you leave the hospital, this is how you will feed yourself:
Glucerna 1.5 at 65 mL/hr x 16 hours
Your insulin regimen has changed, and when you leave the
hospital, this is how you should take your insulin:
Take 12 units of 70/30 insulin at the start of your tube feed
Take 50 units of lantus at bedtime
Take 12 units of Humalog with meals, plus your usual sliding
scale
It was a pleasure caring for you!
Followup Instructions:
___
|
10746056-DS-25
| 10,746,056 | 28,932,362 |
DS
| 25 |
2139-12-15 00:00:00
|
2139-12-20 21:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
Surgical G and J tube placement
History of Present Illness:
___ yo woman with an over ___ year history of poorly controlled
Type 1 DM c/b neuropathy, retinopathy, macular degeneration,
glaucoma, and refractory gastroparesis presenting with nausea,
vomiting, and abdominal pain. She was admitted two weeks ago for
a gastroparesis flare, had a GJ tube placement on ___, and was
discharged ___. On ___ in the afternoon, the patient
started vomiting. The vomit was non-bloody, non-bilious and
looked just like her tube feeds. Her last episode of emesis was
1pm this afternoon. In the ED she was complaining of nausea and
chest pain and feels as if "food is stuck in my chest," but
denies any urinary or bowel changes, fevers, chills, or SOB or
palpitations. She is complaining of chest pain that radiates up
her neck and down her R arm and also to her back.
In the ED, initial vital signs were: 98.7 142/89 99 16 100%RA
Labs were notable for Cl 94, HCO3 34, Agap 16, WBC 7.5, glucose
187
Patient was given Dilaudid 1mg IV x2, metoclopramide 10mg IV x1,
Zofran 4mg IV x1, Ativan 2mg IV x1
On Transfer Vitals were: 98.4 127/77 89 18 98%RA
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.4 127/77 89 18 98%RA
General: AAOx3, appears uncomfortable
HEENT: atraumatic, normocephalic, PERRLA, legally blind, sclera
anicteric
Lymph: no cervical lymphadenopathy appreciated
CV: RRR, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, ronchi, or rales
Abdomen: hypoactive bowel sounds, soft, diffusely tender, no
rebound or guarding. GJ-tube insertion site is clean, dry and
intact
GU: No foley in place
Ext: warm and well perfused, 2+ DP pulses appreciated
bilaterally
Neuro: CN2-12 intact, moving all four extremities purposefully
and spontaneously
Skin: no visible concerning skin lesions or ulcers
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.4, 130/75, 75, 18, 98 RA
General: AAOx3, sitting on elevated bed with TV on but
sleeping, appears comfortable
HEENT: normocephalic, atraumatic, EOMI, no cervical LAD
appreciated
Lungs: CTAB, no wheezes/ronchi/rales
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, discomfort above and on left lateral portion of
surgical site, no rebound or guarding, GJ tube sites c/d/i
Ext: warm and well perfused, no edema
Neuro: moving all 4 extremities purposefully and spontaneously
Pertinent Results:
ADMISSION LABS:
===============
___ 01:15PM BLOOD WBC-7.5 RBC-4.29 Hgb-12.4 Hct-38.5 MCV-90
MCH-28.9 MCHC-32.2 RDW-14.4 RDWSD-46.7* Plt ___
___ 01:15PM BLOOD Neuts-72.3* ___ Monos-6.7
Eos-0.8* Baso-0.4 Im ___ AbsNeut-5.39 AbsLymp-1.45
AbsMono-0.50 AbsEos-0.06 AbsBaso-0.03
___ 01:15PM BLOOD Plt ___
___ 01:15PM BLOOD Glucose-187* UreaN-17 Creat-0.8 Na-139
K-4.5 Cl-94* HCO3-34* AnGap-16
___ 01:15PM BLOOD cTropnT-<0.01
___ 07:10AM BLOOD Calcium-9.7 Phos-4.4# Mg-1.8
IMAGING STUDIES:
===============
GJ Tube Check - Malpositioned GJ tube with one limb extending
superiorly into the esophagus, distal tip not visualized.
DISCHARGE LABS:
================
___ 06:40AM BLOOD WBC-7.8 RBC-3.82* Hgb-11.0* Hct-35.0
MCV-92 MCH-28.8 MCHC-31.4* RDW-13.5 RDWSD-45.0 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-190* UreaN-13 Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-33* AnGap-11
___ 06:40AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ female with PMHx significant for
IDDM c/b neuropathy, severe gastroparesis with frequent flares,
macular degeneration with legal blindness, and obesity who had a
GJ tube placed ___ and was discharged on ___. She re-presented
to the ___ with nausea/vomiting, pain, and inability to
tolerate tube feeds.
#NAUSEA/VOMITING/GASTROPARESIS. Pt was discharged from ___ on
___. She was admitted for a gastroparesis flare, had an abnormal
gastric emptying study, and had a GJ tube placed by ___ on ___.
Since being discharged she had nausea/vomiting and abdominal
pain. A tube study showed that her G tube had migrated up
towards her esophagus. Surgery was consulted and felt that
surgical placement of separate G and J tubes would decrease the
likelihood of her G tube migrating again, so she had a separate
G and J tubes placed on ___ with surgery. On discharge, her G
tube was being used for venting and decompression only. Her J
tube was being used for tube feeds and medication
administration. Prior to discharge she was on tube feeds per
nutrition recommendations and was tolerating cycled feeds. She
was taking in only sips and ice chips as tolerated by mouth. She
was scheduled to follow-up with GI as an outpatient.
#PAIN CONTROL. The patient had a significant amount of abdominal
pain prior to and after surgical placement of G and J tubes.
After her G and J tube were placed her pain was controlled with
a Dilaudid PCA and oxycodone 20mg q4h. Palliative care was
consulted and helped manage her pain control. Ultimately the PCA
was stopped, her oxycodone was weaned to 20mg q6h from Q4H, and
she was started on methadone 5mg per J tube BID. Prior to
discharge the patient felt that her pain was well controlled on
this regimen and had an appointment to follow-up with palliative
care as an outpatient.
#IDDM. The patient was diagnosed with DM1 at age ___, and she has
been poorly controlled. The insulin regimen during her last
hospitalization was 12u ___ at start of TF; 50u lantus qHS;
12u mealtime; Humalog with ISS (new regimen per ___ recs).
During this hospitalization she was on 34U Glargine at bedtime
and was on a Humalog insulin sliding scale.
- 34U glargine at bed time
- Humalog ISS
#ANXIETY/DEPRESSION. The patient has a significant amount of
anxiety surrounding her medical condition. Throughout the
admission she was tearful and concerned about her prognosis and
how it was affecting her daily life. Palliative care, social
work, and spiritual care were all following. She was given
Ativan PRN. She had been taking duloxetine as an outpatient for
her anxiety, but this could not go through her J-tube so she was
switched to liquid escitalopram 10mg upon discharge.
#PRIMARY HTN. She was continued on her home Lisinopril 20 mg
(restarted ___ and amlodipine 10 mg daily
Transitional Issues:
- Patient is s/p surgical G-J tube placement with surgery on
___ which she tolerated well
- Started on methadone 5mg BID and oxycodone liquid ___ q6h
prn for pain control. Stopped oxycodone tablets and oxycontin as
cannot be crushed
- Plan for palliative care to manage pain regimen
- Changed insulin regimen to lantus 50units qHS and 2:50 SSI.
Continue to monitor blood glucose as an out-patient
- Pt. would benefit from outpatient psychiatry.
- Has ___ services for tube feeds
- Follow-up with GI regarding her gastroparesis and ability to
tolerate PO feeds
- Instructed to keep G-tube to gravity during immediate
recovery. All medications through J-tube.
- Plan to follow-up in ___ clinic 2 weeks post-discharge
- CODE: Full
- Contact: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 65 ml/hr
oral DAILY
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN c
4. Docusate Sodium 100 mg PO BID
5. Dronabinol 2.5 mg PO BID
6. DULoxetine 60 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
9. Omeprazole 20 mg PO BID
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Simethicone 40-80 mg PO QID:PRN gassy feeling
13. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
NPH 12 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg J TUBE DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
2. Lexapro (escitalopram oxalate) 10 mg ORAL DAILY
RX *escitalopram oxalate 5 mg/5 mL 10 mg by mouth daily
Refills:*0
3. Methadone 5 mg PO BID
RX *methadone 5 mg 1 tab by mouth twice a day Disp #*35 Tablet
Refills:*0
4. Nystatin Oral Suspension 5 mL PO BID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth twice a day
Refills:*0
5. OxycoDONE Liquid ___ mg PO Q6H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL ___ mg by mouth every 6 hours
Refills:*0
6. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. amLODIPine 10 mg PO DAILY
8. Bisacodyl 10 mg PR QHS:PRN c
9. Docusate Sodium 100 mg PO BID
10. Dronabinol 2.5 mg PO BID
11. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 65 ml/hr
oral DAILY
12. Lisinopril 20 mg PO DAILY
13. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
14. Simethicone 40-80 mg PO QID:PRN gassy feeling
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Gastroparesis, Type I Diabetes Mellitus
Secondary: Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ because ___ were having nausea and
vomiting and were unable to tolerate tube feedings. Imaging was
done of the GJ tube ___ had placed in ___, and it showed that
the G (gastric) portion had migrated up into your esophagus.
This is what was causing ___ to vomit and feel as though ___ had
something stuck in your throat. ___ underwent surgery for
placement of a separate G (gastric) and J (jejunal) tube as this
is less likely to migrate and cause the same problems ___ were
having before. The purpose of your J-tube is for feedings and
medication administration. The purpose of your G-tube is to
drain fluid from your stomach so that ___ do not vomit. ___
tolerated the surgery well and tube feeds were started through
your J-tube. After one day of continuous tube feeds ___ were
transitioned to cycled tube feeds and ___ also tolerated that
well. Your symptoms improved significantly during this hospital
stay and ___ were discharged home with follow-up with your
primary care physician, palliative care for pain control, GI for
your gastroparesis, and surgery to make sure ___ are having no
problems following the surgery.
The following medications were added or changed:
- Methadone 5mg BID
- Lexapro 10mg daily
Please attend your follow up appointments as listed below.
Thank ___ for choosing ___ for your health care needs. It has
been a pleasure taking care of ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10746056-DS-27
| 10,746,056 | 24,027,961 |
DS
| 27 |
2139-12-31 00:00:00
|
2140-01-10 20:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
J-tube replacement ___
History of Present Illness:
___ F w ___ IDDM c/b diabetic retinopathy and macular
degeneration, gastroparesis w G/J tube (GJ revision with
separate tube sites done ___, anxiety and depression presenting
with abdominal pain and vomiting. Of note the patient was
recently admitted ___ for similar symptoms. The patient
felt well until ___. She had slowly taking PO when she began
vomiting. On ___, she was instructed by GI to vent G tube which
was done successfully, but without improvement in symptoms.
Today, she had a sudden increase in abdominal pain associated
with intractable vomiting starting 2 hours prior to
presentation. Abdominal pain was described as sharp,
non-radiating and epigastric. At that time it was noted that the
J tube had been displaced. Pt is on methadone and oxycodone for
pain at baseline, but had not taken these meds on the day of
admission. She denied fevers.
Notable information from past hospitalization: She was recently
admitted from ___ with ongoing nausea and vomiting.
Symptoms were well controlled with Zofran and venting of the G
tube. She was evaluated by GI who provided teaching on proper
use of the G and J tubes. Symptoms were attributed to a
gastroparesis flare and patient misunderstanding of proper tube
utilization.
In the ED, initial vitals were:
96.6, ___, 22, 98% RA
Exam notable for: Tachycardia and Hypertension. Continuous
vomiting. Heart/lung exam normal. Diffuse TTP on abd exam. Both
tube sites are purulent, J tube out.
Labs notable for: WBC 12.5, Chem 10 wnl, LFTs wnl, Lipase 17,
Lactate 2.1
Imaging notable for:
- J tube study showing position of J tube intralumen, with
significant extraluminal contrast, recommendation dedicated J
tube evaluation
Patient was given:
IV HYDROmorphone (Dilaudid) 1 mg
IV Ondansetron 4 mg
IVF 1000 mL NS 1000 mL
IV HYDROmorphone (Dilaudid) 1 mg
IV HYDROmorphone (Dilaudid) 1 mg
IV Ondansetron 4 mg
IV Lorazepam 1 mg
IV HYDROmorphone (Dilaudid) .5 mg
Surgery was consulted and replaced the J tube at the bedside.
Sutured in place for anticipated advancement under ___ in the
morning. No use of J tube overnight until cleared by ACS.
On the floor, the patient is endorsing significant pain and
anxiety, requesting Ativan. Denies fevers and other infectious
symptoms. Does not know how her tube fell out but is
significantly distressed by her readmission.
ROS:
(+) Per HPI
(-) Denies fever, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vital Signs: 98.2, 146 / 88, 96 18 99 RA
General: Alert, oriented, appears to be in significant pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Poor inspiratory effort ___ pain, anterior lung fields
CTAB.
Abdomen: Soft, +BS, G and J tube in place with evidence of mild
purulence and minimal erythema surrounding insertion sites,
significant tenderness to light palpation ___ and ___.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength not assessed due to pain, gait
deferred.
DISCHARGE PHYSICAL EXAM:
=======================
Vital Signs: 98.4, 124-157/67-92, 73-81, 18 99%RA
General: AAOx3, NAD, pleasant
HEENT: MMM, oropharynx clear, no OP lesions, no evidence of
bleeding
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, good air movement b/l
Abdomen: Soft, hypoactive BS, G and J tube in place, mild
tenderness to light palpation of LUQ, no rebound, no guarding
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
===============
___ 03:52PM BLOOD WBC-12.5*# RBC-5.02 Hgb-14.3 Hct-44.1
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-44.6 Plt ___
___ 03:52PM BLOOD Neuts-78.7* Lymphs-13.1* Monos-6.4
Eos-0.7* Baso-0.6 Im ___ AbsNeut-9.81* AbsLymp-1.63
AbsMono-0.80 AbsEos-0.09 AbsBaso-0.08
___ 03:52PM BLOOD ___ PTT-27.9 ___
___ 03:52PM BLOOD Glucose-194* UreaN-15 Creat-0.6 Na-141
K-4.5 Cl-98 HCO3-32 AnGap-16
___ 03:52PM BLOOD ALT-17 AST-13 AlkPhos-68 TotBili-0.3
___ 03:52PM BLOOD Albumin-3.9 Calcium-9.8 Phos-3.6 Mg-1.9
___ 03:52PM BLOOD HCG-<5
DISCHARGE LABS:
===============
___ 07:50AM BLOOD WBC-8.9 RBC-4.16 Hgb-11.8 Hct-37.6 MCV-90
MCH-28.4 MCHC-31.4* RDW-13.4 RDWSD-44.2 Plt ___
___ 03:51PM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-99 HCO3-33* AnGap-9
___ 03:51PM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
Brief Hospital Course:
MS. ___ is a ___ ___ DM, legal blindness, severe
gastroparesis s/p recent surgical G and J tube placement ___
who p/w nausea and vomiting secondary to J-tube displacement. ___
replaced the J-tube on ___ with tube feeds and medications
restarted through the J-tube on ___. For pain, she received IV
dilaudid 1 mg as needed. She was weaned to her home regimen of
oxycodone 20mg q6h and methadone 5mg BID. On ___, an area of
fluctuance and erythema was noted around her G-tube site.
Surgery saw her and stated that it had been seen previously;
their suspicion for infection was low and nothing was done. She
continued to remain clinically and hemodynamically stable and
was discharged with instructions on how to properly use and
clean her G/J-tubes. She was advised to follow-up with her PCP
and palliative care within the week of discharge and to attend
her GI appointment in ___.
TRANSITIONAL ISSUES:
-discharged with 7 day course of methadone for PAIN. Palliative
care to continue pain regimen
-follow up on blood cultures obtained in ED
-patient to follow up with PCP for any additional prescriptions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. LORazepam 1 mg PO Q8H:PRN anxiety
6. OxycoDONE Liquid 20 mg NG Q6H
7. Escitalopram Oxalate 10 mg PO DAILY
8. Simethicone 40-80 mg PO QID:PRN bloating
9. Ondansetron ODT 4 mg NG Q8H:PRN nausea
10. nystatin 100,000 unit/mL oral BID:PRN
11. Methadone 5 mg PO BID Pain
Discharge Medications:
1. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. OxycoDONE Liquid 20 mg NG Q6H
3. amLODIPine 10 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Escitalopram Oxalate 10 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q8H:PRN anxiety
9. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO BID
FOR PAIN
RX *methadone 5 mg/5 mL 5 mg by mouth twice daily Disp #*70
Milliliter Refills:*0
10. nystatin 100,000 unit/mL oral BID:PRN
11. Ondansetron ODT 4 mg PO Q8H:PRN nausea
12. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Nausea and vomiting, secondary to J-tube displacement
Secondary: Diabetes mellitus, severe gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to ___ for nausea and vomiting likely due to
accidental removal of your J tube. The J-tube was replaced with
a new one during your stay. The J tube is for feeding and
medication administration. All of the medications on your
medication list can be given through your J tube. Your G-tube is
for venting and draining fluid from your stomach. ___ may eat as
tolerated and use the G-tube to vent. Please be cautious in
terms of your oral intake, and if ___ are feeling nauseous then
allow your G-tube to vent, take Zofran 4mg through your J-tube,
and do not take in anything orally until ___ are feeling better.
If the nausea is persisting, ___ can call your
gastroenterologists office at ___. ___ will resume your
tube feeds as ___ had been taking them prior to hospitalization.
___ can clean any crusted drainage from your tubes with warm
soap and water. ___ can flush your tubes with clean tap water
after each use.
There were no changes made to your medications.
Please attend your follow-up appointments as listed below. If
Palliative Care does not reach out to ___ by ___, please
call them at ___ to set up an appointment. Please also
call your PCP to make an appointment within one week.
Thank ___ for choosing ___ for your healthcare needs. It was a
pleasure taking care of ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10746056-DS-28
| 10,746,056 | 24,242,202 |
DS
| 28 |
2140-01-14 00:00:00
|
2140-01-15 01:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
G-tube site drainage
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o with h/o diabetes gastroparesis s/p G tube and J-tube
placement one month ago. She reports 5 days of worsening
abdominal pain that is constant and ___. She presented to the
ED on ___ after her visiting nurse noticed purulent
discharge from the G tube site this morning. The patient says
she has
experienced chills for the last 2 days, but has not felt
feverish. She denies any nausea or vomiting. She recently had
her J-tube replaced on ___ after it became displaced.
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
Gen: AAOx3, NAD, lying comfortably in bed
HEENT: MMM, no scleral icterus
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, ND, mild tenderness to palpation over G-tube
site
J-tube site C/D/I
G-tube site with mild serous drainage as well as fibrinous
material visible. Around G-tube site is 3x3cm area of erythema
and induration which is stable/not spreading since admission
Ext: WWP, no edema, 2+ DP
Physical examination upon discharge: ___:
vital signs: 98.5, hr=98 bp=153/77, rr=18 o2 sat 100% room
air
CV: ns1, s2, -s3,-s4
LUNGS: clear
ABDOMEN: hypoactive BS, soft, G-tube with 2" opaque center,
oozing sero-sanguinous drainage., J tube clamped, mild erythema
insertion site
EXT: no pedal edema, no calf tenderness bil.
NEURO: sleepy, oriented x3, speech clear, no tremors
Pertinent Results:
___ 05:15AM BLOOD WBC-8.4 RBC-4.04 Hgb-11.0* Hct-35.2
MCV-87 MCH-27.2 MCHC-31.3* RDW-13.3 RDWSD-42.3 Plt ___
___ 05:15AM BLOOD Glucose-168* UreaN-13 Creat-0.7 Na-136
K-4.0 Cl-92* HCO3-33* AnGap-15
___ 05:15AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.7
___ 10:11PM BLOOD Lactate-1.5
___: cat scan abdomen and pelvis:
. 4.8 x 1.7 cm fluid collection adjacent to the gastrostomy tube
in the
anterior abdominal wall without intraabdominal extension,
consistent with
abscess.
2. Unremarkable left anterior abdominal jejunostomy.
3. Intra and extra-hepatic biliary dilation, stable since ___.
4. Cholelithiasis.
Brief Hospital Course:
Ms. ___ is a ___ old woman who was admitted for
observation of cellulitis of her G-tube site with associated
purulent fluid collection. The site was noted to be erythematous
and indurated upon evaluation in the ED (about 3x3cm area).
Spontaneous purulent drainage was noted from the site, with some
fibrinous material at the site also visible. The wound was
further manipulated to assist in the drainage of this purulent
fluid by the surgery team, and was subsequently felt to be
adequately drained. She was placed on a 10day course of PO
clindamycin to treat the associated cellulitis.
She was admitted to the hospital for observation subsequently.
On HD#2, she was doing well, with improved pain, and tolerating
home tube feeds and regular diet by mouth for comfort with no
nausea/vomiting or pain. The wound was inspected and noted to
have some serous drainage with minimal purulent drainage. The
cellulitis around the G-tube site appeared to be stable.
Her vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. She was initially given IV
before tube feeds were restarted, which were discontinued when
she was tolerating PO's and tube feeds resumed. Her tube
feedings were cycled over 16 hours. She was voiding adequate
amounts of urine without difficulty. She was encouraged to
mobilize out of bed and ambulate as tolerated, which she was
able to do independently. Her pain level was routinely assessed
and well controlled at discharge with her home PO/J-tube pain
regimen as needed.
On HD#3, she was discharged home with scheduled follow up in ___
clinic with Dr. ___ on ___. She had an appointment
with the Wound nurse at ___ which will need to be
rescheduled. The patient has been informed of this.
Medications on Admission:
insulin aspart [Novolog],
bisacodyl
lansoprazole
lorazepam
methadone
oxycodone
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Clindamycin Solution 450 mg PO Q8H
last dose ___
RX *clindamycin palmitate HCl 75 mg/5 mL 30 ml by mouth q8hrs
Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. LORazepam 1 mg PO Q8H:PRN anxiety
7. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO BID
8. OxycoDONE Liquid 20 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cellulitis, G-tube site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of purulent drainage from your G tube site which was
accompanied by several days of abdominal pain. You were found to
have a small pocket of pus around the G tube site, which has now
been drained. You are recovering well and are now ready for
discharge. Please follow the instructions below 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. You are being discharged on
antibiotics to manage the skin infection that has developed
around the G tube site. Please finish all the antibiotics that
you have been prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*Please look at the site every day for signs of worsening
infection (increased redness or pain, swelling, odor, yellow or
bloody discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10746096-DS-9
| 10,746,096 | 26,874,710 |
DS
| 9 |
2141-08-18 00:00:00
|
2141-08-21 21:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Headache; shortness of breath; cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o HCV, HTN, and tobacco abuse
presenting with frontal headache x4 days and cough with
shortness of breath.
The patient first developing a frontal dull headache about four
days prior to admission. She does not normally get headaches.
Was using aspirin at home without improvement. Denied blurry
vision or diplopia. Also reports that about the same time she
developed a dry cough with associated shortness of breath.
Denies fevers although reports chills wearing extra layers and
blankets at home. Decreased appetite over the past few days. At
baseline at home able to walk up ___ flights of stairs slowly
secondary to knee pain. Denies orthopnea, PND, or lower
extremity swelling. She is a chronic smoker and has been
admitted twice before for pnuemonia ___ and ___. Denies any
sick contacts or recent travel.
In the ED, initial vitals were: 99.8 107 148/68 16 97% 2L Nasal
Cannula
- RA sat 89%
- EKG: SR @ 99, normal axis; non specific STTW changes
- Labs were significant for: WBC 6.7 (82%N), Hb 11.5, K 3.2,
lactate 1
- Bl cx sent
- CXR with moderate pulm edema and small bilateral effusions; CT
head neg
- CTA of chest with diffuse opacities, some GGO and some more
confluent and concerning for multifocal infectious process
- The patient was given: CTX + azithro, tylenol, KCl
Vitals prior to transfer were: 100.2 88 127/62 25 92% Nasal
Cannula
- Flu swab was done and was negative.
Upon arrival to the floor, the patient reports ongoing mild dull
headache. Reports continued dry cough without significant
shortness of breath. Denies abdominal pain, nausea, vomiting,
diarrhea, or dysuria. No back pain.
Past Medical History:
- HCV: genotype 1b, without cirrhosis
- HTN
- Tobacco use
- Vitiligo
Social History:
___
Family History:
- Mother: HTN, killed in MVA by drunk driver
- Father: Healthy until killed in MVA by drunk driver
- Brother: HTN, ESRD
- Sister: ___
Physical Exam:
ADMISSION EXAM:
============
Vitals: Tc: 99.4 BP:141/79 HR:89 RR:20 O2:94% on 3L
General: Alert, oriented; appears comfortable in NAD: speaking
full sentences without any evidence of increased WOB
HEENT: Sclera anicteric, MMM, oropharynx clear, 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, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly distended, nontender; central vertical
abdominal scar; +BSG
GU: No foley
Ext: Warm, well perfused, 2+ pulses, trace ankle edema
Neuro: Grossly intact ambulating around the room without
difficulty, ___ strength upper/lower extremities, grossly normal
sensation
DISCHARGE EXAM:
============
Vitals: Tc 98.3 HR 82 BP 115/69 RR 18 O2 98 RA; 95% with stairs
General: Alert, oriented; pleasant, appears comfortable in NAD:
speaking full sentences without any evidence of increased WOB
HEENT: Sclera anicteric, MMM, oropharynx clear, 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, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly distended, nontender; central vertical
abdominal scar; +BSG
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, trace ankle
edema
Neuro: Grossly intact ambulating around the room without
difficulty
Skin: soft, no tenting
Pertinent Results:
ADMISSION LABS:
============
___ 12:27AM BLOOD WBC-6.7# RBC-4.00* Hgb-11.5* Hct-32.9*
MCV-82 MCH-28.7 MCHC-35.0 RDW-13.3 Plt ___
___ 12:27AM BLOOD Neuts-82.5* Lymphs-12.6* Monos-4.3
Eos-0.5 Baso-0.1
___ 12:27AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-133
K-3.2* Cl-94* HCO3-28 AnGap-14
___ 12:27AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:27AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.1
___ 12:34AM BLOOD Lactate-1.0
DISCHARGE LABS:
=============
___ 07:15AM BLOOD WBC-4.6 RBC-4.07* Hgb-11.9* Hct-33.8*
MCV-83 MCH-29.3 MCHC-35.3* RDW-12.8 Plt ___
___ 07:15AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-133 K-3.7
Cl-97 HCO3-27 AnGap-13
___ 07:15AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4
URINE STUDIES:
==========
___ 11:35PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-8* pH-6.5 Leuks-LG
___ 11:35PM URINE RBC-3* WBC-33* Bacteri-FEW Yeast-NONE
Epi-4
___ 11:35PM URINE CastHy-12*
MICROBIOLOGY:
============
___ 04:50AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:27 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES:
=============
CXR (___):
1. Multifocal airspace opacities are concerning for a
multifocal infectious process, or alternatively chronic
eosinophilic pneumonia could also be considered.
2. Hyperexpanded lungs.
3. Mediastinal and hilar lymphadenopathy is seen dating back to
___.
ECGStudy Date of ___ 10:42:06 ___
Sinus rhythm. Non-specific ST segment changes. Compared to the
previous tracing of ___ the overall findings are similar.
Intervals Axes
RatePRQRSQTQTc (___) ___
___
CT Chest w/ Contrast (___):
IMPRESSION:
1. Diffuse pulmonary intraparenchymal opacities, some which
demonstrate ground-glass appearance, and some of which are more
confluent, and are concerning for multifocal infectious process.
Chronic eosinophilic pneumonia could also be considered.
2. Enlarged mediastinal and hilar lymphadenopathy may be
reactive. Recommend attention on followup.
3. Small hiatal hernia.
CT Head w/o Contrast (___): No acute intracranial process.
Brief Hospital Course:
___ with h/o HCV, HTN, and tobacco abuse with prior hx of
multifocal PNA presents for evaluation of headache x4 days and
cough with shortness of breath found to have findings consistent
with multifocal PNA on imaging, currently improved on
levofloxacin.
ACTIVE ISSUES:
# Community acquired pneumonia: Pt presenting headache, cough,
and shortness of breath on presentation. CXR with pulmonary
effusions and a CT with diffuse pulmonary opacities and GGOs,
consistent with multifocal pneumonia. The patient was initially
requiring 3L of oxygen by nasal cannula. She was started on
levofloxacin 750mg po daily and her symptoms resolved. She was
weaned to room air, although continued to desaturate on ___ to
the mid-80s with ambulation. On ___, she was able to ambulate
and walk up stairs with a lowest saturation of 89% (mostly 95%,
also on 95% on stairs), so she was discharged home to complete a
7-day course of levofloxacin 750mg po daily.
# Headache: Pt presenting with dull frontal headache on
admission. CT head negative and neurologically intact. No visual
changes. Pain resolved with treatment of pneumonia as above. Pt
ambulating around the floor prior to discharge without any gait
abnormalities.
CHRONIC ISSUES:
# HTN: Normotensive during admission. Continued on her home
regimen of diltiazem 120mg po daily and hydrochlorothiazide 25mg
po daily.
# Tobacco use: Currently reports smoking about ___ ppd.
Attempting to wean and has been given nicotine patch and gum at
home. The patient was counseled to quit smoking especially in
the setting of her history of pneumonia. Given new RX for
nicotine patch as only requires 14mg patch given current usage
in addition to her nicotine gum.
# Vitiligo: Noted on her neck. Continued on fluocinonide 0.05%
ointment 1 Appl TP BID
***TRANSITIONAL ISSUES***
-Please continue levofloxacin 750mg po daily to complete a 7-day
course of antibiotics (last day ___
-Pt with history of multiple pneumonias in the past. Consider
further work-up for other pulmonary processes given effusions
and findings on CT chest demonstrating mediastinal
lymphadenopathy.
-U/A with microscopic hematuria. Consider repeat as outpatient.
-Encourage further smoking cessation
-Code: DNR/DNI
-Contact: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Fluocinonide 0.05% Ointment 1 Appl TP BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
6. Nicotine Polacrilex 2 mg PO Q2H:PRN nicotine craving
7. Vitamin D 5000 UNIT PO DAILY
8. Acetaminophen 500 mg PO DAILY:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Fluocinonide 0.05% Ointment 1 Appl TP BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Nicotine Polacrilex 2 mg PO Q2H:PRN nicotine craving
6. Vitamin D 5000 UNIT PO DAILY
7. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
8. Acetaminophen 500 mg PO DAILY:PRN pain
9. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Please apply to skin Daily Disp #*28
Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Community acquired pneumonia, Hypoxia
Secondary Diagnosis: Tobacco use; hypertension; hepatitis C
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 ___ for
headache, cough, and shortness of breath. A chest Xray showed
that you had some fluid around your lungs and a CT scan of your
chest was consistent with a pneumonia. You were started on
antibiotics and your cough and shortness of breath improved. We
were able to wean you off of oxygen, and you were discharged
home on ___.
Please continue to take levofloxacin 750mg daily to complete a
7-day course of antibiotics.
It is also extremely important that you stop smoking to help
with your lung function. Please follow-up with Dr. ___ at
the appointment listed below. A post-discharge team will follow
you after hospitalization.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10746889-DS-15
| 10,746,889 | 22,331,055 |
DS
| 15 |
2117-06-11 00:00:00
|
2117-06-11 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine / ___
Attending: ___.
Chief Complaint:
Word Finding Difficulty
Major Surgical or Invasive Procedure:
___ stereotactic brain biopsy
History of Present Illness:
___ year old female presented to ___ with 6 days of
word finding difficulty. The patient reports that she initially
reached out to her long-time Psychologist report new-onset of
intermittent expressive aphasia, and he recommended that she see
her PCP for further workup. She then called her PCP, who was
booking out until ___, therefore her husband took her to
___ for further evaluation. At ___, she
underwent
a NCHCT that identified left frontal vasogenic edema, likely w
representing an underlying mass. She has not had any further
imaging, however she has a pacemaker (which will complicate
getting an MRI). She has no known primary cancer. She is
neurologically intact other than occasional WFD that she can
overcome when given pause to collect herself.
Past Medical History:
Sick sinus syndrome (has pacemaker)
Diabetes
Hypertension
Gout
hypercholesterolemia
GERD
Social History:
___
Family History:
Brother - leukemia, alive
Mother - lung cancer. Deceased in ___ decade of life
Physical Exam:
PHYSICAL EXAM (on admission):
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL ___
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 with occasional pauses for word-finding
difficulty. Good comprehension and repetition. No dysarthria or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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
Handedness: Right
====================================================
PHYSICAL EXAM (on discharge):
A&Ox3, PERRL ___, ___, no drift. ___ strength. very mild WFD
but naming intact, incision CDI with staples
Pertinent Results:
Please see relevant imaging in OMR
Brief Hospital Course:
# Left frontal brain lesion
The patient was admitted on ___ and underwent workup for
a left frontal lesion. CT torso was negative for malignancy. She
was started on Keppra for seizure prophylaxis and Decadron for
cerebral edema. On ___, she underwent a stereotactic
brain biopsy of the lesion. The procedure was uncomplicated. For
further procedure details, please see separately dictated
operative report by Dr. ___. The patient was extubated in
the operating room and transported to the PACU for recovery.
Once stable, she was transferred to the ___ for close
neurological monitoring. Routine post-operative NCHCT showed
expected post-operative changes. On POD#___ontrolled, she was tolerating PO diet, and was transferred to
the floor in stable condition. Radiation and neuro oncology were
consulted. She was cleared for safe discharge to home on POD 2
with home ___ and home ___. She was given prescriptions and
follow up information.
Medications on Admission:
Metoprolol tartrate 75 mg BID
Simvastatin 20 mg qHS
Fluticasone one spray BID
Amiloride 5 mg daily
Hydrochlorothiazide 12.5 mg daily
Potassium chloride 20 mEq daily
Zantac 150 mg BID
Amlodipine 10 mg daily
Metformin XR 500 mg TID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Senna 8.6 mg PO BID:PRN constipation
6. aMILoride 5 mg PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
13. Metoprolol Tartrate 75 mg PO BID
14. Ranitidine 150 mg PO BID
15. Simvastatin 20 mg PO QHS
16.Rolling walker
Diagnosis: Left frontal lesion
Prognosis: Good
Length: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left frontal brain lesion
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:
Discharge Instructions
Brain Tumor
Surgery
You underwent a biopsy. A sample of tissue from the
lesion in your brain was sent to pathology for testing.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10747214-DS-11
| 10,747,214 | 25,727,864 |
DS
| 11 |
2123-12-06 00:00:00
|
2123-12-07 16:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Loss of consciousness, bilat upper extremity shaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ M without known pmh who presented to ___
___ after a seizure-like event.
He was in his usual state of health (woke up at normal time and
felt good, ate breakfast and headed to work) until earlier this
morning when while looking at a cell phone with his friend at
work had sudden loss of consciousness, followed by witnessed
shaking of the upper limbs bilaterally. Witnesses to the event
are not available at this time but by report the event lasted
less than 1minute. He woke up on the ground in a confused state.
Shortly thereafter his boss sent him in a taxi to the hospital
at which time he underwent NCHCT which showed a 12mm left
internal capsule lesion. He was transfered for neurosurgical
eval. He was seen by neurosurgery who loaded him with Keppra but
deferred mangement to Neurology. He currently feels back to his
baseline.
He has no history of seizures, strokes. He has no significant
neurological history. He notes seasonal allergies as the only
past medical problem. He has no hx of HTN, DM, vascular disease
___ disease. He has not family members with known
intracranial pathologies and denies head/neck trauma.
Of note, he is originally from ___ but denies significant
past history of infections such as TB. He has been told multiple
times in the past that he has low white blood cells. He has been
tested for HIV multiple times in the past, including since
immigrating to ___.
On ROS, he endorses 2 months of intermittent right flank pain
aggravated by lifting heavy objects. He also endorses mild
global constant pressure headache since the event this morning.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
seasonal allergies
Social History:
___
Family History:
no known neurological disease, states that his family is in good
health
Physical Exam:
Physical Exam:
Vitals: 98.8 BP: 108/68 HR: 60 R: 16 O2Sats: 100%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAM:
GENERAL: Awake, alert, oriented x 3
HEENT: MMM, EOMI
CV: RRR, nl S1, S2
PULM: CTAB
ABD: Soft, NTND
EXTREM: No C/C/E
NEUROLOGICAL: No sensory or motor deficits bilat UE and ___,
cranial nerves ___ in tact, heal-shin in tact, negative
Romberg, rapid alternating hand movements in tact, gait normal,
tandem gait normal
MS: oriented x 3, could repeat 3 works after 5 mins
Pertinent Results:
LABS:
___ 09:10PM BLOOD WBC-3.4* RBC-4.87 Hgb-14.2 Hct-42.7
MCV-88 MCH-29.2 MCHC-33.3 RDW-12.2 Plt ___
___ 09:10PM BLOOD Neuts-40.9* Lymphs-47.9* Monos-6.3
Eos-3.1 Baso-1.8
___ 09:10PM BLOOD ___ PTT-34.9 ___
___ 09:10PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-104 HCO3-26 AnGap-11
MRI/MRA HEAD W & W/O CONTRAST:
IMPRESSION:
Left basal ganglia lesion consistent with a small cavernous
malformation with late subacute blood products. No infarct.
EEG: reviewed by team, official report pending
Brief Hospital Course:
___ M with no PMH who presented to ___ after a
syncopal event ___ AM (sudden LOC, bilat UE shaking, no
post-ictal state, no loss of bowel/bladder, no tongue biting).
MRI/MRA with and without contrast showed a small cavernous
malformation with late subacute blood. An EEG was obtained...,
EKG had no abnormalities, and orthostatic BPs were normal. The
team contacted patient's friend who witnessed the event and
reports similar events as the patient (see HPI). Patient
recevied Keppra 1000mg BID while in house. He was kept on
seizure precautions. He did not require ativan during this
hospital stay and did not have any seizure-like activities or
loss of consciousness. He was noted to have a leukocytopenia,
however, patient reported having this lab abnormality since his
___ and has been tested multiple times (including since his
immigration to the ___) for HIV, therefore HIV testing at this
time was deferred. Patient was given heparin SC for DVT
prophylaxis while in hospital.
Medications on Admission:
None
Discharge Medications:
1. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Syncopal episode
Cavernous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of loss of consciousness
and reported upper arm shaking. We took images of your brain and
monitored the electrical activity of your brain, and we did not
find a source for your loss of consciousness. On your brain
imaging, you have a cavernoma - a small pocket in the brain -
which you have probably had for most of your life. This can be a
normal variant. However, we think that this cavernoma caused you
to have a seizure, so we will start you on a medication called
Keppra (Levetiracetam) to prevent them.
**DO NOT TAKE any blood thinning medications such as aspirin or
plavix as this can increase the risk of bleeding in your brain.
We have made the following changes to your medications:
START
Keppra 1000mg twice per day
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10747238-DS-6
| 10,747,238 | 27,548,189 |
DS
| 6 |
2124-04-08 00:00:00
|
2124-04-08 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Seroquel / Chantix Starting Month Pak / NSAIDS
Attending: ___.
Chief Complaint:
PRIMARY:
Hypomagnesemia
Hypokalemia
Orthostatic Hypotension
Dizziness
SECONDARY:
Alcoholic Liver Disease
Alcoholic Dependence/Abuse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ a PMH of ETOH abuse, Hep C, cirrhosis and anxiety p/w
dizziness and presyncope since this morning. Patient reports
that she has had increasing anxiety since this ___ when she
was confronted by a lawyer for her housing complex and was told
that she was being evicted in 30 days. Since then she has
increased her EtOH intake, last night consuming 2 ___ and 5
nips. This morning, she became acutely dizzy when moving around
in bed. She reports her dizziness is worse with sitting upright.
Also reports occasional palpitations, which are not necessarily
associated with dizziness. Denies paresthesias or muscle cramps.
She is additionally reporting diarrhea which began this morning.
She describes it as nonbloody and and not black and says she had
approximately 4 episodes. Denies fevers, chills, nausea,
vomiting. She also reports chest pain which she describes as
being located in her left shoulder and spreading across the top
of her chest above the sternum. Chest pain does not radiate to
the back and is nonpleuritic. This has been occurring for the
past several months and she attributes it to a fall on the black
ice in the ___. Also reports generalized abdominal pain and
bloating since that time. Denies associated dyspnea. Reports
intermittent chronic cough.
In the ED initial vitals were:98.4 89 161/86 18 98% ra. guaiac
negative on rectal exam
- Labs were significant for severe hypomagnesemia to 0.6 and
hypokalemia to 3.2. Also has known abnormal LFT's and
pancytopenia at baseline.
- Patient was given PO magnesium and potassium repletion
- RUQ U/S showed cirrhotic liver but no other acute process.
- Hepatology was consulted regarding her pancytopenia and felt
that her lab results were at baseline and did not require
intervention.
- Orthostatics prior to transfer were: 171/82 standing (HR 73),
159/91 standing (HR 76), and 136/90 standing (HR 89).
Vitals prior to transfer were:72 156/85 20 98% RA
On the floor, patient continued to report intermittent dizziness
with movement.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
# Hepatitis C
# EtOH/Hep C cirrhosis
# EtOH Dependence
# Hypothyroidism
# Fibromyalgia with chronic chest/abdominal/neck pain
# Anxiety
# History of severe emotional, physical, domestic abuse
Social History:
___
Family History:
Mother died in ___ of a "GI cancer". No CAD. No history of
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 98.1 BP: 150/79 HR: 77 RR: 18 02 sat: 98%/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. diffuse chest
wall tenderness to palpation
LUNG: few crackles in bilateral bases, but breathing comfortably
and lungs otherwise clear
ABDOMEN: soft, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. A and O x 3, able to say months of year
backwards without issues. mild fine tremor, no asterixis
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
VITALS: 97.3, 153/73, 73, 18, 98% on RA, CIWA 8-->5-->4-->4,
Tele = Sinus, 60s-80s, No Alarms
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. diffuse chest
wall tenderness to palpation
LUNG: few crackles in bilateral bases, but breathing comfortably
and lungs otherwise clear
ABDOMEN: soft, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. A and O x 3, able to say months of year
backwards without issues. mild fine tremor, no asterixis.
Cerebellar and gait examination normal.
SKIN: warm and well perfused
Pertinent Results:
___ 03:15PM BLOOD WBC-3.7* RBC-3.12* Hgb-8.6* Hct-27.7*
MCV-89 MCH-27.4# MCHC-30.8* RDW-20.4* Plt Ct-29*#
___ 07:40AM BLOOD WBC-3.9* RBC-3.27* Hgb-8.7* Hct-28.8*
MCV-88 MCH-26.5* MCHC-30.1* RDW-20.5* Plt Ct-28*
___ 03:15PM BLOOD Neuts-54.0 ___ Monos-4.5 Eos-2.3
Baso-0.6
___ 03:54PM BLOOD ___ PTT-32.8 ___
___ 07:40AM BLOOD ___ PTT-31.9 ___
___ 03:15PM BLOOD Glucose-122* UreaN-5* Creat-0.5 Na-137
K-3.2* Cl-102 HCO3-24 AnGap-14
___ 07:40AM BLOOD Glucose-135* UreaN-6 Creat-0.5 Na-130*
K-3.9 Cl-96 HCO3-25 AnGap-13
___ 03:15PM BLOOD ALT-34 AST-60* AlkPhos-87 TotBili-1.3
___ 04:31AM BLOOD CK(CPK)-131
___ 03:15PM BLOOD Albumin-3.4* Mg-0.6*
___ 07:40AM BLOOD Calcium-7.2* Phos-2.6* Mg-2.2
RUQ ULTRASOUND ___ =
Nodular, heterogeneous, hyperechoic liver consistent with known
cirrhosis. No focal liver mass is definitely identified. No
acute cholecystitis.
PHYSICAL THERAPY ___ =
___ consult recieved and appreciated. ___ RN RE Pt
status. Pt is currently at baseline level of mobility and has no
acute ___ needs. Will sign off for now and please reconsult if
status changes.
SOCIAL WORK ___ =
The pt. is a ___ year old Caucasian female who reports that she
has been drinking with increased intensity for approximately the
past year. The pt. reports that she has too much on her plate
to consider any treatment for her alcohol abuse at this time.
The pt. reports that even thinking about getting help is causing
her anxiety to ramp up. At this time the pt. declines all
social work referral services.
Social work will remain available to provide support to the pt.
as needed.
Brief Hospital Course:
___ w/ a PMH of ETOH abuse, Hep C, cirrhosis and anxiety
presents with dizziness and presyncope x1 day along with
hypokalemia/hypomagnesemia. Her electrolytes were repleted and
she was given information about EtOH cessation, detox centers,
and housing.
# Dizziness / Presyncope: Felt to be secondary to dehydration
and hypokalemia/hypomagnesemia in the setting of chronic alcohol
abuse. Orthostatics were positive in the ED. On the floor,
orthostatics were negative (supine 141/85 and 75, sitting 148/87
and 67, standing 156/91 and 73), electrolytes were repleted,
patient could walk around the floor unsupported with minimal
difficulty. Neurological examination within normal limits.
# Hypokalemia / Hypomagnesemia: Most likely secondary to EtOH
abuse and recent diarrhea. also with mild hypocalcemia, most
likely related to low Mg. She was aggressively repleted, she
was monitored on telemetry, and her magnesium in ___ AM was
3.0.
# Alcohol Abuse: Patient reports significant chronic and recent
EtOH intake. Patient was monitored on CIWA scale, had a social
work consult for substance abuse, and was maintained on
thiamine/folate/MVI for nutrition.
# Chronic Chest/Abdominal/Neck Pain: Patient has had chest and
abdominal and neck pain for about ___ year. EKG and troponins x2
were unrevealing. Patient had variable tenderness. RUQ
ultrasound showed only old cirrhosis. She was kept on low-dose
APAP and oxycodone for pain control.
# Thrombocytopenia / Anemia: Thrombocytopenia likely secondary
to cirrhosis, somewhat decreased from plt ___ in ___.
Normocytic anemia, but stools guaiac negative, and HCT
relatively stable from 31 in ___. She had an active type and
screen maintained.
# Bibasilar Crackles on Exam: Patient had no dyspnea and no
other signs of volume overload.
# ETOH/HCV Cirrhosis: Followed as outpatient by Dr ___.
Patient reports active ETOH use. MELD 13. She was continued on
nadolol and had an outpatient hepatology appointment scheduled.
Social Work offered substance abuse resources but patient
declined them.
# Hypothyroidism: Chronic stable issue continued on home
levothyroxine.
# Fibromyalgia: Chronic stable issue on home gabapentin.
# Anxiety: Chronic stable issue on home risperidone, trazodone,
and benztropine.
# Housing Situation: Patient was informed by a lawyer that she
would be evicted from her apartment in the ___
___. Social work consult gave relevant materials and
services were offered but declined. She had wanted to stay in
order to avoid a Housing Authority eviction hearing on ___.
# Code Status: Full Code presumed, no Healthcare Proxy
# ___: Home without Services via Cab Voucher
# TRANSITIONAL ISSUES:
___ w/ a PMH of ETOH abuse, chronic hepatitis C, cirrhosis and
anxiety presents with lightheadedness and presyncope x1 day
along with hypokalemia/hypomagnesemia. Had normal cardiac
enzymes, normal ECG, and no evidence of significant alcohol
withdrawal. Her cirrhosis was compensated and a right upper
quadrant US showed no liver lesions or portal vein thrombus. She
had stable pancytopenia, with platelets in the ___ range. She
was not orthostatic. She declined alcohol abuse referral
resources. She was discharged ___ without services no longer
feeling lightheaded and with otherwise stable symptoms. She had
hepatology and PCP follow up.
* Hypomagnesemia/Hypokalemia: Repleted with PO K+ and IV Mg, Mg
3.0 and K 3.5 on discharge
* EtOH Dependence/Liver Disease: Monitored on CIWA which
remained <10, LFTs and blood indices stable, maintained on
cirrhosis meds and folate/thiamine/MVI, Social work evaluated
patient and gave information on detox and housing, will followup
with hepatology
* Dizziness: Orthostatics negative and electrolytes repleted by
time of discharge, dizziness likely secondary to alcoholic
cerebellar dysfunction which can only be improved by EtOH
cessation, consider meclizine for dizziness as outpatient, also
consider reducing doses of medications as outpatient
(gabapentin)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO HS
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Gabapentin 100 mg PO TID
4. RISperidone 2 mg PO HS
5. TraZODone 100 mg PO HS
6. Benztropine Mesylate 1 mg PO BID
7. Benztropine Mesylate 0.5 mg PO BID:PRN rigidity, restlessness
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Benztropine Mesylate 1 mg PO BID
2. Benztropine Mesylate 0.5 mg PO BID:PRN rigidity, restlessness
3. Gabapentin 100 mg PO TID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Nadolol 20 mg PO HS
6. RISperidone 2 mg PO HS
7. TraZODone 100 mg PO HS Insomnia
8. FoLIC Acid 1 mg IV Q24H
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
9. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Omeprazole 20 mg PO DAILY
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypomagnesemia
Hypokalemia
Dizziness
SECONDARY:
Alcoholic Liver Disease
Alcoholic Dependence/Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having dizziness
and were found to have low blood magnesium and potassium. You
were given more magnesium and potassium and were given
additional nutritional supplements. Best of luck to you in your
future health.
Please do not drink alcohol. Take all medications as
prescribed, attend all doctor appointments as scheduled, and
call a doctor if you have any questions or concerns.
Followup Instructions:
___
|
10747475-DS-10
| 10,747,475 | 28,720,293 |
DS
| 10 |
2142-08-14 00:00:00
|
2142-08-14 15:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
left facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Neurology Resident Stroke Admission Note
Neurology at bedside for evaluation after code stroke
activation
within: 10 minutes
Time/Date the patient was last known well: 11:10 AM on ___
Pre-stroke mRS ___ social history for description): 0
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: Low NIHSS
Endovascular intervention: []Yes [x]No
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale - Total [3]
1a. Level of Consciousness -
1b. LOC Questions -
1c. LOC Commands -
2. Best Gaze -
3. Visual Fields -
4. Facial Palsy - 1 (left)
5a. Motor arm, left -
5b. Motor arm, right -
6a. Motor leg, left -
6b. Motor leg, right -
7. Limb Ataxia -
8. Sensory - 1 (left leg)
9. Language -
10. Dysarthria - 1
11. Extinction and Neglect -
HPI:
Mr. ___ is a ___ man with a history of liver
transplant for hepatitis C cirrhosis and hepatocellular
carcinoma, and hypertension, who presents after developing
sudden
room spinning and lightheadedness.
He states that he was in the ___ for clinic
appointments. He was getting lunch in the cafeteria, and was
last well at 11:10 AM. Then suddenly he developed a sensation
of
room spinning, with lightheadedness, and feeling "rubbery" and
weak all over. His vision was blurry and he felt a "rash" in
his
chest. He thought he might feel better if he was able to lie
down, so he went to the ___ floor of the far building, where
his
support group is located, to lie down. A caseworker who knows
him well saw him at approximately noon and noted that he had
weakness of his left face and slurring of the speech. He was
brought to the ED for further evaluation.
Currently the patient states he feels slightly better, but is
still not back to normal.
ROS: As per HPI. All other systems negative.
Past Medical History:
1. hepatitis C/alcoholic cirrhosis c/b HCC status post liver
transplantation ___, complicated by recurrent hep C
infection requiring recent initiation of therapy ___.
2. Persistent transaminitis attributed to recurrent hep C
virus.
3. Possible latent TB.
4. History of cellulitis of the left great toe, resolved.
5. History of MSSA infection with associated line infection.
6. ORIF R elbow L shoulder, pelvis, ___ PTX after ___ fall.
7. Alcohol abuse and alcoholic Cirrhosis c/w esophogeal and
gastric varices with bleeding x1 in ___, encephalopathy
Social History:
___
Family History:
Mother died at age ___ she had hypertension and diabetes. Father
is alive in his ___ with hypertension. He has three sisters in
good health. No family history of liver disease or liver cancer.
.
Physical Exam:
Admission physical exam
Vitals:
98.0 72 138/78 19 97% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G, no carotid bruits
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. Mild dysarthria. Normal prosody. Able to register
3
objects and recall ___ at 5 minutes. No evidence of
hemineglect.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch or
pinprick bilaterally. Left nasolabial fold flattening with
slightly slower activation on the left. Hearing intact to finger
rub bilaterally. Palate elevation symmetric. SCM/Trapezius
strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
Areflexic throughout
Plantar response flexor bilaterally
- Sensory: Left leg decreased fine touch (70% of normal),
decreased pinprick (60% of normal), normal proprioception.
Otherwise, sensation intact. Normal graphesthesia. No
extinction to DSS.
- Coordination: No dysmetria with finger to nose or heel to
shin
testing bilaterally.
- Gait: Normal initiation. Narrow base. Slightly unsteady but
no listing to one side.
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================================================================
Discharge physical exam
Objective:
Vitals: Tc 98.2 BP 127/78 (112-139/70-80) HR 64 (59-66) RR 18
SpO2 90% RA (90-98RA)
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: Warm, well perfused
Pulmonary: No increased work of breathing on room air
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x3. Able to relate overnight and
subjective concerns without difficulty. Language is fluent with
full sentences , intact repetition, and intact verbal
comprehension. No paraphasias. No dysarthria appreciated on
repetition of ___, ___, papa. Normal prosody. No
left-right confusion. Able to follow both midline and
appendicular commands.
Cranial Nerves: EOMI, no nystagmus, no diplopia on prolonged
upgaze. No facial movement asymmetry. Hearing intact. Tongue
midline.
Motor - Normal bulk and tone. No fatigability with repetitive
muscle movements.
[Delt] [Bic] [Tri] [ECR] [IP] [FEx] [Ffx] [IO] [TA]
[Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch appreciated.
Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
Gait - Normal initiation, narrow base, normal stride length and
arm swing. Negative Romberg- stable without sway.
Pertinent Results:
CT brain negative for acute infarct. CTA notable for mild
atherosclerosis in the b/l internal carotid arteries and carotid
siphons.
MRI w/o contrast
1. No acute intracranial abnormality including hemorrhage,
infarct, or
suggestion of mass.
2. Trace scattered white matter signal abnormality, nonspecific,
which may
reflect chronic small vessel ischemic disease.
3. Minimal paranasal sinus disease, as described.
ECHO: No atrial septal defect or patent foramen ovale is seen by
2D, color Doppler or saline contrast with maneuvers. Moderate
left atrial dilation and mild right atrial dilation. Grade I
(mild) left ventricular diastolic dysfunction. Normal
biventricular cavity size and systolic function
LDL 113
A1c 4.5
TSH 0.57
Troponin <0.01
140 104 16
============<91
3.7 25 0.9
Ca 8.6 Mg 1.9 P 3.3
13.2
6.7> ---------< 153
40.2
Brief Hospital Course:
This is a ___ male with history of HCV cirrhosis and HCC
s/p liver transplant in ___ and HTN who presented with sudden
onset vertigo, with reported L facial droop and dysarthria. Exam
largely improved with slight dysarthria and L facial droop
(markedly improved from admission). CT brain negative for acute
infarct. CTA notable for mild atherosclerosis in the b/l
internal carotid arteries and carotid siphons. MRI findings
which were negative for stroke. Overall presentation of
remaining subtle left sided findings suspicious of small infarct
not seen on MRI vs TIA. At this time etiology is unclear. There
is no history of cardiac disease nor atrial fibrillation (with
none captured while monitored inpatient thus far) to suggest
cardioembolic source. However will recommend patient undergo a
___ of Hearts holtor monitor as outpatient.
Hospital course by system
# Neuro:
- F/u stroke risk factors: A1c 4.5, TSH 0.57, ldl 113
- Started ASA 81 mg daily
- pcp to begin LDL therapy as outpatient
- Dr. ___ patient for liver transplant) notified
regarding potential initiation of LDL therapy in the future
- ___ consulted, cleared for d/c home
- Distributed stroke education packet
# ___:
- Monitored on telemetry, no evidence of afib
- ___ of Hearts monitor as outpatient
- Goal SBP <180 and DBP <105 as above
- Hold home amlodipine for permissive hypertension to facilitate
increased cerebral perfusion pressure, restart on ___
#ID/Tox/Metabolic:
- UA: likely contaminant
- CXR: no focal consolidation
- LFTs within normal limits
- Continue home everolimus as pt is s/p liver transplant on
chronic immunosupression
#Endocrine
- TSH, A1c pending
- QID FSG with HISS with goal of normoglycemia
#Renal and FEN:
- Regular diet as passed RN bedside swallow screen
#Ppx:
- DVT: Pneumoboots, SQH
- Bowel: Docusate, Senna prn
- Precautions: Fall
- Code status: Full
- Dispo: home
Transitional issues:
- outpatient ___ of Hearts monitor
- PCP to monitor LDL and initiate statin therapy
- hold home amlodipine till ___ to allow for sbp autoregulation
- started on ASA, continue 81mg ASA as outpatient
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 113 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: waiting for approval from liver
transplant physicians as patient of everolimus and statins may
interact, pcp to initiate treatment as outpatient]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: pcp to initiate ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 200 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. TraZODone 100 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*11
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*11
3. Calcium Carbonate 1000 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Everolimus 3 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. BuPROPion (Sustained Release) 200 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. TraZODone 100 mg PO QHS
10. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until ___
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left facial droop
resulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
temporarily blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High lipids
High blood pressure
We are changing your medications as follows:
Started on Aspirin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10747596-DS-17
| 10,747,596 | 23,068,619 |
DS
| 17 |
2168-07-24 00:00:00
|
2168-07-27 17:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactroban / Im___
Attending: ___
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ RHF with a history of CAD, HTN, HLD, and
possible history of atrial fibrillation on ASA 81, who presented
as a transfer from ___ after an episode of left
visual field deficit for 10 minutes at 730am.
A code stroke was called and I evaluated the patient within 5
minutes. The patient was last known well at 7:30am on ___.
Initial NIHSS was 0. TPA was not considered as her symptoms had
completely resolved. OSH CT images were uploaded and reviewed
upon arrival. There was no evidence of hemorrhage or early sign
of ischemia.
The patient was last well this morning, when at 730 am, while
reading a card, she noticed that she could not read the left
side
of the card. This did not improve after covering either her
left
or right eye. She described it as her vision just not being
present to see the left side of the page. This completely
resolved within 10 minutes and has not recurred. No prior
similar episodes. She did not see black/bright spots or
squiggly
lines or other visual obscuration. She did not have diplopia.
She did not have sensory symptoms or weakness. While she did
not
have a headache at that time, she developed slight head pressure
at the back of her head one hour later, which has since
completely resolved.
She initially presented to ___, where initial vitals
were T97.9 P72 R18 BP 139/62 POX100% ra. NCHCT showed no
hemorrhage or large infarct. CXR negative. Initial labs
included Cr 0.7, tropI 0.03, INR 1.0. She was transferred to BI
for further managment.
At the bedside, she confirms that she has not had prior similar
episodes. When asked about an arrhythmia, she says that she may
have had an irregular heart beat in the past, but that this
resolved. She was quite confident that she did not have atrial
fibrillation. She also denied a history of chronic headaches
and
migraines.
Interestingly, in further review of her OMR, I have come across
"atrial fibrillation" listed in her PMH, but only one EKG from
___ which did not show afib. There was also mention of one
epsidode of ocular migraine (characterized by no headache, but
presence of visual blurring lasting minutes resolving
spontaneously).
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with producing
or
comprehending speech. Denies blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies
muscle weakness.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. Denies dysuria or
hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
1. CAD: 50% RCA obstruction s/p several cardiac catheterizations
2. Possible Atrial fibrillation - listed in OMR, but not known
to
patient.
3. Hypertension
4. Hyperlipidemia
5. Rosacea
6. Left Bell's palsy ___
7. s/p cholecystecomy
8. s/p removal of Squamous cell carcinoma on right calf ___ and
right ankle ___.
9. s/p total thyroidectomy in ___ for a right thyroid nodule
with suspicious cytology. Final pathology "benign follicular
adenoma"
10. ? one episode of occular migraine in ___
Social History:
___
Family History:
Her mother and 2 sisters with breast cancer (not
brca positive). Father with MI in his ___. Multiple brothers
with CAD noted in their ___.
Physical Exam:
Physical Examination:
VS 97.9 62 137/82 16 99% RA
General: NAD, comfortably sitting in bed
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, no rashes
___ Stroke Scale - Total [0]
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -0
5a. Motor arm, left -0
5b. Motor arm, right -0
6a. Motor leg, left -0
6b. Motor leg, right -0
7. Limb Ataxia -0
8. Sensory -0
9. Language -0
10. Dysarthria -0
11. Extinction and Neglect -0
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Able to
recite months of year backwards. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Content of speech demonstrates intact naming (high and low
frequency) and no paraphasias. Normal prosody. No dysarthria.
Verbal registration and recall ___. No apraxia. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
Pertinent Results:
ADMISSION LABS
___ 06:24PM %HbA1c-5.2 eAG-103
___ 01:10PM URINE HOURS-RANDOM
___ 01:10PM URINE HOURS-RANDOM
___ 01:10PM URINE UHOLD-HOLD
___ 01:10PM URINE GR HOLD-HOLD
___ 01:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:36PM GLUCOSE-81 NA+-145 K+-4.0 CL--105 TCO2-28
___ 12:33PM CREAT-0.8
___ 12:33PM estGFR-Using this
___ 12:20PM UREA N-12
___ 12:20PM cTropnT-<0.01
___ 12:20PM CHOLEST-120
___ 12:20PM TRIGLYCER-78 HDL CHOL-53 CHOL/HDL-2.3
LDL(CALC)-51
___ 12:20PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 12:20PM WBC-6.0 RBC-4.28 HGB-13.9 HCT-39.6 MCV-93
MCH-32.4* MCHC-35.0 RDW-12.3
___ 12:20PM NEUTS-57.9 ___ MONOS-5.0 EOS-1.0
BASOS-1.3
___ 12:20PM PLT COUNT-204
___ 12:20PM ___ PTT-27.4 ___
DISCHARGE LABS
___ 05:15AM BLOOD WBC-6.3 RBC-3.95* Hgb-12.6 Hct-36.6
MCV-93 MCH-31.9 MCHC-34.4 RDW-12.4 Plt ___
___ 05:15AM BLOOD Glucose-88 UreaN-14 Creat-0.7 Na-144
K-3.8 Cl-106 HCO3-28 AnGap-14
___ 05:15AM BLOOD Triglyc-82 HDL-49 CHOL/HD-2.3 LDLcalc-48
___ 05:15AM BLOOD %HbA1c-5.4 eAG-108
___ 05:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA head and neck
1. Confluent areas of low attenuation in the subcortical white
matter are nonspecific and may represent changes due to small
vessel disease.
2. CTA of the head with no evidence of flow-limiting stenosis,
dissection or aneurysms.
3. CTA of the neck demonstrates dense vascular arthrosclerotic
calcifications with no evidence of critical or significant
stenosis.
MRI Brain ___. There is no evidence of acute intracranial process or
diffusion abnormalities to indicate acute or subacute ischemic
changes.
2. Scattered foci of T2 and FLAIR high signal intensity are
present in the subcortical and periventricular white matter,
which are nonspecific and may reflect changes due to small
vessel disease
Echo ___
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Dilated ascending aorta. Increased PCWP. No definite structural
cardiac source of embolism identified.
Brief Hospital Course:
The patient is a ___ RHF with a history of atrial fibrillation on
ASA 81, CAD, HTN, HLD, who presented as a transfer from ___
___ after an episode of left visual field deficit for 10
minutes at 730am.
The description of her visual deficit is best characterized as
left homonymous hemianopsia, localizing her deficit to behind
the optic chiasm. NCHCT and CTA were unremarkable. Given her
resolved symptoms and normal ___ and CTA, she was not a TPA
candidate. She was transfered to ___ and admitted for a stroke
work up. MRI brain showed no acute stroke but prior vascular
disease. Given his history of vascular risk factors and atrial
fibrillation, this episode was felt to represent a TIA, and her
Aspirin was advanced to rivaroxiban to protect against stroke.
Her BP medications were initially held on admission to allow BP
to autoregulate, but her BP remained stable even off these
medications (atenolol had been ordered but was never given
during admission due to holding parameters). Thus, BP
medications stopped at time of discharge. ___ saw the patient and
recommended outpt ___.
She was found to have mild parkinsonian symptoms which could
represent vascular parkinsons vs. parkinsons plus syndrome. She
should follow up as an outpatient with neurology for further
evaluation of this.
TRANSITIONAL ISSUES
- F/U with PCP, in the future consider restarting BP medications
if needed
- outpt ___
- F/U with Neurology
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
48) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL > 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation - rivaroxiban] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL PRN chest pain
5. Omeprazole 20 mg PO DAILY
6. Levothyroxine Sodium 137 mcg PO 6X/WEEK (___)
7. Vitamin D 1000 UNIT PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Citrucel (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 2 tablets oral daily
11. Ketoconazole 2% 1 Appl TP DAILY
12. Centrum Silver 0.4-300-250 mg-mcg-mcg oral daily
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Levothyroxine Sodium 137 mcg PO 6X/WEEK (___)
4. Omeprazole 20 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth dinnertime
Disp #*30 Tablet Refills:*3
7. Centrum Silver 0.4-300-250 mg-mcg-mcg oral daily
8. Citrucel (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 2 tablets oral daily
9. Ketoconazole 2% 1 Appl TP DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Outpatient Physical Therapy
Physical therapy for gait training
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. transient ischemic attack
Secondary diagnosis
1. atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for symptoms
concerning for a transient ischemic attack (mini-stroke), which
consisted of a left visual field cut, which resolved after 10
minutes. Given your history of atrial fibrillation (irregular
heart beat), you were transitioned from aspirin to rivaroxiban
to prevent future stroke. While you are on the rivaroxiban you
should STOP taking the aspirin. Your blood pressure medications
were stopped on admission, and your blood pressure remained
stable, so these were continued to be held at time of discharge.
As an outpatient, you should discuss with your primary doctor if
these medications need to be restarted.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10747596-DS-18
| 10,747,596 | 29,597,979 |
DS
| 18 |
2171-03-29 00:00:00
|
2171-03-31 14:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactroban / Imdur / adhesive
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of CAD (50% RCA stenosis medically
managed), afib on xarelto, HTN, HLD who presents with 2 weeks of
intermittent chest tightness. She states that the chest pressure
comes and goes and is mild, approx. ___. It is diffuse
throughout the chest, nonradiating, no associated
nausea/vomiting, no diaphoresis, no SOB. She states that it
worsens with exertion and resolves with rest. She has not taken
anything for the pain. Of note, she reports that she has had an
ongoing cough approx. 2 weeks that is productive of white sputum
as well as rhinorrhea. Denies sore throat, denies fevers, denies
SOB. She denies sick contacts, denies myalgias, has not taken
anything for this.
Of note, patient was referred to ED by her cardiologist who was
concerned for ischemic etiology of CP. She was planned for 2
sets of troponins and discharge from the ED but ___ EKG was
concerning for Twave changes and ongoing chest tightness that
was self-resolving but ongoing in ED and so pt admitted.
In the ED, initial vitals: T 98.1 HR 74 BP 155/62 RR 18 98% RA
- Exam unremarkable
- Labs notable for: Troponin neg x2, Cr 0.8, WBC 5.1, INR 1.2
- Imaging notable for: negative for cardiopulmonary process
- Patient given: aspirin 243 mg
- Vitals prior to transfer: T 97.6 HR 74 145/95 RR 16 98% RA
On arrival to the floor, pt denies any chest pain
Past Medical History:
1. CAD: 50% RCA obstruction s/p several cardiac catheterizations
2. Atrial fibrillation
3. Hypertension
4. Hyperlipidemia
5. Rosacea
6. Left Bell's palsy ___
7. s/p cholecystecomy
8. s/p removal of Squamous cell carcinoma on right calf ___ and
right ankle ___.
9. s/p total thyroidectomy in ___ for a right thyroid nodule
with suspicious cytology. Final pathology "benign follicular
adenoma"
10. ? one episode of occular migraine in ___
Social History:
___
Family History:
Mother with CAD, unsure of age
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:T 149/69 HR 99 RR 20 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ ___ edema b/l
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
ADMISSION LABS
___ 07:52AM BLOOD WBC-5.7 RBC-3.78* Hgb-12.4 Hct-35.6
MCV-94 MCH-32.8* MCHC-34.8 RDW-12.0 RDWSD-41.3 Plt ___
___ 07:52AM BLOOD ___ PTT-35.8 ___
___ 07:52AM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-142
K-3.7 Cl-105 HCO3-25 AnGap-16
___ 07:52AM BLOOD ALT-6 AST-12 AlkPhos-46 TotBili-1.0
___ 07:52AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:52AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1
EXERCISE STRESS TEST ___
INTERPRETATION: This ___ year old woman with h/o HTN and HLD; s/p
catheterization in ___ with ~50% RCA lesion was referred to the
lab for
evaluation of chest pain. The patient exercised for 9.25 minutes
of a
Gervino protocol (~ ___ METS), representing an average exercise
tolerance for her age. The test was stopped due to fatigue. No
chest,
neck, back, or arm discomforts were reported by the patient
throughout
the study. Mild lightheadedness was noted prior to exercise,
improving
with the exertion. There were no significant ST segment changes
throughout the study. The rhythm was sinus with rare, isolated
VPBs
throughout the study. Blunted blood pressure and heart rate
response to
exercise in the presence of beta blocker therapy.
IMPRESSION: Average functional exercise capacity. No anginal
type
symptoms or ischemic EKG changes to achieved workload. Blunted
hemodynamic response to exercise in the setting of beta
blockade.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with h/o CAD, afib on xarelto,
HTN, HLD who presented to ED with 2 weeks of intermittent chest
tightness. She had two sets of cardiac enzymes which were
negative. She had an ECG with 1mm STEs in V2. Due to ongoing
symptoms she was amitted and underwent exercise stress test
which was normal without anginal symptoms or ECG changes.
Etiology of CP is unknown but may be ___ lung process (she has
URI symptoms) vs GERD. She will follow up with her PCP and
cardiologist.
TRANSITIONAL ISSUES:
-Consider further workup for GERD/gastritis or pulmonary sources
as possible etiology of CP
-No medications changes
___ yo F with history of CAD, afib on Xarelto, HTN, HLD who
presented. with 2 weeks of intermittent chest tightness.
#Chest tightness | CAD: Troponins negative x2 and ECG in ED
showed 1mm STE in V2 prompting admission. Given this and the
exertional component of chest pain, pt admitted for closer
monitoring and stress test. Of note, patient has known RCA
stenosis on prior cath (___) without intervention; no other
PCIs or caths since that time. She underwent exercise stress
test which was normal without angina symptoms or ECG changes.
Etiology of CP remaiend unclear but may be secondary to lung
process (given URI symptoms) or GERD. She was discharged on home
medications with plan to follow up with PCP/cardiologist.
#Afib on xarelto: In normal sinus rhythm here. Continued
rivaroxaban.
#HTN: Home amlodipine held but restarted on discharge.
___ disease: continued home Carbidopa-Levodopa (___)
1 TAB PO TID
#GERD: continued home omeprazole 20 mg PO BID
#Hypothyroidism: continued home levothyroxine Sodium 112 mcg PO
DAILY
# CODE STATUS: Presumed Full
# CONTACT: ___ (daughter) ___
TRANSITIONAL ISSUES:
-Consider further workup for GERD/gastritis or pulmonary sources
as possible etiology of CP
-No medications changes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rivaroxaban 20 mg PO DAILY
2. Ranolazine ER 500 mg PO BID
3. amLODIPine 2.5 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Atorvastatin 20 mg PO QPM
6. Omeprazole 20 mg PO BID
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Omeprazole 20 mg PO BID
6. Ranolazine ER 500 mg PO BID
7. Rivaroxaban 20 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Chest pain
Secondary
Coronary artery disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having chest
pain. Your ECG was reassuring, as were the blood test we sent.
You had a stress test which was normal. This is great news. The
chest pain may be related to the cold symptoms you are having,
or due to reflux. You are being discharged home. You should
follow up with your usual doctors.
___ was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
10747648-DS-10
| 10,747,648 | 24,552,314 |
DS
| 10 |
2157-05-15 00:00:00
|
2157-05-16 20:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ history of MI s/p ___ placement ___ in ___ who
presents with chest discomfort x1 week with chest pain on
exertion that has been worsening over the last 2 days.
Patient recently had an MI s/p ___ in ___ in ___.
No records, but single cath image in chart. States he was in
usual state of health until 1 week ago when he noted general
left-sided chest discomfort x1. 6d ago, experienced episode of
intense squeezing pressure in left chest. Does not recall
activity prior to onset of discomfort. Lasted 5 minutes. 4d ago,
was walking quickly and experienced similar squeezing discomfort
on left side of chest. Resolved after 5 minutes of rest. Over
the past 2 days pain has been more constant with mild discomfort
at rest with worsening with exertion for which he presented.
Substernal without radiation. He reports that he has been
compliant with Plavix and Aspirin (missed 2 doses in 6
months).Denies diabetes or hypertensive history. Is on a statin
(10mg atorvastatin). Former smoker ___ packyears), quit at
time of MI. No SOB, palpitations, orthopnea or PND.
Of note, patient lives in ___ but is visiting long term (until
___ with his Daughter in ___. Does not currently
have insurance beyond emergency visits. Family is working on
getting him longer term insurance but are worried about paying
for visit out of pocket.
Past Medical History:
MI ___. (s/p ___ to LAD)
Social History:
___
Family History:
Strong family history of CAD
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
VS: T 98.1 BP 130/75 HR 55 RR 16 O2 SAT 98RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP flat
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
===============================
DISCHARGE PHYSICAL EXAM
===============================
VS: T 97.6 125/82 55 16 98%RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3. Mood, affect appropriate.
NECK: Supple. JVP flat
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 04:50PM BLOOD WBC-5.3 RBC-4.55* Hgb-14.3 Hct-42.1
MCV-93 MCH-31.4 MCHC-34.0 RDW-11.7 RDWSD-39.2 Plt ___
___ 09:00PM BLOOD Glucose-255* UreaN-17 Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
==========================
DISCHARGE LABS
==========================
___ 05:15AM BLOOD WBC-5.4 RBC-4.30* Hgb-13.5* Hct-39.6*
MCV-92 MCH-31.4 MCHC-34.1 RDW-11.9 RDWSD-39.5 Plt ___
___ 05:15AM BLOOD Glucose-86 UreaN-18 Creat-0.7 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-14
___ 05:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
==========================
IMPORTANT LABS
==========================
___ 05:15AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:50PM BLOOD cTropnT-<0.01
==========================
IMAGING
==========================
Chest radiograph. ___
FINDINGS:
The cardiomediastinal and hilar contours are within normal
limits. The lung
fields are clear. There is no pneumothorax, fracture or
dislocation.
IMPRESSION:
No acute cardiopulmonary abnormality.
=========================
STUDIES
==========================
EKG ___
sinus bradycardia, no ST or T wave changes.
Brief Hospital Course:
___ yo male s/p MI ___ to LAD in ___ (in ___, has
records on him), compliant with aspirin/Plavix, presents with
one week history of progressively worsening exertional anginal
symptoms.
#Stable Angina:
Patient presented with a pattern of chest pain concerning for
crescendo angina. His troponin was negative x 3 and his EKG was
non-ischemic. He reported excellent medication complication with
his ASA and Plavix since ___ placement in ___ in ___.
He required a heparin gtt on the floor, but did not need
nitroglycerin to control his chest pain.
After further clarification with Mr. ___ his chest pain was
exertional in nature and was not having symptoms at rest. As
such, we felt it was safe for Mr. ___ to be discharged with
explicit instructions to return to the hospital if he
experiences chest pain that does not go away with rest or his
nitroglycerin.
The patient is well informed regarding the risks of this
decision and understands how to use NTG and was given strict
instructions to return to the ED if chest pain is resistant to
NTG.
Discharge Medications:
- ASA 81mg daily
- Plavix 75mg daily
- Atorvastatin 80mg daily
- Started Metoprolol XL 12.5mg daily given history of MI
- NTG 0.3 mL SL Q5 min prn chest pain
- Contact Dr. ___ direct admit for cath once insurance
obtained.
*****TRANSITIONAL ISSUES*****
#CODE: Full (confirmed)
#CONTACT: ___ (son-in-law, ___
#Secondary prevention labs follow up: A1C, lipids
#Started a beta blocker
#To return to for cath once obtains insurance
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Unstable angina.
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 stay at ___
___.
You came to the hospital because you were having chest pain.
Your lab work and EKG showed us you were not having a heart
attack.
However, given your history of a heart attack in ___ - our
team is still concerned that your new chest pain is related to
your heart.
Normally, the next step in your workup is a cardiac
catheterization. Patients usually stay in the hospital until
this is performed. However, you had expressed concern regarding
the cost of your hospitalization given your lack of insurance
coverage, suggesting that you leave and come back for cardiac
cath once you obtain coverage.
We had a long discussion regarding the risks and benefits of
this decision. After a detailed review of the history of your
symptoms they were indeed exertional in nature and ultimately
makes this procedure non-urgent. However, as discussed, please
return to the hospital if you have chest pain that does not
respond to the nitroglycerin tablet we are sending you home
with. Either way, call Dr. ___ you have coverage so
you can be scheduled as a direct admit for cardiac
catherization.
****If you have chest pain that does not go away with rest or
nitroglycerin come to the emergency room immediately****
We started you on a new medication called metoprolol. This is
in a class of medications known as beta-blockers. Patients who
take beta blockers after a heart attack are proven to live
longer. It is very important that you take this medication
every day.
Please continue to take all of your old medications as
prescribed.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10747648-DS-11
| 10,747,648 | 29,187,337 |
DS
| 11 |
2157-05-24 00:00:00
|
2157-05-26 20:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___: Cardiac catheterization s/p 3 DES to left circumflex
History of Present Illness:
___ y/o M history of MI s/p DES to mid-LAD ___ in ___
who presents with progressive exertional angina after recent
hospitalization on ___ (___).
Per prior discharge summary and patient, Mr. ___ had chest
discomfort on exertion that was worsening 1 week prior to his
last admission. He first experienced chest discomfort lasting
for a few seconds while he was pushing a stroller. Few days
later, he had it while he was walking around the house; both
times, lasted only a few minutes. Over a couple days, the pain
worsened and he presented to the hospital. He was ultimately
discharged because of insurance status, but instructed to return
once he had acquired insurance.
He reports that he has been compliant with Plavix and Aspirin
(missed 2 doses in 6 months). During his last hospitalization,
trops were neg x 3 and EKG was non-ischemic. He was on a heparin
gtt on the floor and continued on aspirin/Plavix. Atorvastatin
increased to 80 mg and discharged on metoprolol succinate XL
12.5 mg daily. He was also provided sublingual nitro to take if
he has recurrence of pain.
Last night, 8PM, suddenly had chest pain, but no shortness of
breath. Did not take sublingual nitro last night. Associated
diaphoresis, without radiation, and no nausea/vomiting. No
swelling. Patient reports numbness that has been present since
his stent placement in ___ and started at the time of his MI.
Of note, patient lives in ___ but is visiting his daughter in
___ (until ___.
-In the ED initial vitals were: 98.0 66 125/78 16 100% RA
-Labs/studies notable for: mild thrombocytopenia to 130, normal
chemistry panel, trop neg x 1
-CXR showed no acute cardiopulmonary abnormality.
-Patient was given: aspirin 324 mg
-Vitals on transfer: 52 117/68 16 99% RA
On the floor he appears well without any difficulty. He feels
like if he moves, he would experience chest pain. He also notes
that he has had a neck pain since ___ that is worst when he
moves his head left and right, this is not associated with any
other symptoms (no visual changes, no radiating pain).
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
MI ___. (s/p stent to LAD)
Social History:
___
Family History:
mother with stroke, died of MI. Brother with stroke. Sister w/
stroke and had 3 stents placed.
Physical Exam:
Physical Exam on Admission
==========================
VS: T 98.2 BP 109/68 HR 55 RR 15 O2 SAT 98 RA, wt: 68.9
GENERAL: Well developed, well nourished M in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP <8cm. some tautness of trapezius muscles, but
no tenderness to palpation. no step-offs noted on cervical
spine.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. CTAB, No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Radial 2+ b/l, dorsalis pedis 2+ b/l
Neuro: sensation to touch intact b/l UEs, LEs. Strength normal
in UEs, LEs, b/l.
Physical Exam on Discharge
==========================
VS: T afebrile BP 100s-120s/50s-70s HR ___ RR 18 O2 SAT 98
RA, wt: 68.9
GENERAL: Well developed, well nourished M in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP <8cm. some tautness of trapezius muscles, but
no tenderness to palpation. no step-offs noted on cervical
spine.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. CTAB, No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No rashes.
PULSES: 2+ DP pulses.
Neuro: sensation to touch intact b/l UEs, LEs. Strength normal
in UEs, LEs, b/l.
Pertinent Results:
Labs at Admission:
==================
___ 11:20AM BLOOD WBC-5.9 RBC-4.44* Hgb-13.9 Hct-40.5
MCV-91 MCH-31.3 MCHC-34.3 RDW-11.9 RDWSD-39.3 Plt ___
___ 11:20AM BLOOD ___ PTT-42.2* ___
___ 11:20AM BLOOD Glucose-99 UreaN-17 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
___ 11:20AM BLOOD cTropnT-<0.01
___ 09:15PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD %HbA1c-5.7 eAG-117
Labs at Discharge:
==================
___ 06:25AM BLOOD WBC-7.1 RBC-4.31* Hgb-13.3* Hct-39.4*
MCV-91 MCH-30.9 MCHC-33.8 RDW-11.7 RDWSD-39.1 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-84.5* ___
___ 06:25AM BLOOD Glucose-102* UreaN-17 Creat-0.6 Na-138
K-4.4 Cl-103 HCO3-24 AnGap-15
___ 06:25AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0
Studies:
========
___ Cardiac Catheterization:
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is. Normal
* Left Anterior Descending
The LAD is 50% distal.
The ___ Diagonal is long 80%.
* Circumflex
The Circumflex is 90% after OM origin.
The ___ Marginal is 70% mid.
* Right Coronary Artery
The RCA is minimally diseased.
The Right PL is 80% narrowed off of a branch.
Interventional Details
A 6 ___ XB 3.5 guide was used to engage the left main with
excellent support. A Pro Water wire was used to cross the LCX
lesion with minimal difficulty. The lesion was pre dilated with
a 2.0 and 2.25 X 12 NC balloon at 12atm, then stented with a
2.25 X 12 DES at 18atm. There was a proximal edge hazziness that
was treated with a 2.25 X 8 DES. Another proximal hazy lesion
that developed was treated with a 2.25 X 8 DES. At the end no
residual, TIMI 3 flow and no evidence of dissection.
Intra-procedural Complications:
None
Impressions
:1. Multivessel dz with LCx likely culprit.
2. s/p balloon angioplasty and 3x DES to LCx
Recommendations
1. DAPT for one year
2. Continue medical management
___ ECHO:
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 63 %). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified.
Brief Hospital Course:
Mr. ___ is a ___ y/o M history of MI s/p DES to LAD ___ in
___ who presented with chest pain/pressure after recent
hospitalization on ___ (___) with concern for unstable
angina.
# Chest Pain:
He presented with chest pain during a recent admission, but at
that time he declined cardiac catheterization given lack of
insurance. He returned given recurrence of chest pain and
establishment of insurance. He underwent catheterization with
DES x3 placed to left circumflex on ___. He tolerated the
procedure well and he was continued on Aspirin, Plavix,
Atorvastatin, Metoprolol. TTE showed normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function with EF (biplane LVEF = 63 %).
# Neck Pain:
At admission, Mr. ___ complained of neck pain and some
bilateral upper extremity numbness. The neck pain began in ___,
but he had been having the numbness for several months prior.
The etiology of the pain was thought to be musculoskeletal and
not a cervical radiculopathy. He was given acetaminophen for
pain. At discharge, his pain was reduced and he was recommended
to follow up the issue with his primary care doctor.
TRANSITIONAL ISSUES
===================
# Cardiac meds on discharge were same as on admission: aspirin
81 mg, Plavix 75 mg, metoprolol succinate XL 12.5 mg daily. He
was provided with a 30-day supply of medications.
# Please help patient ensure he has cardiology follow-up in ___
weeks.
# Patient noted to have neck pain during his hospitalization
that was felt to be musculoskeletal. Please assess at follow-up.
# CODE: Full
# CONTACT: ___ (son-in-law, ___
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
# Unstable angina
SECONDARY DIAGNOSIS
==================
# Coronary artery 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 taking care of you during your hospitalization
at ___. You were admitted after
having recurrence of your chest pain. You were recommended to
have a cardiac catheterization during your last hospitalization
and now that you have insurance, you received this procedure. It
showed a blockage in one of your coronary arteries (left
circumflex) and you received three stents to open up the
blockage. You tolerated this procedure well. You received an
echocardiogram that showed good heart function. You should
continue your medications as previously prescribed and we have
provided you with a 30-day supply. Please speak with your
primary care physician about getting more medication while you
are here in the US. We will also arrange for you to receive a CD
with your cath films.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
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2139-01-03 00:00:00
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2139-01-03 17:49:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin (porcine)
Attending: ___.
Chief Complaint:
dark stools x 1 week
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: ___
ADMIT TIME: 0500
.
___ year-old male with a history of CAD s/p CABG, atrial
fibrillation on coumadin, AAA s/p repair, htn, PMR,
___ tear ___ and prostate cancer who presents from
rehab with dark stools, hematocrit drop and abdominal pain.
.
Patient reports black stool x one week with ___ bowel movements
per day. Also with nausea and one episode of vomiting 3 days
ago (non-bloody). Endorses lightheadedness with standing. Mild
intermittent epigastric abdominal pain x 1 week, described as a
"dull ache". Decreased appetite, poor po intake and 10 lbs
weight loss. Had an episode of chest pain ___ days ago, that
lasted several seconds then recurred 2 more times, associated
with shortness of breath. No EGD in the past, last colonoscopy
was ___ years ago - per patient had polyps. Hx of duodenal ulcer
during ___.
.
Stool was found to be guaiac positive at rehab facility
yesterday. Labs checked and notable for an acute decrease in
hematocrit from 34.8 (on ___ to 28.7 (___). Patient
sent to the ED for further evaluation.
.
Patient has been residing at ___ in ___,
___ since ___ after being discharged from ___.
Initially admitted to ___-N on ___ with back pain and found
to have compression fracture of thoracic spine. Course
complicated by severe constipation due to opiate pain
medications. Transferred to ___ on ___ then back
to BI-N on ___ due to severe confusion and combative
behavior. Found to have secondary adrenal insufficiency,
treated with high-dose IV steroids then changed to prednisone
taper. For compression fracture transitioned to po oxycodone
and tramadol with scheduled tylenol. Hospital course
significant for elevated troponins and EKG changes (not detailed
in discharge summary). Noted to have difficult to control blood
pressure. Also with ___ due to prerenal state (Cr to 1.7) that
resolved with IVFs (baseline Cr 1.2-1.4).
.
Per last rehab note on ___, patient was receiving pip/tazo
for gram negative bacteremia. It is unclear when the blood
culture was obtained and if it had been speciated. He also had
recent mental status changes attributed to delirium in the
setting of infection and had improved with antibiotic treatment.
Apparently, patient had been on oral vancomycin
prophylactically due to loose stools however this has since been
d/c'ed because C. diff was negative. The note does not mention
black stools. Hematocrit ranging 34-35 since ___, then
28.7 on ___. INR was 2.9 on ___ and 1.8 on ___.
.
ED: Pulse: 99, RR: 16, BP: 147/85, O2Sat: 99; guaiac positive
with very dark brown stool; CXR negative for free air; abdominal
CT negative for active bleeding however did show biliary ductal
dilatation; LFTs added on to ED labs and pending; NG lavage
clear with bilious return; given protonix 80 iv and vitamin K 10
iv. GI consulted and will see in am
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
1. Endovascular repair of abdominal aortic aneurysm with modular
stent graft, ___
2. R eye cataract surgery
3. CAD s/p MI (___) and CABGx4 (___)
4. paroxysmal atrial fibrillation
5. ___ tear in ___, not requiring transfusion
6. Vertebral compression fractures, osteoporosis.
7. L CEA ___
8. S/p umbilical hernia repair
9. Prostate Ca, not actively treated
10. HTN
11. polymyalgia rheumatica on chronic steroids
12. Left hip surgery ___
13. GERD
14. Hyperlipidemia
15. Hypothyroidism
16. Bilateral knee surgeries.
17. s/p pacemaker due to tachybrady syndrome in ___
Social History:
___
Family History:
Parents - cerbral hemorrhages
Physical Exam:
VS 97.4 195/80 102 20RR 98%RA
Appearance: AAOx3, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, slight distension, +bs, no rebound/guarding
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical ___: guaiac positive in ED with very dark stool
Pertinent Results:
.
___ EKG: 77 a-paced, left anterior fascicular block, no
change from ___
.
___ CXR:
IMPRESSION: No evidence of acute disease, including no evidence
for free air.
.
___ A/P CT with Contrast:
ABDOMEN: A hepatic cyst is stable. Compared to ___, there
is new mild left-lobe intrahepatic biliary ductal dilatation.
There is increased
prominence of the common bile duct, which measures within normal
limits and tapers at the level of the ampulla without evidence
for obstructing stone. The gallbladder is mildly distended with
minimal layering hyperdense material, which may represent sludge
or small stones; there is no CT evidence for acute inflammation.
The spleen, pancreas, adrenal glands, right kidney, and
visualized portions of the ureters are within normal limits.
Note is again made of a splenule. Two hypodensities in the left
kidney are stable in size and appearance and most likely
represent cysts. The stomach and small bowel are within normal
limits. Few colonic diverticula do not demonstrate evidence for
inflammation. There is no free intraperitoneal air or ascites.
PELVIS: The bladder, seminal vesicles, and rectum are
unremarkable. An
enlarged prostate is again noted, which contains coarse
calcifications.
An infrarenal aortic aneurysm with bi-iliac stent graft is
stable in size and appearance without evidence for aortoenteric
fistula. The origins of the celiac trunk and superior mesenteric
artery appear patent. No lymph nodes are seen which meet CT
criteria for pathologic enlargement.
An ovoid cutaneous hyperdensity in the left anterior lower
chest/upper
abdominal wall is stable (2:8).
There is a compression deformity of the T10 vertebral body which
is new
compared to chest radiographs dated ___, but age
indeterminate.
Increased sclerosis of the vertebral body suggests some
chronicity, but this is not specific. There is minimal
retropulsion at this level without
significant canal narrowing. Additional compression deformities
in the spine appear similar. Note is again made of a Tarlov
cyst. Left femoral hardware is again noted. Non-displaced prior
right anterior rib fractures are noted.
IMPRESSION:
1. Mild left-lobe intrahepatic biliary dilation without
extrahepatic
dilation, new since ___. Clinical correlation with liver
enzymes is
recommended.
2. T10 vertebral body compression deformity, new since ___, age
indeterminate. Clinical correlation for pain at this level is
recommended.
.
RUQ u/s ___:
IMPRESSION:
1. Minimal central left intrahepatic biliary dilation on
preceding CT is
subtle and not definitely appreciable on current limited exam
with CBD within normal limits. In a patient of this age this
could represent mild sphincter dysfunction. Recommend
correlation with liver function test and if abnormal, follow-up
exam could be performed.
2. Gallstone or sludge ball. No evidence of cholecystitis.
.
___ echo:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are mildly thickened/sclerotic
(?#). No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
major change.
.
___ URINE URINE CULTURE-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT -negative
___ SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-FINAL INPATIENT -negative
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
Brief Hospital Course:
Pt is a ___ y.o male with h.o CAD s/p MI, PAF on coumadin, s/p
AAA repair, prostate ca, PMR-on prednisone, hypothyroidism,
GERD/?ulcer, GNR bacteremia at rehab who presented with dark
stool, abdominal pain and anemia.
.
#melena, acute blood loss anemia (AVM, esophageal
stricture)-unclear from history if true melena, but dark brown
guaiac positive stool per report. Guaiac + in E on admission
with dark brown stool. NG lavage negative. This was initially
considered to likely be a slow upper GIB especially given that
patient is taking asa, coumadin, and prednisone as an
outpatient. Per report, pt with ___ tear and
duodenal ulcer years ago. Per report, last colonoscopy ___ ago
with "polyps". Pt was initially made NPO and given IV PPI BID.
Serial HCT's were monitored and remained between ___. Pt did
not require a blood transfusion. Pt has an active T+S. Coumadin
and aspirin were intially held. Pt was given vitamin K by the ED
on admission. GI was consulted and pt underwent EGD on ___
finding a duodenal AVM and benign appearing esophageal stricture
(possibly due to bisphosphonate therapy??). AVM was cauterized
and stricture was dilated. Pt tolerated this procedure well and
diet was advanced to regular, soft diet. This can be advanced to
a regular diet. Pt was restarted on his asa and coumadin on
___ (day of DC). HCT on DC 28 and INR 1.1. Pt will continue
BID 40mg omeprazole upon DC.
.
#abdominal pain-Not an active issue during admission. Abdominal
pain in ED per report and prior to admission. Etiologies
considered were gastritis/PUD. CT scan of the abd/pelvis was
performed on admission and revealed known t10 compression
fracture and mild biliary dilatation (LFTs/bili/lipase normal).
RUQ u/s was performed showing the mild dilatation as well. Pt
did not display any signs of colitis or cholangitis during
admission. Pt found to have duodenal AVM and esophageal
stricture as above. Pt's diet was successfully advanced. Pt
never had fever or leukocytosis. Bowel habits were normal. No
diverticulitis or other abdominal pathology noted on CT.
.
___ rehab notes. No culture data in our
system. Urine neg, CXR negative. Rehab noted altered mental
status on ___ and infectious w/u was pursued. BCX returned
positive for pan-sensitive ___ per report. Per report urine cx
negative. Rehab facility placed patient on zosyn IV and PICC was
placed. Per report from family, pt with prior midline/PICC and
this was replaced after bacteremia found??. Unclear if
subsequent cultures were drawn. Prior rehab facility had outpt
ID appointment scheduled for ___. Upon admission to ___,
repeat cultures were sent, BCX, UCX, stool. Initial inciting
source unclear. However, case was discussed with ID. Pt
underwent an echo that did not show any signs of
endocarditis/pacer lead involvement. CT imaging was reviewed and
per radiology compression fx more likely to be a pathologic
fracture from possible metastasis rather than osteomyelitis. (Pt
without fever or leukocytosis this admission). Initial source
could have been PICC/midline?. Also consider bowel source of
infection, but CT scan negative. No evidence for prostatitis. Pt
did have dilated bile ducts on imaging, but no fever, jaundice,
RUQ pain, transaminitis or other evidence for cholangitis.
Nonetheless, treatment course will be PO cipro to total a 14 day
course of therapy (starting ___ for pan-sensitive ___
bacteremia. (Rehab facility stated ___ to
"everything"). Last day of therapy through ___. Pt has an ID
appointment scheduled for ___ ___ at ___
for follow up.
.
#dementia with ___ rehab notes and per family pt with
delerium in the setting of bacteremia and with initiation and
titration of opioid therapy. Per family, pt has been at his
baseline mental status recently at rehab and during this
hospitalization. Tsh, B12/folate were normal. Brain imaging was
deferred as pt did not display delerium or confusion during this
admission. Neuro exam was normal and family confirmed that
patient was at his baseline mental status. Pt also ruled out for
MI.
.
#T10 compression fx/osteoporosis-recently hospitalized at
___ and has been getting pain medication and ___ at ___.
Prior rehab facility raised concerns that pain was intractable
and requested eval for ___. Pt was continued on his
prior regimen of oxycodone ER 10mg QHS (pt's daugther reported
pt doing well on this regimen) and prn oxycodone. However, pt
often declined the prn formulation. Pt was continued on a
lidocaine patch and given tylenol. He was also continued on
calcitonin, calcium and vitamin D. Pt had been on fosamax as an
outpatient and this has been discontinued with the idea that
pt's osteoporosis is refractory to this medication. This may
also have been the cause of esophageal stricture. Pt should
follow up with his endocrinologist after DC for continued
discussion. In addition, pt had a scheduled appointment with the
___ at ___ but the previous appointment had been
cancelled. This appointment has been rescheduled to ___ at
the ___ consideration of ___. This was not
entertained this admission due to treatment for bacteremia. OF
note, pt without any pain at rest. Pt with pain during pt
sessions, but at times declines prn oxycodone. This would
greatly benefit patient to receive prn prior to ___ sessions.
Discussed possible etiologies of compression fx. Radiology
reviewed the images as subacute fracture. Pt with known
osteoporosis. Per radiology, possibly pathologic fracture from
?prostate cancer metastasis unlikely to be osteomyelitis.
.
#anemia-normocytic. Last recent baseline ~38. Recently HCT 34 at
rehab. Likely due to slow GIB as above. Stable during this
admission. HCT ___. 28 on day of discharge.
.
#chest pain-none during admission. currently. Per report, pt
reported CP at rehab ___ days prior to admission. Troponins
were flat x3. Pt was monitored on tele and continued on his BB,
statin. ASA was restarted.
.
#rehab concerns-discussed above rehab concerns of AMS, ___
bacteremia, back pain with patient's family-DTR and grandson on
___. Pt's family believes that patient was doing well at
rehab just prior to admission. Family reports pt has been at
baseline mental status since adjusting to opioid therapy and
believes that AMS was due to opioids. Pt's family believes that
back pain was well controlled prior to this admission. Discussed
etiology of ___ bacteremia with family and consideration of ID
consult. Family agrees that source may not be elucidated, but we
will treat for 2 week course. Family does not believe that brain
imaging is indicated at this time as pt is back at baseline MS.
___ terms of ___, pt already has an appointment scheduled
with ___ MD in ___.
.
#secondary adrenal insufficiency-s/p pred taper. Monitor for
signs of insufficiency.
Pt was continued on his outpatient daily dose of 5mg.
.
#h.o prostate cancer-per records "not being actively treated".
Pt can follow up with his outpatient urologist after DC.
.
#afib-s/p pacemaker for tachybrady syndrome. Continued
metoprolol. Initially held asa/coumadin but this was resumed on
___
.
#CAD s/p MI and CABG-resumed asa, continued BB/statin
.
#PMR-continued pred daily dose of 5mg. Continued PPI
.
#GERD-continued PPI
.
#hypothyroidism-continued levothyroxine
.
FEN:ADAT to regular from soft regular diet.
.
DVT PPx: venodynes
.
Precautions for: falls
.
Lines: midline dc'd
.
CODE: DNR/DNI
.
Contact:patient
HCP dtr ___ ___ ___
.
Medications on Admission:
Tylenol ___ TID
Calcitonin 1 spray daily
Calcium carbonate 650mg bid
Vitamin D3 1000 units daily
Fluticasone intranasal 12h
Lactobacillus 1 tab BID
Levothyroxin 50mcg daily
Lidocaine patch daily (off qhs)
Metoprolol 25mg bid
Omeprazole 40mg daily
Zosyn 2.25 q6h (started ___
Pravastatin 80mg daily
Warfarin 0.5mg daily - held on ___
Oxycodone ER 10mg qhs
Prednisone 5mg daily
Oxycodone 5mg QID prn pain
Discharge Medications:
1. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal DAILY (Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three
times a day: max daily dose 4g.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO HS (at bedtime).
16. oxycodone 5 mg Tablet Sig: ___ Tablet PO Q4H (every 4
hours) as needed for pain: please give prior to ___ sessions.
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO QMOWEFR.
18. warfarin
0.5mg ___, tue, ___, sat
19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days. Tablet(s)
20. lactobacillus acidophilus Capsule Sig: One (1) Capsule
PO twice a day.
21. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute blood loss anemia/GI bleeding
duodenal AVM
esophageal stricture
back pain due to vertebral compression fracture
recent history of ___ bacteremia
.
Chronic
AAA
CAD
PAF
osteoporosis
prostate ca
hypothyroidism
s/p pacemaker
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of dark stools and anemia. You
underwent an endoscopy that showed an abnormal blood vessel in
your stomach that was fixed. Your blood counts remained stable.
Your antibiotics were changed from IV zosyn to oral Cipro to
treat for the blood infection. You will need to continue to
receive adequate pain control for your compression fracture in
your back. Please take the pain medication that was prescribed
to you.
.
Medication changes:
1.Please start PO cipro 500mg BID for 6 more days
2.increase omeprazole to 40mg BID for at least ___ months
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
___
|
10747985-DS-16
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2146-09-09 00:00:00
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2146-09-09 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Latex
Attending: ___.
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
ORIF L ankle fracture
History of Present Illness:
___ yo ___ with several medical problems includign
significant heart disease who sustained a fall and trip on her
stairs taking her laundry down. She subsequently felt immediate
pain in her left ankle. She denied any loss of consiousness.
She reports taht she lives with her son, but drives, does her
own
laundry, and shopping. She denies any numbness or tingling.
She
denies any other pain in her other extremities. No new pain
currently.
Past Medical History:
CAD, s/p MI, 3 stents, s/p CABG
Atrial fibrillation - not on coumadin, but on Plavix and ASA
h/o Colon CA of the sigmoid ___
? slight stroke in the past
Hypercholesterol - not on statin because it gave her leg cramps
and doesn't want to re-try
HTN
Constipation: has had some ED visits for this
Social History:
___
Family History:
NC
Physical Exam:
VSS AF
GEn: NAD, AO
Resp: unlabored
CV: RRR
LLE: edemtous and deformed left ankle with palpable pulses, pain
with palpation, intact ___, sensation intact throughout the foot
to light touch.
Pertinent Results:
___ 07:58PM WBC-8.1 RBC-4.39 HGB-13.0 HCT-39.8 MCV-91
MCH-29.6 MCHC-32.7 RDW-14.0
___ 07:58PM GLUCOSE-173* UREA N-27* CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-19
initial imaging reveals a bimal ankle fracture with some
lateral subluxation of the talus.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with L ankle fracture. Patient was taken to the
operating room and underwent ORIF L 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 LLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB LLE in post-op splint. 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 this
hospitalization and he did not require any transfusions/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 recieved SC heparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, 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 her pre-operative ASA and plavix as DVT
prophylaxis. All questions were answered prior to discharge and
the patient expressed readiness for discharge.
Medications on Admission:
Meds: ASA 1 Tablet(s) by mouth daily
___ ___ 18:55)
Nitrostat 0.4 mg Sublingual Tab
1 Tablet(s) sublingually prn chest pain
___ ___ 18:55)
Plavix 75 mg tablet
one Tablet(s) by mouth once a day
___ ___ 18:55)
furosemide 40 mg tablet
___ tablet(s) by mouth once a day alternating with 1 tablet
daily
___ ___ 18:55)
losartan 50 mg tablet
one Tablet(s) by mouth once a day
___ ___ 18:55)
metoprolol tartrate 25 mg Tab
1 (One) Tablet(s) by mouth daily
___ ___ 18:55)
Discharge Medications:
1. Acetaminophen 650 mg PO TID Pain
2. Aspirin EC 325 mg PO DAILY
3. Calcium Carbonate 1250 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 2 TAB PO HS
11. Vitamin D 800 UNIT PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L 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 and dry until your 2 week
post-op visit. Any stitches or staples that need to be removed
will be taken out at your 2-week follow up appointment.
******WEIGHT-BEARING*******
Touchdown Weight Bearing, L Lower extremity in splint
******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******
Continue your pre-operative aspirin and plavix
Weigh yourself every morning, call MD if weight goes up more
than 3
lbs.
Physical Therapy:
TDWB LLE in post-op splint
Knee ROMAT
Treatments Frequency:
None
Followup Instructions:
___
|
10747985-DS-21
| 10,747,985 | 29,333,883 |
DS
| 21 |
2147-03-27 00:00:00
|
2147-03-27 19:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea followed by constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with a hx of colon cancer,
constipation, sCHF, afib, and CAD s/p MI, stent, & CABG who
presents with abdominal pain and 1 week of diarrhea followed by
1 week of constipation. The diarrhea, which she reports was
nonbloody, began 2 weeks PTA and was likely triggered by
antibiotics (cipro + Flagyl) that she received 6 weeks PTA for
an infected surgical site of her left ankle, which she fractured
on ___ after a fall. The diarrhea ended 1 week PTA, and
over the past week, she has experienced constipation
characterized by severe rectal pressure and an urgent need to
defecate followed by the inability to pass stool despite
straining. One day PTA, she was feeling fine and ate lunch
(chicken), but that night, she experienced a particularly
painful episode of constipation. In addition to intense rectal
pressure/pain and the urge to defecate, she felt sweaty and
began experiencing ___, "crampy," hypogastric abdominal pain.
She described the pain as non-radiating, intermitent (every 10
min), and not relieved or worsened by anything. During this
episode, she was able to pass gas and small, black,
"raisin-like" stools that did not float, contained mucus but no
blood, and did not appear sticky upon flushing. Given her severe
pain, Ms. ___ presented to the ED.
Of note, her ___ collected a stool sample that tested positive
for C. difficile by PCR at ___ on ___.
She has also had new onset of thin-caliber stools that she first
noticed 3 weeks PTA. She has also lost 25 lbs (146 -> 121) since
___. She has felt fatigued recently but denies fevers
or chills throughout this episode.
In the ED, VS on admission were normal: T 97.8, HR 69, BP
152/66, RR 20, 96% on RA. Labs were significant for WBC 11.7
(86% N), BUN 53, Cr 1.5, glucose 132, lipase 124, negative UA,
and lactate 1.0. Otherwise Chem7, CBC, and LFTs were
unremarkable. Urine and blood cultures were sent. CT
abdomen/pelvis revealed: 1. No acute intra-abdominal process
with normal enhancement and mucosal thickness of the colon; 2.
Pneumobilia, presumably from a prior sphincterotomy. Ms. ___
refused treatment with metronidazole, which has previously
caused significant nausea. Instead, she received PO vancomycin
and IV nicardipine (which seems to have caused hypotension). She
was transfered to the inpatient floor for further management of
her abdominal pain. VS on transfer were T 98.1, HR 59, BP 97/49,
RR 18, 97% on RA.
Past Medical History:
# Colon cancer of her sigmoid (___)
- Treated with surgery and chemotherapy
- Past colonoscopies have not showed recurence; last colonoscopy
was ___ yrs ago
# Constipation
- Hx of ED visits for this
# Hemorrhoids
- Last bothered her in ___ when she was hospitalized
for her left ankle fracture; blood on wiping
# Left ankle fracture s/p ORIF (___) and I&D (___)
- Confined to a wheelchair as a result
# Systolic CHF (LVEF 50-55%, ___
# CAD s/p MI, 3 stents, CABG
# Atrial fibrillation
- Taking Plavis and Aspirin (Ecotrin) instead of Coumadin
# Hypercholesterolemia
- Not taking a statin due to side effect of leg cramps
# HTN
# Anemia: baseline Hct in high ___
# Stroke: 1990s; presented to the ED with heavy tongue, slurred
speech, and right facial drooping; hospitalized and received
speech therapy afterwards; no permanent sequelae
Social History:
___
Family History:
- Mother: passed away at age ___ from MI; hx of HTN
- Father: passed away at age ___ from colon cancer
- Brother: passed away at age ___ from MI
- 6 children: 4 daughters and 2 sons; one son with CAD s/p
stenting in his ___ (currently alive at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
- VS: T 97.8, BP 135/110, HR 76, RR 16, 96% on RA
- ___: well-appearing; NAD; laying quietly in bed watching
TV
- Neuro: alert; cooperative; CN II-XII intact; ___ strength
throughout except ___ strength of left ankle flexion/extension
- HEENT: PERRL; EOMI; no scleral icterus; dry mucus membranes;
nonerythematous oropharynx; no oral lesions; dried blood in
right nare
- Neck: supple; no LAD; no JVD; no thyromegaly
- CV: irregularly irregular rhythm; normal S1/S2; no m/r/g; 2+
radial, DP, and ___ pulses bilaterally
- Lungs: bilateral basilar crackles more prominent on the left;
no egophany, decreased fremitus, dullness to percussion, or
whispered pectoriloquy
- Abdomen: +BS in all 4 quadrants; soft; nontender;
nondistended; no hepatosplenomegaly; no rebound or guarding
- Back: no CVA tenderness
- GU: no Foley; Depends pad in place
- Extremities: warm; cap refill 2 sec; mild edema of left foot;
no calf tenderness; no cyanosis or clubbing
- Skin: midline sternal CABG scar; crusted 1-inch scab on the
medial left ankle without surrounding erythema, exudate, or
other signs of infection; no rashes
DISCHARGE PHYSICAL EXAM:
- VS: Tcurrent/Tmax 98.0/98.0, BP 122/80, HR 72, RR 18, 97% on
RA
- I/O: 320 PO/bath room privileges
- ___: well-appearing; no acute distress; laying quietly in
bed
- Neuro: alert; cooperative
- HEENT: no scleral icterus; moist mucus membranes
- Neck: supple; no lymphadenopathy; no JVD
- CV: irregularly irregular rhythm; normal S1/S2; no m/r/g; 2+
radial, DP, and ___ pulses bilaterally
- Lungs: left basilar crackles (improved)
- Abdomen: +BS in all 4 quadrants; soft; nontender;
nondistended; no hepatosplenomegaly; no rebound or guarding
- GU: no Foley; Depends pad in place
- Extremities: warm; cap refill <2 sec; slight edema of left
foot (improved); no calf tenderness; no cyanosis or clubbing
- Skin: midline sternal CABG scar; crusted 1-inch scab on the
medial left ankle with clean dressing and no surrounding
erythema, exudate, or other signs of infection; ecchymoses on
abdomen LLQ and right upper arm that were tender to palpation
Pertinent Results:
ADMISSION LABS:
___ 12:20AM BLOOD WBC-11.7*# RBC-4.36 Hgb-12.1 Hct-36.5
MCV-84 MCH-27.7 MCHC-33.2 RDW-14.1 Plt ___
___ 12:20AM BLOOD Neuts-86.3* Lymphs-8.2* Monos-4.3 Eos-0.9
Baso-0.3
___ 12:20AM BLOOD Plt ___
___ 12:20AM BLOOD Glucose-132* UreaN-53* Creat-1.5* Na-138
K-4.1 Cl-99 HCO3-29 AnGap-14
___ 12:20AM BLOOD ALT-14 AST-25 AlkPhos-85 TotBili-0.3
___ 12:20AM BLOOD Lipase-124*
___ 12:20AM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.6 Mg-2.3
___ 12:34AM BLOOD Lactate-1.0
___ 04:00AM URINE Color-Straw Appear-Clear Sp ___
___ 04:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:58PM URINE Hours-RANDOM UreaN-631 Creat-51 Na-24
K-24 Cl-16
___ 4:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-4.5 RBC-4.00* Hgb-11.2* Hct-34.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.3 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-154* UreaN-20 Creat-0.9 Na-142
K-3.8 Cl-105 HCO3-26 AnGap-15
___ 07:45AM BLOOD Calcium-9.7 Phos-2.3* Mg-2.4
___ 07:25AM BLOOD calTIBC-294 Ferritn-90 TRF-226
___ 12:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:25 am BLOOD CULTURE # 2.
Blood Culture, Routine (Pending):
___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
This test was cancelled because a FORMED stool specimen
was received,
and is NOT acceptable for the C. difficle DNA
amplification testing..
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
Brief Hospital Course:
Ms. ___ is a ___ yo woman with a history of colon cancer,
chronic constipation, systolic congestive heart failure, atrial
fibrillation, and coronary artery disease s/p stent & coronary
artery bypass graft who presented with abdominal pain, diarrhea,
and constipation in the setting of recent antibiotic exposure
and positive C. difficile test by ___.
ACUTE DIAGNOSES:
# Abdominal pain/diarrhea/constipation:
Given the recent antibiotic exposure and positive C. difficile
PCR test, the most likely cause is C. difficile colitis. The CT
scan showed no signs of an acute bowel process (no toxic
megacolon, intestinal rupture, or bowel wall thickening). Since
the patient refused metronidazole due to prior history of nausea
with this medication, she instead received oral vancomycin. She
received intravenous fluids and was kept NPO until her abdominal
pain improved on hospital day 2. Her diet was advanced as
tolerated, and she improved.
The patient had a bowel movement on ___ which was well formed
and could not be sent for C. difficile testing. It contained
tiny specks of blood, likely secondary to the patient's known
history of hemorrhoids.
# ___:
Given that the calculated FENa 0.51% (<1%), urine Na is 24
(low), and serum BUN/Creat ratio is 35.3 (>20), the most likely
cause of her elevated BUN and creatinine (baseline 1.1-1.3) is
prerenal azotemia secondary to diarrhea-induced hypovolemia.
Normal lactate (1.0) was reassuring (no end-organ
hypoperfusion). The patient was given intravenous fluids, and
losartan and torsemide were held. BUN and creatinine were
monitored for further elevations. The patient agreed to restart
her losartan and torsemide at home on the day of discharge.
# Elevated lipase:
This was unlikely to be clinically significant since elevated
lipase occurs in ___ of patients admitted for
non-pancreatic abdominal pain (e.g. renal failure, duodenal
ulcer, bowel obstruction/infarction). Given the improvement of
symptoms, lipase levels were not rechecked.
CHRONIC DIAGNOSES:
# Left ankle fracture:
The surgical site was intact without any signs or symptoms of
infection (no fever, erythema, warmth, exudate). Daily dressing
change and wound care were administered, and the site was
monitored for infection.
# systolic CHF
The patient's home losartan and torsemide were discontinued
during her hospital course given the concern for
diarrhea-induced hypovolemia and acute kidney injury. The
patient agreed to restart her losartan and torsemide at home on
the day of discharge. The patient's home metoprolol was
continued throughout her hospital course.
# Atrial fibrillation:
The patient was continued on her home Plavix and Aspirin
(Ecotrin).
Medications on Admission:
1. Aspirin EC 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Torsemide 40 mg PO DAILY
6. Senna 2 TAB PO HS:PRN constipation
7. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Metoprolol Tartrate 25 mg PO BID
5. Senna 2 TAB PO HS:PRN constipation
6. Losartan Potassium 50 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Vancomycin Oral Liquid ___ mg PO Q6H
Please continue this medication through ___ (for total 14-day
course).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: C. difficile colitis, acute kidney injury
Secondary diagnoses: chronic systolic congestive heart failure,
chronic hypertension, chronic atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for abdominal pain, diarrhea,
and subsequent constipation concerning for C. difficile colitis.
You were treated with antibiotics (oral Vancomycin) and
intravenous fluids. You felt better and tried some bland foods,
which you tolerated well. You improved over the course of your
hospital stay, and we recommend close follow up with your
outpatient primary care physician.
For your pre-existing heart disease, please weigh yourself every
morning, and call your physician if your weight increases more
than 3 lbs.
You STARTED vancomycin 125 mg PO q 6 hrs on ___ and should
continue through ___.
Followup Instructions:
___
|
10748105-DS-10
| 10,748,105 | 29,657,236 |
DS
| 10 |
2128-01-19 00:00:00
|
2128-01-19 16:08:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___
Chief Complaint:
Status post fall, presenting with left flank and rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is an ___ year old male with an history of asthma, DM,
HTN, presenting about 12 hours after a fall from standing in the
shower. He was wearing shower slippers when he fell backwards
and
hit his L side on the railing in the shower. No head strike or
LOC. Complaining of moderate L flank and hip pain. Recalls
entire
event. Pain is moderate, but he is able to breathe deeply. Feels
apprehensive to walk because of the hip pain. Does not take
anticoagulants. No fevers, chills, sweats, chest pain, dyspnea,
n/v.
Past Medical History:
Past Medical History:
ASTHMA
CATARACT
CHEST PAIN
COUGH
DIABETES TYPE II
DIABETIC FOOT ULCERS
GASTROESOPHAGEAL REFLUX
H PYLORI POSITIVE
HERPES ZOSTER
HODGKIN'S DISEASE
HODGKIN'S DISEASE
HYPERTENSION
IMPOTENCE
KNEE PAIN
LOWER EXTREMITY EDEMA
PERIPHERAL NEUROPATHY
PERIPHERAL VASCULAR DISEASE
SHOULDER PAIN
SPINAL STENOSIS
TRANSIENT ISCHEMIC ATTACK
DIABETIC RETINOPATHY
RX COVERAGE
Past Surgical History:
-Left hallux osteomyelitis debridement ___
-L SFA stenting ___
-R Cervical LNBx ___ w/ Dr. ___ surgery ___ and ___
-Retina surgery ___
Social History:
___
Family History:
No family history of cancer. Father died of a stroke.
Physical Exam:
Admission Physical Exam:
Vitals: 99.1 | 88 | 158/66 | 16 | 95 RA
GEN: A&O3, NAD
HEENT: NC/AT, EOMI, PERRLA, No scleral icterus, nares patent,
mucus membranes moist, OP clear
Neck: supple, non-tender
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
Chest: mild focal tenderness over posterior lower thoracic ribs
on L side
Back: no spinal tenderness, no ecchymoses, no perianal sensation
ABD: Soft, nondistended, nontender, no rebound or guarding, no
palpable masses
Pelvis: Stable
Ext: No ___ edema, ___ warm and well perfused
Neuro: CNII-XII non-focal, sensorineural intact
Discharge Physical Exam:
Vitals: T 98.2, BP 169/63, HR 68, RR 18, SpO2 95%RA
Gen: NAD, alert, awake, oriented. ___ only
HEENT: NC/AT, EOMI, mucus membranes moist
Neck: supple, non-tender
CV: RRR
Resp: Respirations non-labored, no use of accessory muscles
Chest: Mild focal tenderness over posterior mid-left chest wall
Back: no spinal tenderness, no ecchymoses, no perianal sensation
ABD: Soft, nontender, benign abdomen, no rebound or guarding, no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
Neuro: Sensation and strength grossly intact
Pertinent Results:
LABS
___ 04:35AM BLOOD WBC-7.9 RBC-3.77* Hgb-10.9* Hct-32.3*
MCV-86 MCH-28.9 MCHC-33.7 RDW-13.9 RDWSD-43.1 Plt ___
___ 11:50PM BLOOD WBC-11.7* RBC-4.22* Hgb-12.0* Hct-36.1*
MCV-86 MCH-28.4 MCHC-33.2 RDW-13.7 RDWSD-42.5 Plt ___
___ 11:50PM BLOOD Neuts-76.0* Lymphs-16.4* Monos-5.7
Eos-0.8* Baso-0.4 Im ___ AbsNeut-8.89* AbsLymp-1.92
AbsMono-0.67 AbsEos-0.09 AbsBaso-0.05
___ 04:35AM BLOOD Plt ___
___ 02:03AM BLOOD ___ PTT-24.3* ___
___ 04:35AM BLOOD Glucose-116* UreaN-19 Creat-1.4* Na-139
K-4.9 Cl-103 HCO3-25 AnGap-11
___ 04:35AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.1
MICROBIOLOGY
___ 2:18 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
___, CT Head:
Impression: No evidence of fracture, hemorrhage, mass or
infarction.
___, CT Chest/Abd/Pelvis:
1. Comminuted fracture of the left twelfth rib and a
nondisplaced fracture of the left tenth rib.
2. There are 6 lumbar type vertebral bodies (L6 demonstrates
transitional
anatomy). There are nondisplaced fractures of the left
transverse processes of L2 and L3.
3. Atrophic pancreas with coarse calcifications, likely sequelae
of chronic pancreatitis. 5 mm coarse calcification in the
pancreatic body may be in the duct or causing mass effect on
the duct. This calcification is unchanged since ___, however upstream dilatation of the main pancreatic duct
measuring up to 5 mm is new. Findings could be further
evaluated with contrast enhanced MRCP of the pancreas as
clinically indicated.
___ CT C-SPINE
IMPRESSION: No evidence of fracture or subluxation. Degenerative
disease with spinal canal and neural foraminal narrowing.
___: CXR
IMPRESSION: No consolidation, pleural effusion or pneumothorax.
___: ABDOMINAL XR
IMPRESSION: Prominent stool and air-filled loops of colon
suggestive of constipation.
Brief Hospital Course:
Mr. ___ is an ___ year old male who was admitted to the
hospital after a fall backwards while in the shower. There was
no reported loss of consciousness. Upon admission, the patient
reported left flank and hip pain. The patient underwent imaging
and was noted to have left sided 10, 12 rib fractures and a
non-displaced fracture of the left transverse processes of L2
and L3. These were planned for non-operative management and
there was no need for spinal brace. The patient's pain was
controlled with oral analgesia (tramadol, Tylenol) and lidocaine
patch. During his hospitalization, he was reported to have
abdominal distention. An x-ray of the abdomen was done which
showed stool in the colon and likely constipation. A bowel
regimen was ordered. Despite this, the patient's bowel function
was slow to return and was uptitrated. He did make one bowel
movement in the 24 hours prior to discharge, was benign on
abdominal exam, and was tolerating a regular diet. Physical
therapy was consulted to evaluate the patient's discharge status
and recommendations were made for discharge to a rehabilitation
facility where the patient could regain his strength and
mobility. Home medications were restarted, though he did remain
hypertensive to SBPs in the 150s-170s. We have arranged a
follow-up appointment with his PCP and added ___ oral
hydralazine for particularly elevated systolic pressures for his
time in the inpatient and rehab setting.
The patient was discharged to an extended care facility on the
afternoon of ___. At the time of discharge, his vital signs
were stable and he was tolerating a regular diet. He had return
of bowel function and was voiding without difficulty. His rib
pain was controlled with oral analgesia. Discharge instructions
were reviewed and questions answered with the help of a ___
interpreter. A follow-up appointment was made with his primary
care provider.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze/sob
2. amLODIPine 10 mg PO DAILY
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
4. Carvedilol 12.5 mg PO BID
5. compress.stocking,knee,reg,med miscellaneous ASDIR
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
7. Furosemide 20 mg PO DAILY
8. Glargine 90 Units BedtimeMax Dose Override Reason: home dose
9. Ipratropium Bromide MDI 2 PUFF IH QID
10. Losartan Potassium 100 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Pregabalin 50-100 mg PO BID:PRN pain
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Acetaminophen 1000 mg PO Q8H
15. Aspirin 81 mg PO DAILY
16. camphor-menthol 0.5-0.5 % topical BID
17. Cetirizine 10 mg PO DAILY
18. mineral oil-hydrophil petrolat topical BID
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Bisacodyl ___ID:PRN constipation
3. Docusate Sodium 100 mg PO BID
Hold for loose stool.
4. HydrALAZINE 25 mg PO Q6H:PRN SBP>180
5. Lidocaine 5% Patch 1 PTCH TD QAM Left ribs
Apply 12 hours on; 12 hours off.
RX *lidocaine [Lidoderm] 5 % Apply to left chest wall once a day
Disp #*30 Patch Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation.
7. Senna 17.2 mg PO HS
8. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
9. Acetaminophen 1000 mg PO Q8H
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze/sob
11. amLODIPine 10 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. camphor-menthol 0.5-0.5 % topical BID
14. Carvedilol 12.5 mg PO BID
15. Cetirizine 10 mg PO DAILY
16. compress.stocking,knee,reg,med miscellaneous ASDIR
17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
18. Furosemide 20 mg PO DAILY
19. Glargine 90 Units BedtimeMax Dose Override Reason: home
dose
20. Ipratropium Bromide MDI 2 PUFF IH QID
21. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
22. Losartan Potassium 100 mg PO DAILY
23. mineral oil-hydrophil petrolat topical BID
24. Omeprazole 40 mg PO DAILY
25. Pregabalin 50-100 mg PO BID:PRN pain
26. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Left rib fractures 10, 12
non-displaced fractures of left transverse processes
of L2 and L3.
Discharge Condition:
Mental Status: Clear and coherent ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___nd found to have left sided rib fractures and
fractures to your lumbar spine. You were given pain medication
and encouraged to take deep breaths. You were seen and evaluated
by the physical therapy team who recommended discharge to a
rehabilitation facility to continue your recovery.
You are now doing better, tolerating a regular diet, and ready
to be discharged from the hospital to continue your recovery.
Please note the following discharge instructions:
* Your injury caused Left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10748105-DS-11
| 10,748,105 | 26,818,111 |
DS
| 11 |
2129-08-06 00:00:00
|
2129-08-06 20:56:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
H___
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 10:58AM WBC-13.2* RBC-3.31* HGB-9.9* HCT-28.3* MCV-86
MCH-29.9 MCHC-35.0 RDW-12.7 RDWSD-39.6
___ 10:58AM NEUTS-76.4* LYMPHS-10.2* MONOS-12.1 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-10.10* AbsLymp-1.34 AbsMono-1.60*
AbsEos-0.02* AbsBaso-0.02
___ 10:58AM GLUCOSE-186* UREA N-27* CREAT-1.4*
SODIUM-120* POTASSIUM-5.0 CHLORIDE-87* TOTAL CO2-21* ANION
GAP-12
___ 10:58AM ALBUMIN-3.7
___ 10:58AM proBNP-5009*
___ 10:58AM cTropnT-<0.01
___ 10:58AM ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-110 TOT
BILI-0.8
___ 10:58AM LIPASE-30
___ 06:03AM BLOOD calTIBC-265 Ferritn-160 TRF-204
___ 05:39AM BLOOD %HbA1c-8.1* eAG-186*
Notable Discharge labs:
=========================
___ 08:14AM BLOOD WBC-9.2 RBC-2.86* Hgb-8.1* Hct-25.4*
MCV-89 MCH-28.3 MCHC-31.9* RDW-12.4 RDWSD-40.0 Plt ___
___ 08:14AM BLOOD Plt ___
___ 08:14AM BLOOD Glucose-92 UreaN-34* Creat-1.3* Na-133*
K-5.2 Cl-96 HCO3-26 AnGap-11
Studies/Imaging:
===============
-TTE (___): moderate symmetric LVH with normal systolic
function. Mildly dilated RV with mild systolic dysfunction. Mild
MR. ___ appears mildly dilated. Biatrial dilatation.
Indeterminate PASP and diastolic parameters. Compared with prior
TTE (___) the RV is mildly hypokinetic.
-CXR (___):
FINDINGS:
Mild cardiac enlargement as seen previously. Increased
interstitial markings seen throughout the lungs. No new
consolidation. There are small bilateral pleural effusions, new
since prior. No acute osseous abnormalities.
IMPRESSION:
Pulmonary edema and small bilateral pleural effusions.
-CXR (___):
IMPRESSION:
Compared to ___.
Previous mild pulmonary edema has nearly cleared. Mild
cardiomegaly
unchanged. Small minimal pleural effusions persist.
DISCHARGE PHYSICAL EXAM
=======================
VS: T 97.9, 142/67, 56, 18, 94% RA
GEN: well developed, well nourished man in NAD.
HEENT: Sclera anicteric. EOMI.
CARDIOVASCULAR: Regular rhythm, regular rate. Non-tachycardic.
Normal S1, S2. No murmurs, rubs, or gallops. JVD ~9-10 cm
LUNGS: Respiration non-labored. Clear lungs, no wheezes or
rhonchi.
ABDOMEN: soft, BS+, mildly distended, non-tender
EXTREMITIES: Warm, well perfused. 1+ pitting edema bilaterally
to shins.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AOx3, no gross deficit CNII-XII
Brief Hospital Course:
========================
TRANSITIONAL ISSUES
========================
[] obtain PFTs for amiodarone monitoring
[] Colonoscopy and EGD to evaluate for possible source of
bleeding and appropriate cancer screening
[] repeat CBC for thrombocytopenia in 2 weeks
[] monitor Cr, discharge Cr was 1.3 and discharged on full dose
apixaban and resumed metformin
[] Irbesartan 300mg daily held, please restart if hypertensive,
monitor K
[] discharged on reduced dose carvedilol ER 50mg daily, consider
titrating back to home dose carvedilol ER 80mg daily pending HR
and blood pressure
[ ]Monitor sugars and consider increasing lantus as outpatient
as needed
DISCHARGE WEIGHT: 217 pounds
DISCHARGE Cr: 1.3
DISCHARGE DIURETIC: torsemide 30mg daily
MEDICATION CHANGES
- NEW: amiodarone 200mg BID, apixaban 5mg BID
- STOPPED: irbesartan
- CHANGED: torsemide 30mg QD, pregabalin 100mg BID, carvedilol
ER 50mg daily
#CODE STATUS: Full Code
#CONTACT: ___ (son): ___
========================
BRIEF HOSPITAL COURSE
========================
___ ___ speaking with HFpEF (55%, ___, asthma, T2DM,
Hodgkin Lymphoma (CR since ___, hypertension, past TIA
presented with five days of shortness of breath and
palpitations, found to have acute on chronic HFpEF and
hyponatremia. Course complicated by new atrial fibrillation >___
felt to be secondary to his severe volume overload, chemically
converted back to sinus rhythm with amiodarone. Hypervolemic
hyponatremia and volume overload improved with diuresis.
ACTIVE ISSUES
# Shortness of Breath
# Acute on Chronic HFpEF (EF 63%, ___
Patient had 5 days of orthopnea, weight gain, PND, distension in
belly and legs, with recent clinic increase of torsemide
5mg->10mg for concern of volume overload, found to be in AoC
HFpEF. Negative for ischemic etiology by EKG or trop. Does not
carry prior diagnosis of atrial fibrillation and unclear if afib
serves as precipitant or sequelae. Concern also remains for
medication and dietary non-compliance, and notably patient also
with SBPs to 170s on admission. Provided lasix diuresis up to
160mg IV with good effect then titrated to torsemide 30mg daily.
Decreased home carvedilol ER 80 dosing to 25mg BID, discharged
on carvedilol ER 50mg daily. TTE with preserved EF but mild
increased RV hypokinesis.
# Hypervolemic Hyponatremia
Pt presenting with Na 120 on BMP, most likely ___ hypervolemia
___ heart failure exacerbation. Improved to Na 133 with
diuresis.
# Paroxysmal Atrial Fibrillation
No past history of atrial fibrillation. Reported more frequent
palpitations intermittently over the past week. Presented past
48 hour window and also in AoC heart failure. Unclear if atrial
fibrillation is precipitant vs sequelae for this patient in AoC
HFpEF. CHA2DS2-Vasc of at least 4. Initially started on
rivaroxaban due to concerns about med adherence however switched
to apixaban per cardiology recommendation, was on heparin due to
concern of ___ but apixaban restarted when Cr stabilized.
Returned to ___ on amiodarone. As Cr improved to 1.3, he is
discharged on full dose apixaban.
# Acute on Chronic Kidney Disease
Recent Cr 1.3-1.5 prior to admission, around baseline on
admission, however increased possibly ___ diuretics for CHF
exacerbation per above. Improved to baseline 1.3.
# Urinary retention
# Constipation
# Spinal stenosis
Reported urinary retention of one week, initially reporting
constipation of one year but on later report one week. Has
history of spinal stenosis in problem list, with CT C-spine
imaging in ___. Unclear reports of numbness in ___
region. Given chronicity, and lack of back pain and lack of
lower extremity neurologic deficit, less concern for cord
compression. Condom cath placed, no urinary difficulty or
retention iso high output diuresis. Bowel movements normalized
with bowel regimen.
# Hypertension
Presenting with BP 173/69. Home meds amlodipine 7.5mg daily,
irbesartan 300mg daily, Carvedilol ER 80mg. Initially held
irbesartan iso ___ and not restarted given hyperkalemia this
admission. Discharged on amlodipine 7.5mg daily.
# Normocytic Anemia
Presenting Hb 9.9; last in ___ hgb 11.3. Patient reports no
hematochezia, hemoptysis, blood in stool. Concerning for anemia
of chronic disease vs iron deficiency exacerbated by poor gut
absorption. Hematocrit downtrending likely in the setting of
frequent blood draws while monitoring electrolytes with active
diuresis. Patient notably a ___'s witness and was started on
iron supplementation.
#Fatigue
Multifactorial secondary to delirium, anemia, and severity of
HFpEF. Infectious workup negative.
CHRONIC/RESOLVED ISSUES
# Hyperkalemia: improved
Had rising K to 5.8, unclear etiology, resolved after 15mg
kayexelate. Perhaps in setting ___ on CKD and less aggressive
use of loop diuretics. ___ held on discharge.
# T2DM c/b neuropathy
Concern for patient not remembering home dose; managed with
lantus and ISS inpatient with labile blood sugars. Lantus dose
decreased from home to 45u daily with plan to continue
titration. For neuropathy, pregabalin increased to 100mg BID (pt
wife reported was taking this at home). Metformin restarted on
discharge.
# Asthma
Received Duonebs PRN while inpatient
Continued home cetirizine, fluticasone, montelukast
# GERD
Continued home omeprazole
# Chronic pancreatitis
Seen by GI in past, thought to have constipation and chronic
pancreatitis with known pancreatic stone. Continued home bowel
regimen, home Creon, Dicyclomine
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge. Patient seen and examined on day of
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. irbesartan 300 mg oral DAILY
4. Pregabalin 50 mg PO DAILY
5. Pregabalin 100 mg PO QHS:PRN pain
6. Simethicone 80 mg PO TID:PRN abdominal pain
7. DICYCLOMine 10 mg PO TID:PRN abdominal pain
8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
9. CARVedilol 80 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
12. Bisacodyl 5 mg PO DAILY:PRN Constipation - Second Line
13. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Fluticasone Propionate NASAL 1 SPRY NU BID
16. Creon 12 3 CAP PO TID W/MEALS
17. amLODIPine 7.5 mg PO DAILY
18. Montelukast 10 mg PO DAILY
19. Torsemide 10 mg PO DAILY
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
21. Omeprazole 40 mg PO DAILY
22. Cetirizine 10 mg PO DAILY
23. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN cough,
dyspnea
24. Glargine 90 Units BreakfastMax Dose Override Reason:
pre-admit med
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Apixaban 5 mg PO BID atrial fibrillation
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. carvedilol phosphate 50 mg oral DAILY
Please hold for SBP<100 or HR<55
6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
8. Ramelteon 8 mg PO QPM insomnia
9. Glargine 45 Units Breakfast
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: pre-admit med
10. Pregabalin 100 mg PO BID pain
11. Torsemide 30 mg PO DAILY
12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
cough, dyspnea
14. amLODIPine 7.5 mg PO DAILY
15. Bisacodyl 5 mg PO DAILY:PRN Constipation - Second Line
16. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
17. Cetirizine 10 mg PO DAILY
18. Creon 12 3 CAP PO TID W/MEALS
19. DICYCLOMine 10 mg PO TID:PRN abdominal pain
20. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
21. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
22. Fluticasone Propionate NASAL 1 SPRY NU BID
23. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
24. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
25. MetFORMIN (Glucophage) 500 mg PO BID
26. Montelukast 10 mg PO DAILY
27. Omeprazole 40 mg PO DAILY
28. Senna 8.6 mg PO BID:PRN Constipation - First Line
29. Simethicone 80 mg PO TID:PRN abdominal pain
30. HELD- irbesartan 300 mg oral DAILY This medication was
held. Do not restart irbesartan until instructed by your
physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Heart failure exacerbation
SECONDARY DIAGNOSES: Atrial fibrillation, acute kidney injury,
hypertension, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
================================================
PATIENT DISCHARGE INSTRUCTIONS
================================================
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
================================
- You were admitted because of shortness of breath
WHAT HAPPENED IN THE HOSPITAL?
================================
- Your shortness of breath was due to a condition called heart
failure, which causes excess fluid to build up in your body. You
were provided you medications to help remove that fluid through
urination.
- Your heart went into an abnormal rhythm (atrial fibrillation)
which converted back to normal with medications
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Your weight at discharge is 217 pounds. Please weigh yourself
today and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in one day.
- Important NEW MEDS: amiodarone 200mg twice a day, apixaban 5mg
twice a day, aspirin 81mg once a day, atorvastatin 80mg once a
day.
- CHANGED MEDS: torsemide 30mg once a day, pregabalin 100mg
BID, carvedilol ER 50mg daily
- STOP MEDS: Irbesartan - stop until a doctor tells you to
restart
- Be sure to take your medications as prescribed and attend the
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10748105-DS-9
| 10,748,105 | 27,367,234 |
DS
| 9 |
2122-10-02 00:00:00
|
2122-10-03 08:26:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough X 15 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of Hodgkin's lymphoma ___ now in remission and IDDM
presents with cough X 15 days. Cough is persistent, frequenlty
keeping him up at night. It is wet but productive of only scant
sputum. Endorses subjective fevers and chills at home but temp
never above 99 at home. Patient was seen at ___ visit ___ at
___ and was presumed to have an asthma exacerbation vs atypical
PNA. Was prescribed 5 day course of Prednisone and 7 day course
of doxycycline. Per patient, these have not improved his
symptoms.
Patient also notes dyspnea on exertion and dizziness after
ambulating 1 block. Also endorsing chest tightness that is
similar to his prior asthma exacerbations. Sick contacts include
a ___ year old son who had the flu within the last month.
Patient's wife also felt flu-like symptoms approximately 3 weeks
ago.
He had a flu vaccine one month ago.
In the ED, initial vs were: 98.7 96 184/64 18 98%. Patient was
given levofloxacin, vancomycin. Vitals on Transfer: 97.2 86
148/59 18
Review of sytems:
(+) Per HPI and also mild headache
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
ONCOLOGIC HISTORY:
# stage IIIB classical Hodgkin lymphoma, nodular sclerosis
subtype:
- initially presented to his PCP ___ ___ with 1.5 months of
fevers, night sweats, and fatigue and associated cervical and
supraclavicular lymphadenopathy. He underwent ultrasound-guided
FNA and core biopsy of a right cervical lymph node on ___
cytology and flow cytometry were nondiagnostic, and pathology
from the core needle biopsy showed an atypical lymphoid
infiltrate. He underwent excisional cervical lymph node biopsy
on
___ pathology from this was diagnostic of classical Hodgkin
lymphoma, nodular sclerosis subtype.
- His symptoms continued and on ___ he was sent to the ED by
his PCP after complaining of intractable B type symptoms
including daily fevers to 101-102, night sweats, as well as
extreme fatigue and was admitted to the hematologic malignancy
service. On ___ he had a CT torso showing extensive
supraclavicular, axillary, retroperitoneal, and pelvic
lymphadenopathy, some of which showed interval enlargement
compared to CT on ___, and normal size spleen. He also had
bone marrow biopsy on ___ showing hypercellular bone marrow
for age with maturing trilineage hematopoiesis without
involvement by Hodgkin lymphoma. Cytogenetic analysis did not
reveal any abnormality.
- He was treated with prednisone ___ and ___ and then received
C1D1 of ABVD on ___. His night sweats persisted and his
fevers
continued intermittently. Infectious workup was negative. He
underwent port placement on ___ and was discharged home the
same day. He was re-admitted ___ with non-neutropenic
fever
with a negative workup.
- ___ C1D1 ABVD, ___ C1D15 ABVD
- ___ C1D1 ChlVPP (switched due to concern for anemia and
worsening DLCO)
- ___ C2D1 ChlVPP
- ___ C3D1 ChlVPP - vinblastine (both day 1 and ___) held
because of neuropathy
- ___ C4D1 ChlVPP - vinblastine given without dose
adjustment
- PET/CT on ___ and ___ following two and four cycles
of
chemotherapy showed no evidence of FDG-avid disease.
.
OTHER MEDICAL HISTORY:
1) Jehovah's witness - his wife has a form that states that he
does not want transfusions of whole blood, red cells, white
cells, plasma, or platelets. The form also states that he
refuses all "minor fractions of blood" except "recombinant
products that are not taken from blood and that may be
prescribed
in place of some blood fractions. In talking to him and his
wife,
they do not want any products derived from blood, even in the
case of life-threatening illnesses.
2) Diabetes type II, c/b peripheral neuropathy - ___ A1C
8.9%
3) Hypertension
4) GERD
5) Spinal stenosis
6) Osteoarthritis
7) Asthma
8) h/o TIA - per review of records - he and his wife are unsure
of the exact details
9) Colonic polyps
10) cataract surgery - 2 and ___ years ago
11) left ankle/tendon surgery - 4 or ___ years ago
Social History:
___
Family History:
No family history of cancer. Father died of a stroke.
Physical Exam:
ON ADMISSION
Vitals: T: 98.1 BP: 180/90 P: 91 R: 18 O2:96RA
General: Alert, oriented, no acute distress, ___ speaking
only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated,no adenopathy
Lungs: coarse breath sounds at bases, R side slightly worse than
L, no wheezes,or ronchi appreciated
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: CN II-XII intact, no gross focal deficits
ON DISCHARGE
Vitals: T: 99.1 BP: 148/64 P: 91 R: 18 O2:98RA
General: Alert, oriented, no acute distress, ___ speaking
only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated,no adenopathy
Lungs: coarse breath sounds at bases, R side slightly worse than
L, no wheezes,or ronchi appreciated
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: CN II-XII intact, no gross focal deficits
Pertinent Results:
ON ADMISSION
___ 12:21PM BLOOD WBC-11.5*# RBC-3.87* Hgb-11.8* Hct-34.3*
MCV-89 MCH-30.5 MCHC-34.4 RDW-13.1 Plt ___
___ 12:21PM BLOOD Glucose-125* UreaN-33* Creat-1.3* Na-137
K-5.0 Cl-102 HCO3-23 AnGap-17
___ 12:45PM BLOOD Lactate-1.4
ON DISCHARGE
___ 06:45AM BLOOD WBC-10.2 RBC-3.79* Hgb-11.6* Hct-34.4*
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.1 Plt ___
___ 06:45AM BLOOD Glucose-141* UreaN-31* Creat-1.4* Na-135
K-4.8 Cl-100 HCO3-26 AnGap-14
___ 06:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
Notable Studies
CXR ___
FINDINGS: AP and lateral images of the chest were obtained. The
lungs are
Preliminary Reportclear bilaterally with no focal consolidation
or congestive heart failure.
Preliminary ReportThere is no pneumothorax or pleural effusion.
The cardiomediastinal
Preliminary Reportsilhouette is normal. There are no bony
abnormalities. There is no free air
Preliminary Reportbelow the right hemidiaphragm.
Preliminary ReportIMPRESSION: No acute intrathoracic process.
Influenza- DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Reported to and read back by ___ ___ ___ 1240PM.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Legionella Urine Ag- negative
Blood Cx ___- pending
Urine culture- no significant growth
Brief Hospital Course:
___ with PMHx Hodgkin's Lymphoma in ___ in remission s/p
Bleomycin tx p/w 15 days of cough refractory to course of
prednsione and doxycycline, found to have Influenza A.
#Influenza A
Patient had positive nasal swab. Has been kept on droplet
precautions in house. Patient and family educated on best way to
prevent spread of virus. While in hospital, continued to
experience his cough and sweating at night. Patient did endorse
mild headache but no myalgias.
#h/o Hodgkin's Lymphoma
Well followed by ___ service here. On exam in house, patient had
posterior fullness in L cervical chain, non-tender. This should
continue to be folowed as outpatient.
#HTN
-continued home diovan and amlodipine with holding parameters
#DM
-continued home insulin and ISS
#CKD
Creatinine 1.3, which appears to be his new baseline. Likely
from his HTN and DM.
#Asthma
-standing neb treatments
#GERD
-continued home omeprazole
#PVD s/p left ___ stent ___
-continued clopidogrel
Transitional Issues
-Blood Cultures from ___ need to be followed.
-On exam in house, patient had posterior fullness in L cervical
chain, non-tender. This should continue to be folowed as
outpatient.
-Patient has ___ with PCP and ___ within next
week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Amlodipine 10 mg PO DAILY
Hold for SBP<100
3. Chlorthalidone 25 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pregabalin 100 mg PO HS
7. Valsartan 320 mg PO DAILY
Hold for SBP<100
8. NPH 75 Units Breakfast
NPH 45 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Aspirin 81 mg PO DAILY
12. Colchicine 0.6 mg PO EVERY OTHER DAY
13. Docusate Sodium 100-200 mg PO DAILY:PRN constipation
14. Simethicone 80 mg PO QID:PRN constipation
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. NPH 75 Units Breakfast
NPH 45 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Amlodipine 10 mg PO DAILY
Hold for SBP<100
3. Chlorthalidone 25 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pregabalin 100 mg PO HS
7. Valsartan 320 mg PO DAILY
Hold for SBP<100
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
10. Colchicine 0.6 mg PO EVERY OTHER DAY
11. Docusate Sodium 100-200 mg PO DAILY:PRN constipation
12. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
13. Simethicone 80 mg PO QID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Influenza
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
___ speaking only
Discharge Instructions:
You came to the hospital with a cough and nightsweats for 2
weeks. This was caused by influenza which is a viral infection.
Your exam and chest x-ray did not show signs of pneumonia. Your
cough may last up to ___ weeks.
Please follow-up with Dr ___ at the appointment listed
below. If you still have symptoms at this time, this cough may
be from other causes and you made need mroe diagnostic tests.
You also have an appiointment with your ___
Doctors. please tell them if you are continuing to experience
these symptoms
No changes have been made to your medications.
It was a pleasure taking care of you, Mr ___.
Followup Instructions:
___
|
10748180-DS-16
| 10,748,180 | 20,356,373 |
DS
| 16 |
2157-08-09 00:00:00
|
2157-08-09 11:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
back and neck pain and tingling and numbness in hands
Major Surgical or Invasive Procedure:
1. Partial corpectomy of C3 with greater than 50% removal
of the vertebral body on the right side.
2. Application interbody cage C3-4.
3. Application of anterior cervical plate C3-4.
4. Application of local autograft from the partial
corpectomy mixed with allograft.
5. Application and removal of ___ tongs for
cervical traction.
6. Spinal cord monitoring.
1. C3, C4, bilateral laminectomy, medial facetectomy, and
foraminotomy.
2. C2-C5 posterior spinal arthrodesis.
3. C2-C5 posterior spinal instrumentation.
4. Application and removal ___ tongs.
5. Application of local autograft.
6. Spinal cord monitoring.
History of Present Illness:
___ presenting with upper back and neck pain. The patient
reports that over the last 5 months he has had upper thoracic
back and neck pain which has been intermittent. Fell in
___ after a trip and fall at work. Was evaluated
afterwards but workup was reassuring. Symptoms started about 1
month after that. Gets better with ibuprofen but nothing seems
to make it worse. Associated with tingling of the ulnar hands
and forearm and clumsiness of the right hand. Denies
bowel/bladder incontinence/retention. Denies fever. Denies
weakness. Denies headache, vision changes, neck stiffness. The
patient was seen as an outpatient and an MRI without constrast
showed a mass at C3-4 with cord compression. The patient was
then seen in the ED for the same complaint. An MRI of the Cspine
with contrast was performed and concerning for an epidural
hematoma. An MRI of the T and L spine and a CT scan was
recommended but the patient left AMA. He saw his outpatient
orthopedist who also recommended that he come to the ED for
further evaluation, so he came back.
Past Medical History:
BPH
Social History:
SH: Works as a ___. +Cocaine, last use > ___ year ago.
+Marijuana. Denies IVDU.
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: 4+/5 Del/Tri/Bic/WE/WF/FF/IO
All fingers WWP, brisk capillary refill, 2+ distal pulses
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
___ 05:40AM BLOOD WBC-19.1* RBC-3.43* Hgb-11.5* Hct-35.5*
MCV-104* MCH-33.5* MCHC-32.4 RDW-12.8 RDWSD-48.8* Plt ___
___ 05:35AM BLOOD WBC-17.1* RBC-3.09* Hgb-10.5* Hct-32.6*
MCV-106* MCH-34.0* MCHC-32.2 RDW-13.0 RDWSD-50.2* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-114* UreaN-8 Creat-0.8 Na-137
K-3.5 Cl-99 HCO3-31 AnGap-11
___ 05:35AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-142
K-3.2* Cl-109* HCO3-25 AnGap-11
___ 05:40AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.4*
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.___ was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's. Speech N Swallow were consulted for a
swallow eval post-op given concern for aspiration. CXR was
negative for pneumonia or signs of aspiration. Speech and
swallow recommended nectar thickened diet. The patient
swallowing improved by ___ and was cleared for a solft solid
diet for discharge. This was discussed with the speech n swallow
team and are in agreement with this plan. Hospital course was
otherwise unremarkable.On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
Flomax
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may be taken over the counter
2. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medication
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
please do not operate heavy machinery, drink alcohol or drive
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
1. Spinal cord injury C3.
2. Cervical myelopathy.
3. Large disk herniation C3-4.
4. Status post partial corpectomy of C3 with interim with
interbody cage and fusion at C3-4 on ___.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Cervical Fusion
You have undergone the following operation: Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Cervical Collar / Neck Brace:You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks.You may remove the collar to take a
shower.Limit your motion of your neck while the collar is
off.Place the collar back on your neck immediately after the
shower.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time.If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Followup Instructions:
___
|
10748191-DS-3
| 10,748,191 | 20,303,710 |
DS
| 3 |
2150-01-28 00:00:00
|
2150-02-17 20:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: self inflicted stab wounds
Major Surgical or Invasive Procedure:
___: suturing of superficial stab wounds left chest
___: suturing of superficial stab wound right neck
___: suturing of superficial stab wound bilateral temples
History of Present Illness:
___ Yo M BIBA who presents to ED with pain due to multiple
self-inflicted stab wounds to anterior chest which occurred
at approximately 10:00 today. Patient admits he was trying
to end his life due to stress. Denies SOB, abdominal pain,
nausea, vomiting, or other symptoms at this time.
Per EMS, patient self inflicted stab wounds to anterior
chest with 4 inch Buck knife. He was reported missing to
police this morning and found in an alley in ___.
Timing: Sudden Onset
Severity: Severe
Duration: 10:00 today
Location: chest, bilateral temporals
Associated Signs/Symptoms: stress
Past Medical History:
DJD of lower back and right knee
Social History:
___
Family History:
Uncle with history of paranoia
no hx suicide attempts or substance abuse
Physical Exam:
PHYSICAL EXAMINATION: ___
HR: 115 BP: 109/68 Resp: 26 O(2)Sat: 99 Normal
Constitutional: patient is poor historian due to
hypovolemia and critical state
HEENT: 2cm lacerations over bilateral temporals
superifical submandibular laceration
Chest: No subcutaneous air. Clear to auscultation
bilaterlly. multiple stab wounds over chest: 6.
Extr/Back: BLE 2+ and equal. dried blood over BLE.
Physical examination upon discharge: ___:
vital signs: t=98.1, bp=141/89, hr=98, rr=16, 98% room air
General: Resting in bed
HEENT: ___ ecchymosis
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non -tender, mild distention, hypoactive BS
EXT: no calf tenderness bil.,no pedal edema bil.
NEURO: alert and oriented x 3, speech clear
SKIN: Ecchymosis across chest, sutures frontal scalp, chest
with single suture, abrasions across knees
Pertinent Results:
___ 06:11AM BLOOD WBC-5.8 RBC-2.37* Hgb-7.7* Hct-22.0*
MCV-93 MCH-32.3* MCHC-34.8 RDW-13.8 Plt ___
___ 11:40AM BLOOD WBC-5.1 RBC-2.50* Hgb-8.1* Hct-23.3*
MCV-93 MCH-32.4* MCHC-34.7 RDW-13.8 Plt ___
___ 11:28PM BLOOD WBC-13.0* RBC-3.17* Hgb-10.0* Hct-28.8*
MCV-91 MCH-31.6 MCHC-34.7 RDW-13.3 Plt ___
___ 06:20PM BLOOD WBC-22.9* RBC-3.87* Hgb-12.3* Hct-36.6*
MCV-95 MCH-31.6 MCHC-33.5 RDW-13.1 Plt ___
___ 06:11AM BLOOD Plt ___
___ 05:21AM BLOOD ___ PTT-24.4* ___
___ 05:21AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-137
K-3.9 Cl-105 HCO3-24 AnGap-12
___ 06:20PM BLOOD UreaN-16 Creat-1.3*
___ 06:11AM BLOOD ALT-45* AST-48* CK(CPK)-448* AlkPhos-50
TotBili-0.3
___ 11:40AM BLOOD CK(CPK)-857*
___ 06:11AM BLOOD TSH-PND
___ 06:11AM BLOOD T4-PND
___ 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:26AM BLOOD Lactate-1.4
___ 06:39PM BLOOD Glucose-183* Lactate-11.7* Na-134 K-4.2
Cl-101 calHCO3-16*
___ 10:47PM BLOOD freeCa-1.05*
___ 06:39PM BLOOD freeCa-1.05*
___: chest x-ray:
Unremarkable chest x-ray
___: cat scan of the c-spine:
No acute fracture or traumatic subluxation. Subcutaneous
stranding and air without large hematoma on the neck on the
right.
___: cat scan of the head:
No acute intracranial process.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Fat stranding and hematomas in the subcutaneous tissues of
the anterior left chest relate to recent trauma.
2. Patchy ill-defined bilateral ground-glass opacities in the
lungs could relate to fluid resuscitation.
3. No acute abnormalities are seen in the abdomen or pelvis.
___ 6:45 pm URINE TRAUMA.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old gentleman who was admitted to the hospital with pain
due to multiple
self-inflicted stab wounds to the anterior chest, neck and
temples. As reported in the record, the patient reported that he
was trying to end his life due to stress. Upon admission, the
patient was made NPO, given intravenous fluids, and underwent
radiographic imaging. The patient was monitored in the intensive
care unit he remained alert and oriented. His hemodynamic
status remainded stable. The psychiatry service was consulted
and made recommendations for a 1:1 sitter and montoring of the
blood work. The patient was started on zyprexa as per Psychiatry
recommendations.
Cat scan imaging of the neck showed no acute fracture or
traumatic subluxation. There was subcutaneous stranding and air
without a large hematoma on the right side of the neck. Imaging
of the head cat scan was normal. The patient underwent a cat
scan of the abdomen which showed superficial left chest trauma,
but no significant injuries. The patient was transferred to the
surgical floor on HD # 2. His vital signs remained stable.
Because of his injuries, he underwent serial hematocrit checks.
His hematocrit stabililzed at 22.0 upon discharge. He was
placed on oral iron supplements. The electrolytes remained
stable with thyroid levels pending. There was a mild elevation
in the liver enzymes. He has been tolerating a regular diet and
he has been afebrile. He was evaluated by the Psychiatry
service and recommendations were made for admission to a
psychiatric floor for additional monitoring. On HD # 4, he was
discharged. Follow-up appointments were made with the acute
care service for removal of the sutures.
The patient has been stable and medically cleared for discharge
by the Acute care service to an inpatient psychiatric facility.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nicotine Patch 21 mg TD DAILY
6. OLANZapine 5 mg PO BID:PRN anxiety
7. Thiamine 100 mg PO DAILY
8. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: self inflicted stab wounds
hypovolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after self inflicted stab
wounds to left chest, right neck and and head. You required
suturing of the wounds. You were monitored in the intensive care
unit. YOur vital signs have been stable. Because of the injury
incurred upon yourself, you were seen by the Psychiatrist and
recommendations made for additional hospitalization on a
psychiatric floor.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
10748474-DS-7
| 10,748,474 | 26,103,174 |
DS
| 7 |
2111-09-22 00:00:00
|
2111-09-22 17:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / Fish Containing Products
Attending: ___.
Chief Complaint:
abdominal wall hematoma
Major Surgical or Invasive Procedure:
___ embolization
History of Present Illness:
___ on therapeutic anticoagulation presents with hematoma on
his abdomen. He is s/p b/l lap inguinal hernia repair (TEP) and
umbilical hernia repair (underlay) with Dr ___ at ___
___
on ___. He stopped coumadin a few days prior to surgery and
started lovenox 80 BID, including a dose ___, which he
restarted
the morning after surgery; his last dose of lovenox was ___
AM.
He took 10 mg of Coumadin ___ and ___. He never skipped a
dose of his aspirin.
After his operation he noted bruising of his abdomen and scrotum
almost immediately afterwards, which he thought was normal; he
also had constipation. On the day of presentation, ___, he was
on the toilet having a bowel movement when he had an episode of
"blankness" and "inability to find the right words," likely a
vagal episode, after which his wife took him to the ___
ED.
There, he underwent a CT scan and got labs, then was transferred
to ___. Currently, he reports some abdominal pain and nausea.
Last BM was in the morning, non bloody. No chest pain, dyspnea,
emesis, fevers, chills, night sweats.
He has been on coumadin and aspirin since his MI in ___ per
the
notes it appears this is for LV hypokinesis. He also had a
question of a thrombus in his LV on an Echo done in ___ and
subsequent Echos also mention this questionable thrombus.
Past Medical History:
PMHx: GERD, MI s/p 2 bare mental stents ___, LV hypokinesis/?LV
thrombus, diastolic dysfunction, HLD, asthma
PSHx: lap b/l inguinal hernia repair (TEP) and umbilical hernia
repair ___ ___, AICD placement ___, R shoulder surgery
___, knee surgery
Social History:
___
Family History:
FH: NC
Physical Exam:
PE:
Vitals: T 98,5, HR 94, BP 112/65, RR 18, sat 96%/RA
Gen: NAD, A&Ox3, looks comfortable
CV: RRR no M/R/G
pulm: CTA b/l
abd: well healing port site incisions, bruising on lower
anterior abdpominal wall more on the R than L side, soft, mildly
distended, NT, no rebound guarding, no nex hematoma,
erythema/edema.
ext: no e/c/c. + pulse b/l
Pertinent Results:
___ 11:45PM HCT-25.2*
___ 09:41PM GLUCOSE-136* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 09:41PM estGFR-Using this
___ 09:41PM cTropnT-<0.01
___ 09:41PM WBC-11.2* RBC-3.07* HGB-9.4* HCT-27.8* MCV-91
MCH-30.7 MCHC-34.0 RDW-12.9
___ 09:41PM NEUTS-82.2* LYMPHS-10.8* MONOS-6.4 EOS-0.4
BASOS-0.2
___ 09:41PM PLT COUNT-207
___ 09:41PM ___ PTT-34.1 ___
Brief Hospital Course:
___ on therapeutic anticoagulation presents after having b/l
inguinal hernia repair (TEP) and umbilical hernia repair
(underlay) ___ with abdominal wall hematoma. he was admitted to
ICU unit. Please see the ICU transfer note for details. He had
___ embolization of the left inferior epigastric artery and right
deep circumflex iliac artery. While in the unit he got 2 units
of FFP and 1 unit of pRBC. He was transferred to the floor in
stable condition with Hct of 24.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with Po pain
medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO for ___
embolization. After the procedure his diet was advanced to
regular. He was tolerating it well, without nausea or vomiting.
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: Hct remained stable while on the floor.
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
with stable vital signs. The patient was tolerating regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Testosterone Cypionate 100 mg/mL SC Q10DAYS
2. irbesartan 75 mg oral ONCE
3. Ipratropium-Albuterol Neb Dose is Unknown NEB Frequency is
Unknown
4. Carvedilol 12.5 mg PO BID
5. Warfarin 5 mg PO 5XWEEK, 7,5MG 2 DAYS A WEEK
6. Rosuvastatin Calcium 40 mg PO QPM
7. Montelukast 10 mg PO DAILY
8. Nitroglycerin SL Dose is Unknown SL Frequency is Unknown
9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
11. esomeprazole magnesium 40 mg oral BID
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Montelukast 10 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. esomeprazole magnesium 40 mg oral BID
7. Ipratropium-Albuterol Neb 0 NEB NEB Frequency is Unknown
8. irbesartan 75 mg oral ONCE
9. Nitroglycerin SL 0 mg SL Frequency is Unknown
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 to 2 tablet(s) by
mouth every four (4) hours Disp #*30 Tablet Refills:*0
11. Testosterone Cypionate 100 mg/mL SC Q10DAYS
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal wall hematoma, s/p ___ embolization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were in the hospital because you had some bleeding in your
abdominal wall a few days after your surgery. You were taking
coumadin, and probably that was the reason you had this
bleeding. You may notice some bruising on your abdominal wall
which is normal after this type of bleeding and should disappear
over time. If you notice new swelling, redness, increased pain,
increased bruising, fatigue/weakness, palpitation, visual field
changes you should call to your surgeon or come to the
___ department. Please stop taking coumadin as
echocardiographic evaluation of your heart failed to reveal any
thrombus. Please see your Primary care doctor within ___ days
after discharge.
Avoid strenuous exercises. Resume physical activity when site
of surgery does not hurt without pain medication performing said
activity.
Consume a diet with plenty of non caffienated fluids, plenty of
fiber. Consider use of a fiber supplement like Konsyl,
Metamucil, Benefiber or Citrucel. All these measures will
prevent constipation and thus straining.
11. You can perform all your acitvities of daily living. AVOID
lifting weights heavier than 30lbs for a total duration of 6
weeks. Please note chronic cough, chronic constipation,
excessive lifting of heavy weights and weight gain predispose to
recurrence of hernia.
Call the office at ___ if you have any of
the following:
A.Persistent drainage of blood or pus from the incision,
increased bruising, redness, swelling, pain of your abdmominal
wall.
B.A fever higher than 101 degrees.
C.If the skin around the incision or incision is very red,
painful, swollen; looks infected
Followup Instructions:
___
|
10748951-DS-11
| 10,748,951 | 21,689,255 |
DS
| 11 |
2172-07-11 00:00:00
|
2172-07-23 08:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
HPI: ___ year old woman presenting with 48 hours of low mid /
left
abdominal pain. She informs he pain started yesterday morning
when she woke up, describes it as an increasing discomfort in
the
mid to left suprapubic area. Associated nausea, dry heave,
anorexia, bloating and chills. Denies diarrhea, constipation,
fever, vomiting, BRBPR or any other symptoms.
Last BM today. + Flatus. Last meal: Pretzels this pm
Past Medical History:
HTN
Social History:
___
Family History:
Father died of lymphoma ___. Mother family with
hx of "heart problems
Physical Exam:
PHYSICAL EXAMINATION upon admission ___
Temp: 98.7 HR: 72 BP: 138/75 Resp: 16 O(2)Sat: 100 room air
Normal
Constitutional: Comfortable
HEENT: Extraocular muscles intact, Pupils equal, round and
reactive to light
Mucous membranes moist
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds
without murmur
Abdominal: The abdomen is soft with normal bowel sounds.
There is moderate tenderness suprapubic and just to the
right of the suprapubic region. She does have mild rebound
tenderness.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No edema or calf tenderness
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 04:55PM BLOOD WBC-13.4* RBC-4.34 Hgb-13.6 Hct-38.4
MCV-89 MCH-31.3 MCHC-35.3* RDW-12.8 Plt ___
___ 04:55PM BLOOD Neuts-88.3* Lymphs-7.9* Monos-2.8 Eos-0.1
Baso-0.9
___ 04:55PM BLOOD ___ PTT-28.9 ___
___ 04:55PM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-137
K-3.4 Cl-100 HCO3-27 AnGap-13
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Abnormally enlarged, fluid-filled appendix with wall
thickening and
hyperemia, compatible with appendicitis. The cecum is normal.
2. Small amount of right lower pelvic fluid suggesting a small
focus of
ascites. Hydrosalpinx is also a possibility and can be assessed
with
ultrasound when clinically appropriate.
3. 2.6 x 2.4 cm left adnexal cyst. Further evaluation with a
pelvic
ultrasound examination is warranted following resolution of
acute symptoms
noting the patient's age.
Brief Hospital Course:
___ year old female admitted to the acute care service with
abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent radiographic imaging. She was
reported to have an abnormally enlarged, fluid-filled appendix
with wall thickening and hyperemia suggestive of appendicitis.
On HD #2, she was taken to the operating room for laparoscopic
appendectomy. The operative course was stable with minimal
blood loss. She was extubated after the procedure and monitored
in the recovery room.
Her post-operative ___ has been stable. She is afebrile with
stable vital signs. She is tolerating a regular diet without
complaints of nausea or vomitting. She is preparing for
discharge home with follow-up with the acute care team.
Of note: pt informed of need to follow up with PCP for pelvic
US: finding on ct abdomen ? left adnexal cyst.
Medications on Admission:
HCTZ 12.5'
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: may cause increased drowsiness, avoid
driving while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with lower abdominal pain.
You were found on cat scan to have appendicitis. You were taken
to the operating room where you had your appendix removed. You
are now preparing for discharge home where you can fully
recover. You are being discharged with the following
instructions:
Followup Instructions:
___
|
10749008-DS-19
| 10,749,008 | 22,005,629 |
DS
| 19 |
2178-04-12 00:00:00
|
2178-04-12 20:15:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
productive cough, wheezing, dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old F with PMH of asthma with frequent
exacerbations, DM II, HTN, HLD, hypothyroidism who p/w 3 weeks
of productive cough, wheezing and progressive dyspnea consistent
with bronchitis and asthma exacerbation. Patient initially
developed cough productive for yellow sptum 3 weeks ago. She
took Levaquin 500mg qd x days, but the symptoms persisted. She
has also now taken Avelox 400mg qd x10 days. In addition to
sputum production, she has developed worsening dyspnea, chest
tightness, and wheezing. States she feels that it is difficult
to get air into her lungs. Denies fevers. Currently, she is
also on day 9 of prednisone 30mg qd but still not improving.
For the last 12 days, she has been using her albuterol inh ___
times daily, while at baseline she does not use it at all.
Given multiple episodes of bronchitis/asthma exacerbations in
the past, patient has had multiple courses of antibiotics over
the years and may have developed resistance. Patient reports
DOE not relieved by inhalers at home.
.
On arrival to the ER, vitals were T 98.6 HR 87 BP 140/83 RR 16
O2 95%ra. Labs were remarkable for WBC count of 12 (N 82.9 L
12.5), glucose 227, lactate 1.7, chem 7 wnl. Blood cultures
drawn. Chest x-ray did not demonstrate a focal consolidation
(my read). She received 1 combineb and was given Ceftazadine 1g
IV x1. Vitals prior to transfer to the floor were T 99.3, BP
153/74, HR 81, RR 18, O2 98% RA.
.
On the floor, patient states that her breathing is somewhat
improved after nebulizers.
Past Medical History:
-Asthma
-DM (poorly controlled)complicated by autonomic neuropathy and
peripheral neuropath
-HTN
-HLD
-Hypothyroidism
-Achalasia
-Adrenal insufficiency (isolated ACTH deficiency)
Social History:
___
Family History:
-mother: asthma, grave's disease,COPD
-father: asthma, dementia
Physical Exam:
Physical Exam on Admission:
.
Vitals: T:98.6 BP:118/68 P:98 R:20 O2:97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: breathing non labored, scattered wheezes R>L, no
crackles/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: CN II-XII intact. Strength ___ throughout. motor
function grossly normal
.
Physical Exam on Discharge:
.
Vitals: T:98 Tm 98.2 BP: ___ P:77 R:18 O2:97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: breathing non labored, scattered wheezes R>L, improved
from admission, no crackles/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: alert and oriented, motor function grossly normal
Pertinent Results:
Labs on Admission:
.
___ 12:10PM WBC-15.0* RBC-4.03* HGB-13.3 HCT-40.1
MCV-100* MCH-33.1* MCHC-33.2 RDW-12.7
___ 12:10PM NEUTS-82.9* LYMPHS-12.5* MONOS-4.2 EOS-0.4
BASOS-0.1
___ 12:10PM GLUCOSE-227* UREA N-30* CREAT-1.0 SODIUM-137
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
___ 12:24PM LACTATE-1.7
.
Imaging:
.
Chest x-ray:
FINDINGS: PA and lateral views of the chest were obtained. The
lungs are clear and well expanded. No focal consolidation,
effusion, or pneumothorax. Cardiomediastinal silhouette is
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
.
Labs on Discharge:
.
___ 07:35AM BLOOD WBC-18.2* RBC-3.80* Hgb-12.5 Hct-38.4
MCV-101* MCH-32.9* MCHC-32.6 RDW-13.0 Plt ___
___ 07:35AM BLOOD Glucose-169* UreaN-25* Creat-0.8 Na-137
K-5.3* Cl-101 HCO3-28 AnGap-13
___ 07:35AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.1
Brief Hospital Course:
Mrs. ___ is a ___ year old F with PMH of asthma with frequent
exacerbations, DM II, HTN, HLD, hypothyroidism who p/w 3 weeks
of productive cough, wheezing and progressive dyspnea consistent
with bronchitis and asthma exacerbation.
.
ACUTE ISSUES:
.
# Acute asthma exacerbation: Patient had productive cough x3
weeks not responsive to full course of both Avelox and Levaquin
as well as 9 days of prednisone. She continued to have
wheezing/chest tightness not relieved by inhalers at home and
had progressive dyspnea. On exam, she had scattered wheezes,
R>L. Labs did demonstrate a leukocytosis, however, patient was
on prednisone. No focal consolidation on CXR to indicate a
pneumonia. Sputum sample was not able to be produced, thus
could not send anything for culture. Patient was initially
treated with IV steroids, IV Ceftazadime, nebulizer treatments.
Given rapid improvement, it seemed unlikely that antibiotics
contributed to improvement, thus Ceftazadime was discontinued.
Blood cultures remained negative. Mrs. ___ was discharged
home on a 9 day prednisone taper (40,40,40,30,30,20,20,10,10).
She will follow up with her PCP and her pulmonologist, Dr.
___.
.
#DM II: Glucose increased to 300 on initiation of Solumedrol.
___ was following and adjusting insulin pump settings
throughout the admission.
.
#Hypertension: Patient hypertensive to 172/90 during the
hospitalization. She does have history of HTN and was
previously on HCTZ and Lisinopril. However, these medications
were causing her to be lightheaded and hypotensive and were
stopped by PCP. She checks her BP at home every other day and
it is well controlled. Was well controlled on admission. HTN
likely ___ initiation of high dose steroids. She responded well
to a low dose of hydralazine.
.
CHRONIC ISSUES:
.
#Hypothyroidism: Continued home dose of synthroid ___ qd.
.
#Adrenal insufficiency: Continued home dose of hydrocortisone
15mg qam adn 5mg qpm
.
#HLD: Continued lipitor 40mg qd.
.
#Depression: Continued Zoloft 50mg qd.
.
TRANSITIONAL ISSUES:
-Dr. ___ will arrange for patient to have a nebulizer at
home per patient's request
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled four times a day as needed for shortness of
breath or wheezing
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider: ___
-
40 mg Tablet - 1 Tablet(s) by mouth
FLUDROCORTISONE [___] - (Prescribed by Other Provider) -
0.1 mg Tablet - 1 (One) Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 to 2 sprays(s) in
each
nostril daily as needed for allergy symptoms
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - ___ puffs(s)
inhaled twice a day through a spacer then rinse mouth
HYDROCORTISONE - (Prescribed by Other Provider) - 10 mg Tablet
-
1.5 (One and a half) Tablet(s) by mouth in the AM and a half tab
in the ___
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) -
Dosage uncertain
LEVOTHYROXINE [SYNTHROID] - (Prescribed by Other Provider) -
125
mcg Tablet - 1 (One) Tablet(s) by mouth once a day
LORATADINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
METOCLOPRAMIDE - (Prescribed by Other Provider) - 10 mg Tablet
-
1 Tablet(s) by mouth three times a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
PREDNISONE - 10 mg Tablet - 4 (Four) Tablet(s) by mouth once a
day for 5days then taper as directed as needed for asthma flare
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 (One)
inhalation(s) twice a day
SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 50 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - Contents of one capsule inhaled once a day
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider;
___) - 600 mg-400 unit Tablet - 2 (Two) Tablet(s) by mouth once
a
day
GUAIFENESIN [MUCINEX] - 600 mg Tablet Extended Release - 1 (One)
Tablet(s) by mouth twice daily
NICOTINE (POLACRILEX) [NICORETTE] - (OTC) - 2 mg Gum - 1 piece
chewed as directed at each significant urge to smoke
OMEGA-3 FATTY ACIDS-FISH OIL [FISH OIL OMEGA ___ -
(Prescribed by Other Provider; OTC) - 300 mg-1,000 mg Capsule,
Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day
Discharge Medications:
1. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: ___
Sprays Nasal once a day as needed for allergies.
5. Flovent HFA 220 mcg/actuation Aerosol Sig: ___ Inhalation
twice a day.
6. hydrocortisone 10 mg Tablet Sig: 1.5 Tablets PO QAM.
7. hydrocortisone 10 mg Tablet Sig: 0.5 Tablet PO QPM.
8. Novolog Subcutaneous
9. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. loratadine 10 mg Tablet Sig: One (1) Tablet PO qd ().
11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
14. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: Two (2) Capsule PO once a day.
18. Mucinex ___ mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day as needed for cough.
19. nicotine (polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H
(every hour) as needed for urge to smoke.
20. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
21. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: Please taper predisone on this schedule:
-40mg for 2 days
-30mg for 2 days
-20mg for 2 days
-10mg for 2 days.
Disp:*20 Tablet(s)* Refills:*0*
22. Guaifenesin DAC ___ mg/5 mL Syrup Sig: One (1) PO at
bedtime as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Severe acute asthma exacerbation
Bronchitis
.
Secondary:
-Diabetes
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Adrenal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
.
It was a pleasure taking care of you during your admission to
the hospital. You came in with an asthma
exacerbation/bronchitis along with some difficulty breathing.
We treated you with intravenous steroids, antibiotics, and
nebulizer treatments. You responded well and your breathing
improved. On discharge, you should complete a prednisone taper.
The high dose steroids caused your blood sugars to be very
high. You were seen by the ___ (___) team who adjusted
the settings on your insulin pump.
.
We have made the following changes to your medications:
-START Prednisone taper: 40mg for 2 days (starting on ___
___, 30mg for 2 days, 20mg for 2 day, 10mg for 2 days and then
stop.
-START Robitussin with codeine as needed for cough at bedtime
.
Please follow up with your primary care physician, ___.
___ your pulmonologist, Dr. ___ as scheduled
(see below).
.
We wish you all the best!
Followup Instructions:
___
|
10749008-DS-20
| 10,749,008 | 22,821,143 |
DS
| 20 |
2178-05-03 00:00:00
|
2178-05-08 09:46:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
cough, fever, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of IDDM, Addison's, and asthma
presents with chief complaint of fever and dyspnea. Patient with
intermittently productive cough and chest congestion that has
not improved despite prednisone, multiple asthma medications,
including albuterol nebs at home, and courses of levofloxacin
and moxifloxacin. Four days prior to admission, Dr. ___
___ her inhalers. She was still not improved by the night
prior to admission and felt fatigued. Nevertheless, she threw a
holiday party for 75 people. This morning she woke up feeling
extremely fatigued as if "she was hit by a truck". She slept
until 4pm this afternoon when her physician husband found her
lethargic, febrile to 101, coughing and vomiting with R>L
crackles. ___ was 85. She was sent to the ED by Dr. ___.
___ the ED, initial VS: 99.2, 101, 127/57, 28, 89%/RA. She
triggered for respiratory distress. Improved with nebs. Labs
notable for WBC 17.4, nl differential, creatinine 0.8 with BUN
27, lactate 1.0. Blood and sputum culture sent. Noted to have
CXR with right pna and given levofloxacin IV. Received 125mg
solumedrol. FSBS 41 and given 1 amp D50. Insulin pump was turned
off. VS on transfer: 100.4, 101, 96/3L, 163/82.
Currently, she feels dehydrated and has a productive cough. She
set her insulin pump to resume ___ monitoring at midnight.
ROS:
+Per HPI, vomiting after coughing - not new
-Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Asthma
-DM (poorly controlled)complicated by autonomic neuropathy and
peripheral neuropath
-HTN
-HLD
-Hypothyroidism
-Achalasia
-Adrenal insufficiency (isolated ACTH deficiency)
Social History:
___
Family History:
-mother: asthma, grave's disease,COPD
-father: asthma, dementia
Physical Exam:
Physical Exam on Admission:
VS - 98.5 154/77 88 22 96% on 3L 155.2lbs FS210
GENERAL - ill-appearing female ___ NAD, uncomfortable,
appropriate, coughing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits, no LAD
LUNGS - right sided rhonchi, diffuse wheezes
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - bilateral excoriations with scabs on anterior shins
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Physical Exam on Discharge:
VS - Tm 98.7 BP 144-163/63-81 HR ___ RR 18 99 on RA
GENERAL - NAD, comfortable, appropriate,
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits, no LAD
LUNGS - right sided rhonchi, several scattered wheezes
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - bilateral excoriations with scabs on anterior shins
NEURO - awake, A&Ox3
Pertinent Results:
Labs on Admission:
___ 06:20PM WBC-17.4* RBC-3.59* HGB-12.1 HCT-36.3
MCV-101* MCH-33.8* MCHC-33.4 RDW-13.2
___ 06:20PM NEUTS-69.6 ___ MONOS-4.9 EOS-1.6
BASOS-0.5
___ 06:20PM GLUCOSE-54* UREA N-27* CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
___ 06:29PM LACTATE-1.0
___ 08:00PM URINE MUCOUS-RARE
___ 08:00PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
Microbiology:
Time Taken Not Noted ___ Date/Time: ___ 10:52 pm
URINE
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
___ 1:51 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Imaging:
FINDINGS: The heart is normal ___ size. The mediastinal and hilar
contours
appear within normal limits. There is a new focal opacity,
substantial ___
size, along the right lower lung, probably at least ___ part
involving the
right middle lobe, although the main part may be centered ___
either the right middle or lower lobe. There is no pleural
effusion or pneumothorax.
IMPRESSION: Findings consistent with pneumonia ___ the right
lower lobe, new since the recent prior examination.
Labs on Discharge:
___ 07:00AM BLOOD WBC-13.7* RBC-3.57* Hgb-11.2* Hct-34.2*
MCV-96 MCH-31.5 MCHC-32.8 RDW-13.3 Plt ___
___ 07:00AM BLOOD Glucose-262* UreaN-17 Creat-0.7 Na-138
K-4.7 Cl-102 HCO3-30 AnGap-11
Brief Hospital Course:
Mrs. ___ is a ___ yo female with history of IDDM, Addison's,
hypothyroidism, and asthma who presented with fever, cough, SOB,
and hypoxia and was found to have a right lower lobe pneumonia.
# Acute bacterial pneumonia: Patient with fever, cough, hypoxia
on admission and with an infiltrate on chest x-ray. Given
recent hospitalization, patient was treated for HCAP to cover
MRSA/pseudomonas with vancomycin/levofloxacin/cefepime. Urine
legionella was neg. Patient quickly defervesced and respiratory
status improved. On d/c, patient no longer had an O2
requirement. Sputum cultures were positive for MRSA sensitive
to doxycyline. Thus, patient was discharged on doxycycline with
instructions to complete an 8 day course of antibiotics.
# Asthma: Mild wheezing on exam. Treated with albuterol nebs,
ipratropium nebs standing. Continued outpatient singulair,
serevent, fexofenadine (instead of loratadine)and increased
glucocorticoid dosing by continuing stress dose steroids for a
full 10 days (as opposed to the usual three). Patient reported
much improved respiratory status at discharge.
# Adrenal insufficiency: At risk for adrenal insufficiency given
infectious stressor. Tripled hydrocortisone doses and
discharged patient with instructions to complete 7 day course of
stress dose steroids and then return to home dose. Continued
florinef without signs of hemodynamic instability or electrolyte
abnormalities.
# IDDM: Eratic blood sugars ___ the setting of infection. ___
was following closely. Continued insulin pump and low
carbohydrate diet.
# Hypothyrodisim: Continued levothyroxine.
# HTN: Continued lisinopril.
# HL: Continued atorvastatin.
TRANSITIONAL ISSUES:
-full code
Medications on Admission:
Lipitor 40 mg Tab daily
Singulair 10 mg Tab daily
calcium carbonate-vitamin D3 600 mg-400 unit Tab 2 daily
Novolog 100 unit/mL Sub-Q pump min 0.45, max 0.85
Spiriva with HandiHaler 18 mcg & inhalation Caps daily
Fish Oil Omega ___ 300 mg-1,000 mg Cap, Delayed Release daily
Aspirin 325 mg Tab daily
Florinef 0.1 mg Tab daily
albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb Solution up to aid
ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 puffs qid prn sob
lisinopril 10 mg Tab daily
hydrocortisone 10 mg Tab 1.5qAM, 0.5qPM
Mucinex ___ mg Tab bid prn
Synthroid ___ mcg Tab daily
sertraline 50 mg Tab daily
Nicorette 2 mg Gum prn
Loratadine 10 mg Tab daily
Flovent HFA 220 mcg/Actuation Aerosol Inhaler ___ puffs(s) inh
bid
Serevent Diskus 50 mcg/Dose for Inhalation bid
Discharge Medications:
1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: Two (2) Capsule PO once a day.
4. novolog 100u/mL Sub-Q pump min 0.45, max 0.85 Sig: One (1)
as per glucose.
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
6. Fish Oil Omega ___ 300-1,000 mg Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
once a day.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every ___ hours as needed
for shortness of breath or wheezing.
10. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath
or wheezing.
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Mucinex ___ mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day as needed for cough.
13. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Nicorette 2 mg Gum Sig: One (1) Buccal five times a day as
needed for desire to smoke.
16. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Flovent HFA 220 mcg/actuation Aerosol Sig: ___ Inhalation
twice a day.
18. Serevent Diskus 50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
19. hydrocortisone 10 mg Tablet Sig: 4.5 tabs ___ am, 1.5 tabs ___
pm Tablets PO twice a day for 4 days: -take 45mg (4.5 tabs) ___
the morning
-take 15mg (1.5 tabs) ___ the evening
-resume your usual dose (15mg ___ the morning, 5mg ___ the
evening).
Disp:*24 Tablet(s)* Refills:*0*
20. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia
Asthma exacerbation
Secondary:
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
.
It was a pleasure taking care of you during you admission to
___. You came ___ with a
productive cough and shortness of breath and found to have
pneumonia. The final sputum culture showed that you have MRSA.
We treated you with antibiotics for the infection. We also
increased the dose of your steroids. For symptom control, we
treated you with nebulizer treatments. On discharge, you will
take an antibiotic, Linezolid, which treats MRSA.
.
During the admission, we increased your dose of steroids. The
___ consult team saw you to adjust your insulin pump
settings.
.
We have made the following changes to your medications:
-START Doxycycline 100mg twice per day for 4 days
-INCREASE Hydrocortisone from 15mg ___ the morning to 45mg ___ the
morning for 4 days, and then resume normal home dose (resume
home dose on ___
-INCREASE Hydrocortisone from 5mg ___ the evening to 15mg ___ the
evening for 4 days as above
.
On discharge, please follow up with Dr. ___ as scheduled
below.
.
We wish you all the best and happy holidays!
Followup Instructions:
___
|
10749008-DS-21
| 10,749,008 | 29,184,435 |
DS
| 21 |
2178-06-28 00:00:00
|
2178-06-30 09:24:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Cough, Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with h/o adrenal insufficiency, asthma, HTN
and recent admission for MRSA PNA who presents with cough and
SOB. Patient was recently admited to ___ with RLL pneumonia,
she had MRSA growth in sputum; she was discharged on ___
with PO doxcyllin which was then changed by her pulmonologist
Dr. ___ to PO ___ of which she completed a two week
course. Since her discharge patient has been experiencing some
residual DOE but otherwise has been feeling well until 2 days
ago when developed subjective fever, chills, resting dyspnea,
wheezing and cough, productive but unable to produce sputum.
Pt's husband is a physician and he arranged for out patient work
up at ___ last night showing WBC of 31k and CXR also at
___ showed LLL infiltrate that's new compared with CXR from
late ___.
.
Patient denied recent sick contacts. No pets. No travel. No
other exposures. Did not recall any aspiration eposides.
.
Of note patient has esophageal achalasia with esophagus filled
with fluid on recent CT chest which also showed diffuse
peribronchial ground-glass opacities in all lobes of unknown
chronicity and mediastinal lymphadenopathy which is probably
reactive. Per CT report the combination of these findings may be
due to aspiration, chronic eosinophilic pneumonia, cryptogenic
pneumonia, or, least likely multifocal bronchioalveolar
carcinoma.
.
Pt is on hydrocortizone 15mg and 5mg daily for her asthma. Also
recently had laryngoscopy for work up of hoarsness which
demonstarted laryngeal thrush consistent with acute fungal
infections of the vocal cord. Patient's inhaled steroids were
held and she was started on Diflucan. She's also awaiting
surgery on ___ for rotator cuff injury.
Past Medical History:
-Asthma
-DM (poorly controlled) complicated by autonomic neuropathy and
peripheral neuropath
-Achalasia
-HTN
-HLD
-Hypothyroidism
-Adrenal insufficiency (isolated ACTH deficiency)
-Depression
Social History:
___
Family History:
-mother: asthma, grave's disease,COPD
-father: asthma, dementia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 99.5 F, BP 170/90 , HR 86 , R 20 , 95% O2-sat % 2L,
92% on RA
GENERAL - patient mildly tachypnic and dyspneic while lying in
bed but she is able to finish sentences. Coughs often.
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - some diffuse bronchial breath sounds, no focal
crepitations are heard, no wheezing, good air movement
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS: T 98.3 HR ___ BP ___ RR 18 SPO2 96%RA
GEN: Sleeping in bed with head elevated 45 deg, alert and
oriented, comfortable, talking in whole sentences without
difficulty, NAD.
CV: RRR, normal S1,S2. No murmur, rubs, or gallops.
PULM: Good air movement throughout. Quiet crackles at L base and
mid-lung, otherwise no adventitious lung sounds.
ABD: +BS. Soft, nontender. Mildy distended, no masses.
EXT: ___ warm and well perfused, mild edema if feet bilaterally.
2+ DP pulses bilaterally.
NEURO: Mental status grossly intact.
Pertinent Results:
___ 10:30PM BLOOD WBC-26.5*# RBC-3.76* Hgb-12.6 Hct-37.9
MCV-101* MCH-33.4* MCHC-33.1 RDW-14.5 Plt ___
___ 08:28AM BLOOD WBC-23.6* RBC-3.78* Hgb-12.2 Hct-37.7
MCV-100* MCH-32.2* MCHC-32.2 RDW-14.7 Plt ___
___ 04:35AM BLOOD WBC-20.0* RBC-3.48* Hgb-11.2* Hct-34.5*
MCV-99* MCH-32.3* MCHC-32.5 RDW-14.6 Plt ___
___ 05:55AM BLOOD WBC-21.6* RBC-3.61* Hgb-11.5* Hct-36.2
MCV-100* MCH-31.9 MCHC-31.8 RDW-14.7 Plt ___
___ 06:27AM BLOOD WBC-17.0* RBC-3.45* Hgb-11.3* Hct-34.0*
MCV-99* MCH-32.7* MCHC-33.2 RDW-14.4 Plt ___
___ 04:53AM BLOOD WBC-16.5* RBC-3.43* Hgb-11.2* Hct-33.8*
MCV-99* MCH-32.5* MCHC-33.0 RDW-14.3 Plt ___
___ 10:30PM BLOOD Neuts-91.8* Lymphs-5.2* Monos-2.3 Eos-0.6
Baso-0.2
___ 10:30PM BLOOD Glucose-196* UreaN-26* Creat-0.7 Na-136
K-5.2* Cl-96 HCO3-23 AnGap-22*
___ 05:00AM BLOOD Glucose-246* UreaN-21* Creat-1.0 Na-137
K-5.1 Cl-99 HCO3-28 AnGap-15
___ 05:55AM BLOOD Glucose-198* UreaN-21* Creat-0.8 Na-134
K-5.1 Cl-99 HCO3-25 AnGap-15
___ 08:28AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.6
___ 04:35AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9
___ 08:28AM BLOOD Vanco-33.0*
___ 01:40PM BLOOD Vanco-14.6
___ 10:47PM BLOOD Lactate-4.0*
___ 06:35AM BLOOD Lactate-2.0
IMAGING STUDIES:
CXR (___): IMPRESSION: Rapidly evolving multifocal areas of
consolidation, one of which has a discretely round configuration
in the left mid lung area. Observed findings are suggestive of a
multilobar pneumonia; cryptogenic organizing pneumonia is also
possible. Follow up chest radiographs are recommended to
document resolution following appropriate therapy.
CHEST CT (___):
IMPRESSION:
1. Multifocal bilateral ground-glass opacities have progressed
and in
combination with lower lobar bronchiectasis and significant
fluid within the esophagus are consistent with sequalae of
aspiration.
2. New small consolidations in both lower lobes could be
aspiration
pneumonia.
3. Given the findings consistent with chronic aspiration and
fluid within the esophagus, a esophageal motility should be
considered.
4. Moderate coronary artery calcifcations of the LAD and
posterior descending artery.
5. Small non-hemorrhagic pericardial effusion.
ESOPHAGEAL BARIUM SWALLOW (___): FINDINGS: Multiple
fluoroscopic images were obtained while this patient
ingested thick barium. The distal esophagus appeared narrowed
with a bird's beak configuration. The distal two-thirds of the
esophagus were dilated and no normal peristalsis was observed.
Multiple tertiary contractions were present. The esophageal
mucosa and gastric mucosa appeared grossly unremarkable. Upon
laying the patient supine, residual esophageal barium reached
the mid cervical level.
IMPRESSION: Achalasia.
Brief Hospital Course:
Ms. ___ is a ___ woman with h/o esophageal achalasia,
severe asthma, adrenal insufficiency, HTN and recent MRSA
pneumonia who presents with dyspnea and productive cough of two
days duration in the setting of recurrent respiratory
infections/pneumonia since ___ found to have multifocal
infiltrates on CXR and was treated for aspiration pneumonia.
.
# Multifocal pneumonia: The pt came to the hospital with fevers,
cough and SOB. Imaging of her chest was consistent with
multifocal pneumonia. Sputum cultures were positive for H.
Influenzae, and gram positive cocci in pairs an clusters. The pt
was treated for a MRSA pneumonia several weeks prior to this
admission with ___. She was treated with Vancomycin and
Levofloxacin initially and then switched to ___ and
Levofloxacin to complete a 14 day course. She clinically
improved on this regimen, remained afebrile with a decreasing
leukocytosis. She was encouraged to continue to eat and sleep
using aspiration precautions. Dr. ___ pt's out
patient pulmonologist, was consulted throughout this admission
and assisted with management decisions.
.
# Esophageal Achalasia: The pt has known esophageal achalasia.
This was felt to be the cause of her recurrent aspiration
pneumonia. Gastroenterology and surgery were consulted. It was
recommended that she have a repeat barium swallow. This study
showed persistent esophageal achalasia. Dr. ___
the pt and determined that she was a candidate for ___
myotomy which will be performed as out patient once she recovers
from her current pneumonia. We continued Omeprazole 20mg daily.
She also was placed on strict aspiration precautions and was
encouraged to continue this while at home awaiting surgery.
.
# Asthma: We continued to hold her inhaled maintenance steroid
inhalers while she is being treated for a fungal laryngitis. We
continued Prednisone 10mg daily started by Dr. ___ as an
out patient to help control the inflammation from asthma while
her inhaled steroids were being held. She did not experience an
asthma exacerbation while being hospitalized. We continued her
on nebulizers, montelukast, tiotroprium and salmeterol during
this hospitalization.
.
# Fungal Laryngitis: She was diagnosed by ENT as out pt with a
fungal laryngitis and was placed on Fluconazole for treatment.
Her inhaled steroids were being held while she was being treated
for this infection. The pt remained hoarse after completing a
week of therapy prior to this hospitalization. ENT re-evaluated
the pt and stated that on laryngoscopy it appeared that her
infection was improving. They recommended continuing Fluconazole
for a total of three weeks.
.
# DM: Patient has an insulin pump to manage her diabetes at
home. A ___ and nutrition consult were obtained and the pt
managed her insulin pump and glucose control while she was being
hospitalized.
.
# Depression: She takes Sertraline at home for depression. This
was held when ___ was started due to the known drug
interaction. The pt was instructed to ___ taking Sertraline
the day after her ___ course was finished. She showed no
active signs of depression during this hospitalization.
.
# HTN: continued lisinopril.
.
# Adrenal Insufficiency: Pt has known primary adrenal
insufficiency. We continued her outpt doses of both
fludrocortisone and hydrocortisone. She did not require stress
dose steroids. Even with the addition of 10mg of prednisone, the
pt was below the total steroid burden required to treated for
PCP ___.
.
# HLD: continued atorvastatin
.
# Hypothyroidism: continued levothyroxine
.
# Acute Kidney Injury- Cr elevated from 0.5 to 1.0 during this
admission. A vancomycin trough was obtained and was elevated.
She also had just received a CT with contrast as well.
Vancomycin was held and she was given an IV fluid bolus. Her
kidney function improved back to her baseline.
.
#Transitional- The pt was instructed to continue antibiotics for
6 more days to complete a 14 day course. She also was instructed
to continue aspiration precautions while at home. She has follow
up appointments with her PCP, ___
___ will be in contact to set up a surgery date.
Medications on Admission:
- Lipitor 40 mg daily
- Singulair 10 mg daily
- Calcium carbonate-vitamin D3 daily
- Novolog 100u/mL Sub-Q pump min 0.45, max 0.85
- Spiriva with HandiHaler 18 mcg daily
- Fish Oil Omega ___ 300-1,000 mg daily
- Aspirin 325 mg Tablet daily
- Fludrocortisone 0.1 mg daily
- Albuterol sulfate 2.5 mg /3 mL NEB Q4-6H:PRN
- ProAir HFA 2 puffs QID:PRN
- Lisinopril 5 mg daily
- Levothyroxine 125 mcg daily
- Sertraline 50 mg daily
- Nicorette 2 mg Gum 5 times daily
- Loratadine 10 mg dialy
- Flovent HFA 220 mcg/actuation Aerosol 2 puffs BID - stopped
due to fungal infection
- Serevent Diskus 50 mcg/dose Disk BID
- Hydrocortisone 15mg in the morning, 5mg in the evening
- Omeprazole 20mg daily (recently started)
- Diflucan ___ daily for total of 14 days
- celebrex ___ daily
- prednisone 10mg daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit
Tablet Sig: One (1) Tablet PO once a day.
4. Novolog 100 unit/mL Solution Sig: Sub-Q pump min 0.45, max
0.85 U Subcutaneous as directed .
5. Fish Oil Omega ___ 300-1,000 mg Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
once a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every ___ hours as needed
for shortness of breath or wheezing.
9. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Nicorette 2 mg Gum Sig: One (1) Buccal 5 times daily.
13. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
15. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
16. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
19. Celebrex ___ mg Capsule Sig: One (1) Capsule PO once a day.
20. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. ___ ___ mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
22. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*6 Tablet(s)* Refills:*0*
23. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Aspiration Pneumonia
Secondary Diagnosis:
Asthma
Esophageal Achalasia
Fungal Laryngitis
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___ was a pleasure taking care of you at ___
___. You were admitted to the hosptial with a
pneumonia. We believe the cause of this pneumonia is aspiration
from your known esophageal achalasia. We are treating your
pneumonia with antibiotics. You were also evaluated during this
hospitalization by ___ to have a surgical procedure to
hopefully fix this problem.
Please see below for changes to your medications:
STOP:
Sertraline, this medication can be restarted the day after
stopping ___
Flovent, resume this medication when told by Dr. ___
___ ___ twice per day for 6 more days
Levofloxacin 750mg daily for 6 more days
Continue diflucan for 7 more days
Please see below for follow up appointments that have been made
for you.
Followup Instructions:
___
|
10749008-DS-25
| 10,749,008 | 25,567,435 |
DS
| 25 |
2180-08-08 00:00:00
|
2180-08-12 10:27:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats / dogs / environmental
Attending: ___.
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
PICC was placed on ___ and subsequently removed on ___ when
sputum cultures grew H. Flu.
History of Present Illness:
She is a ___ female h/o DM1, Addison's on steroids,
asthma, esophageal dysmotility (w/frequent aspirations), recent
dx of MSSA PNA (treated with Keflex as outpt), distant h/o
C.diff who is being admitted for pneumonia. One week prior, her
husband and family had a viral URI. Three days prior to
admission she woke up with fatigue, bodyaches, worsening SOB.
She was febrile to 102.4 and had associated sweats and chills.
She was seen on the day prior had labs drawn white count of 16,
and a chest x-ray that showed a right lower lobe infiltrate. She
had a negative flu swab. She was given Keflex but she only took
one dose the am of admission which she believes she vomited
during an episode of post-tussive emesis. and called back today
and told to come to ___ for admission.
Of note patient had a hx of c diff colitis as well as sputum
culture that grew MRSA ___ past. She also states she missed 2
doses of her home meds.
Today, however, noted increasing wheezing, O2 sats 89% on RA
(has home oximeter) and thus came ___ to ED here for
___ the ED, initial vital signs were: 99.5 102 134/58
Tm 100.5
Labs were notable for WBC 17.5, H/H 11.3/35.2 VBG 7.37/___/32,
Lactate 1.7. CXR showing bibasilar opacities. Patient was given
Ceftriaxone, azithromycin, Flagyl, Vanc, Hydrocortisone
100mg/2mg x2, tylenol, and ibuprofen
On Transfer Vitals were: 97.6 86 144/65 3099%
Review of Systems:
(+) Fevers, chills, sweats, headache, productive cough,
shortness of breath, fatigue, myalgias
(-) Diarrhea, nausea, vomiting, URIs
Past Medical History:
LUMBAR FUSION SURGERY L3-S1 complicated by revision of
transforaminal lumbar fusion with allograft spacer and
re-instrumentation ___ ___, complicate further by
bilateral foot drop.
ACHALASIA s/p myotomy ___
ACUTE BRONCHITIS AND PNEUMONIAS h/o admissions to ICU and
intubations due to prior PNA
ADRENAL INSUFFICIENCY
ASTHMA
DEPRESSION
DIABETES MELLITUS complicated by myonecrosis HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
ORTHOSTATIC HYPOTENSION
SHOULDER SURGERY
VITAMIN B6 and B12 DEFICIENCY
Social History:
___
Family History:
No known family history of interstitial lung disease, mother
with COPD, metastatic lung cancer (+tob) and father with asthma
Physical Exam:
ADMISSION:
Vitals- 98.4 150/66 85 22 96% 4L
General: Comfortable, unable to speak full sentences,
HEENT: Clear oropharynx
Neck: supple, no JVD
CV: RRR, no m/r/g
Lungs: Tachypneic, good air movement, decreased sounds at bases,
crackles at bases, decreased tactile fremitus at bases
Abdomen: Obese, Soft, NTND
GU: no foley
Ext: no edema, 2+ radial pulses
Neuro: AAOx name, ___ FARR2, Month, Obama, b/l foot drop, able
to move all extremities
Skin: no rash/lesions
DISCHARGE:
Vitals- 98.8 96 167/68 (160-180s/70-90s) 18 97% 1L
POC: - - ___
General: Comfortable, able to speak full ___ sentences but appers
slightly out of breath when talking,
HEENT: Clear oropharynx, mmm
Neck: supple,
CV: RRR, no m/r/g
Lungs: good air movement, decreased sounds at bases, crackles at
bases, scattered wheezes
Abdomen: Obese, Soft, NTND (+) BS
GU: no foley
Ext: no edema
Neuro: Alert and conversant, b/l foot drop, able to move all
extremities.
Skin: no rash/lesions
Pertinent Results:
ADMISSION:
===========
___ 01:25PM PLT COUNT-512*
___ 01:25PM NEUTS-83.1* LYMPHS-10.3* MONOS-5.5 EOS-0.5
BASOS-0.6
___ 01:25PM WBC-17.5*# RBC-3.43* HGB-11.3* HCT-35.2*
MCV-103* MCH-32.8* MCHC-32.0 RDW-13.6
___ 01:25PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 01:25PM GLUCOSE-84 UREA N-21* CREAT-0.7 SODIUM-139
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
___ 01:42PM LACTATE-1.7
___ 01:42PM ___ PO2-34* PCO2-54* PH-7.37 TOTAL
CO2-32* BASE XS-3 COMMENTS-GREEN TOP
___ 05:35PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:08PM LACTATE-1.4
___ 07:08PM ___ PO2-72* PCO2-34* PH-7.47* TOTAL
CO2-25 BASE XS-1 COMMENTS-GREEN TOP
DISCHARGE:
===========
___ 06:00AM BLOOD WBC-11.5* RBC-3.21* Hgb-9.9* Hct-32.6*
MCV-102* MCH-30.7 MCHC-30.2* RDW-14.0 Plt ___
___ 06:00AM BLOOD Glucose-199* UreaN-17 Creat-0.5 Na-134
K-3.8 Cl-100 HCO3-27 AnGap-11
___ 06:00AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.9
___ 06:30AM BLOOD TSH-0.021*
___ 06:30AM BLOOD Vanco-15.7
MICRO:
=========
___ 3:18 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
**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 for further
information.
IMAGING:
=========
Chest XRAY ___
Bibasilar opacities progressed since yesterday's exam with more
dense consolidation at the right lung base, worrisome for
pneumonia.
Increased interstitial opacities extending more superiorly ___
the lungs, which could also represent a component of infection
as well. Recommend repeat after treatment to document
resolution
Brief Hospital Course:
She is a ___ female history of DM1, Addison's on
steroids, asthma, esophageal dysmotility (w/frequent
aspirations), recent dx of MSSA PNA (treated with Keflex as
outpt), distant h/o C.diff who is being admitted for pneumonia
#Pneumonia: Patient presented with cough, Dyspnea, fevers found
to have bibasilar opacities that have progressess since ___
imaging. Patient has history of MRSA pneumonia. Flu swab was
negative at PCP's. Respiratory Viral swab was negative here. She
received IV steroids ___ the ED and then was downtitrated to 20mg
Prednisone. She was started on Vancomycin and Cefepime which was
then transitioned to Levaquin when her sputum grew back H.
Influenzae. Her respiratory status improved and she was
discharged with prednisone 20mg and levaquin with scheduled
follow up with her PCP.
#Asthma: Patient has long listory of asthma flares exacerbated
by PNA including prior intubation during these episodes. She was
given prednisone 20mg, continued on her home maintainece
inhalers as well as standing nebulizers. Her oxygen requirements
improved and she was discharged home.
#Adrenal insufficiency: Patient has history of Addison's disease
requring supplemental steroid dosing. Continued Florinef and
hydrocortisone
#Diabetes: Patient has history of DM currently on insulin pump.
Her glucose was elevated during admission and her continuous
glucose monitoring was inaccurate with readings. ___ was
consulted and assisted ___ re-education regarding patient's
insulin pump as it appears she was not managing it correctly.
She briefly required being on a sliding scale with lantus but
was transitioned back to her insulin pump before discharge.
#Hypothyroid: Continued synthroid
#Hypertension: Continued lisinopril
#Depression: Continued Sertraline
# Code: FULL
# Emergency Contact: ___ Husband
**TRANSITIONAL ISSUES**
-continue prednisone 20mg daily through ___ and taper thereafter
as indicated
-continue levofloxacin 750mg daily through ___
-f/u blood sugars ___ the setting of insulin pump changes
-trend BPs and obtain chem7 at PCP appointment with new increase
___ lisinopril to 20mg daily
-TSH was found to be low; please adjust levothyroxine
accordingly
-repeat chest X ray ___ 6 weeks to confirm resolution of
pneumonia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
4. Hydrocortisone 15 mg PO QAM
5. Hydrocortisone 5 mg PO QPM
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q4-6H
7. Levothyroxine Sodium 175 mcg PO DAYS (___)
8. Levothyroxine Sodium 350 mcg PO DAYS (___)
9. Lisinopril 10 mg PO DAILY
10. Metoclopramide 5 mg PO QIDACHS
11. Montelukast 10 mg PO DAILY
12. PredniSONE Dose is Unknown PO DAILY
13. Ranitidine 150 mg PO BID
14. salmeterol 50 mcg/dose inhalation BID
15. Sertraline 50 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. travoprost 0.004 % ophthalmic daily
18. Aspirin 81 mg PO DAILY
19. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
daily
20. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 packet nasal daily
21. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Hydrocortisone 15 mg PO QAM
4. Hydrocortisone 5 mg PO QPM
5. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 4am: .6 Units/Hr
4a - 7a: .75 Units/Hr
7a - 11a: .7 Units/Hr
11a - 2p: .9 Units/Hr
2p - 9p: .95 Units/Hr
9p - 11:30p: .75 Units/Hr
11:30p - MN: .7 Units/Hr
Meal Bolus Rates:
Breakfast = 1:8
Lunch = 1:8
Dinner = 1:9
High Bolus:
Correction Factor = 1:
Correct To ___ mg/dL
6. Levothyroxine Sodium 175 mcg PO DAYS (___)
7. Levothyroxine Sodium 350 mcg PO DAYS (___)
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Metoclopramide 5 mg PO QIDACHS
10. Montelukast 10 mg PO DAILY
11. PredniSONE 20 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
12. Ranitidine 150 mg PO BID
13. Sertraline 50 mg PO DAILY
14. travoprost 0.004 % ophthalmic daily
15. Tiotropium Bromide 1 CAP IH DAILY
16. salmeterol 50 mcg/dose inhalation BID
17. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 packet nasal daily
18. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q4-6H
19. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
20. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
daily
21. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob
22. Levofloxacin 750 mg PO DAILY
last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
23. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet extended release(s) by mouth
twice a day Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Discharge Worksheet-Discharge
___, MD on ___ @ 1559
Primary Diagnosis:
Community Acquired Pneumonia
Asthma
Type 1 Diabetes Mellitus
Secondary Diagnosis:
Addison's
Hypothyroidism
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 during your admission at
___. You came to the hospital because of shortness of breath,
fever, and cough. You were found to have pneumonia. You were
treated with antibiotics and steroids, and your symptoms
improved. You should continue your antibiotics through ___
and continue 20mg prednisone daily until your appointment with
Dr. ___ on ___. He will decide whether to taper down to
10mg or continue 20mg daily.
While you were here you were seen by ___ who made some
changes to your pump. They would like you to call ___
___ on ___ at the ___ to relay your
blood sugar readings by phone. They will adjust your pump
settings thereafter.
Please follow up at your appointments below.
Followup Instructions:
___
|
10749008-DS-26
| 10,749,008 | 25,069,295 |
DS
| 26 |
2180-12-25 00:00:00
|
2180-12-28 00:17:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats / dogs / environmental / levofloxacin / Bactrim
Attending: ___
Chief Complaint:
Elective metatarsal resection for osteomyelitis
Cough
Major Surgical or Invasive Procedure:
Resection of ___ metatarsal head, right foot: ___
History of Present Illness:
___ year old woman with a history of bilateral foot drop,
diabetes I on insulin pump, achalasia, adrenal insufficiency,
asthma, chronic ulcerations, who presents for scheduled ___
metatarsal head resection on ___, after she was
found to have osteomyelitis. On the night of admission she was
noted to have a cough with sputum productiona and CXR revealed
multifocal pneumonia. Notably, she was also found to have
hyponatremia and hyperkalemia, the latter without resultant EKG
changes and intially treated in the ED. Of note, she presented
with blood sugar of 27, was taken off of her insulin pump, and
started on a sliding scale. She is now being transferred to
medicine from the podiatry service for further management of
pneumonia and insulin dependent diabetes. Podiatry will continue
to follow.
Past Medical History:
DM type I c/b myonecrosis
HTN
HLD
asthma
acute bronchitis and pneumonias
hypothyroidism
adrenal insufficiency
asthma
depression
lumbar Fusion L3-S1
Social History:
___
Family History:
No known family history of interstitial lung disease, mother
with COPD, metastatic lung cancer (+tob) and father with asthma
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Tmax 98.6 121-156/50-64 ___ >95%/RA
General: NAD, AOx4, pleasantly conversant
HEENT: NCAT, PERRL, anicteric sclerae, MMM, good dentition
Neck: Supple, no LAD
CV: RRR, nl S1/S2, no m/r/g
Lungs: Diffuse crackles, good air movement
Abdomen: Soft, NT/ND. NABS
Ext: Plantar ___ met ulceration with surrounding erythema, no
drainage. Palpable ___ pulses.
Neuro: Grossly nonfocal
DISCHARGE PHYSICAL EXAM:
VS - Tmax 98.6 120s-150s/70s-90s 70-90s >95%/RA
General: NAD, AOx4, pleasantly conversant
HEENT: NCAT, PERRL, anicteric sclerae, MMM, good dentition
Neck: Supple, no LAD
CV: RRR, nl S1/S2, no m/r/g
Lungs: Expiratory wheezes diffusely with good air movement. Soft
crackles at bilateral bases.
Abdomen: Soft, NT/ND. NABS
Ext: Plantar ___ met ulceration with surrounding erythema, no
drainage. Palpable ___ pulses.
Neuro: Grossly nonfocal
Pertinent Results:
ADMISSION LABS:
===========
___ 08:30PM BLOOD WBC-15.8* RBC-3.69* Hgb-11.1* Hct-37.0
MCV-100* MCH-30.0 MCHC-29.9* RDW-14.3 Plt ___
___ 08:30PM BLOOD Neuts-82.5* Lymphs-11.4* Monos-4.9
Eos-0.7 Baso-0.5
___ 09:07AM BLOOD ___ PTT-36.1 ___
___ 08:30PM BLOOD Glucose-115* UreaN-20 Creat-1.0 Na-130*
K-5.6* Cl-93* HCO3-26 AnGap-17
___ 08:48PM BLOOD Lactate-2.7*
___ 12:54AM BLOOD Lactate-2.1*
DISCHARGE LABS:
===========
___ 07:45AM BLOOD WBC-8.5 RBC-3.57* Hgb-10.9* Hct-34.9*
MCV-98 MCH-30.4 MCHC-31.1 RDW-14.6 Plt ___
___ 07:45AM BLOOD Glucose-284* UreaN-14 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-26 AnGap-16
___ 07:45AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.8
MICROBIOLOGY:
==========
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
IMAGING:
======
CXR ___
IMPRESSION: Findings suggesting multifocal pneumonia in the
left lung. Small
suspected calcified nodule in the right lung, not significantly
changed.
Foot XR ___
IMPRESSION:
Soft tissue defect overlying the right fifth metatarsal head. No
subjacent
osseous erosion.
Brief Hospital Course:
___ with type 1 diabetes mellitus, asthma, and recurrent
pneumonia who was admitted for elective metatarsal resection for
osteomyelitis and was found to have community-acquired pneumonia
prior to procedure.
#Community-acquired pneumonia: She was treated empirically with
vancomycin and piperacillin-tazobactam for both
community-acquired pneumonia and osteomyelitis coverage for a
total of 6 days, with symptomatic improvement, downtrending WBC
count and normalized lactate.
#right foot Osteomyelitis: She was treated empirically with
vancomycin and piperacillin-tazobactam for both CAP and
osteomyelitis coverage. On ___, she underwent resection of
her right ___ metatarsal head without complications. Culture
data and pathology are pending at the time of discharge, but
preliminary swab from the osteomyelitic site showed MSSA. She
was discharged on amoxicillin-clavulanate for both
community-acquired pneumonia and osteomyelitis coverage to
complete a 10-day course. She will follow up in ___ clinic
within a week after discharge.
#Diabetes mellitus type 1: At admission, Mrs. ___ also had an
episode of hypoglycemia to 27 and her insulin pump was stopped
in favor of sliding scale Humalog. ___ endocrinologists were
consulted and successfully restarted her insulin pump with
appropriate adjustments in the setting of infection and
podiatric procedure, and her blood sugars were in the 110s-270s
range by day of discharge.
CHRONIC ISSUES
===========
#Asthma
- Continued home inhalers
#Hypothyroidism
- Continued levothyroxine
#HTN
- Continued lisinopril
#Adrenal insufficiency
- Continued fludrocortisone and hydrocortisone
#Achalasia/esophageal dysmotility
- Continued metoclopramide and ranitidine
#Depression
- Continued sertraline and trazodone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Hydrocortisone 15 mg PO QAM
4. Hydrocortisone 5 mg PO QPM
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoclopramide 5 mg PO TWICE DAILY, WITH DINNER AND AT
BEDTIME
8. Montelukast 10 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Sertraline 50 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. salmeterol 50 mcg/dose inhalation BID
13. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 packet nasal daily
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob
15. Guaifenesin ER 600 mg PO DAILY AT 1800
16. estradiol 0.01 % (0.1 mg/gram) vaginal qhs
17. Flovent HFA (fluticasone) 220 mcg/actuation inhalation bid
18. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
19. mucus clearing device miscellaneous tid
20. travoprost 0.004 % ophthalmic daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob
2. estradiol 0.01 % (0.1 mg/gram) vaginal qhs
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. Guaifenesin ER 600 mg PO DAILY AT 1800
5. Hydrocortisone 15 mg PO QAM
6. Hydrocortisone 5 mg PO QPM
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Metoclopramide 5 mg PO TWICE DAILY, WITH DINNER AND AT
BEDTIME
10. Montelukast 10 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Sertraline 50 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Flovent HFA (fluticasone) 220 mcg/actuation inhalation bid
15. Aspirin 81 mg PO DAILY
16. mucus clearing device 0 MISCELLANEOUS TID
17. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 packet nasal daily
18. salmeterol 50 mcg/dose inhalation BID
19. travoprost 0.004 % ophthalmic daily
20. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 3 AM: .55 Units/Hr
3 AM - 6:30 AM: .6 Units/Hr
6:30 AM - 10 AM: .6 Units/Hr
10 AM - 11 AM: .7 Units/Hr
11 AM - 2 ___: .95 Units/Hr
2 ___ - 9 ___: .9 Units/Hr
9 ___ - 11:30 ___: .7 Units/Hr
11:30 ___ - ___ MN: .65 Units/Hr
Meal Bolus Rates:
Breakfast = 1:8
Lunch = 1:8
Dinner = 1:8
High Bolus:
Correction Factor = 1:50
Correct To ___ mg/dL
MD has completed competency
21. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
___ to ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Community-acquired pneumonia, right foot osteomyelitis
SECONDARY: Diabetes mellitus type 1, Asthma, Hypertension,
Hypothyroidism, Adrenal Insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(orthotic device).
Discharge Instructions:
Dear ___,
___ were admitted to ___ for elective resection of
osteomyelitis of your right foot. ___ developed pneumonia prior
to your surgery, and we treated ___ with IV antibiotics for both
your pneumonia and your osteomyelitis. Given that blood sugar
can be unpredictable during infection and surgery, we monitored
your blood sugar closely and adjusted your insulin pump use
accordingly with the help of endocrinologists from ___
___.
Your pneumonia symptoms improved, and ___ were able to undergo
the podiatry procedure successfully without complications. ___
were discharged on an oral antibiotic, Augmentin, to complete a
10-day course. Please also follow up with your doctors as
detailed below.
Thank ___ for allowing us to participate in your care.
Followup Instructions:
___
|
10749008-DS-30
| 10,749,008 | 27,752,670 |
DS
| 30 |
2183-11-21 00:00:00
|
2183-11-21 15:50:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats / dogs / environmental / Cipro / Bactrim / Levaquin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with hx of T1DM c/b diabetic retinopathy, bilateral
foot
drop, esophageal dysmotility with recurrent aspiration
pneumonias
presenting with progressive SOB x2 days. She reports that she
was
staying at their ___ cabin for a week prior to admission,
returning on ___ she believes that the mold/mildew at the
cabin triggered her breathing and cough. The cough feels wet,
but
she has been unable to mobilize her secretions. She did have an
episode of emesis on the morning of admission, by which time her
breathing had already become labored. She denies chest pain, but
with temp as high as 103 at home. She is unaware of having had
any sick contacts, although she has spent time around young kids
in the preceding two weeks. She does endorse a headache which
bitemporal, unrelieved by Tylenol, dull, aching, ___, without
meningismus. The ___ cabin is in ___. She is not
aware of having been exposed to ticks, and does not spend time
in
the woods. She endorses chronic intermittent edema of RLE since
an ankle fracture. She sleeps at 80 degrees overnight, in an
adjustable bed, which is chronic, and is for "asthma, reflux,
and
many cases of aspiration pneumonia." Pt's husband is apparently
MD, and administered ceftriaxone 1 gm IM x1 prior to
presentation. Pt denies dysuria, abdominal pain.
Pt's husband subsequently arrives and reports that pt had
episode
of hypoglycemia on ___ at 2:30 am, prior to onset of her
symptoms of dyspnea. He awoke and noted her to be "comatose,"
checked her BS, found it to be 21. She was subsequently
apparently awake enough to take orange juice, with recovery of
her BS. He reports that, over the past ___ years, he has had to
give her IV dextrose on "half a dozen" occasions. He wonders if
this is the event that led to aspiration. Pt was apparently
previously on insulin pump, and now on basal/bolus. They believe
that her most recent hypoglycemic episode was due to
overcorrection - she typically has very high BS after ___
food, and may have overcorrected after eating ___ food the
previous night.
In the ___ ED:
VS 101.8, 105, 123/52, 83% RA->96% 3L
Bilateral rales, tachypnea, subsequently without respiratory
distress
Labs notable for WBC 14.7, Hb 10.5, Plt 447, BUN 23, Cr 1.1,
Lactate 1.8, VBG 7.40/46, BNP 968
CXR with bilateral LL pna
Received nebs, Tylenol, azithromycin, vancomycin, insulin,
methylpred, IVF
On arrival to the floor, she continues to report headache, ___,
still having trouble catching her breath.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
PMH:
- Asthma.
- Abnormal GI motility with food and fluid filled esophagus.
- Recurrent aspiration pneumonia with resistant organisms,
likely due to problem 2.
- Bronchiectasis in bilateral lower lobes, likely due to
recurrent aspiration pneumonia.
- T1DM (last A1C 8.2) previously on insulin pump, no longer.
- Depression.
- Adrenal insufficiency.
- Hyperlipidemia
- Hypothyroidism.
- Bilateral foot drop secondary to lumbar fusion.
- Past history of alcoholic hepatitis - pt does not recall this
Social History:
___
Family History:
No known family history of interstitial lung disease, mother
with COPD, metastatic lung cancer (+tob) and father with asthma.
Physical Exam:
Admission
Physical Exam:
VS: 98.3 PO 154 / 72 88 94 RA RR is 28 measured by me, without
accessory muscle use
GEN: alert and interactive, cushingoid, comfortable, no acute
distress, speaking in 1 word sentences
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic
murmur,
no rubs or gallops
LUNGS: bibasilar rhonchi with diffuse expiratory wheeze
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: trace bilateral pitting edema, R slightly >L
GU: no foley
SKIN: diffuse excoriations distributed over UE and ___
bilaterally
NEURO: cranial nerves II-XII intact, strength ___
in UE bilaterally, diminished L dorsiflexion and plantar
flexion,
___, gait deferred, no tremor or pronator drift
PSYCH: normal mood and affect
Discharge exam:
Vitals: Afebrile, P 80-90, SBPs 160s. 97 on RA
Gen: Sitting upright in bed, appears well, breathing comfortably
on room air
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Bibasilar inspiratory crackles, but much improved
from
yesterday. no egophony, clearing upper lung fields, no rhonchi
or
wheezing.
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 11:00AM TYPE-ART PO2-24* PCO2-46* PH-7.40 TOTAL
CO2-30 BASE XS-1
___ 10:56AM LACTATE-1.8
___ 10:45AM GLUCOSE-74 UREA N-23* CREAT-1.1 SODIUM-139
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-23*
___ 10:45AM estGFR-Using this
___ 10:45AM proBNP-968*
___ 10:45AM WBC-14.7* RBC-3.83*# HGB-10.5* HCT-34.2
MCV-89 MCH-27.4 MCHC-30.7* RDW-17.4* RDWSD-56.8*
___ 10:45AM NEUTS-78.4* LYMPHS-12.1* MONOS-5.5 EOS-3.1
BASOS-0.5 IM ___ AbsNeut-11.53* AbsLymp-1.78 AbsMono-0.81*
AbsEos-0.46 AbsBaso-0.08
___ 10:45AM PLT COUNT-447*
BCx x2: NGTD
Sputum: NG
CXR: bil. lower lobe PNA
Brief Hospital Course:
Very pleasant ___ female with type 1 diabetes
complicated by diabetic retinopathy, bilateral footdrop,
esophageal dysmotility, recurrent aspiration pneumonia, labile
blood sugars, admitted with dyspnea, cough, low oxygen
saturations, and fever to 103 at home.
#Aspiration pneumonia: Her symptoms were felt to be due to
recurrent aspiration pneumonia, given her fever, high white
count and findings on chest x-ray. On the day her symptoms
started she had been hypoglycemic to 21, and her husband thinks
she may have had an aspiration event at that time. On admission
she was placed on IV ceftriaxone/azithromycin, and experienced
rapid improvement in her overall condition. She was weaned off
oxygen completely on hospital day 1. All cultures were
negative. She was eventually narrowed to IV ceftriaxone
monotherapy, as atypical pneumonia was felt to be unlikely given
the clinical history. White blood count initially rose from
14.7-20.9, though this may have been a side effect of increasing
her steroids, as the white count dropped to 13.9 the following
day. By ___ she was nearly back to baseline, ambulating off
oxygen, and was cleared for discharge home. Given her rapid
overall improvement, he will be treated with a shortened 5 day
course of antibiotics total, and will complete 3 more days of
p.o. Cefpodoxime on discharge.
#Diabetes: As noted above, patient had an episode of
hypoglycemia to 21 early in the morning when her symptoms
started. ___ was consulted, and recommended an
adjustment/decrease to her bedtime sliding scale, essentially to
where she would only get insulin for BG is greater than 200.
Her Lantus 10 units every morning and 5 units q. at bedtime was
kept the same. Her blood sugars remained well-controlled during
her stay on this regimen, and she will follow-up closely with
her endocrinologist Dr. ___ on ___, 3 days after
discharge.
#Adrenal insufficiency: On admission she was briefly placed on a
stress dose of her prednisone, increased from 2.5 mg to 20 mg
daily. She was never hypotensive nor did she exhibit any signs
of adrenal insufficiency during her stay, so on discharge she
will resume her home dose of 2.5 mg of prednisone and PTA dose
of Hydrocortisone.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. GuaiFENesin ER 600 mg PO DAILY
6. Hydrocortisone 20 mg PO QAM
7. Hydrocortisone 10 mg PO QPM
8. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
9. Levothyroxine Sodium 87.5 mcg PO 1X/WEEK (___)
10. Metoclopramide 5 mg PO BID
11. Montelukast 10 mg PO DAILY
12. PredniSONE 2.5 mg PO DAILY
13. Ranitidine 150 mg PO BID
14. mucus clearing device 1 use miscellaneous TID
15. Budesonide 0.25 mg/2 mL inhalation BID
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
17. acetylcysteine 100 mg/mL (10 %) miscellaneous BID:PRN
18. prasterone (dhea) 50 mg oral DAILY
19. travoprost 0.004 % ophthalmic DAILY
20. TraMADol 25 mg PO Q6H:PRN pain
21. BuPROPion (Sustained Release) 200 mg PO QAM
22. Sertraline 150 mg PO QHS
23. Glargine 10 Units Breakfast
Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
2. Glargine 10 Units Breakfast
Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. acetylcysteine 100 mg/mL (10 %) miscellaneous BID:PRN
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Budesonide 0.25 mg/2 mL inhalation BID
9. BuPROPion (Sustained Release) 200 mg PO QAM
10. Fludrocortisone Acetate 0.1 mg PO DAILY
11. GuaiFENesin ER 600 mg PO DAILY
12. Hydrocortisone 20 mg PO QAM
13. Hydrocortisone 10 mg PO QPM
14. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
15. Levothyroxine Sodium 87.5 mcg PO 1X/WEEK (___)
16. Metoclopramide 5 mg PO BID
17. Montelukast 10 mg PO DAILY
18. mucus clearing device 1 use miscellaneous TID
19. prasterone (dhea) 50 mg oral DAILY
20. PredniSONE 2.5 mg PO DAILY
21. Ranitidine 150 mg PO BID
22. Sertraline 150 mg PO QHS
23. TraMADol 25 mg PO Q6H:PRN pain
24. travoprost 0.004 % ophthalmic DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration Pneumonia
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with an episode of aspiration pneumonia. you
improved with IV antibiotic treatment, and were cleared for
discharge on ___. Your instructions are as follows:
- Continue PO Cefpodoxime (an oral antibiotic) for 3 more days
(5 days total)
- Continue Lantus 10 units sc qAM and 5 units sc qPM
- Change Humalog BREAKFAST scale (increase by 1 unit) to the
following: 101-150: 2 units, 151-200: 4 units, 201-250: 6 units
- Keep the same lunch and dinner Humalog scales for now
- Change the bedtime sliding scale to the following:
71-200: 0 units, 201-250: 2 units, 251-300: 3 units, 301-350: 4
units, 351-400: 5 units
- Check BG fasting, 3AM, premeal, and bedtime
Followup Instructions:
___
|
10749160-DS-16
| 10,749,160 | 26,522,930 |
DS
| 16 |
2140-04-11 00:00:00
|
2140-04-11 21:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ p/w 24 hours of epigastric pain. Pain started last night,
sharp, continuous, non-radiating. Pain associated with nausea
and vomiting. Last BM two days ago, no flatus since symptoms
started. Endorses abd distention. Denies fevers, chills, chest
pain, shortness of breath, BRBPR, dysuria, or hematuria. Had a
similar episode one year ago that resolved conservatively.
Past Medical History:
PMH: GERD, H pylori, migraines, varicose veins
PSH: tubal ligation, cholecystectomy, cataract surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission:
==========
VITALS: 98.8 66 113/72 16 97RA
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, distended, TTP along lower abd, no rebound or
guarding, no palpable masses or hernias, well healed surgical
incisions
Ext: No ___ edema, ___ warm and well perfused
Discharge:
==========
Vitals:
General: NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
Pulm: No difficulty breathing, lungs clear to auscultation
bilaterally
Abdomen: soft, nondistended, minimally TTP in the epigastric
region, no rebound or guarding, no palpable masses or hernias,
well healed surgical incisions
Ext: No ___ edema, ___ warm and well perfused
Neuro: AAOx3
Psych: mood, affect appropriate
Pertinent Results:
Admission:
==========
___ 03:31PM BLOOD WBC-9.1# RBC-4.52 Hgb-14.2 Hct-42.6
MCV-94 MCH-31.4 MCHC-33.3 RDW-12.8 RDWSD-43.8 Plt ___
___ 05:55AM BLOOD ___ PTT-27.9 ___
___ 03:31PM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-139
K-4.6 Cl-99 HCO3-24 AnGap-16
___ 03:31PM BLOOD ALT-17 AST-26 AlkPhos-72 TotBili-0.6
___ 03:31PM BLOOD Lipase-30
___ 03:31PM BLOOD cTropnT-<0.01
CT Abd/Pelvis (___) Impression:
1. High-grade small bowel obstruction with acute transition
point in the
midline of the lower abdomen with distal decompression.
2. Small amount of perihepatic ascites and pelvic free fluid is
noted.
3. Patient is status post cholecystectomy with a dilated common
bile duct
measuring up to 11 mm.
Discharge:
==========
___ 07:31AM BLOOD WBC-5.5 RBC-3.52* Hgb-11.3 Hct-33.1*
MCV-94 MCH-32.1* MCHC-34.1 RDW-12.4 RDWSD-42.7 Plt ___
___ 07:31AM BLOOD Glucose-66* UreaN-15 Creat-0.8 Na-139
K-3.7 Cl-102 HCO3-17* AnGap-20*
___ 07:31AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8
Brief Hospital Course:
The patient was admitted to ___ from the ED on ___ for a
small bowel obstruction. The patient was made NPO, started on
IVF, and given an NG tube to decompress her stomach. On hospital
day 2 the patient reported passing flatus and the NG tube was
clamped for several hours. When reattached to suction, there was
no residual in the NG tube, so the NG tube was removed that
evening. On hospital day 3 the patient reported a bowel
movement, and he diet was increased to a regular diet, which she
tolerated well. On hospital day 4 the patient was deemed ready
to be discharged home.
At the time of discharge the patient was tolerating a regular
diet, voiding without issue, passing flatus and moving her
bowels, ambulating without assistance, and denying pain. The
patient was provided with the appropriate discharge and follow
up instructions, and was then discharged home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 1000 mg PO Q12H
2. Clarithromycin 500 mg PO Q12H
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO Q12H
5. Calcium Carbonate 500 mg PO DAILY
6. Vitamin E 400 UNIT PO DAILY
7. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Cyanocobalamin 250 mcg PO DAILY
2. Amoxicillin 1000 mg PO Q12H
3. Calcium Carbonate 500 mg PO DAILY
4. Clarithromycin 500 mg PO Q12H
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Omeprazole 20 mg PO Q12H
7. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted from the Emergency Department to ___
___ the morning of ___ for a small
bowel obstruction. You were given fluids, and at first food and
liquids were held, until you started passing gas. Once you
started passing gas, you were given liquids and then solids,
which you tolerated well, and are now deemed medically cleared
to be discharged home. Please read the following discharge
instructions to assist with a successful 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.
*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.
*Any change in your symptoms, or any new symptoms that concern
you.
Medications:
===========
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Activity:
=========
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. You may return to
your regular diet.
Follow Up:
==========
Please follow up with your primary care physician ___ ___ weeks.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10749160-DS-17
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| 17 |
2141-05-25 00:00:00
|
2141-06-21 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ female with PMH of gastritis,
migraines, hyperlipidemia, prior SBO managed conservatively and
PSH including lap chole, possible C-section who presented to the
ED with generalized abdominal pain since
___. It has been associated with nausea and vomiting; she
reports 2 episodes of emesis today which appeared brown and
green. At the moment she endorses only mild nausea. Last bowel
movement was on ___ morning and was yellowish and formed.
She does not think she has passed any flatus since the bowel
movement. She denies any associated fevers or chills and has no
sick contacts. Of note, she has had prior episodes of small
bowel obstruction in the past. She was admitted at ___ in
___ and improved with conservative management (please see
imaging reads from that admission below). She was also admitted
to an OSH in ___ she provides paper records of a CT
scan at that time which
were significant for a small bowel obstruction with transition
point in the lower mid abdomen. She denies any personal or
family history of IBD or GI cancers. She also denies any cough,
chest pain, shortness of breath, or dysuria. Of note, she is
___ speaking only was interviewed via ___ interpreter
this evening.
Past Medical History:
Past Medical History:
-Hyperlipidemia
-Gastritis
-Migraines
Past Surgical History:
-Laparoscopic cholecystectomy (___)
-Lower midline abdominal incision consistent with ?C-section
Social History:
___
Family History:
Negative for inflammatory bowel disease or gastrointestinal
cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T 99.4, HR 86, BP 93/52, RR 16, SpO2 99%RA
GEN: Well-nourished elderly woman sitting in stretcher in NAD.
Noted to have two episodes of belching during our interview and
exam.
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Very soft, very mildly distended, tender in all four
quadrants, more so in the LLQ and RLQ, no rebound/guarding or
other peritoneal signs, no palpable masses
Ext: No ___ edema b/l
Discharge Physical Exam:
VS: T: 98.5 PO BP: 110/73 L Sitting HR: 63 RR: 16 O2: 96% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: no respiratory distress, breathing comfortably on room air
ABD: soft, non-distended, non-tender to palpation
EXT: no edema b/l
Pertinent Results:
IMAGING:
___: CXR:
1. No acute cardiopulmonary abnormality.
2. Dilated loops of small bowel concerning for small bowel
obstruction. No free intraperitoneal air. Findings can be
better assessed with dedicated CT of the abdomen and pelvis with
intravenous contrast if needed.
___: CT Abdomen/Pelvis:
1. Multiple loops of mildly dilated fluid-filled small bowel
with gradual
caliber change in the right lower quadrant and a loop of small
bowel in the left lower quadrant demonstrating wall thickening
and edema. Findings are suggestive of partial small bowel
obstruction in the setting of an enteritis, which may be
infectious, inflammatory or ischemic in etiology.
2. Fluid-filled colon, which can be correlated for clinical
symptoms of
diarrhea.
LABS:
___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:25PM GLUCOSE-93 UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15
___ 04:25PM ALT(SGPT)-19 AST(SGOT)-27 ALK PHOS-59 TOT
BILI-1.1
___ 04:25PM LIPASE-15
___ 04:25PM ALBUMIN-3.3*
___ 02:48PM LACTATE-1.6
___ 02:45PM WBC-6.9 RBC-4.60 HGB-14.6 HCT-41.9 MCV-91
MCH-31.7 MCHC-34.8 RDW-12.4 RDWSD-40.5
___ 02:45PM NEUTS-73.8* LYMPHS-16.2* MONOS-9.6 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-5.05 AbsLymp-1.11* AbsMono-0.66
AbsEos-0.00* AbsBaso-0.02
___ 02:45PM PLT COUNT-177
___ 02:45PM ___ PTT-25.2 ___
Brief Hospital Course:
Ms. ___ is a ___ female with PMH of gastritis,
migraines, hyperlipidemia, prior SBO managed conservatively and
PSH including lap cholecystectomy, possible C-section who
presented to the ED with generalized abdominal pain since
___. CT abdomen/pelvis revealed a small bowel obstruction
within the LLQ. The patient was admitted to the Acute Care
Surgery service. Abdomen was distended, however the patient did
not have nausea/vomiting. On HD2, the patient passed flatus and
had a bowel movement. On HD3, diet was advanced to clear liquids
which she tolerated. Diet was later advanced to regular which
she tolerated and abdomen remained benign.
A plan for outpatient MRE was arranged to assess the portion of
small intestine which is prone to bowel obstruction, to
determine whether this is an inflammatory bowel process, a
mechanical surgical issue, or malignancy.
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 without any pain medication. On ___ AM, the
discharge plan was discussed with the patient and daughter with
a ___ interpreter present with understanding and agreement
verbalized. The plan was again discussed with the patient, her
husband and daughter via interpreter in the afternoon prior to
discharge. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Calcium supplements
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Good
Discharge Instructions:
Discharge Instructions: Dear Ms. ___,
You were admitted to the Acute Care Surgery Service with
abdominal pain and vomiting. You had a CT scan that was
concerning for a partial small bowel obstruction. You were given
bowel rest and intravenous fluids and your abdominal pain
improved. Your diet was gradually advanced and well tolerated.
You are now ready to be discharged home. You are scheduled to
have an outpatient MRI (enterography) to assess the portion of
small intestine which is prone to bowel obstruction. The results
of the MRI will be discussed with you at your follow-up
appointment in the Acute Care Surgery clinic.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10749769-DS-19
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| 19 |
2168-07-21 00:00:00
|
2168-07-21 19:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right hemiface and arm sensory changes
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ RH M w PMHx of DM2, chronic back
pain with RLE numbness, and R hand cellulitis with residual pain
and numbness who presents to ___ ED with several days of new R
facial drooping and numbness.
Mr. ___ reports that he noticed his symptoms after awakening
on ___ morning. He states that the evening prior he had
been at a party and had snorted cocaine. He slept in his own
bed
and in his usual position. He did not notice any symptoms when
he went to bed. However when he woke up ___ morning he
reports that his "face was twisted up" as well as "numb and
tingling". He states that over the weekend his symptoms "got a
little worse" and adds that while he did notice some slurring of
his speech on ___ morning it has gotten worse over the past
few days. He also states that he "felt like I could not chew
right" stating that he felt weak. He denies any associated
dysphasia or coughing when attempting to swallow solids or
liquids. He denies any numbness in the mouth or tongue. He
denies any changes to his taste. He denies any new visual or
auditory symptoms. His sister is a ___ and urged him to come
to the emergency department for evaluation of a possible stroke.
Mr. ___ has multiple other neurological complaints. He
states that he has had some right arm weakness and numbness
since
an episode of cellulitis this past ___. He states that he
gets intermittent sharp, shooting pains in his right hand, and
that the fingertips feel numb. He also reports numbness and
tingling of the fingertips on the left hand that has been
present
for several months.
Mr. ___ also has a history of lower back pain since his mid
___. He states that his right leg has been numb for the last ___
years. He states that he is unable to feel his right forefoot,
as well as the sole of his foot. He states "it feels like I am
walking on a bubble."
In addition, Mr. ___ has a history of chronic pain
characterized by intermittent sharp pains throughout all parts
of
his body. These have been unchanged. He also has intermittent
neck pain that has been present for years.
Review of systems is significant for new boils that Mr. ___
states have been present for the last few months. He currently
has a boil under his mouth on the left side, and states that a
boil on his left cheek just recently resolved. He also reports
nausea since ___ without any vomiting. He reports dyspnea
on exertion which has been going on for at least the last month.
He denies any cough or fevers. He denies any chest pain or
heart
palpitations. He does work in ___ and ___ and
has been outside recently. He has not noticed any bug bites or
skin changes.
Past Medical History:
DM2
HTN
HLD
back pain
Social History:
___
Family History:
Mother - deceased at age ___, colon cancer
Father - living, age ___, colon cancer
Sister - living, brain aneurysm s/p surgery
Physical Exam:
ADMISSION PHYSICAL EXAM
GEN - well appearing, well developed
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Recalls a coherent history. Transposes
___ on MOYB though corrects himself, misses ___.
Structure
of speech demonstrates fluency with full sentences, and normal
prosody. No paraphasic errors. Intact repetition, naming, and
comprehension. No evidence of apraxia or neglect.
CN - [II] PERRL 3->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] Reports marked decrement to PP and
LT
over R hemiface, ~10% of normal. Splits to vibration. [VII] Mild
R NLFF at rest, activates well. Cheek puff symmetric. [VIII]
Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. Slight lisp while speaking which wife and
patient state is new. [XI] SCM/Trapezius strength ___
bilaterally. [XII] Tongue midline with full ROM.
MOTOR - Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]
[EDB]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 4+ 5 5 5 5 5 4+
R 5 5 5 5 4+ 5 5 5 5 5 4+
Toe flexion - 4+ bilaterally
SENSORY - Reports patchy sensory loss over the RUE and RLE.
Reports "no feeling" on initial testing, though agrees when I
suggest "50%" of normal. Decrement to LT and PP over R hand
(circumferential) and distal finger tips in L hand; R lateral
leg
and R medial forefoot. Reports total loss of vibration and
proprioception at R great toe, intact at L great toe.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response flexor bilaterally.
COORD - No dysmetria with finger to nose testing. Good speed and
intact cadence with rapid alternating movements. Negative
Romberg.
GAIT - Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway.
***************
DSICHARGE PHYSICAL EXAM
As above, with exception of inconsistent sensory loss in right
lower extremity, not fitting within any clear neuroanatomic
pattern.
Pertinent Results:
LABORATORY DATA
___ 05:20AM BLOOD WBC-6.5 RBC-4.64 Hgb-14.7 Hct-43.1 MCV-93
MCH-31.7 MCHC-34.1 RDW-12.6 RDWSD-42.9 Plt ___
___ 05:20AM BLOOD Neuts-49.5 ___ Monos-9.1 Eos-2.5
Baso-0.6 Im ___ AbsNeut-3.21 AbsLymp-2.46 AbsMono-0.59
AbsEos-0.16 AbsBaso-0.04
___ 05:20AM BLOOD Glucose-214* UreaN-16 Creat-0.7 Na-135
K-4.0 Cl-101 HCO3-24 AnGap-14
___ 12:06PM BLOOD ALT-72* AST-33 AlkPhos-71 TotBili-0.3
___ 12:06PM BLOOD Lipase-112*
___ 12:06PM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.7
___ 02:18PM BLOOD %HbA1c-9.1* eAG-214*
___ 01:03PM BLOOD Triglyc-159* HDL-44 CHOL/HD-4.2
LDLcalc-110 LDLmeas-123
___ 01:03PM BLOOD TSH-1.3
___ 01:03PM BLOOD HIV Ab-Negative
___ 12:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:48PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
___ 12:48PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 12:48PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
IMAGING DATA
MRI Head w/o contrast:
1. No evidence of acute territorial infarction, hemorrhage,
enhancing mass, or abnormal enhancement.
2. Slightly prominent sulci for the patient's age suggesting
mild cortical volume loss.
3. Numerous subcortical and periventricular foci of high signal
intensity
detected on FLAIR and the T2 weighted images, which are
nonspecific and may reflect changes due to small vessel disease.
4. Paranasal sinus disease, as above.
MRI C-Spine w/o contrast:
1. No evidence of cord compression, cord edema, or abnormal
enhancement.
2. Multilevel cervical spondylosis as above with mild spinal
canal stenosis from C3-C4 through C5-C6 levels with multilevel
neural foraminal narrowing, as above.
CTA Head/Neck: No large vessel occlusion or aneurysm.
Brief Hospital Course:
Summary: ___ year old man with history of type 2 DM, chronic back
pain with RLE numbness and right hand numbness who presented
with several days of new right facial "droop", and right face
and arm sensory changes. Given acute onset of symptoms in
setting of cocaine use and multiple vascular risk factors, he
was admitted with concern for stroke. He underwent MRI brain
which was negative for stroke. He did have an MRI cervical spine
which revealed multilevel cervical spondylosis and degenerative
changes. Clinically, he had evidence of a bilateral carpal
tunnel syndrome as well. He was started on a soft cervical
collar and wrist splints. On exam, he did not have any evidence
of a facial droop; rather, it was left lip swelling related to a
recent boil, for which he was instructed to see his PCP to be
started on an antibiotic that was used last time when he had the
same problem.
#Right facial and arm numbness: Attributed to cervical
spondylosis and carpal tunnel syndrome. Started on soft cervical
collar and wrist spints.
#Poorly controlled T2 DM: Noted during workup to have hemoglobin
A1c of 9.1. Patient educated about importance of improved
glucose control. Follow up arranged with PCP ___
(___) as scheduled on ___ at 10:15 AM to address
this.
#left lip swelling/boil: Likely etiology for patient's right
facial asymmetry. Follow up arranged with PCP ___
(___) as scheduled on ___ at 10:15 AM to address
this.
TRANSITIONAL ISSUES:
- Follow up with PCP urgently to address boil on lip and poorly
controlled diabetes
- Wear soft cervical collar for cervical spondylosis
- Wear bilateral wrist splints for carpal tunnel syndrome
- No neurologic follow up necessary at this time. We will
continue to be available for questions or concerns if needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. glyBURIDE-metformin 10mg-100mg oral BID
2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
3. Omeprazole 20 mg PO BID
4. Pregabalin 75 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. glyBURIDE-metformin 10mg-100mg oral BID
2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
3. Omeprazole 20 mg PO BID
4. Pregabalin 75 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6.Soft Cervical Collar
Dx: Cervical spondylosis (ICD ___.___)
Prognosis: good
Anticipated duration: 6 weeks
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical spondylosis
Carpal tunnel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with symptoms of right face
numbness and tingling, as well as right hand sensory changes. To
look into your symptoms, we did an MRI of your brain and neck
(cervical spine). This did not reveal any evidence of a stroke.
It did reveal that you had some degenerative disc disease in
your neck--likely related to "wear and tear" changes over time.
You also had signs of nerve compression in your hands.
Moving forward, it will be important for you to wear a soft
cervical collar to help the sensory symptoms in your face and
neck. Also, you should wear wrist splints at night to help with
the nerve compression issue--this can be obtained over the
counter at your local pharmacy. Finally, you should see your
primary care physician (PCP) to address the boil on your lip and
your poorly controlled diabetes.
It was a pleasure taking care of you.
Sincerely,
your ___ care team
Followup Instructions:
___
|
10749816-DS-8
| 10,749,816 | 22,714,257 |
DS
| 8 |
2181-03-06 00:00:00
|
2181-03-06 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking male with a past medical
history of type II diabetes, hypertension, psoriasis,
alcoholichepatitis presenting with a 2-day history of atraumatic
left lower extremity pain, erythema, and swelling. Patient
denies recent hospitalization, bedbound status, travel/long
flight, or
malignancy. Also denies insect bites to the area. Denies fevers,
chills, nausea, vomiting, cough, chest pain, shortness of
breath, dyspnea, DOE, PND. He also reports polyuria and
polydipsia.
Past Medical History:
Alcoholic Cirrhosis
Diabetes, type II
Hypertension
Psoriasis
Hypercholesterolemia
Back pain
Social History:
___
Family History:
Father- ___, HTN, Fatal MI
Sister- ?___ dysfunction
Physical Exam:
ADMISSION EXAM:
VITALS: 98.4PO, 138/81 L Lying, 92, 16, 98% RA
GENERAL: NAD
HEENT: PERRL, EOMI, MMM
NECK: No JVD, no cervical LAD
CARDIAC: RRR, +S1/S1, no murmurs
LUNGS: CTAB, no wheezes/rales, rhonchi
ABDOMEN: soft, NT/ND, no shifting dullness
EXTREMITIES: LLE warm with 1+ pitting edema and tender to
palpation
SKIN: diffuse plaques with silver scale, diffusely erythematous
LLE within demarcated area
NEUROLOGIC: AAOx3, grossly intact strength and sensation in
upper
and lower extremities
DISCHARGE EXAM:
Vitals: 98.2, 111/71, HR 88, RR 18, 97% RA
General: alert, oriented, no acute distress
Eyes: Sclerae with mild icterus
HEENT: MMM, oropharynx clear
Resp: clear to auscultation bilaterally
CV: regular rate and rhythm
GI: soft, non-tender, non-distended
Skin: Demarcated area of erythema on the left lower extremity
which is improving. Still mildly warm/swollen. It does not
extend down to the foot. There are numerous scaly plaques on
the
bilateral ___, as well as elbows, with excoriations.
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-6.2 RBC-3.29* Hgb-11.1* Hct-31.7*
MCV-96 MCH-33.7* MCHC-35.0 RDW-13.9 RDWSD-48.5* Plt Ct-76*
___ 12:45PM BLOOD Neuts-57.5 ___ Monos-12.8
Eos-0.2* Baso-0.7 Im ___ AbsNeut-3.54 AbsLymp-1.72
AbsMono-0.79 AbsEos-0.01* AbsBaso-0.04
___ 06:10AM BLOOD ___ PTT-30.7 ___
___ 12:45PM BLOOD Glucose-407* UreaN-8 Creat-0.6 Na-127*
K-4.4 Cl-89* HCO3-27 AnGap-11
___ 06:10AM BLOOD ALT-30 AST-52* LD(LDH)-145 AlkPhos-149*
TotBili-3.1*
___ 06:10AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.6 Mg-1.9
___ 02:16PM BLOOD %HbA1c-9.2* eAG-217*
___ 01:19PM BLOOD Lactate-2.8*
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-4.4 RBC-3.17* Hgb-10.6* Hct-30.9*
MCV-98 MCH-33.4* MCHC-34.3 RDW-14.0 RDWSD-49.5* Plt Ct-88*
___ 06:10AM BLOOD ___
___ 06:10AM BLOOD Glucose-151* UreaN-11 Creat-0.5 Na-134*
K-3.5 Cl-97 HCO3-26 AnGap-11
___ 06:10AM BLOOD ALT-29 AST-60* AlkPhos-158* TotBili-2.2*
___ 06:10AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.5*
LLE US:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Limited evaluation of the left calf veins due to overlying
moderate to severe soft tissue swelling with normal color flow
of the left posterior tibial veins and nonvisualization of the
left peroneal veins.
Brief Hospital Course:
___ with a h/o EtOH cirrhosis, Type 2 diabetes, and psoriasis,
who presents with LLE cellulitis and hyperglycemia. He was
treated with antibiotics for cellulitis, and was initiated on
Lantus for diabetes.
# Cellulitis: He presented with 2 days of left leg erythema,
swelling, warmth, and pain. LLE US showed no evidence of DVT. He
was not febrile or toxic appearing. Mechanism of infection was
likely bacterial entry via open skin wound/pore from psoriasis.
Given lack of purulence, MRSA was not covered. He was started on
IV Cefazolin and treated with this for several days as his
cellulitis improved. He was transitioned to PO Cephalexin on
___ as he had improved. He will continue this as an outpatient
to complete a 10 day course on ___.
# Type 2 Diabetes, poorly controlled: He presented with blood
sugars >400. He had previously been treated for Diabetes with
Metformin 500mg daily, no other meds. ___ was consulted. He
was initiated on nighttime Lantus and he received education on
how to administer his insulin. His metformin was increased to
1000mg BID. He will be discharged on 24 units Glargine nightly.
# EtOH Cirrhosis c/b esophageal varices and portal hypertensive
gastropathy: LFT's and INR were at baseline, and were trended.
Continued Nadolol and Omeprazole.
# Hyponatremia: Likely related to cirrhosis as well as
hyperglycemia. This was monitored.
# Weight Loss: Seems like this was related to his Otezla. Also
on the differential would be progression of diabetes, but weight
loss has plateaud.
# Thrombocytopenia/Anemia: Stable. Likely related to cirrhosis
and EtOH. Has seen Heme as an outpatient and is scheduled for
outpatient f/u.
# Psoriasis: Will need outpatient Derm follow up after
discharge. Can continue topical steroid, but he should avoid
placing it on the LLE.
TRANSITIONAL ISSUES
=============================
- Continue diabetes education
- Uptitrate Glargine as tolerated for improved glycemic control
- Metformin increased to 1000mg BID
- Please monitor cellulitis for improvement at follow up visits.
- Continue Cephalexin after discharge, 500mg QID, last day ___
- Avoid topical steroid on the left lower extremity until
cellulitis has resolved
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times per day
Disp #*28 Capsule Refills:*0
2. Glargine 24 Units Dinner
RX *blood sugar diagnostic [FreeStyle Lite Strips] check blood
sugar as directed Disp #*100 Strip Refills:*1
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 24 Units at
night Disp #*3 Vial Refills:*1
RX *blood-glucose meter [FreeStyle Freedom Lite] check blood
sugar as directed Disp #*1 Kit Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge check blood sugars as
directed Disp #*100 Each Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ult-Fine
II] 31 gauge x ___ administer insulin AS DIRECTED Disp #*90
Syringe Refills:*0
3. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
5. Nadolol 10 mg PO DAILY
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you. You were admitted to our
hospital for an infection of your leg, called "cellulitis." You
were also found to have high blood sugars as well, due to
diabetes.
You were treated with antibiotics for your infection. Please
continue the pill antibiotics after discharge, and please
complete the entire amount of antibiotics which have been
prescribed.
You were started on Insulin injections for your diabetes.
Please continue these after discharge. You will do your insulin
injection in the evening.
When you are resting, please elevate your left leg.
Please do not put any of your Psoriasis cream on the infected
area of your left leg.
We wish you all the best,
___
Followup Instructions:
___
|
10749983-DS-10
| 10,749,983 | 28,375,818 |
DS
| 10 |
2142-07-20 00:00:00
|
2142-07-23 04:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History is obtained from OSH ED notes (which have some
conflicting information) and mom. Patient is nonverbal. History
from mom is extremely limited as mom primarily speaks ___ but
states she understands ___ well and declined interpreter
twice. Also, mom has very limited knowledge/ability to describe
___ medical history
Mr. ___ is a ___ year old man with history of cognitive
impairment and nonverbal at baseline who presents from ___ after sudden onset facial droop (unclear which side) and left
arm/leg weakness. Per OSH ED notes: Patient was in ___'s office
for a routine follow up visit and was noted to have sudden right
sided facial droop and LUE/LLE weakness. (another note states L
facial droop) On EMS transport, ___ was 60 and he was given 1 amp
of D50 with no improvement in symptoms. On arrival to the ED, he
was noted to have left gaze deviation with intermittent rapid
left beating nystagmus though he was following commands and
responding to questions with nodding/shaking his head
appropriately at this time. He ahd slight LUE weakness still
and intermittent
twitching/contraction of left face. NCHCT did not show an acute
process. Tele stroke at ___ was consulted, did not recommend
tPA, recommended loading with Keppra 1000mg IV x1 and giving
ativan.
Mom tells me that they were at ___'s office today, and ___
had a headache which is unusual for him. The day before, he was
not feeling well and had some abdominal pain. While waiting for
PCP, mom saw that he had some twitching of the pointer finger,
she does not remember on which hand. Then, his right eye
started watering. Next, he was making unusual mouth movements
and shortly thereafter could not move his RIGHT upper extremity
(per OSH ED note, LUE/LLE weakness). She denies that he has a
history of HTN, HLD or DM II. She states that his development
was normal, but that he could only talk at age ___ after he had
"surgery on his nose, throat and ears." However, at around age
___, he woke up one morning and could not speak. He has not
spoken since. Per OSH ED notes, his little brother apparently
says it was thought to be a stress reaction due to bullying.
Mom said he had work up at ___ including an MRI brain which did
not show stroke. She does not think he has ever had a seizure
in the past. Though, he did have similar episode to today when
he was ___ years old, worked up at ___, she does not know any
details.
She says that his development was otherwise normal. He follows
commands, reads and writes. Was in special classes in high
school, did not graduate. Patient has not had significant head
trauma or CNS infections. On a typical day, ___ stays at
home, watches TV, reads books and the bible.
On neuro ROS, the pt endorses headache, denies photophobia.
denies loss of vision, blurred vision, diplopia, dysphagia,
lightheadedness, vertigo. Denies difficulties comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention.
On general review of systems, 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:
Cognitive impairment
Mutism of unclear etiology at age ___ - ENT and genetic
evaluations done at ___ which were normal
Social History:
___
Family History:
Paternal grandmother with strokes
Physical Exam:
Admission Physical Exam:
Vitals: T 97.3 HR 70 BP 100/56 RR 16 O2 100% RA
General: Awake, somnolent but easily arousable, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Somnolent, but easily arousable. Nonverbal at
baseline. Able to follow midline and appendicular commands.
Nods/shakes his head appropriately. When shown pictures and
asked to point to specific objects, does so correctly. When
shown written command "Lift up your right arm" he follows
command. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF grossly to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: On initial evaluation, decreased activation of right lower
face, but on repeat evaluation facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: unable to visualize palate
XI: ___ strength in trapezii and SCM bilaterally.
XII: Does not show me his tongue.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Reports decreased sensation to light touch on right
hemibody-face/arm/leg.
-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 dysmetria on FNF but
movements very slow.
-Gait: attempted to test, patient was unsteady, so deferred.
Discharge Physical Exam: Mental status exam notable for
nonverbal patient with normal written language. Intact verbal
comprehension and calculations.
There is concern for bilateral facial paresis, most pronouced at
right mouth. However there is likely a functional overlay to
this weakness as he has symmetric activation on natural smile.
Confrontational strength testing was confounded by functional
overlay as well. Gait with stooped posture, normal stance,
slowed stride.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-6.0 RBC-4.59* Hgb-13.8* Hct-42.6
MCV-93 MCH-30.1 MCHC-32.4 RDW-13.0 Plt ___
___ 08:30PM BLOOD Neuts-55.5 ___ Monos-5.8 Eos-2.4
Baso-0.7
___ 08:30PM BLOOD ___ PTT-35.6 ___
___ 01:15PM BLOOD ESR-10
___ 10:45AM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-137
K-4.2 Cl-104 HCO3-26 AnGap-11
___ 08:30PM BLOOD ALT-18 AST-21 AlkPhos-53 TotBili-0.6
___ 10:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:15PM BLOOD Calcium-9.3 Phos-2.1* Mg-2.3
___ 05:00PM BLOOD CRP-2.1
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG.
MICROBIOLOGY:
___ LYME SEROLOGY: NO ANTIBODY TO B. BURG___ DETECTED
BY EIA.
IMAGING:
CXR ___: No acute cardiopulmonary abnormality. Mild elevation
of the left
hemidiaphragm.
MRI BRAIN ___: No acute infarction. No evidence of a seizure
focus. Small veins adjacent to the nerve roots exit/entry zones
of the seventh and eighth cranial nerves bilaterally, of
uncertain clinical significance. If clinically warranted, the
facial nerves could be better assessed by selected
high-resolution sequences from MRI IAC protocol, including a
three-dimensional gradient-echo sequence such as FIESTA or
CISS.
Brief Hospital Course:
The patient is a ___ year-old man with a history of cognitive
impairment and an unusual history of being suddenly nonverbal at
age ___. He presented with sudden onset of right facial droop
and question of left arm and leg weakness.
He was initially seen by ___ tele neuro and received Keppra load
given concern for seizure activity (facial droop and forced eye
deviation). He was then taken to ___ ED where code stroke was
called and NIHSS was 7 (language, loc question, sensory, facial
droop). Notably there was no activity concerning for seizures
and there was no hemiparesis.
Neurological exam was difficult as there was a significant
functional overlay to his right facial droop that corrected with
spontaneous smile. There was no clear weakness of his
extremities, but rather poor effort on exam that resolved over
the span of our neuro exam. Interestingly, there was evidence
of left sided synkinesis on left eye blink indicating a prior
left Bell's palsy. Also notable on examination was significant
depression and apathy.
He was admitted to the general neurology service for further
workup which included a normal routine EEG, normal MRI head.
ESR and CRP were within normal limits. Given his complex
history and difficulty obtaining medical details from the
patient and family, review of his past medical records was done
through both his PCP and ___. This
records reflected a complete ENT workup that was normal and
neurology clinic visits wherein his presentation was more
consistent with psychological etiology than organic seizures or
genetic disorders.
At the time of discharge, the exact diagnosis remained unclear,
but was thought to represent ___ syndrome (a
triad of lip swelling, fissured tongue, and facial droop caused
by granulomatous disease). To treat for this, he was started on
prednisone 60mg daily with planned course for 10 days (ending
___. He will be seen in Neurology clinic for follow-up
regarding continuation of steroids based on his improvement.
Given the propensity of ___ syndrome to coincide
with Crohns and sarcoidosis, ACE level was sent (pending at
discharge). CXR did not show hilar lymphadenopathy.
There was also significant concern for his depression and
anxiety given his flat affect and apathy about going home for
___. He also had frequent somatic complaints when ___ MD
was in the room. These were namely headache and chest pain. EKG
and troponins ruled out acute ischemic cardiac event.
Also on the differential was a variant of GBS (guillain ___
syndrome), given concern for possible facial diplegia and
tachypnea. PFTs were obtained, but unfortunately given patient
compliance this was nondiagnostic. On discharge there were no
respiratory concerns.
TRANSITIONAL ISSUES:
1) PCP appointment booked for ___ at 10:45 am
2) Neurology appointment will be booked by patient who is aware
of this and has clinic number.
3) Course of prednisone and omeprazole to be completed within 8
days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*24 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth daily Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- right facial droop
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 while you were admitted to
___. You were admitted because of a right facial droop. Most
likely, your facial droop is the result of a virus and this will
resolve with time. We have started you on prednisone which will
help your recovery. You should continue prednisone through
___. Also, we performed a number of tests while you were
here including an MRI of your brain which was reassuring.
Please understand that you did NOT have a stroke.
We have arranged follow-up for you with Dr. ___ below)
and Dr. ___ in our ___ clinic.
Followup Instructions:
___
|
10750036-DS-12
| 10,750,036 | 28,728,264 |
DS
| 12 |
2110-09-08 00:00:00
|
2110-09-08 17:41:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracoscopy for pleural biopsies + left sided tunneled pleural
catheter placement for pleural drainage
History of Present Illness:
___ is a ___ man with HTN, HLD, atrial myxoma s/p
resection c/b stroke and recent admission ___ with
dyspnea iso large left pleural effusion c/f malignancy, who
presents with worsened dyspnea on exertion and palpitations.
On last admission, pt presented with SOB and rib pain, found to
have large left pleural effusion and underwent thoracentesis and
chest tube placement (___) with pleural fluid studies c/f
lymphocytic exudate and cytology suspicious for malignancy. Has
appointment for lung biopsy tomorrow. Upon discharge ___, pt
noted pain in his left lateral mid-back. Endorses worsened pain
two nights ago, has been taking oxycodone with relief. Sleeps
upright due to pain. Pt reports DOE starting yesterday, can only
walk ___ ft before needing to stop, sob improved with rest.
Notes sensation of heart beating out of chest.
In the ED:
- Initial Vitals: T97.4, HR85, BP112/61, RR16, 98% on RA
- Exam notable for: NAD, diminished lung sounds in LLL otherwise
CTAB.
- Labs notable for: WBC 22.8, Hgb 8.6, Plt 702, Na 125, K 5.9,
Cl
88, Bicarb 22, BUN/Cr ___, proBNP 672, trop <0.01, UA small
leuks, neg nitrite
- Imaging/Studies:
-- CXR: Interval increase in large left-sided pleural effusion
causing whiteout of the lung with worsening rightward
mediastinal
shift. Resultant atelectasis/collapse of the left lung.
-- EKG: LBBB, NSR at 85
- Patient was given: oxy 5mg, 1L NS
- Consults: IP - plan for tap and biopsy tomorrow, unless
emergent drainage is indicated
Vitals on transfer: T98, HR 80, BP 113/64, RR 16, O2 99% on 1L
NC
Upon arrival to the floor, patient endorsing mild sob with
movements, however comfortable when resting in bed. No back pain
currently, states he typically takes 5mg in AM, 10mg in ___ due
to
increased pain at night. Has sensation of "strong heart beat"
with exertion, associated with DOE and sweating, improved with
rest. Endorses constipation. Has had 10lb weight loss since the
___, currently 10 lbs up from discharge weight last week,
however thinks this is "fluid weight" from his pleural effusion.
Has had poor PO intake over past several weeks, decreased
appetite, and decreased sensation of thirst. Otherwise, denies
fevers/chills, night sweats, upper respiratory symptoms, chest
pain, abdominal pain, n/v, diarrhea, dysuria.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Hypertension, essential
Hyperlipidemia
History of atrial myxoma
History of embolic stroke
Melanoma in situ of back
Colonic adenoma; fhx of polyps (in brothers)
___ artery disease involving native coronary artery of
native heart without angina pectoris
Melanoma of right upper arm (vs atypical nevus)
Family history of melanoma
BPH (benign prostatic hyperplasia)
Social History:
___
Family History:
Brother Alive ___
Father ___ ___/PV___
Mother ___ - Type II; Hypertension
Sister ___ at age ___ Hypertension; Lymphoma [OTHER]
Son ___ - ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 97.9, HR 82, BP 113/73, RR 18, O2 97% on 2L NC
GENERAL: Well developed man breathing between sentences.
HEENT: Sclera anicteric. PERRL. EOMI. Oropharynx without
erythema or exudate. Mildly dry mucous membranes.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. No
murmurs, rubs, or gallops. no JVD.
LUNGS: Decreased lung sounds on the left, clear to auscultation
on the right without adventitious sounds. on NC.
ABDOMEN: Soft, BS+, non-distended, non-tender in all four
quadrants, no rebound or guarding
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No rashes. Several nevi on back, possible seborrheic
keratoses.
PULSES: Distal pulses palpable and symmetric.
NEURO: A&Ox3. CN II-XII grossly intact. Strength ___ bilaterally
in upper and lower extremities. Sensation intact symmetrically.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 98.0 BP 104/64 HR 76 RR 20 SpO2 96% RA
GENERAL: Thin elderly man in no acute distress
HEENT: NCAT. PERRLA. EOMI. MMM.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. No
murmurs, rubs, or gallops. no JVD.
LUNGS: Decreased lung sounds on the left, clear to auscultation
on the right
ABDOMEN: Soft, non-distended, non-tender in all four quadrants,
no rebound or guarding. Small 3cm mobile subcutaneous mass
palpable in RLQ; skin overlying mass is absent of rashes,
lesions.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No rashes. Multiple nevi on back and arms.
BACK: Tenderness to palpation along left flank
NEURO: A&Ox3. No focal deficits. Sensation grossly intact.
Pertinent Results:
ADMISSION LABS
==============
___ 09:27PM URINE HOURS-RANDOM SODIUM-<20
___ 09:27PM URINE OSMOLAL-648
___ 09:27PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:27PM URINE RBC-8* WBC-4 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 07:03PM GLUCOSE-132* UREA N-26* CREAT-0.7 SODIUM-124*
POTASSIUM-5.3 CHLORIDE-89* TOTAL CO2-20* ANION GAP-15
___ 07:03PM CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-1.9 URIC
ACID-6.4
___ 07:03PM HAPTOGLOB-453*
___ 07:03PM OSMOLAL-259*
___ 12:00PM GLUCOSE-150* UREA N-27* CREAT-0.8 SODIUM-125*
POTASSIUM-5.9* CHLORIDE-88* TOTAL CO2-21* ANION GAP-16
___ 12:00PM ALT(SGPT)-29 AST(SGOT)-22 LD(LDH)-213 ALK
PHOS-127 TOT BILI-0.2
___ 12:00PM cTropnT-<0.01
___ 12:00PM proBNP-672*
___ 12:00PM ALBUMIN-3.2*
___ 12:00PM WBC-22.8* RBC-2.91* HGB-8.6* HCT-26.5* MCV-91
MCH-29.6 MCHC-32.5 RDW-13.4 RDWSD-44.6
___ 12:00PM NEUTS-86.4* LYMPHS-6.3* MONOS-6.1 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-19.67* AbsLymp-1.43 AbsMono-1.38*
AbsEos-0.02* AbsBaso-0.06
___ 12:00PM ___ PTT-28.1 ___
INTERVAL LABS
=============
___ 07:52AM BLOOD WBC-22.2* RBC-2.61* Hgb-7.7* Hct-23.8*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.4 RDWSD-45.1 Plt ___
___ 07:07AM BLOOD Neuts-80.4* Lymphs-9.8* Monos-7.8
Eos-0.7* Baso-0.3 Im ___ AbsNeut-15.13* AbsLymp-1.85
AbsMono-1.46* AbsEos-0.14 AbsBaso-0.06
___ 07:07AM BLOOD Anisocy-1+* Poiklo-2+* Polychr-1+*
Spheroc-1+* Ovalocy-1+* Echino-1+* RBC Mor-SLIDE REVI
___ 06:59AM BLOOD Poiklo-OCCASIONAL Polychr-OCCASIONAL
Echino-OCCASIONAL RBC Mor-SLIDE REVI
___ 07:52AM BLOOD Glucose-87 UreaN-19 Creat-0.6 Na-130*
K-5.3 Cl-97 HCO3-22 AnGap-11
___ 05:06PM BLOOD Glucose-127* UreaN-23* Creat-0.7 Na-130*
K-5.1 Cl-96 HCO3-21* AnGap-13
___ 07:52AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
___ 07:07AM BLOOD calTIBC-213* Ferritn-923* TRF-164*
___ 06:40PM BLOOD PEP-HYPOGAMMAG IgG-785 IgA-257 IgM-50
IFE-NO MONOCLO
___ 10:09PM URINE Hours-RANDOM Creat-103 Na-<20 TotProt-14
Prot/Cr-0.1
___ 10:09PM URINE U-PEP-TRACE ___
___ 02:00PM PLEURAL TotProt-3.8 Glucose-<2 LD(LDH)-2098
Albumin-1.8 Cholest-49 Triglyc-43
___ 02:00PM PLEURAL TNC-2609* ___ Polys-47*
Lymphs-26* ___ Macro-27*
DISCHARGE LABS
===============
___ 07:45AM BLOOD Cortsol-22.6*
___ 07:31AM BLOOD WBC-27.0* RBC-3.37* Hgb-9.7* Hct-30.2*
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.1 RDWSD-47.7* Plt ___
___ 06:59AM BLOOD Neuts-82.7* Lymphs-7.0* Monos-7.1
Eos-0.9* Baso-0.4 NRBC-0.1* AbsNeut-23.53* AbsLymp-2.00
AbsMono-2.03* AbsEos-0.25 AbsBaso-0.10*
___ 07:31AM BLOOD Glucose-91 UreaN-27* Creat-0.7 Na-130*
K-5.3 Cl-94* HCO3-23 AnGap-13
___ 07:31AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3
IMAGING
=======
___ CT CHEST W CONTRAST
1. Interval increase in size of a loculated large left pleural
effusion which fills nearly the entire left hemithorax and
causes worsened right mediastinal shift and compression of the
left ventricle, as well as inferior depression of the left
hemidiaphragm and worsened near complete collapse of the left
lung.
2. Redemonstration of diffuse thickening and nodularity of the
left pleura
concerning for malignancy, and interval increase in size of a
right posterior pleural based nodule, currently measuring up to
14 mm compared with 10 mm on recent outside CT.
___ CT ABD/PELVIS W/WO CONTRAST
1. 2.5 cm soft tissue lesion in the musculature of the right
lower anterior
abdominal wall, concerning for metastatic disease.
2. 2.3 x 1.8 cm rounded density adjacent to the anterolateral
aspect of the L2 vertebral body, possibly reflecting
extramedullary hematopoiesis however
further evaluation with an MRI of the lumbar spine with and
without contrast is recommended.
3. 1.5 cm hepatic hypodensity in segment IVB adjacent to the
falciform
ligament likely represents focal fat deposition, however this
could be
confirmed with MRI.
4. Mass effect on the spleen which is displaced anteriorly and
inferiorly due to inferior depression of the left hemidiaphragm
by large loculated pleural effusion.
5. Horseshoe kidney.
6. Cholelithiasis.
MICROBIOLOGY
=============
___ 2:50 pm TISSUE LEFT PLEURAL BIOPSY.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 2:00 pm PLEURAL FLUID LEFT PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
PATHOLOGY
=========
___ Pleural nodules, left, biopsy:
- MALIGNANT POORLY DIFFERENTIATED SPINDLE AND EPITHELIOID
NEOPLASM, consistent with MALIGNANT MESOTHELIOMA, biphasic
(sarcomatoid and epithelioid) type, invasive into adipose
tissue.
- Immunohistochemical stains show the following profile in tumor
cells: Positive: Cytokeratin AE1/AE3, EMA (patchy), D2-40
(patchy)
Negative: WT-1 (cytoplasmic only), Calretinin, TTF-1, Desmin,
___, ERG
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ]Patient has been referred to ___
close follow-up appointment. If the patient does not hear from
___ by ___, he will call ___, of
___ Hem/___, and schedule a follow-up appointment with her.
[ ]Patient's oncologist should order an outpatient MRI head and
PET for staging to determine surgical candidacy.
[ ]Pending results to follow: anterior abdominal wall mass
biopsy results
[ ]The patient was started on an oxycontin 10mg BID and
oxycodone ___ q4h:prn pain regimen. He was counseled on the
risks of opioid pain medication. He received a 1 week course of
MS contin 15mg BID and oxycodone ___ q6h:prn (insurance
coverage limitations) due to uncertainty of the timing of
appointments. This should be managed by his oncologist or PCP.
[ ]If the patient is a surgical candidate, he should obtain
followup with Dr. ___, of Thoracic Surgery, at ___.
[ ]If non-surgical candidate, treatment would be chemotherapy,
likely palliative, with standard first line being
platinum/pemetrexed. IM B12 1000mcg was given on ___ and
daily folic acid was started.
[ ]Patient's PCP has been made aware of his new diagnosis and he
will have close follow-up with PCP after discharge.
[ ]***Please check chemistries at next appointment - patient was
hyperkalemic and hyponatremic during admission (K on discharge
5.3, Na on discharge 130)***
ACTIVE ISSUES:
===============
# Reaccumulation of large pleural effusion:
# Dyspnea/hypoxia:
# Left-sided back pain
Patient's CT chest showed with abnormal pleural nodules. His
recurrent effusions and
cytology were suspicious for malignancy. He was recently
admitted for pleural effusion, s/p chest tube and drainage, now
with reaccumulation and subsequent whiteout and
atelectasis/collapse of the lung as well as worsened rightward
mediastinal shift. He was originally on ___ NC with O2 sats
>92%, with some dyspnea. He was evaluated by IP and planned for
thoracoscopy for pleural biopsies + left sided TPC placement for
pleural drainage on ___. Admitted to medicine afterward
for monitoring and management of other medical issues (see
below). After procedure, he remained on ___ NC without dyspnea
at rest. O2 was weaned and he maintained >92% on RA. Walking
oximetry showed 95-97% on RA. Due to rapid reaccumulation of
pleural effusion, pleural catheter was drained daily (1L). He
was started on oxycontin 10mg BID + oxycodone ___ q6h:PRN for
pain management. Pleural fluid studies was positive for
malignant cells. Final pathology report revealed malignant
mesothelioma. A CT torso with onc tables was performed, which
noted worsening R mediastinal shift, masses noted in musculature
of R lower anterior abdominal wall, and a density adjacent to
anterolateral aspect of the L2 vertebral body, possibly
reflecting extramedullary hematopoiesis. Atrius Hem/Onc made
referrals to ___ Mesothelioma Center follow-up and
suggested outpatient PET for further staging. IP arranged
outpatient follow-up and home services for management of pleural
catheter. IM B12 1000mcg was given on ___ and daily folic
acid was started in preparation for potential chemotherapy. Upon
discharge, the patient endorses relief of dyspnea with pleural
drainage and controlled pain with current medication regimen.
# Hyperkalemia (improved)
K was 5.9 on admission. Patient was asymptomatic; denied chest
pain or palpitations. No EKG changes. K improved to normal
limits after 1L NS in ED. He received another 1L NS when his K
increased to 5.7 during admission, with improvement. When his K
increased again, he received 15g of kayexalate. Uric acid was
6.4 (WNL), LDH WNL, AM cortisol 22.6. His K remained stable in
normal limits after kayexalate. He was started on PO Lasix 20mg
for diuresis. This was discontinued on discharge. On discharge,
he remains without chest pain or palpitations, his K is 5.3.
Please check electrolytes at next appointment.
# Hyponatremia (improving)
This was like hypovolemic hyponatremia in the setting of poor PO
intake, as the patient had poor intake the week prior to
admission. Na was 125 on admission, UNa <20. AM cortisol 22.6.
Patient did not have AMS, nausea/vomiting, or seizures. Na
slowly improved with fluids. Na correction goal was no more than
___ mEq in 25 hours. Patient was encouraged to increase PO
intake during and after admission. On discharge, his Na is 130.
Please check electrolytes at next appointment.
# Leukocytosis:
WBC ___ on admission, previously ___ on prior admission.
Likely reactive in the setting of malignancy. Diff showed
increase in neutrophils and lymphocytes. Pt afebrile. Pt also
hypoxic, likely ___ pleural effusion, however cannot rule out
PNA given white out of left lung. Pt without cough or sputum
production, less c/f PNA. Can consider infected pleural
effusion, however negative for infection on pleural fluid
studies ___. No dysuria, abd pain, diarrhea. UA negative. Pt's
back/flank pain is new as of last week, concerning for
metastasis. SPEP WNL and UPEP showed trace albumin. No
antibiotics were given. On discharge, the patients' WBC is 27.
# Acute on chronic anemia:
Hgb 8.6 on admission, previously ___. MCV wnl. Suspect anemia
of chronic disease/inflammation in the setting of malignancy. No
signs of active bleeding at this time. TBili 0.2, haptoglobin
453 (elevated but also acute phase reactant), LDH 213 (WNL),
TIBC 213 (low), ferritin 923 (high), transferrin 164 (low), Fe
60 (WNL). SPEP WNL, UPEP showed trace albumin. On ___, Hgb
dropped to 7.1 and the pt received 1u pRBC, with an appropriate
increased in Hgb to 9.0. On discharge, Hgb was 9.7.
# Thrombocytosis:
Plts 700s on admission, previously 400-500s during prior
hospitalization. Likely elevated in the setting of malignancy.
On discharge, platelets are 609.
CHRONIC ISSUES:
===============
#Hypertension
Previously taking amlodipine 10mg and lisinopril 40mg however
recently held iso normotensive. Pt remains normotensive during
this admission. On discharge, these medications will continue to
be held until patient sees his PCP.
#Hyperlipidemia
#Hx CVA
Pt with prior CVA iso atrial myxoma. Previously on ASA 325mg
daily, however states he is no longer taking. Continues to take
home statin.
- Continued home atorvastatin 20mg qPM
#Atrial myxoma s/p resection c/b stroke - no residual deficits
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Finasteride 5 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
6. Senna 17.2 mg PO DAILY:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
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:*0
4. Morphine SR (MS ___ 15 mg PO BID pain
HOLD FOR SEDATION OR RR<14
RX *morphine [Arymo ER] 15 mg 1 tablet(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*42 Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once a
day Refills:*0
7. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Atorvastatin 20 mg PO QPM
9. Finasteride 5 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: malignant mesothelioma, hyponatremia,
hyperkalemia, leukocytosis, anemia, thrombocytosis
Secondary diagnoses: hypertension, hyperlipidemia, history of
atrial myxoma, embolic stroke, melanoma in situ, benign
prostatic hyperplasia, schwannoma removal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you underwent a thoracoscopy
with biopsy of your lung pleura and placement of a pleural
catheter to drain fluid out of your chest. You were monitored
closely after your procedure.
- You were found to have low sodium and high potassium levels
in your blood.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- After the placement of your pleural catheter, your catheter
was drained daily to relieve the fluid buildup in your chest
cavity.
- You received fluids and medications to manage your low sodium
and high potassium levels.
- You were started on medications to help manage your pain.
- Your lung tissue was tested by the Pathologists and you were
informed about your diagnosis.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed.
- Please follow up with all the appointments scheduled with
your doctors
Thank ___ for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10750036-DS-13
| 10,750,036 | 29,275,627 |
DS
| 13 |
2110-09-21 00:00:00
|
2110-09-21 18:40:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS
===============
___ 01:40PM BLOOD WBC-33.9* RBC-3.12* Hgb-8.9* Hct-28.0*
MCV-90 MCH-28.5 MCHC-31.8* RDW-14.9 RDWSD-47.6* Plt ___
___ 01:40PM BLOOD Neuts-86.9* Lymphs-4.8* Monos-6.5
Eos-0.4* Baso-0.2 Im ___ AbsNeut-29.48* AbsLymp-1.64
AbsMono-2.19* AbsEos-0.13 AbsBaso-0.06
___ 01:40PM BLOOD ___ PTT-28.9 ___
___ 01:40PM BLOOD Glucose-103* UreaN-39* Creat-0.8 Na-126*
K-6.4* Cl-88* HCO3-24 AnGap-14
___ 05:07AM BLOOD ALT-33 AST-26 LD(LDH)-216 AlkPhos-149*
TotBili-0.3
___ 06:00PM BLOOD proBNP-1143*
___ 05:07AM BLOOD Albumin-2.3* Calcium-9.7 Phos-4.8* Mg-2.0
UricAcd-7.1*
___ 05:07AM BLOOD Osmolal-271*
___ 01:09PM BLOOD ___ pH-7.42 Comment-GREEN TOP
___ 01:55PM BLOOD Lactate-2.7*
___ 06:04PM BLOOD Lactate-3.1* K-5.0
___ 01:09PM BLOOD freeCa-1.19
INTERVAL LABS
=============
___ 05:00AM BLOOD Glucose-90 UreaN-33* Creat-0.8 Na-125*
K-5.6* Cl-88* HCO3-23 AnGap-14
___ 01:04PM BLOOD Glucose-83 UreaN-23* Creat-0.8 Na-130*
K-5.5* Cl-95* HCO3-21* AnGap-14
___ 05:01AM BLOOD Glucose-76 UreaN-19 Creat-0.7 Na-132*
K-5.1 Cl-97 HCO3-20* AnGap-15
___ 06:00AM BLOOD Glucose-81 UreaN-21* Creat-0.5 Na-130*
K-4.9 Cl-98 HCO3-18* AnGap-14
___ 07:10AM BLOOD Glucose-112* UreaN-21* Creat-0.6 Na-128*
K-5.9* Cl-95* HCO3-20* AnGap-13
___ 05:53AM BLOOD Glucose-116* UreaN-32* Creat-0.7 Na-131*
K-5.4 Cl-97 HCO3-18* AnGap-16
___ 06:30AM BLOOD Glucose-63* UreaN-30* Creat-0.7 Na-133*
K-4.1 Cl-97 HCO3-22 AnGap-14
___ 06:08AM BLOOD Glucose-124* UreaN-25* Creat-0.9 Na-140
K-4.4 Cl-104 HCO3-24 AnGap-12
___ 06:07AM BLOOD Glucose-80 UreaN-21* Creat-0.5 Na-136
K-3.8 Cl-99 HCO3-24 AnGap-13
___ 19:32
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 2 < OR = 20 mm/h
___
THIS TEST WAS PERFORMED AT:
___ ___
___
Comment: TAKEN FROM ___
PLEURAL FLUID ANALYSIS
======================
___ 2:38 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
==============
___ 06:07AM BLOOD WBC-15.1* RBC-2.93* Hgb-8.1* Hct-26.2*
MCV-89 MCH-27.6 MCHC-30.9* RDW-15.2 RDWSD-49.1* Plt ___
___ 04:25PM BLOOD Neuts-94* Bands-1 Lymphs-5* Monos-0*
Eos-0* Baso-0 AbsNeut-15.96* AbsLymp-0.84* AbsMono-0.00*
AbsEos-0.00* AbsBaso-0.00*
___ 06:07AM BLOOD Glucose-80 UreaN-21* Creat-0.5 Na-136
K-3.8 Cl-99 HCO3-24 AnGap-13
___ 06:07AM BLOOD Glucose-80 UreaN-21* Creat-0.5 Na-136
K-3.8 Cl-99 HCO3-24 AnGap-13
___ 06:07AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7
REPORTS/IMAGING
===============
___ CTA AORTA/BIFEM/ILIAC RUNOFF
IMPRESSION:
1. Very slow flow into the distal right lower extremity. No
substantial
stenosis through the popliteal. Suspect tibioperoneal stenosis.
Moderately severe disease involving proximal through mid distal
runoff vessels on the right. More distal components are
difficult to assess due to underfilling even on the delayed
images.
2. Findings associated with known metastatic mesothelioma
without short-term change.
___ ART EXT (REST ONLY)
No significant arterial insufficiency identified at rest in the
bilateral
lower extremities.
MICRO
======
___ 2:38 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
#Malignant pleural effusions
[ ]Follow up with the interventional pulmonology team
[ ]Drain PleurX daily
[ ]Continue incentive spirometry
#Lung Abscess:
[ ]Complete course of Augmentin (last day ___
#Metastatic mesothelioma
[ ]Follow up with Dr. ___ at ___ on ___.
#Peripheral Vascular Disease
[ ]Continue aspirin 81 mg daily
[ ]Keep foot elevated if it starts developing fluid swelling.
[ ]If recurrent cold/pulseless foot, present to ED for further
evaluation by vascular medicine/surgery teams.
# CODE: Full
# CONTACT: ___ (wife) ___
SUMMARY:
========
___ is a ___ year old male with a history of HTN,
HLD, atrial myxoma s/p resection c/b stroke, and recently
diagnosed metastatic mesothelioma s/p pleurx drain who initially
presented with a right cool lower extremity concerning for limb
ischemia, also found to have persistent hyponatremia and
malignant pleural effusion with possible insertion site
cellulitis.
-Vascular was consulted and lower extremity arterial studies
were not concerning for ischemia so no intervention was pursued.
-Interventional Pulmonology was consulted for poor PleurX
drainage, for which he was placed to continuous suction, and
subsequently received several doses of tPA and ___.
-He was started on Keflex (___) with concern for cellulitis
at insertion site of pleurex. Flagyl was added on ___ for
anaerobic coverage for concern of empyema, which was broadened
to Vanc/Zosyn on ___, then narrowed to Augmentin at discharge.
-He developed hyponatremia, likely due to hypovolemia as well as
SIADH secondary to his malignancy. He was started on salt tabs,
free water restricted, and received IVF, with improvement in his
sodium.
-He was transferred the oncology service on ___ for initiation
of chemotherapy (Pemetrexed/Carboplatin), with C1D1 occurring on
___.
ACUTE ISSUES
=============
#Metastatic mesothelioma
Pleural Bx showed malignant mesothelioma, poorly differentiated
with sarcomatoid and epithelioid features. Complicated by
pleural effusions, poor nutritional status, and electrolyte
abnormalities. Unerwent C1D1 chemo with pemetrexed/carboplatin
on ___. Patient to follow up with Dr. ___ at ___ after
discharge.
#Malignant pleural effusion
Patient's prior studies were c/w mesothelioma and he underwent
PleurX placement during last hospitalizations due to recurrent
effusions. Poor drainage noted during hospitalization, requiring
3 doses of lytics (5 mg alteplase and 5 mg dnase).
#Cellulitis at insertion site
Keflex was given for possibility of insertion site cellulitis
(___).
#Concern for lung abscess
Patient was broadened from Keflex/Flagyl to Vanc/Zosyn on ___,
with concern for lung abscess. Given clinical stability and lack
of fevers, ID was consulted for further assistance with
antibiotic selection. Abx were narrowed to Augmentin on day of
discharge for total 4 week course (last day ___.
#Pain control:
Continued MS ___ 15mg q12h, oxycodone to ___ q6 PRN
#Hyponatremia
Initially thought to be ___ hypovolemic hypernatremia given
fluid responsiveness last admission. Suspect SIADH given
underlying malignancy. Fluid restricted to 1L daily, started on
salt tabs 1g BID. Sodium 136 on discharge.
#Hyperkalemia
Unclear etiology. Unlikely to be due to adrenal insufficiency
given normal cortisol. K still mildly elevated. Bicarb low.
Initially improved with insulin/dextrose, and IV Lasix on
admission. Temporized with insulin dextrose, and supplemented
with bicarbonate until labs normalized. K 3.8 on discharge.
#Leukocytosis
WBC persistently elevated over the last month, rising the last
few weeks. WBC 33.9 on admission with neutrophil predominance.
Possibly due to immunogenic malignancy, cellulitis, or empyema
(though less likely given afebrile). Downtrended with chemo and
antibiotics.
#PVD
#Cool RLE extremity (resolved)
Presented with one day of a cool, swollen RLE without a history
of PVD. NIAS with weak flow. Vascular surgery re-evaluated
patient on ___, no intervention. Feet warm today. Cool feet
seem to coincide with pedal edema, perhaps due to external
compression from edema. Chemotherapy can also induce
hypercoagulable state,
therefore at risk for recurrence. Restarted on aspirin 81mg
daily. If recurs, would follow up with vascular medicine team.
CHRONIC/STABLE ISSUES:
======================
#Chronic normocytic anemia
#Anemia of chronic disease
H/H stable near prior baseline of ___. No signs of bleeding or
hemolysis.
#Thrombocytosis
Chronic over the last several weeks. Plt 500-700s. Suspect
reactive ___ malignancy, downtrending s/p chemotherapy.
#Hypertension
Previously on amlodipine 10mg and lisinopril 40mg; however held
during both admissions due to normal pressures. BP stable this
admission, held both on discharge.
#Hyperlipidemia
#Hx CVA
Prior CVA iso atrial myxoma. ASA 325mg daily was previously
stopped, restarted at 81 mg for PAD as above.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Finasteride 5 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Senna 17.2 mg PO BID
6. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
8. FoLIC Acid 1 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
10. Morphine SR (MS ___ 15 mg PO BID pain
11. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 24 Days
last day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*48 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth daily as needed
Disp #*10 Tablet Refills:*0
4. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
5. Atorvastatin 20 mg PO QPM
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
7. Finasteride 5 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Morphine SR (MS ___ 15 mg PO BID pain
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*14 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
14. Senna 17.2 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Metastatic mesothelioma
Malignant pleural effusion
Lung abscess
Peripheral vascular disease
SECONDARY DIAGNOSES:
Hyponatremia
Hyperkalemia
Anemia
Thrombocytosis
Leukocytosis
Hypertension
Hypolipidemia
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you had a cool right foot.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your foot was evaluated by the vascular doctors, who
determined that the flow to your feet is a little limited, but
nothing that requires surgery. The right foot tends to get cold
when it is swollen with fluid, so you should try to keep your
feet elevated and warm at all times.
- The lung doctors tried to help improve the drainage from your
PleurX drain. They used various medications to break up the
pockets of fluid around the lung. This took several days, but
ultimately they think it helped to break up the fluid.
- We were concerned that there could be an abscess (infection)
in your lung, so we started you on antibiotics to treat this.
- You received your first dose of chemotherapy (Pemetrexed,
Carboplatin) in the hospital and did well.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Drain the fluid from around your lung every day, unless
instructed otherwise by the lung doctors.
- Please continue to take all of your medications as directed,
especially the antibiotics.
- Please follow up with all the appointments scheduled with your
doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
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2111-02-24 15:41:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
IVDA with needle broken off in RUE
Major Surgical or Invasive Procedure:
exploration, venotomy, removal of needle and ligation of vein of
RUE
History of Present Illness:
___ IVDU reports that he was shooting up yesterday and the
needle popped off and got stuck in his arm. Says he went to ___
where they did an ultrasound and then tried to access the needle
but were unsuccessful. Felt that they were unfriendly there so
decided to leave ___. Woke up and came to ___ this morning.
Denies fevers, chills, sweats. Reports received tetanus shot a
few years ago. Reports HIV neg this year.
Past Medical History:
PMH: none
PSH: none
Social History:
___
Family History:
FH: Non-contributory
Physical Exam:
Vitals: T 98 BP 133/77, HR 60, RR 18, sat 1005/RA
Gen: NAD, A&O x3
CV: RRR
Pulm: CTA b/l , no labored breathing
abd: soft, ND, NT
ext: b/l ___- no edema or sings of infection, RUE- incision on
antecubital fossa is c/d/i, steristrips are in place, no sings
of hematoma or infection. b/l + radial pulses
Pertinent Results:
___ 04:53PM LACTATE-1.7
___ 12:20PM GLUCOSE-98 UREA N-6 CREAT-1.2 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
___ 12:20PM estGFR-Using this
___ 12:20PM WBC-4.5 RBC-4.89 HGB-13.2* HCT-40.9 MCV-84
MCH-27.0 MCHC-32.3 RDW-13.4
___ 12:20PM NEUTS-41.1* LYMPHS-46.9* MONOS-8.3 EOS-3.1
BASOS-0.5
___ 12:20PM PLT COUNT-249
Brief Hospital Course:
The patient presented to Emergency Department on ___ after
having a needle broken off in RUE Given findings, the patient
was taken to the operating room for foreing body removal. There
were no adverse events in the operating room; please see the
operative note for details. Pt was extubated, taken to the PACU
until stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with PO tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: The diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. He was started on IV
cefazolin while in house.
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.
Social work consulted on him and had a conversation about
available resourced for detoxification and drug addiction
treatment.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
please do not take more than 3 grams per day
Discharge Disposition:
Home
Discharge Diagnosis:
IVDA with needle broken off in RUE, s/p exploration, venotomy,
removal of needle and ligation of vein
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
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|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall with C1 and C2 fractures
Major Surgical or Invasive Procedure:
trach and PEG on ___
History of Present Illness:
Mr. ___ is an ___ with a history of stroke who presented
on ___ with light-headedness. The patient fell 2 days prior
to admission after drinking a martini. He developed
light-headedness on the day of admission and his wife noticed
his breathing was shallow. He denied any complaints on arrival
in ED. Denies headache, dizziness, numbness, weakness, tingling,
neck or back pain, chest pain, dyspnea, nausea, vomiting,
blurred vision, double vision, bowel
or bladder incontinence.
Past Medical History:
A-fib, HTN, depression, h/o seizures , hearing loss, osteopenia,
s/p CVA, sleep apnea, hx bezor, Hx Bell's Palsy, GERD
Social History:
___
Family History:
CAD, Depression
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 98.7 HR: 68 BP: 149/85 RR: 16 Sat: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: irregular b/l EOMs intact
Neck: hard collar in place
Extrem: Warm and well-perfused, except for bruising and pain in
left forefinger/knuckle
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: expressive aphasia but can communicate via writing
etc. oriented to month/year
Right nasal labial fold flattened
no pronator drift
Motor:
D B T WE WF G IP Q H AT ___
G
R 5 5 5 5 5 5 5 5 5 5 5
5
L 5 5 5 5 5 4 5 5 5 5 5
5
Sensation: Intact to light touch
Reflexes: Br Pa Ac
Right ___
Left ___
no clonus, no hoffmans
PHYSICAL EXAMINATION ON DISCHARGE:
Awake and alert, nods head appropriately, follows simple
commands, full strength.
CTO brace in place
Pertinent Results:
___ Non-contrast Head CT:
1. Fracture of the anterior arch of C1 and probable fractures
involving the posterior arches. Recommend CT C-spine for
further evaluation.
2. No acute intracranial hemorrhage. Continued
encephalomalacia of the left frontal and parietal lobes
consistent with prior MCA infarct. Atrophy and chronic small
vessel disease.
___ CXR: No acute cardiopulmonary process.
___ Non-contrast Cervical Spine:
1. Acute fractures in the anterior and posterior arches of C1
consistent with ___ fracture with superior displacement of
the posterior arch fragment. Associated widening of the C1 and
occipital condyle articulation on the right, concerning for
ligamentous injury.
2. Type 2 dens fracture with retropulsion of the superior
fragment into the spinal canal. MRI is recommended for further
evaluation of ligamentous injury or spinal cord compromise.
3. Old compression deformities of T2 and T3.
___ Left hand x-ray: Dorsal dislocation of second MCP joint
___ CT Thoracic spine:
Interval progression in the previously demonstrated compression
fractures at T3 and T5 vertebral bodies with associated kyphotic
angulation and mild retropulsion. Diffuse osteopenia and disc
degenerative changes are identified, more significant at T7/T8
level. Bilateral pleural effusions and areas of consolidation
in both lung bases.
___: CT Lumbar:
1. No evidence of lumbar spine fractures. Mild-to-moderate
multilevel disc degenerative changes as described above.
Diffuse osteopenia is noted throughout the lumbar spine.
Schmorl's nodes are present at the level of L3/L4 and L4/L5
levels.
2. Renal cystic formation is noted on the upper pole of the
left kidney,
partially evaluated in this examination, possibly slightly
larger in
comparison with the prior CT of the chest dated ___, correlation with renal ultrasound is recommended if
clinically warranted.
C-SPINE (PORTABLE) ___: Initiation of traction
There is again seen a fracture involving the dens of C2. There
is some
separation measuring approximately 5 mm at the more anterior
aspect of the
site of the fracture. There are degenerative changes, worst at
C3-C4 with
disc space narrowing. No abnormal ___- or retro-listhesis is
seen.
___ C-SPINE NON-TRAUMA ___ VIEWS PORT without traction
There is separation of fracture by 6 mm. The dens and the
anterior arch of C1 appear adjacent to one another. There is
slight subluxation of the dens fragment in relation to the body
of C2. Degenerative changes at C3-C4 are also present.
___ C-spine Xray portable without traction:
There is separation of the fracture fragments by 5mm with
increased posterior displacement of the dens fragment in
relation to the base of C2
measuring 8 mm, previously 4 mm.
___ Chest xray for line placement:
Comparison is made to previous study from ___.
There is an endotracheal tube whose distal tip is 2.2 cm above
the carina. The side port of nasogastric tube is again at the
GE junction. The right-sided central venous catheter has been
pulled back with the distal lead tip in the mid SVC. There is a
persistent left retrocardiac opacity. This is stable. There is
mild atelectasis at the right base.
___ C-spine Xray portable with traction:
Evaluation of the C2 dens fracture is limited. There is
persistent separation of the fracture fragments. The dens
fragment appears in improved alignment with the base of C2,
although the evaluation is limited.
___ CT Cspine with and without traction 10:00:
IMPRESSION:
1. No angulation or subluxation in or out of traction. This is
significantly improved from the prior exam.
2. Stable ___ fracture of the C1 vertebral body.
3. Stable mild distraction of the type 3 dens fracture.
___ CT C-spine without traction 14:30:
IMPRESSION:
1. Since the prior CT at 10 a.m. on the same day, there has been
a slight
increase in the posterior angulation of the fracture through the
body of C2.
2. Stable appearance of the ___ burst fracture through
the anterior and posterior arches of C1.
3. Probable incidental osteochondroma extending off the left
lateral mass of C1.
4. Ossified fragment medial to the lateral mass of C1 is likely
ossification of the transverse ligament or less likely a
fracture fragment. This is stable from the prior exams.
___ C-spine Xray in traction, in CTO brace:
Improved alignment of dens fracture which remains minimally
seperated
___ Chest Xray: PORTABLE SUPINE CHEST RADIOGRAPH: Endotracheal
tube terminates 4.4 cm above the carina. Nasogastric tube
terminates in the proximal stomach slightly higher than on the
prior study and as mentioned previously can be advanced for more
optimal positioning.
Right subclavian catheter terminates in the mid SVC. Left basal
opacity and mild vascular congestion are improved with calcified
granuloma seen in the right apex.
___: CT Cspine without traction:
IMPRESSION: No interval change in the alignment of the
fractures of C1 and C2.
___: CT Abdomen:
IMPRESSION:
1. Bilateral small nonhemorrhagic pleural effusion with
secondary
subsegmental atelectasis.
2. Cholelithiasis without signs of cholecystitis.
3. No findings to suggest prior abdominal surgery
___ CXR:
Semi-upright portable chest radiograph was obtained.
Endotracheal tube
terminates 3.2 cm above the carina. Nasogastric tube is again
seen with side hole at the level of GE junction. Right
subclavian catheter terminates in the mid SVC. Bibasilar left
greater than right atelectasis is unchanged with slight decrease
in edema. A right midlung opacity is more apparent given the
decreased edema and may reflect an early pneumonia. Cardiac
size and tortuosity of the aorta is unchanged.
IMPRESSION: Slightly decreased edema with bibasilar atelectasis
and newly
evident right midlung opacity which may reflect a developing
pneumonia.
Finding was discussed by phone with Dr. ___ by Dr. ___ at
1050 on
___.
___ repeat CXR: There is a new tracheostomy tube, turned to the
left, tip facing the left tracheal wall. There is no
pneumothorax or mediastinal widening. Small right pleural
effusion is new. Heart size is normal. Thoracic aorta is
tortuous, but not focally dilated. Right subclavian line ends
low in the SVC.
Brief Hospital Course:
Mr. ___ was admitted to the Trauma/Surgical ICU on ___
after presenting to the ED with lightheadedness in the setting
of a recent fall. Imaging revealed fractures of C1 and C2 for
which the patient was initially treated with a cervical collar
and monitored with hourly neuro checks. He was also found to
have a dorsal dislocation of the left second metacarpal joint.
On ___, the patient was intubated and found to have irregular
pupils bilaterally. His INR was reversed with 2 units of FFP and
vitamin K. He was found to have a UTI and was bacteremic with
GPC, started on vancomycin. MRI c-spine was done to evaluate for
cord involvement and c-spine x-ray obtained pre-traction for
baseline studies. Patient was placed in traction. The weight of
traction was increased by 5 lbs each time c-spine imaging was
completed and showed no change in subluxation. He was at 15lbs
of traction when c-spine x-ray showed reduction of subluxation.
Hand was consulted for dislocation of ___ MCP joint who reduced
dislocation and recommended a splint and follow up in hand
clinic in ___ weeks. On ___, patient was taken out of traction,
pins remained in place, and he was elevated. C-spine imaging
showed stable C1/C2. Overnight he was febrile and full
cultures were sent.
Morning portable AP and Lateral C-spine xrays on ___
demonstrated increased posterior displacement of the dens
fragment in relation to the base of C2 and so the patient was
placed back in cervical traction to 15lbs. He remained
intubated with an unchanged neurological exam.
On ___ patient's hematocrit was 26 from 31 the day prior.
The patient was transfused with 1 unit of PRBC. The post
transfusion Hct was 28.1. The patient had a CT of the neck in
traction and out of traction with minimal displacement and a
Cervial hard collar with thoracic extension was ordered. The
brace was fitted and the patient had another CT out of cervical
traction that demonstrated posterior displacement of the dens
fragment and subluxation. The patient was placed back in
cervical traction. On exam, the patient was able to move his
extremities antigravity to command off sedation.
On ___ C-spine Xray in traction and CTO demonstrated good
alignment of the fragment with minimal displacement. The
orthotic team was called to adjust the brace to place the
patient in more flexion in order to maintain alignment. His
exam and respiratory status improved and he was following
commands in all 4 extremities with good strength, very attentive
and interactive.
On ___ a trach and PEG was placed.
On ___ he weaned from the vent. He remains interactive,
attentive. Follows simple commands. Moves all extremities full
strength. He was screened and accepted to rehab and was
discahrged.
Medications on Admission:
-coumadin
-keppra 500mg BID
-tamsulosin 0.4mg qhs
-metoprolol succinate 100mg daily
-citalopram 20mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, T>38.5
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Citalopram 20 mg PO DAILY
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Fentanyl Citrate ___ mcg IV Q2H:PRN pain
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. LeVETiracetam Oral Solution 500 mg PO BID seizure d/o
13. Metoprolol Tartrate 50 mg PO BID HTN/hx of afib
hold if SBP<100
14. Piperacillin-Tazobactam 4.5 g IV Q8H
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Tamsulosin 0.4 mg PO HS
17. Warfarin 3 mg PO DAILY
goal INR ___. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
19. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Respiratory failure
C1/2 fracture
atrial fibrilation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dr. ___
Do not smoke
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Wear your hard cervical collar with thoracic extension vest at
ALL TIMES. sponge bath around the vest and collar.
YOU MAY NOT take the collar OFF at any time
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Coumadin may start ___ at a dose of 3 mg qd.
The goal INR is ___ for intermittent Atrial Fibrillation which
has been approved by Dr ___ and Dr ___
___ care physician).
The INR should be rechecked on ___ and the primary
care physician should be notified. The contact information is
Name: ___.
Location: PERSONAL PHYSICIANS HEALTH ___, P.C.
Address: ___, ___
Phone: ___
Fax: ___
Email: ___
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
10750092-DS-12
| 10,750,092 | 20,124,378 |
DS
| 12 |
2199-09-10 00:00:00
|
2199-09-10 19:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ M with Afib on coumadin, HTN, seizures,
h/o ICH and SDH in ___ w residual aphasia, recent admission to
neurosurgery for C1/C2 fracture ___ fall ___, discharged to
rehab with C-collar in place, now returning from home with 1day
of fever to 104 noted by ___.
He was taken to an OSH where neck CT showed an extensive
abscess. He was transferred to ___ for further care. Upon
arrival to the ED, his VS were T 98.8, HR 99, BP 109/70, RR 16,
SpO2 91% RA, and he was minimally responsive to voice, only
shaking head yes and no. Neurosurgery and general surgery was
consulted. Upon removal of the C-collar, approximately 30
maggots were encountered along a large anterior neck abscess
with necrotic tissue, and at the tracheostomy site. Per
neurosurgery note, the abscess spans the entire portion of the
anterior neck. The G-tube was also inspected and found to have 3
maggots at the site.
Labs in the ED showed WBC 5.6, N77, lactate 1.6, UA with 6 WBC
and few bacteria; CT of c-spine w/o significant change. The
patient became hypotensive to ___. Due to the extent of the
abscess and the patient's hypotension, goals of care were
discussed with the family with involvement of the PCP, and the
patient was made CMO.
On the floor, the patient is unarousable, and with his wife and
one of his sons present.
Past Medical History:
A-fib
HTN
Depression
H/o seizures
Hearing loss
Osteopenia
S/p CVA (ICH, ___ in ___
Sleep apnea
h/o Bell's palsy
GERD
Social History:
___
Family History:
CAD, depression
Physical Exam:
Physical Exam on Admission:
CMO
Physical Exam on Discharge:
-breathing comfortably on trach mask 5L02
-normal temperature to touch
-no tachypnea
-clean dressing over chest
Pertinent Results:
Labs on Admission:
___ 06:15PM BLOOD WBC-5.6 RBC-2.80* Hgb-9.1* Hct-27.2*
MCV-97 MCH-32.6* MCHC-33.6 RDW-13.5 Plt ___
___ 06:15PM BLOOD Neuts-77.8* Lymphs-13.5* Monos-8.0
Eos-0.3 Baso-0.3
___ 06:15PM BLOOD ___ PTT-29.9 ___
___ 06:15PM BLOOD Glucose-141* UreaN-32* Creat-1.2 Na-135
K-3.8 Cl-99 HCO3-28 AnGap-12
___ 06:15PM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
___ 06:22PM BLOOD Lactate-1.6
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 06:15PM URINE RBC-142* WBC-6* Bacteri-FEW Yeast-NONE
Epi-0
___ 6:15 pm URINE
URINE CULTURE (Final ___: NO GROWTH.
___ 5:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ yo man with h/o ICH and SDH, now with complicated neck
abscess, fever, hypotension, made CMO in ED.
# Comfort Measures Only. Patient was found to have anterior
neck abscoess, fever, and hypotension in the ED. He was
subsequently made CMO in the ED and admitted to the hospital for
comfort care. While in the hospital, patient initally received
IV morphine for pain. Upon discussion with patient and his
family, it is confirmed that patient would not want to have the
C-collar on, except during transfer to other facilities. In
addition, patient's wife feels that he would enjoy eating if he
is allowed. Patient current does not have any desire to eat or
feel hungry, but risk of aspiration and associated complications
were discussed with him and his family. He was allowed to take
food by mouth as he can tolerate. As his mental status improved
while in the hospital, he expressed symptoms of pruritis.
Patient was given Benadryl for symptom management. It is
thought that morphine is possibly contributing to his itching.
Palliative care was consulted for transition to inpatient
hospice and management of symptoms. Therefore, he was switched
to liquid oxycodone on the day of discharge, which can be
titrated up. Zyprexa was also started for agitation as Ativan
may have worsened his agitation. Scopolamine patch was
discontinued for concern of its effects on his agitation.
Patient was evaluated for wound care who recommended: 1. Sacral
wound: Mepilex to sacral coccyx ulcer. 2. Trach: cleanse
gently with saline then pat dry. Place Allevyn foam trach
sponges under tracheostomy and under the ties - can cut to
create rectangular pieces if desired. Change daily or BID to
manage drainage. Foley catheter was removed because of
discomfort, and he was bladder scanned and straight cathed.
However, Foley was replaced prior to transfer to inpatient
hospice, for comfort during the transfer.
# Sepsis. Based on initial presentation, likely ___ abscess
formation at the anterior neck. Given his goals of care, no
further studies were pursued. Patient was transitioned to
comfort measures only.
# C1/C2 fracture. Not a surgical candidate. Patient was off
C-collar while in the hospital per his preference. C-collar was
replaced only for the transfer to inpatient hospice, but this
can be removed upon arrival to inpatient hospice. Patient will
require 3 people assist with repositioning the patient,
including holding his head/neck in alignment with his body at
the time of repositioning/turning.
# Sacral decubitus. Getting wound care with Mepilex. This
should be continued.
Transitional Issues:
# Follow up: There are multiple follow up appointments set up
for the patient from previous admission. However, these
appointments can be rescheduled/cancelled as necessary
# Code status: DNR/DNI, Hospice
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Citalopram 20 mg PO DAILY
2. LeVETiracetam 1000 mg PO Q12
hold if SBP < 100.
3. Tamsulosin 0.4 mg PO HS
4. Calcium Carbonate 500 mg PO Q8H
5. Chlorhexidine Gluconate 0.12% Oral Rinse 0.5 oz ORAL Q12H
6. ferrous sulfate *NF* 308 mg Oral q12h
equivalent to 325 mg
7. Metoprolol Tartrate 50 mg PO Q12H
8. Pantoprazole 40 mg PO Q12H
9. Ranitidine 150 mg PO Q12H
10. Terazosin 10 mg PO HS
11. water *NF* 200 ml feeding tube TID
12. Acetaminophen 650 mg PO Q6H:PRN pain/fever
13. Albuterol 0.083% Neb Soln 1 NEB IH Q3H PRN SOB
14. Albuterol 0.083% Neb Soln 1 NEB IH TID
15. camphor-menthol *NF* ___ % Topical q6h prn itching
16. Vitamin D 1000 UNIT PO DAILY
17. Finasteride 5 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Senna 2 TAB PO DAILY:PRN constipation
20. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 1 tab Oral
BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Glycopyrrolate 0.2 mg IV Q6H:PRN secretion
4. Miconazole Powder 2% 1 Appl TP BID:PRN rash
5. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO Q6H PRN
agitation
6. OxycoDONE Liquid ___ mg PO Q4H CMO
hold if RR < 12
7. Sarna Lotion 1 Appl TP BID
8. Senna 2 TAB PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Comfort Measures Only
- Sepsis from neck wound/abscess
- Sacral decubitus
Secondary diagnosis:
- C1-C2 fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because of fever.
Your family and you decided that comfort is the most important
thing to maintain at this time. We gave you medications for
your fever, pain, and discomfort while you were in the hospital.
We had conversation about removing the C-collar so that it will
not make you uncomfortable and about eating by mouth, so that
you can enjoy food if you wish to. We also discontinued your
Foley catheter, because it was causing you a lot of discomfort.
You were bladder scanned and straight-cathed when there is a lot
of urine in your bladder. The palliative care team assisted
with transitioning you to inpatient hospice.
We stopped your medications that you were discharged with from
the hospital.
We started you on medications to make you comfortable. The list
to follow this letter is going to include your current
medication that you can use.
Followup Instructions:
___
|
10750124-DS-5
| 10,750,124 | 27,671,440 |
DS
| 5 |
2169-12-03 00:00:00
|
2169-12-03 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Seen in PCP's office on day of admission for decline in
functional status and generalized Right ___ pain and swelling
(per PCP note, calf circumferences 49 cm. RLE, 43 cm. LLE).
Per patient, he noticed leg pain and some difficulty walking
starting about 1 week ago. This has gotten progressively worse
and has been associated with leg swelling. The pain got bad
enough that he was unable to go to work. He also endorses some
abdominal pain that went along with the leg pain. Possibly this
was assoicated with some nausea and chest discomfort. Of note,
the history is somewhat difficult to obtain from the patient due
to cognitive functioning (per patient's brother he is at about a
___ grade level).
In the ED initial VS were 98.2 113 163/89 18 100%RA. Patient was
found to have profoundly large bilateral DVTs. Bedside
ultrasound showed moderate bilateral hydronephrosis with
significant hydroureter on right, and a huge bladder up to
umbilicus. Foley was placed with >2L of urine drained. Initial
labs significant for WBC 12.7, Na 131 K 7.6 Cl 93 HCO3 16 BUN
201 Cr 17.1, with mild improvement in the CHEM panel after foley
insertion.
On arrival to the floor, patient reports some leg pain, but is
otherwise feeling well.
Of note patient has had a rising PSA over the past ___ years (2.9
___ up to 4.7 ___. He has been evaluated by Urology who
were considering prostate biopsy nonurgently. He was seen in ___
clinic on ___ for increased urinary frequency and incontinence;
prostate thought to be enlarged and mildly tender on exam;
patient was started on cipro 500mg BID (planned for 14-day
course) for presumed prostatits.
REVIEW OF SYSTEMS:
Positive for increased urinary frequency. Denies fever, chills,
night sweats, headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
-Autism
-LUTS (increased daytime urinary frequency)
-Elevated PSA (4.3 on ___
Social History:
___
Family History:
- Unable to accurately obtain from the patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================================
VS: 98.1 123/87 96 20 100%RA
General: Awake, alert, conversant. Sitting up in bed, in no
acute distress.
HEENT: PERRL. Sclera nonicteric. MMM.
Neck: No LAD.
CV: Tachycardic in the ___, regular rhythm. No murmur
appreciated though heart sounds somewhat difficult to
distinguish.
Lungs: CTA b/l. Patient cannot fully participate in the exam
(does not understand how to take deep breaths).
Abdomen: BS+. Soft, nondistended. Intitial RLQ tenderness to
palpation, though on repeat was not there. Otherwise nontender.
GU: Foley in place. Draining fruit punch colored urine.
Ext: ___ in ACE. Significant edema in both R>>L,
extending into the thighs. DP pulses intact b/l; pt able to
wiggle toes. ?pitting edema in UEs bilaterally.
Neuro: AOx3. CN2-12 grossly intact. Able to move all four
extremities.
Skin: No rash noted.
DISCHARGE PHYSICAL EXAM:
==================================
Pertinent Results:
LABS:
===============================
___ 11:35AM BLOOD WBC-12.7*# RBC-4.25* Hgb-13.5* Hct-40.0
MCV-94 MCH-31.8 MCHC-33.8 RDW-13.8 Plt ___
___ 11:35AM BLOOD Neuts-89.8* Lymphs-4.0* Monos-4.5 Eos-0.9
Baso-0.8
___ 11:35AM BLOOD ___ PTT-31.8 ___
___ 11:35AM BLOOD Glucose-176* UreaN-201* Creat-17.1*#
Na-130* K-7.6* Cl-93* HCO3-16* AnGap-29*
___ 11:35AM BLOOD Calcium-7.9* Phos-11.5* Mg-3.8*
___ 01:09PM BLOOD K-5.7*
___ 10:40AM BLOOD Glucose-120* UreaN-19 Creat-1.1 Na-143
K-3.8 Cl-105 HCO3-27 AnGap-15
___ 10:40AM BLOOD WBC-14.1* RBC-3.78* Hgb-11.6* Hct-36.2*#
MCV-96 MCH-30.8 MCHC-32.1 RDW-13.8 Plt ___
IMAGING:
===============================
B/L Lower Extremity U/S (___):
FINDINGS:
LEFT: Total occlusion of the venous system in the left lower
extremity from
the proximal femoral vein to the popliteal vein and calf veins
which are
distended. Nearly total occlusion of the common femoral vein
which is not
compressible but shows a sliver of flow with spectral Doppler
imaging. The
greater saphenous vein is patent.
RIGHT: Total occlusion of the venous system in the right lower
extremity from the common femoral vein to the popliteal vein and
posterior tibial veins which are also distended suggesting
acuity. Peroneals not seen. The greater saphenous vein is also
occluded.
IMPRESSION:
Extensive bilateral lower extremity DVT. For details please
refer to the body of the report.
B/L Upper Extremity U/S (___):
IMPRESSION: No upper extremity DVT.
ECHO (TTE) (___):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (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 pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved global
biventricular cavity size and function. Increased left
ventricular filling pressure. No clinically significant valvular
disease. Indeterminate pulmonary artery systolic pressure.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST (___):
IMPRESSION:
1. Lingular segmental pulmonary embolism with questionable tiny
subsegmental emboli in the right upper lobe. Appearance of
filling defect at the junction of the inferior vena cava and
right atrium is
artifactual from inflow from the IVC. No evidence of
malignancy.
2. Known extensive bilateral deep vein thromboses have cephalad
extent to
bilateral external iliac veins.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
===============================================
___ y/o male with a PMHx of autism and elevated PSA presents from
clinic with right lower extremity pain and swelling, found to
have massive bilateral ___ DVTs. Also acute renal failure,
obstructive picture.
ACTIVE ISSUES:
===============================================
# Bilateral ___ DVTs: Patient presented to his PCP's office with
significant lower extremity pain and swelling. In the ED found
to have massive b/l ___ DVTs. Labs were also significant for
acute renal failure (BUN/Cr 202/17, baseline Cr 1.0). Foley
catheter was inserted with immediate drainage of >2L urine. He
was admitted and started on heparin drip. Patient was
tachycardic, but normal blood pressure and oxygen saturations,
EKG with flattened T-waves in lead III, concerning for early
right heart strain. ECHO was performed the following morning,
negative for right heart strain. Kidney funtion improved to
baseline within 3 days. He underwent CTA of the chest as well as
CT abd/pelv with contrast. This was significant for lingular
segmental pulmonary embolism with questionable tiny subsegmental
emboli in the right upper lobe. There was no sign of malignancy
on CT scan; the ___ DVTs had cephalad extent to bilateral
external iliac veins. Vascular Surgery was consulted, who did
not advise IVC filter placement. The patient had improvement in
lower extremity pain and swelling, he was switched from heparin
drip to daily Lovenox injections (1.5mg/kg/day). Lovenox (as
opposed to warfarin) was felt to be a better choice for patient
compliance. He was discharged to an extended care facility, with
a long-term plan for daily visiting nursing services for
assistance once he is discharged to home.
# Acute renal failure: Upon presentation, patient had BUN/Cr of
202/17. Insertion of foley catheter resulted in immediate
drainage of >2L urine. His renal function returned to baseline 2
days after insertion of catheter. He had post-obstruction
diuresis for several days following initial drainage, requiring
IVF boluses and electroylte repletion. Urology was consulted who
recommended foley be kept in place for at least 1-week, with
removal as an outpatient with trial of voiding in the office.
Given his history of elevated PSA as well as elarged prostate on
CT scan, Urology also recommended the patient be started on
tamsulosin, thus he was started on 0.4mg qHS.
# Sinus tachycardia: Patient had persistent tachycardia (HRs
90-120s), sinus rhythm. This was thought to be due to his known
PEs, as well as dehydration from post-obstructive uropathy
(tachycardia improved somewhat with IVFs). ECHO performed ___
showed no signs of right heart strain. Upon discharge HR was
90-110s.
# Prostatitis: Patient had been diagnosed as outpatient prior to
admission on ___. He had been started on Cipro 500mg BID. Upon
admission this was renally dosed to 250mg BID and later returned
to 500mg BID when renal funtion normalized. He had no prostate
abscess seen on CT torso. He should continue his Cipro at 500mg
BID after discharge, with a last day of ___ (which will
complete a 21-day course).
# Health care decision making: Patient has cognitive impairment,
and was not able to make decisions about complicated medical
care. His brother ___ signed a Health Care Proxy form om
___.
TRANSITIONAL ISSUES:
===============================================
- Needs foley removal and trial of voiding within ___ days
post-discharge.
- Started on tamsulosin 0.4mg at night.
- Discharged on Lovenox ___ daily (1.5mg/kg/day) injection.
- Needs 2 more days of Cipro for 21-day course of prostatitis
(last day ___.
- Pt had a few nocturnal oxygen desaturations that were
transient. ___ benefit from outpatient sleep study.
- Patient will need to have ready access to fluids; please
encourage PO intake to ensure proper renal functioning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
**Last day of this medication is ___.
2. Enoxaparin Sodium 135 mg SC DAILY Start: ___, First
Dose: First Routine Administration Time
3. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral lower extremity deep vein thrombosis
Obstructive uropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ for right and
left leg blood clots (deep vein thromboses). You were initially
treated with a medication to thin your blood called heparin;
this was changed to Lovenox. You will need to continue the daily
Lovenox injections until instructed to stop by your Primary Care
Physician.
You also had a foley catheter placed to help you urinate. You
will need to be seen in the ___ to have this catheter
removed.
It was a pleasure to meet and care for you. We wish you all the
best.
-Your ___ team
Followup Instructions:
___
|
10750235-DS-6
| 10,750,235 | 29,688,097 |
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| 6 |
2126-03-25 00:00:00
|
2126-03-25 11:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left patella fracture, left proximal humerus fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation left patella fracture
History of Present Illness:
Mrs. ___ is a ___ who presents after a mechanical fall
after slipping on ice. She denies headstrike or LOC. She denies
neck pain or back pain. She reports left knee pain and shoulder
pain. She presented to outside hospital where imaging
demonstrated patella fracture and proximal humerus fracture. No
numbness or tingling. No other injuries.
Past Medical History:
HTN
Hx of Afib
Social History:
___
Family History:
noncontributory
Physical Exam:
Gen: elderly female in no acute distress
Neuro: alert and interactive
CV: palpable DP pulses bilaterally
Pulm: no respiratory distress on room air
LLE: in knee immobilizer, palpable DP, toes WWP, SILT:
___, fires ___, incision CDI
LUE: in cuff and collar, SILT: AMRU, fires EPL/FPL/DIO, palpable
radial pulse, no gross deformity
Pertinent Results:
___ 06:20AM BLOOD WBC-11.6* RBC-3.60* Hgb-10.4* Hct-32.5*
MCV-90 MCH-28.9 MCHC-32.0 RDW-12.8 RDWSD-42.2 Plt ___
___ 06:20AM BLOOD Glucose-123* UreaN-16 Creat-0.7 Na-140
K-4.2 Cl-103 HCO3-22 AnGap-19
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 patella fracture, left proximal humerus fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for open reduction
internal fixation left patella 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
weight-bearing as tolerated in the left lower extremity in a
___ locked in extension, 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:
Calcium Carbonate 500 mg PO TID
Diltiazem Extended-Release 360 mg PO DAILY
Losartan Potassium 50 mg PO BID
Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours as needed for constipation Disp #*15 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC Q24H
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily Disp #*14
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed for pain Disp #*40 Tablet Refills:*0
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
RX *prochlorperazine maleate [Compazine] 5 mg 2 tablet(s) by
mouth every 6 hours as needed for nausea Disp #*20 Tablet
Refills:*0
6. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tablets by mouth daily as needed
for constipation Disp #*16 Tablet Refills:*0
7. Calcium Carbonate 500 mg PO TID
8. Diltiazem Extended-Release 360 mg PO DAILY
9. Losartan Potassium 50 mg PO BID
10. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
left proximal humerus fracture, left patella 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 in knee
immobilizer at all times. Non-weight bearing left upper
extremity in cuff and collar when upright, ROMAT left elbow and
wrist - please range at least TID.
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 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.
- 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
Physical Therapy:
weight-bearing as tolerated left lower extremity in knee
immobilizer at all times, non-weight-bearing left upper
extremity in cuff and collar when upright. Range of motion as
tolerated left elbow and wrist at least three times per day.
Followup Instructions:
___
|
10750448-DS-6
| 10,750,448 | 27,741,089 |
DS
| 6 |
2150-04-29 00:00:00
|
2150-04-29 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
3 days ago started having severe pain in rectum "deep". felt
like
"she was having a baby". ___. pain worse with trying to
defecate, but did not resolve when she was off commode. there
all
the time. after 3 days felt she had to come in.
When I saw her in am, pain had resolved. received morphine in ED
last night. slept well and ate breakfast without an issue.
also associated with bloating feeling and nausea when she eats.
has not been eating well, lost 5lbs, not drinking. feels very
weak when she stands up. fell 2x in last week when she lost her
balance. no ns, fevers. blood in stool.
complains of constant dry mouth
hx of constipation, but never severe or had symptoms similar
12 pt ROS otherwise negative
Past Medical History:
BREAST CANCER
Breast CA s/p lumpetomy in ___ (invasive tubular adenoCA grade
___, ER/PR+, Her 2 neu neg, -LVI, - margins), declined XRT,
previously taking arimidex. Annual mammogram due in ___.
CARPAL TUNNEL SYNDROME
CATARACTS
DAUGHTER ___ ___
___
DUODENAL ULCER
GASTROESOPHAGEAL REFLUX
HEMORRHOIDS
HYPERTENSION
HYPOTHYROIDISM
LEG EDEMA
OSTEOARTHRITIS
SPINAL STENOSIS
STROKE ___ -Left sided deficit
URINARY INCONTINENCE
VARICOSE VEINS
VERTIGO AND DISEQUILIBRIUM
CERVICAL SPONDYLOSIS
HYPERCHOLESTEROLEMIA
DIABETES MELLITUS
Social History:
___
Family History:
no abd issue
Physical Exam:
afeb 132/63 578-77 98-99% RA
CONS: NAD, comfortable, very anxious
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-distended, bowel sounds present, no rebound
tenderness or guarding, mild TTP in epigastrum
GU- no foley
no anal fissure, tear, healed hemorrhoids, rectal exam
reproduced
pain, large amount of stool in rectal vault,
disimpacted and removed large amount of stool, no blood
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, felt very
weak when she stood up. unwilling to take a step because she was
afraid she would fall.
Pertinent Results:
labs normal except slightly elevated glucose
===========================
ADMISSION ABDOMINAL CT SCAN:
IMPRESSION:
1. No acute intra-abdominal process.
2. Moderate amount of stool is noted in the colon and rectum.
Brief Hospital Course:
___ admitted with rectal pain.
#Based on CT/exam (large amount of stool in vault and pain
reproduced on exam) Likely due to impacted stool. After
disimpaction felt better. Pain recurred and with enema several
large bowel movements. Since that point no recurrence of rectal
pain.
Start miralax. After touching base with PCP stopped ___ of her
meds that she was neither taking or intermittently.
Anti-cholinergic effect of meds for urinary incontinence might
have been culprit.
Did have intermittent epigastric/chest pain/bloating. Unclear
whether related to constipation. Did check EKG/CXR/troponin.
Improved with simethicone.
Would recommend also checking TSH in case contributing to
constipation.
# HTN - did have elevated BP in morning before taking meds.
Recommend takes ACE at night and beta blocker in morning. SBP in
160's but did not increase meds given age and wide pulse
pressure and concern about weakness and falls.
#DM - continue home metformin. glucoses reasonable
#Hyponatremia - mild. with hydration resolved from 132 -> 139
#Weakness - attributed to poor POs for some time and not getting
out of bed. ___ eval felt unsafe to go home and therefore
transfer to rehab.
# Anxiety - during hospital stay, patient became very worried
about many issues - BP, headache, abd pain and idea of going to
rehab. Per family this is baseline.
#TRANSITION
- check TSH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Hydrocortisone Acetate Suppository 1 SUPP PR TID pain
7. Allopurinol ___ mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. NexIUM (esomeprazole magnesium) 20 mg oral Q24H
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Gabapentin 600 mg PO QHS
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. Vesicare (solifenacin) 5 mg oral Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Hydrocortisone Acetate Suppository ___ID:PRN
pain/itching
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Lisinopril 10 mg PO QHS
Please give in evening.
6. Metoprolol Succinate XL 50 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Simethicone 80 mg PO QID:PRN gas/epigastric pain
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Constipation
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:
___, we believe your severe pain in your rectum was due to
constipation. After you were disimpacted and you had the enema
you felt better. Stopping some medications and taking a fiber
every day will help prevent this from happening in future.
You were very weak and we have sent you to a rehab to become
stronger.
Followup Instructions:
___
|
10750448-DS-7
| 10,750,448 | 25,789,654 |
DS
| 7 |
2151-02-20 00:00:00
|
2151-02-20 16:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Open reduction internal fixation, bimalleolar ankle fracture
History of Present Illness:
___ y/o F h/o HTN, GERD, presents s/p mechanical fall at home
with UTI, Tib-fib fx (non-displaced), medial malleolar fx,
admitted to medicine because fractures are non-operative and
trauma survey complete per trauma and orthopaedic consult in ER.
Patient says she was ambulating to her small bathroom at home
and had to leave her walker outside the bathroom due to small
size and she fell. No LOC, no pre-syncope, palpitations,
shortness of breath, chest pain. No history of seizures. She
does endorse some urinary incontinence for the last ___ days
that is new for her. She has been having some suprapubic pain.
No hematuria, dysuria, flank pain, fevers, chills. She was
feeling generally well prior to her fall. She was given CTX and
IVF in ER and admitted after having ortho/trauma consults. She
feels okay on the floor save for RLE pain.
Past Medical History:
BREAST CANCER
Breast CA s/p lumpetomy in ___ (invasive tubular adenoCA grade
___, ER/PR+, Her 2 neu neg, -LVI, - margins), declined XRT,
previously taking arimidex. Annual mammogram due in ___.
CARPAL TUNNEL SYNDROME
CATARACTS
DAUGHTER ___ ___
___
DUODENAL ULCER
GASTROESOPHAGEAL REFLUX
HEMORRHOIDS
HYPERTENSION
HYPOTHYROIDISM
LEG EDEMA
OSTEOARTHRITIS
SPINAL STENOSIS
STROKE ___ -Left sided deficit
URINARY INCONTINENCE
VARICOSE VEINS
VERTIGO AND DISEQUILIBRIUM
CERVICAL SPONDYLOSIS
HYPERCHOLESTEROLEMIA
DIABETES MELLITUS
Social History:
___
Family History:
Reviewed and found to be not relevant to admission for fall and
fracture
Physical Exam:
ADMISSION EXAM:
Afebrile and vital signs stable (reviewed in bedside record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, no JVD
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing trace edema, RLE wrapped in
splint/ace bandage. No obvious deformity.
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ in upper extremity not
tested in RLE. fluent speech.
Psychiatric: pleasant, appropriate affect
GU: Has foley catheter in place with clear urine
Exam on Discharge
Afebrile, aVSS
HEENT: NC/AT, mildly uncomfortable
CV: RRR, no m/r/g
RESP: Breathing comfortably, CTA
ABD: soft, BS present, nontender
EXT: distal RLE with ACE wrap in place, SILT in R toes, able to
move R toes; no swelling of the R knee noted
NEURO: Alert
Pertinent Results:
Admission Labs:
___ 09:30AM BLOOD WBC-11.7* RBC-4.82 Hgb-13.9 Hct-42.8
MCV-89 MCH-28.8 MCHC-32.5 RDW-14.0 RDWSD-45.2 Plt ___
___ 09:30AM BLOOD Neuts-82.1* Lymphs-8.5* Monos-8.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.62*# AbsLymp-1.00*
AbsMono-0.97* AbsEos-0.03* AbsBaso-0.04
___ 09:30AM BLOOD ___ PTT-32.7 ___
___ 09:30AM BLOOD Glucose-176* UreaN-19 Creat-1.1 Na-131*
K-6.9* Cl-94* HCO3-23 AnGap-21*
Discharge Labs:
___ 06:40AM BLOOD WBC-8.7 RBC-3.45* Hgb-10.0* Hct-31.8*
MCV-92 MCH-29.0 MCHC-31.4* RDW-14.2 RDWSD-47.9* Plt ___
___ 06:45AM BLOOD Glucose-141* UreaN-18 Creat-0.9 Na-135
K-5.5* Cl-95* HCO3-25 AnGap-21*
___ 09:54AM URINE Color-Straw Appear-Hazy Sp ___
___ 09:54AM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 09:54AM URINE RBC-7* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
URINE CULTURE (Final ___:
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
RLE Films - IMPRESSION: Acute minimally displaced fractures
involving the proximal and distal shaft of the fibula without
involvement of the syndesmosis/ankle. Minimally displaced
fracture of the medial malleolus. Significant soft tissue
edema.
CT A/P - IMPRESSION:
1. Cystitis with inflammation with left-sided ascending
infection through the level of the left renal pelvis.
Correlation with symptoms and urinalysis is recommended.
2. No evidence of acute fracture or acute malalignment of the
visualized thoracolumbar spine.
3. Unchanged multilevel degenerative changes of the visualized
thoracolumbar spine.
MRI L Spine - IMPRESSION:
1. No definite evidence of lumbar spine fracture. STIR signal
hyperintensity along the superior endplate of L5. This more
likely reflects ___ type 1 degenerative change rather than a
small superior endplate fracture.
2. Severe multilevel degenerative changes, as described above,
most pronounced at L2-3 where a disc protrusion and facet
osteophytes produce severe vertebral canal and moderate to
severe bilateral neural foramen narrowing.
3. Post L3-4 and L4-5 laminectomy. Mild associated enhancing
granulation tissue.
Video Swallow -
Exam extremely limited by patient mobility and body habitus.
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was no gross aspiration.
There was a single episode of penetration with thin consistency
liquids.
Brief Hospital Course:
___ y/o F with mechanical fall w/ resulting tib/fib fx, as well
as probable UTI.
# FALL
# RIGHT TIB FIB FRACTURE: Ortho was involved. She was taken to
the OR on ___ for open reduction internal fixation of
bimalleolar ankle fracture with assessment of external rotation
stress test under fluoroscopy for mortise stability. She also
underwent fixation of syndesmosis to increase overall construct
rigidity and very osteoporotic bone. She is being discharged on
standing Tylenol and PRN oxycodone for pain control. She will
follow up in ___ clinic 14 days post-op. She remains NWB
to the RLE until f/u. She is being discharged to rehab for acute
___, expected length of stay is less than 30 days.
# UTI: Culture growing pan-sensitive e.coli. She was treated
with ceftriaxone x 7 days.
# DYSPHAGIA: Pt endorsed coughing with eating / taking pills.
She was evaluated by SLP who noted coughing with solids only,
raising concern for possible diverticulum. However, she
underwent video swallow which did not show any concerning
findings. She should follow up with GI as an outpatient.
# NAUSEA with VOMITING: Pt initially had some nausea that was
attributed to anesthetic agents given ___. However,
given recurrent episodes of nausea/vomiting after returning from
studies, symptoms ultimately seemed more related to motion
sickness in the setting of transport (family reported
longstanding history of significant motion sickness). She was
maintained on home PPI, as well as PRN Zofran. She was also
given Ranitidine for GERD symptoms. At discharge, she was
written for Dramamine to be given prior to transport. Would
consider giving her Dramamine prior to transport for
appointments.
# FALL: Appears mechanical in nature as patient had no prodromal
symptoms save for urinary incontinence likely related to UTI
above. No LOC, pre-syncope, palpitations.
# HTN: Continued Metoprolol 50mg ER. Home lisinopril was held
and was not restarted on discharge as BP was not elevated during
admission.
# DM: Metformin held in house, restarted on discharge.
# GOUT: On home allopurinol
# HLD: On home statin.
# GERD: On home PPI.
TRANSITIONAL ISSUES:
- PLEASE REPEAT POTASSIUM ON ___. Potassium was mildly
elevated on the day during hospitalization (5.5) without any
concerning ECG changes. If potassium remains elevated, pt may
require treatment of hyperkalemia.
- Ortho follow up on ___
- Consider Dramamine prior to transport for appointments
- Pt should f/u with GI for further evaluation of her dysphagia
- Lisinopril held on discharge. BP should be trended and BP
regimen adjusted as needed.
- Lovenox for 14 days following surgery
Admission is anticipated to be <30 days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Lisinopril 10 mg PO QHS
5. Metoprolol Succinate XL 50 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. Gabapentin 300 mg PO BID
12. Oxybutynin 15 mg PO EXTENDED RELEASE FORMULATION
13. Sertraline 25 mg PO DAILY
14. Aspirin EC 81 mg PO DAILY
15. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
16. Loratadine 10 mg PO DAILY cough
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. Calcium Carbonate 500 mg PO TID
3. DimenhyDRINATE 50 mg PO DAILY:PRN prior to transport
4. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
Start: ___, First Dose: Next Routine Administration Time
Last day ___. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4HR Disp #*15 Tablet
Refills:*0
6. Senna 17.2 mg PO HS
7. Vitamin D 800 UNIT PO DAILY
8. Acetaminophen 650 mg PO Q6H
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Allopurinol ___ mg PO DAILY
11. Aspirin EC 81 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Gabapentin 300 mg PO BID
15. Levothyroxine Sodium 88 mcg PO DAILY
16. Loratadine 10 mg PO DAILY cough
17. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Omeprazole 20 mg PO DAILY
20. Oxybutynin 15 mg PO EXTENDED RELEASE FORMULATION
21. Polyethylene Glycol 17 g PO DAILY
22. Sertraline 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mechanical fall
Right leg tib-fib fracture
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to the hospital after you suffered a fall and a
fracture of your right leg. You were evaluated by the Orthopedic
surgery team and they recommended surgical fixation of your R
ankle. You were also found to have a urinary tract infection
and were treated with intravenous antibiotics. You are now being
discharged to rehab.
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 RLE
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 2 weeks post-operation
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
Followup Instructions:
___
|
10750562-DS-8
| 10,750,562 | 22,391,626 |
DS
| 8 |
2148-10-20 00:00:00
|
2148-10-20 18:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Visual field deficits with associated word-finding difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology Initial Consult Note
***Not code stroke, symptom onset >36hrs***
___ Stroke Scale Score: 2
t-PA administered:
[x] No - Reason t-PA was not given or considered: LKW > 36hrs,
NIHSS2
Thrombectomy performed:
[x] No - Reason not performed or considered: LKW > 36hrs,
NIHSS2,
no large vsl occlusion
NIHSS performed within 6 hours of presentation at: ___, 2200
NIHSS Total: 2
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 1 (right inferior quadrantopsia)
4. Facial palsy: 1 (slight right NLFF)
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: visual changes, word-finding difficulty
HPI:
___ is an ___ year old ___ former ___
with diabetes, hypertension, and diagnosis of focal seizures
with
impaired awareness for which he is maintained on keppra, who
presents for evaluation of 2-days of visual changes followed by
intermittent word-finding difficulty. History obtained by his
daughters at bedside with supplementation from ___.
His daughters, one of which is a ___, spent time with their
father
yesterday and ___ notice anything wrong. However, this
morning, they received a call from their mother saying that
___ has been in a brain fog for the past two days, with
intermittent word-finding difficulty. This word-finding
difficulty was slightly different than the speech arrests that
were thought to be semiology for his focal seizures with
impaired
awareness, as he was frequenting paraphasic errors this morning
rather than stopping to speak intermittently. He also appeared
slightly confused this morning, as he tried to check his blood
sugar and at one point became confused and was unsure if he
should inject with insulin or check his blood sugar. The
daughters heard this and went to visit and ___ then endorsed
that for the past two days he has been seeing a cut in his
visual
field on the right hand side. The daughters also noticed at this
time that he was having some difficulty ending his sentences.
His
gait was also described as more sluggish. His neurologist, Dr.
___, was called and recommended ED evaluation. His blood
sugars were notably normal the past two days. He felt that
something was off so he took 2 baby aspirins a day for the past
two days.
Regarding his prior neurological history, his daughters report
that he carries an unclear diagnosis of focal seizures with
impaired awareness and has been symptom free on keppra for ___
years. He was initially diagnosed with this in ___ after
presenting with transient speech arrest with MRI negative for
stroke and EEG demonstrating left temporal slowing. He was
initially maintained on trileptal but ultimately transitioned to
keppra. His daughters report that he has been symptom free for
years and keppra dose has remained unchanged.
At baseline, he is described as very active ___ year old who
bikes
miles and miles when it is not snowing or icing. To their
chagrin, he rarely wears a helmet.
ROS:
Notable for above findings, otherwise noncontributory. no signs
of infection, sickness leading to this event.
Past Medical History:
1. Benign prostatic hypertrophy.
2. Prostate cancer s/p prostatectomy in ___
3. Coronary artery disease s/p stents to LAD and diagonal ___
4. Insulin dependent-diabetes mellitus.
5. Hypothyroid.
6. Status post partial thyroidectomy in ___, hypothyroidism.
7. Status post release of Dupuytren's contracture of right
fifth finger.
8. Status post cystoscopy
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
===============
Vitals:
General: Pleasant and interactive
HEENT: no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: warm
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
eloquent speech (and without significant distraction. He is
attentive to examiner and to his daughters and is able to follow
midline and appendicular commands. Language is fluent with
intact
repetition and comprehension. Normal prosody. He has frequent
paraphasic errors, referring to glasses as goggles. Able to name
high frequency objects but has some difficulty with
low-frequency
objects ("blood pressure" for "stethoscope"). Able to read my ID
badge without difficulty. No dysarthria. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves: Slight right ptosis with strong eye closure.
PERRL 3>2. EOMI without nystagmus. Right inferior quadrantopsia
to finger counting and finger wiggle. Slight right NLFF with
symmetric activation. Speech is not dysarthric.
-Motor: Slightly increased tone with augmentation on left.
Resting tremor on left. Bilateral dupytren's contractures. No
pronator drift.
[___]
L 5 5 5 5 * * 5 5 5 5 5 5
R 5 5 5 5 * * 4 5 5 5 5 5
*bilateral dupytren's contractures
-Sensory: Diminished sensation to pinprick, vibration in
stocking-glove distribution. No extinction to DSS.
-Reflexes:
Plantar response was extensor bilaterally.
-Coordination: Reduced movement amplitude with left hand opening
compared to right. FNF intact bilaterally.
DISCHARGE EXAM:
===============
VS: Temp: 97.5 (Tm 98.3), BP: 155/77 (112-155/64-83), HR: 69
(69-86), RR: 18 (___), O2 sat: 96% (95-97), O2 delivery: RA
Exam:
General: Pleasant and interactive, EEG in place
HEENT: no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: warm
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to location by hospital and
name.
___ to month. Naming of high and low frequency objects
intact. +snout, +suck, no grasp or palmomental.
-Cranial Nerves: Slight right ptosis with strong eye closure.
PERRL 3>2 sluggish. EOMI without nystagmus. Right inferior
quadrantanopia to finger counting and finger wiggle this
morning.
Slight right NLFF with symmetric activation. Speech is slightly
dysarthric.
-Motor: Slightly increased tone with augmentation on left and
right. Resting tremor on left. Bilateral dupytren's
contractures.
No pronator drift.
[___]
L 5 5 5 5 * * 5 5 5 5 5 5
R 5 5 5 5 * * 4 5 5 5 5 5
*Bilateral dupytren's contractures
Slow finger tapping
Paratonia noted
-Sensory: Deferred this AM
-Reflexes: Deferred this AM
-Coordination: Reduced movement amplitude with left hand opening
compared to right. FNF intact bilaterally.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:50PM GLUCOSE-170* UREA N-21* CREAT-0.9 SODIUM-139
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-9*
___ 04:50PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-183
CK(CPK)-43* ALK PHOS-98 TOT BILI-0.5
___ 04:50PM CK-MB-2 cTropnT-<0.01
___ 04:50PM ALBUMIN-3.6 CHOLEST-120
___ 04:50PM %HbA1c-9.0* eAG-212*
___ 04:50PM TRIGLYCER-91 HDL CHOL-28* CHOL/HDL-4.3
LDL(CALC)-74
___ 04:50PM TSH-4.9*
___ 04:50PM T4-5.1 T3-75*
___ 04:50PM WBC-4.0 RBC-4.30* HGB-13.2* HCT-40.1 MCV-93
MCH-30.7 MCHC-32.9 RDW-11.9 RDWSD-40.5
___ 04:50PM NEUTS-65.4 ___ MONOS-10.1 EOS-4.7
BASOS-0.5 IM ___ AbsNeut-2.64 AbsLymp-0.77* AbsMono-0.41
AbsEos-0.19 AbsBaso-0.02
___ 04:50PM PLT COUNT-162
___ 04:50PM ___ PTT-32.3 ___
___ 10:14PM URINE HOURS-RANDOM
___ 10:14PM URINE UHOLD-HOLD
___ 10:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:14PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:45PM LACTATE-2.0
___ 08:32PM %HbA1c-8.9* eAG-209*
___ 08:13PM GLUCOSE-303* UREA N-21* CREAT-0.9 SODIUM-135
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-26 ANION GAP-12
___ 08:13PM estGFR-Using this
___ 08:13PM ALT(SGPT)-12 AST(SGOT)-29 ALK PHOS-116 TOT
BILI-0.3
___ 08:13PM cTropnT-<0.01
___ 08:13PM CK-MB-3
___ 08:13PM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-1.9
___ 08:13PM TSH-10*
___ 08:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 08:13PM WBC-4.7 RBC-4.51* HGB-14.0 HCT-43.4 MCV-96
MCH-31.0 MCHC-32.3 RDW-11.9 RDWSD-41.7
___ 08:13PM NEUTS-68.0 LYMPHS-18.6* MONOS-9.2 EOS-3.4
BASOS-0.6 IM ___ AbsNeut-3.17 AbsLymp-0.87* AbsMono-0.43
AbsEos-0.16 AbsBaso-0.03
___ 08:13PM PLT SMR-NORMAL PLT COUNT-165
___ 08:13PM ___ PTT-30.9 ___
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-3.9* RBC-4.50* Hgb-14.0 Hct-42.4
MCV-94 MCH-31.1 MCHC-33.0 RDW-11.9 RDWSD-40.7 Plt ___
___ 06:00AM BLOOD Glucose-75 UreaN-18 Creat-0.9 Na-141
K-3.9 Cl-101 HCO3-30 AnGap-10
___ 04:50PM BLOOD ALT-10 AST-13 LD(LDH)-183 CK(CPK)-43*
AlkPhos-98 TotBili-0.5
___ 06:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
___ 04:50PM BLOOD %HbA1c-9.0* eAG-212*
___ 04:50PM BLOOD Triglyc-91 HDL-28* CHOL/HD-4.3 LDLcalc-74
IMAGING:
========
CT Head ___:
Small area of hypodensity with loss of gray-white matter
differentiation in the left occipital lobe suspicious for an
infarct, potentially subacute. MRI may help further establish
chronicity. Otherwise, no change from prior.
CXR ___:
No acute cardiopulmonary process
CTA Head/Neck ___:
1. No flow limiting stenosis, occlusion, or aneurysm greater
than 3 mm within the circle of ___ and its principal
intracranial branches.
2. No flow-limiting stenosis, occlusion, or evidence of
dissection within the carotid and vertebral arteries and their
major branches within the neck.
3. Patent dural venous sinuses.
4. There is an irregular area of opacification within the right
upper lobe
measuring approximately 2.9 cm in the AP plane which extends
from the edge of the scan plane at the level of the T6 vertebra
to the right lung apex. Its appearance appears most like
scarring, although if not previously known, CT follow-up in 3
months is recommended.
5. There is chronic calcified biapical pleuroparenchymal
scarring.
MRI Head without contrast ___:
1. Small patchy acute infarctions in the left occipital lobe.
2. No evidence of hemorrhage.
3. Moderate parenchymal volume loss. Additional findings as
described above.
TTE ___:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional and global
left ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 59 %. There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. 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 tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. High normal estimated
pulmonary artery systolic pressure. No definite structural
cardiac source of embolism identified.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is an ___ year old man with poorly controlled diabetes,
hypertension, CAD, focal seizures with impaired awareness
maintained on Keppra who developed visual field deficits with
associated word-finding difficulty culminating in presentation
to ED.
His exam was notable for slight right ptosis, right nasolabial
fold flattening with symmetric activation, right inferior
quadrantanopia, and snout reflex. He also has slight rigidity
with augmentation maneuvers in ___ upper extremities which had
not been noted previously.
___ demonstrated a hypodensity in the left occipital lobe
consistent with clinical findings and suggestive of subacute
infarct. CTA reassuringly without large vessel occlusion and
without signs of flow-dependent perfusion. MRI showed small
patchy acute infarctions in the left occipital lobe with no
evidence of hemorrhage.
Etiology possibly cardioembolic though no atrial fibrillation
was detected while on telemetry. He was discharged with a
Ziopatch for continuous monitoring for 2 weeks.
Due to moderate intracranial atherosclerosis, the patient was
started on Plavix 75 mg daily as per CHANCE trial (21 days of
dual antiplatelet therapy with aspirin and Plavix) in addition
to aspirin 81 mg daily. LDL was 74 and thus atorvastatin was
increased from 10 mg to 40 mg QHS.
Hemoglobin A1c was 9.0%. ___ was consulted. Patient and wife
received counseling from ___ regarding prior to discharge.
Of note, patient had episodes of confusion which were evaluated
with EEG. Likely delirium as EEG showed left temporal slowing
but no evidence of seizures.
TRANSITIONAL ISSUES:
====================
# Patient discharged with Ziopatch for continuous heart
monitoring for 2 weeks. Patient should return via mail.
# Patient discharged on increased dose of atorvastatin 40 mg
QHS.
# Patient discharged on reduced dose of insulin 18 U QAM.
# Plavix 75 mg daily as per CHANCE trial (21 days of dual
antiplatelet therapy with aspirin and Plavix) in addition to
aspirin 81 mg daily.
# There is an irregular area of opacification within the right
upper lobe measuring approximately 2.9 cm in the AP plane which
extends from the edge of the scan plane at the level of the T6
vertebra to the right lung apex. Its appearance appears most
like scarring, although if not previously known, CT follow-up in
3 months is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
5. LevETIRAcetam 500 mg PO DAILY
6. LevETIRAcetam 1000 mg PO QPM
7. Humalog ___ 30 Units Breakfast
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
Take for a total of 21 days. Then STOP.
RX *clopidogrel 75 mg 1 tablet(s) by mouth Every day Disp #*20
Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*3
4. Humalog ___ 18 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Aspirin 81 mg PO DAILY
6. LevETIRAcetam 500 mg PO QAM
7. LevETIRAcetam 1000 mg PO QPM
8. Levothyroxine Sodium 88 mcg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Uncontrolled diabetes mellitus
Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of visual changes and
word-finding difficulties resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Diabetes
- Hypertension
- High cholesterol
We are changing your medications as follows:
- Started a medication called Plavix. You will take this
medicine through ___, then STOP. Continue to take the
aspirin daily even after stopping the Plavix.
- Increased the dose of your atorvastatin to 40 mg every night
- Started a multivitamin to help with your nutrition.
Please take your other medications as prescribed.
Please follow up with neurology (Dr. ___ and stroke
neurology (Dr. ___ as well as your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10750810-DS-12
| 10,750,810 | 28,879,522 |
DS
| 12 |
2155-09-02 00:00:00
|
2155-09-05 09:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Percocet / Iodine / nitroglycerin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of hiatal hernia s/p
surgery, CAD s/p recent DES to LAD 2 weeks ago, chronic
cryptogenic GI bleeding and chronic nausea, presenting with
chest pain.
Patient reports that his recent past medical history is notable
for devleoping SSCP, nausea and diaphoresis while doing a
___ job in ___ two weeks ago. He presented to
___ where he was taken emergently to the
cath lab and received a Xience stent to the LAD.
That hospitalization was complicated by a GIB in the setting of
starting anti-platelet medications. He was discharged after 5
days. He returnede to ___ and was feeling unwell and so went
to ___ where he was admitted for several days. At
___ had stress test which showed no abnormality he thinks,
but left AMA prior to endoscopy.
He has had intermittment SSCP with nausea and diaphoresis since
his hospitalization. However at 6PM on day of presentation he
developed recurrent SSCP that was non-radiating. He felt it as a
heaviness and throbbing sensation. He had cold sweats and felt
nauseated and vomited so went to the ED.
In the ED, initial vitals were: 8 97.0 66 130/79 18 100% RA
- Exam with patient initially complaining of chest heaviness
that improved with morphine (patient has nitro allergy and
refuses this med) and possible prominence over femoral artery at
prior catheterization site.
- EKG with NSR@60bpm, NA/NI. submillimeter STD in lateral
leads. No Q waves.
- Labs were significant for Hgb of 11.9 from 15.3 (___). TropT
<0.01.
- Imaging revealed ___ with no pseudoaneurysm and CXR with
Basilar atelectasis. Mild cardiomegaly.
- The patient was given:
___ 21:09 PO Lorazepam 1 mg ___
___ 21:29 IV Morphine Sulfate 2 mg ___
___ 21:30 IV Ondansetron 4 mg ___
___ 23:28 IV Morphine Sulfate 2 mg ___
Vitals prior to transfer were: 6 98.9 69 147/93 19 100% RA
Upon arrival to the floor, patient reports that he has very
minimal ongoing chest pain but is comfortable and declines
further meds. HE reports black stools off and on for several
months, not worse or better over past week. Took aspirin today.
Reports compliance with clopidigrel. No DOE, orthopnea, PND,
palpitations.
Past Medical History:
___ esophagus - s/p Nissen fundoplication
- hepatitis C,
- CAD s/p ?myocardial infarction (age ___,
--- Cardiac catheterization (once in ___ several years
ago and once at ___ approximately five months ago)
and most recently in ___ with DES to LAD
- OSA,
- h/o EtOH abuse,
- migraines,
- hiatal hernia,
- depression,
- GERD,
- erectile dysfunction
Social History:
___
Family History:
Notable for a son with melanoma and father with a history of
melanoma and congestive heart failure.
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: 98.4 127/83 78 18 97RA
___: 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: CTAB, good airmovement.
Abdomen: Obese, distended, non-tender.
GU: No foley
Skin: + Skin tags at the axilla.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert oriented. No focal deficits, gait deferred.
PHYSICAL EXAM on discharge:
Vitals: 98.4 127-149/80s
90.7 kg
___: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM.
Neck: Supple, JVP not elevated, no submental and
supraclavicular lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, bronchi
or crackles
Abdomen: Obese, NABS, non distended, mild tenderness to
palpation in the epigastric area.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS
----------------
___ 09:15PM ___ PTT-30.4 ___
___ 08:45PM GLUCOSE-73 UREA N-6 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 08:45PM estGFR-Using this
___ 08:45PM cTropnT-<0.01
___ 08:45PM WBC-7.6 RBC-5.03 HGB-11.9*# HCT-39.9* MCV-79*
MCH-23.7*# MCHC-29.8*# RDW-29.6* RDWSD-81.1*
___ 08:45PM NEUTS-55.6 ___ MONOS-17.0* EOS-5.4
BASOS-0.8 IM ___ AbsNeut-4.25 AbsLymp-1.60 AbsMono-1.30*
AbsEos-0.41 AbsBaso-0.06
___ 08:45PM PLT COUNT-364
IMAGING
---------------
CXR ___:
FINDINGS:
PA and lateral views of the chest provided. Lung volumes are
low limiting
evaluation. There is pleural thickening along the lateral right
mid lung.
There is bibasilar atelectasis without convincing evidence for
pneumonia. A retrocardiac opacity may reflect the presence of a
hiatal hernia. The heart is mildly enlarged. No large effusion
is seen. No pneumothorax. No edema or congestion. Bony
structures are intact.
IMPRESSION:
Basilar atelectasis. Mild cardiomegaly. Possible small hiatal
hernia.
EKG, ___:
Sinus rhythm. Normal ECG. No previous tracing available for
comparison.
FEMORAL VASCULAR US, ___:
FINDINGS:
Limited assessment of the right groin was within normal limits
at site of
abnormality reported by patient. The right common femoral and
greater
saphenous veins demonstrate normal compressibility and color
flow.
Normal spectral Doppler of the right common femoral artery and
right common
femoral vein were obtained. No arteriovenous fistula or
pseudoaneurysm.
IMPRESSION:
No pseudoaneurysm.
Brief Hospital Course:
Mr. ___ is a ___ with a history of hiatal hernia s/p
surgery, CAD s/p recent DES to LAD on ___, chronic cryptogenic
GI bleeding and chronic nausea, presenting with chest pain.
# Chest pain:
Patient presents with recurrent chest pain similar to his prior
anginal equivalent. His chest pain has been intermittent since
his last cath. ECG showed no changes, troponins were negative
x1. Patient recently seen at ___ ___
with similar complaint. Exercise stress MIBI testing showed no
evidence of ischemia at that time. Chest pain resolved upon
admission. Patient with extremely poor venous access, which
limited additional blood testing for troponin elevation, but
given extremely low suspicion for chest pain (which was no
longer present) of a cardiac etiology, aggressive measures to
obtain a second set of troponins was deferred. Pt was continued
on all of his home medications.
# Anemia:
Patient reports chronic dark stools x several months. His Hgb is
11.9. Records from ___ show Hb of 10.5 on ___
which is stable. His vitals are stable. He was hemodynamically
stable and without evidence of acute bleeding. He was instructed
to follow-up with established outpatient gastroenterologist, and
appointment was provided.
CHRONIC:
# ___ esophagus - s/p ___ fundoplication:
- continue PPI
# Hypertension: well controlled. Continue atenolol and
lisinopril.
# Hepatitis C: trial anti-virals in the past. Followed by
___.
- f/u as outpatient
# CAD: continue aspirin/plavix/atorvastatin/atenolol
# OSA: continue CPAP
# depression: Fluoxetine 40 mg PO DAILY
# Conjunctivitis: continue eye drops
TRANSITIONAL ISSUES:
- continue to monitor anemia; may need outpatient endoscopy to
evaluate further
- establish consistent cardiology follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zylet (tobramycin-lotepred) 0.3-0.5 % ophthalmic BID
2. Clopidogrel 75 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Atenolol 12.5 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Lorazepam 1 mg PO TID
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
8. Ondansetron 4 mg PO Q8H:PRN pain
9. Atorvastatin 40 mg PO QPM
10. Ferrous Sulfate 325 mg PO BID
11. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Fluoxetine 40 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Lorazepam 1 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
10. Ondansetron 4 mg PO Q8H:PRN pain
11. Zylet (tobramycin-lotepred) 0.3-0.5 % ophthalmic BID
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
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:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with chest pain, which was initially concerning since you
recently had a stent placed. Fortunately, your bloodwork, ECGs
and recent stress test showed no evidence of a heart attack or a
problem with your stent. This is good news! We are concerned
that your pain may be related to gastroesophageal reflux
disease. We provided you with medications which can help
control your reflux symptoms, but the next step is to follow-up
with your outpatient gastroenterologist, Dr. ___. We have
made an appointment for you to do this.
Since you have a new stent, it is important to take aspirin and
Plavix every single day, and to not miss even ___ single dose.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
10751053-DS-8
| 10,751,053 | 25,725,048 |
DS
| 8 |
2142-01-30 00:00:00
|
2142-01-30 22:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose / diltiazem / Terazosin
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with HTN, Asthma, Type 2 DM,
Gout, B12 deficiency, HLD who is admitted with UTI. Presented
with complaints of weakness, fatigue, decreased UOP, and
forgetfulness. Symptoms developing over the last several days;
pt seemed to have decreased energy and decreased urine output
although pt denies (daughter and son noticed). Per atrius notes,
she was seen ___ for BP check by PCP and they had increased
her lasix to additional 40 mg in the afternoon for a total of
200 mg per day (has 80 mg tabs, takes 2 every am). Since then
she has developed sx fatigue and her day caretaker has noted her
legs seem less swollen than usual. At the visit ___ her
creatinine was 1.04. K 3.5. A1c 7.8. On the day prior to
admission she was seen at the PCP's office again and lasix dose
was decreased due to c/f dehydration and presenting symptoms
noted above. Pt denied vomiting, no abd pain, no SOB, no chest
pain, no HA, no trauma. PCP asked family to collect urine sample
to eval for UTI, but pt did not have UOP in past 24 ours prior
to admission. The family called PCP's who recommended EMS bring
pt to ___ for evaluation. Still pt denied fever/cough. Per family
pt does not admit when anything is wrong or if she has
compliants; unclear if she is fully cognizant that she is even
experiencing these things. Her son states that she may need more
care. She is responsible for taking her own meds and her insulin
at home. She states she did take all of her meds and her insulin
the day of admission.
In the ED admission vitals at 15:30 were 96.9 60 134/54 18 98%
RA. EKG (ED read): sinus 56, PR=0.20, non specific ST-T changes,
no significant change from prior. CXR: (ED read) mild
cardiomegaly, otherwise non acute. Labs: WBC 10,5 ( N:65.2
L:25.0 M:5.5 E:3.6 Bas:0.7), H/H: ___, bun/Cr 35/1.3
(baseline Cr 1.0), UA with WBC>182, large leuks, neg nitrite,
RBC 20, Bact MOD, pH 6.5. Ceftriaxone 1gm given. Vitals Prior to
transfer: 97.8 58 150/53 18 97%.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Asthma
- Diabetes, type 2
- Gout
- B12 deficiency
Social History:
___
Family History:
Mother: mesothelioma
Physical ___:
Admission physical exam:
VS: T 97.2 BP 152/70 HR 57 RR 16 97%RA
GENERAL: well appearing, calm in no distress elderly female
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD:
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: lower extremities with trace to 1+ edema and mild
erythema exending to several cm below the knees. 2+ pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge physical exam:
VS: 97.4/98.1 155/44 51 18 94%RA
GENERAL: well appearing, calm in no distress elderly female
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD:
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, nl S1-S2, I/VI systolic murmur at the base
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, large mobile nontender mass in LLQ
EXTREMITIES: lower extremities with trace to 1+ edema and mild
erythema exending to several cm below the knees. 2+ pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Admission labs:
___ 04:03PM BLOOD WBC-10.5 RBC-5.55*# Hgb-16.0 Hct-49.8*#
MCV-90 MCH-28.8 MCHC-32.1 RDW-13.8 Plt ___
___ 04:03PM BLOOD Neuts-65.2 ___ Monos-5.5 Eos-3.6
Baso-0.7
___ 04:22PM BLOOD ___ PTT-32.9 ___
___ 04:03PM BLOOD Glucose-105* UreaN-35* Creat-1.3* Na-139
K-4.6 Cl-96 HCO3-35* AnGap-13
___ 04:03PM BLOOD cTropnT-<0.01
___ 04:03PM BLOOD Calcium-10.2 Phos-4.1 Mg-2.0
Discharge labs:
___ 06:30AM BLOOD WBC-8.9 RBC-4.81 Hgb-14.2 Hct-43.6 MCV-91
MCH-29.5 MCHC-32.5 RDW-14.1 Plt ___
___ 06:30AM BLOOD Glucose-128* UreaN-34* Creat-1.2* Na-145
K-4.3 Cl-106 HCO3-31 AnGap-12
___ 06:30AM BLOOD Calcium-9.9 Phos-3.1 Mg-2.0
Micro:
___ 10:30 pm
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
Studies:
___ CXR:
Mild enlargement of the cardiac silhouette without overt
pulmonary edema.
Brief Hospital Course:
___ year old woman with type 2 diabetes on insulin, HTN, HLD,
asthma, gout, who presented with altered mental status and was
found to have urinary tract infection and acute kidney injury.
# Urinary tract infection: Patient presented with altered mental
status noted by family with decreased urine output. She denied
dysuria but urinalysis in the ED was concerning for infection
with > 182 white blood cells, large leukocyte esterase, and
moderate bacteria. Culture was sent and returned with > 100,000
gram negative rods. Given her diabetes, this was treated as a
complicated urinary tract infection. She was initially started
on ceftriaxone in in the ED (day 1 = ___ and was
transitioned to Bactrim on ___ to complete a 7 day total
course to finish on ___. Her mental status was resolving
toward her baseline by the time of discharge.
# ___: Creatinine increased to 1.3 from baseline of 1.0. Likely
pre-renal in etiology in the setting of recently increasing her
home Lasix dose and oliguria on admission. Urine lytes were not
obtained during the oliguria, so FENa was not calculated. While
CXR showed worsening cardiomegaly, decompensated heart failure
is less likely in the setting of decreased PO intake and
increased Lasix. Creatinine improved mildly to 1.2 with
decreasing her dose of Lasix back to 160 mg PO daily. On
discharge, we further reduced her Lasix dose to 120 mg daily.
This dose can be further titrated in the outpatient setting.
# AMS: On admission, patient was oriented to person, date, but
not place. She likely has mild dementia at baseline although
seems to have worsened over the few days prior to admission
according to her family, coinciding with finding of UTI. Husband
reports she has exhibited similar confusion with prior UTIs. No
evidence of other infections currently, and labs without
significant metabolic derangements.
# Type 2 diabetes, hypoglycemia: Finger stick glucose 60 mg/dL
on arrival to the floor, which improved w/ juice. This was
likely due to very poor PO intake and taking normal insulin
dose. As her appetite returned, serum glucose remained in the
100s on home lantus and an insulin sliding scale while in house.
# Hypertension: BP elevated to 152 on arrival to the floor and
increased to 180s overnight. It is possible that this is related
to decreasing home dose of lasix recently and receiving IV
fluids. Atenolol and lisinopril were also held in the setting
of renal failure, and were restarted ___ with improvement of
SBPs to 140-150s.
# Transitional issues:
- Emergency contact: HCP/daughter ___ or ___
- Code status: DNR/DNI confirmed with patient in the presence of
her son
- ___ culture with gram negative rods, speciation and
sensitivities pending at the time of discharge. Should be
followed up to ensure proper antibiotic coverage.
- Lasix dose decreased to 120 mg daily due to ___ and concern
for overdiuresis, despite lower extremity edema. Her lower
extremity edema may be only partially related to heart failure
and also to venous stasis. In addition, blood pressure was well
controlled on her other antihypertensives.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
hold for hr<60 or sbp<100
2. Simvastatin 40 mg PO DAILY
3. Glargine 30 Units Breakfast
4. Lisinopril 40 mg PO DAILY
hold for sbp<100
5. Furosemide 160 mg PO DAILY
6. Aspirin 81 mg PO ONCE
7. Fluticasone Propionate NASAL ___ SPRY NU DAILY
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Naproxen 250 mg PO Q12H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO ONCE
2. Atenolol 25 mg PO DAILY
3. Furosemide 120 mg PO DAILY
RX *furosemide 40 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
4. Glargine 30 Units Breakfast
5. Lisinopril 40 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please continue through ___.
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fluticasone Propionate NASAL ___ SPRY NU DAILY
10. Multivitamins 1 TAB PO DAILY
11. Naproxen 250 mg PO Q12H:PRN pain
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Urinary tract infection
- Toxic metabolic encephalopathy
- Acute kidney injury
Secondary diagnoses:
- Hypertension
- Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
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 were
admitted to the hospital because you were more confused than
usual. We found that you had a urinary tract infection that was
causing these symptoms. We started antibiotics and you should
continue taking Bactrim as prescribed below through ___.
START Bactrim 1 DS tab by mouth twice daily through ___
DECREASE Lasix to 120 mg by mouth daily
Followup Instructions:
___
|
10751641-DS-25
| 10,751,641 | 24,386,315 |
DS
| 25 |
2149-04-23 00:00:00
|
2149-04-24 20:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Keflex / Iodine-Iodine Containing /
Tetracycline / Lipitor / Ace Inhibitors / Glyburide / Metformin
/ Clonidine / Percocet / Benadryl / Flovent Diskus / Spiriva
with HandiHaler / hydralazine / chlorthalidone
Attending: ___.
Chief Complaint:
Chest pain; Dyspnea
Major Surgical or Invasive Procedure:
Cardiac Catheterization, ___
History of Present Illness:
___ Female w/ CAD s/p PCI x2, PVD, pAfib on Coumadin p/w chest
pressure and burning x1 day with associated dyspnea on exertion
and cough.
Patient was in state of usual health until ___ when she had a
couple episodes of palpitations, lasting minutes and
spontaneously resolving. Then on ___, felt vaguely unwell all
day ("just blah"), and at 23:30pm while lying in bed, had sudden
onset of chest pressure and substernal burning. The burning
resolved with 1 tab of SL NTG but pressure persisted. This felt
like an episode she had had in the past while walking. She was
able to sleep, but felt dyspneic on exertion and presented to
the ED.
Patient stated that when she arrived at the hospital, she felt
suddenly dizzy, went white, and had a slow heart rate. This was
documented as bradycardia in the ___, and resolved.
In the ED initial vitals were: 97.9, 32, 157/53, 18, 99% on RA.
EKG per Ed dash showed sinus bradycardia with PACs
Labs/studies notable for: Cr 1.6, pBNP 2858, INR 2.7, trop <0.01
CXR clear.
Patient was given: 325mg ___ 30mL, Viscous
lidocaine 10mL
Vitals on transfer notable for HR 58, BP 153/92
On the floor, patient still feeling short of breath.
Past Medical History:
- CAD: s/p D1 (___), OM1 (___), and proximal RCA (___)
stents. Pharmacologic stress test from ___ does not
demonstrate evidence of ischemia. LHC ___: Selective coronary
angiography of this right dominant system revealed no evidence
of obstructive, flow-limiting disease. The LMCA was free of
critical stenoses. The LAD had mild luminal irregularities and a
40% stenosis in the D1 branch distal to a widely patent stent.
The LCx had a 20% ISR of the OM1 stent. The RCA had 40% ISR of
the proximal stent which appeared unchanged from prior studies.
- PAD status post multiple peripheral vascular interventions in
the right superficial femoral artery. ___ peripheral
angiogram in her LLE, with subsequent two stents to L SFA. s/p R
CIA stent w/ R EIA ___ stenosis. Aorta has diffuse
atherosclerosis.
- Diabetes mellitus type 2. Complicated by retinopathy and
neuropathy.
- Diabetic retinopathy/wet macular degeneration
- Hypertension.
- Hypercholesteremia.
- Paroxysmal atrial fibrillation. On anticoagulation.
- Mild obstructive lung disease.
- Hearing loss.
- Hypothyroidism.
- Osteoarthritis.
Social History:
___
Family History:
Mother died of MI age ___. Father lived to age ___. Daughter with
carcinoid tumor. Daughter with lung cancer, colon cancer, and
OA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.3 HR=58 BP=160/53 RR=16 O2 sat=99% RA
GENERAL: Elderly female in NAD but mildly short of breath with
___ word dyspnea.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 11-12 cm above sternal angle.
CARDIAC: RRR, soft S1/S2 with ___ harsh systolic murmur.
LUNGS: Bibasilar crackles, R>L.
ABDOMEN: Soft, NTND.
EXTREMITIES: Warm. Trace edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
Vitals: 97.4 | 55 | 147/50 | 20 | 96% RA
I/O= ___ (8hrs), 1150/1650 (24hrs)
Weight: 80.0 kg <- 79.7 kg <- 79.0 kg <- 82.1 kg <- 82.6 kg <-
84.8 kg <- 84.5 kg <- 81.5kg <- 80.3 kg <- 80.3 kg <- 80.8 kg <-
80.4 kg <- 80.5kg (standing)
Weight on admission: 81.7 kg
Telemetry: 60s, sinus, no alarms.
General: Elderly female in NAD.
HEENT: PERRL. EOMI.
Neck: JVP not elevated above clavicle seated upright
Lungs: Scattered crackles b/L. No wheezes or rhonchi.
CV: RRR, +S1/S2. Harsh ___ systolic murmur.
Abdomen: Soft, nondistended, nontender.
Ext: No ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 10:15AM BLOOD WBC-6.2 RBC-3.85* Hgb-11.3 Hct-35.8
MCV-93 MCH-29.4 MCHC-31.6* RDW-13.2 RDWSD-45.0 Plt ___
___ 10:15AM BLOOD Neuts-58.4 ___ Monos-14.0*
Eos-7.4* Baso-0.6 Im ___ AbsNeut-3.64 AbsLymp-1.20
AbsMono-0.87* AbsEos-0.46 AbsBaso-0.04
___ 10:15AM BLOOD ___ PTT-44.8* ___
___ 10:15AM BLOOD Glucose-132* UreaN-51* Creat-1.6* Na-142
K-5.3* Cl-113* HCO3-18* AnGap-16
___ 10:15AM BLOOD proBNP-2858*
___ 10:15AM BLOOD cTropnT-<0.01
KEY LABS:
___ 10:15AM BLOOD cTropnT-<0.01
___ 07:28PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:15PM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-6.0 RBC-3.10* Hgb-9.0* Hct-28.6*
MCV-92 MCH-29.0 MCHC-31.5* RDW-12.5 RDWSD-41.9 Plt ___
___ 07:50AM BLOOD ___ PTT-41.0* ___
___ 07:50AM BLOOD Glucose-183* UreaN-57* Creat-1.6* Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
___ 07:50AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.6
IMAGING/REPORTS:
___ ECG: Rate=56, Sinus bradycardia. Probable left
ventricular hypertrophy. Compared to the previous tracing of
___ no change.
___ CHEST XR: The cardiac silhouette is mildly enlarged. The
aorta is calcified and slightly tortuous. No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen. The lungs remain hyperinflated, with flattening of the
diaphragms. No pulmonary edema is seen.
___ CHEST XR: FINDINGS:
Moderate cardiomegaly is unchanged. Subtle interstitial changes
are mildly
increased from prior imaging. Atelectasis at the lung bases
bilaterally is
mild. The pulmonary vasculature is unremarkable. Aortic
calcifications are
dense. A small amount of pleural thickening or pleural fluid is
seen at the right costophrenic angle.
IMPRESSION:
1. Subtle increased interstitial changes could represent
progression of mild interstitial lung disease, interstitial
pneumonia or asymmetric edema.
2. Aortic valve calcifications on prior CT were considerable
and could be
contributing to the patient's symptoms.
___ CARDIAC CATH:
Coronary Anatomy:
Dominance: Right
The ___ had no angiographically apparent CAD. The LAD had mild
luminal irregularities with ___ plaques. The diagonal had 40%
plaquing. The Cx and OM had ___ plaques. The RCA had proximal
40% ISR and 70% hazy distal RCA stenosis and more distal 60%
stenosis.
Interventional Details:
A 6 ___ JR4 guiding catheter was used to engage the RCA and
provided adequate support. A 180-cm Runthrough guidewire was
then successfully delivered across the lesion. Predilated with a
2.5 mm balloon. Deployed a 2.5 x 18 mm Resolute stent. Distal
disease was either pleating artifact or disease and with removal
of the wire it was clear that this would pose an outflow
problem. Recrossed with a Pilot 50 wire and deployed a 2.5 x 24
mm Promus stent. Final angiography revealed normal flow, no
dissection and 0% residual stenosis. The patient described back
and central chest pain so supravavular aortography was performed
showing no AR, no aortic dissection and no subclavian artery
dissection.
Ultimately, the pain was reproducible with palpation of the back
and relieved with massage. She left the catheterization
laboratory in stable condition.
Impressions:
1. Successful stenting of the RCA with DES.
Recommendations:
1. Secondary prevention CAD.
2. OK to use dual therapy with Plavix and warfarin without
aspirin.
Brief Hospital Course:
Ms. ___ is an ___ Female with CAD s/p coronary stenting
x3, ___, paroxysmal atrial fibrillation who presented with
dyspnea and chest pain.
Patient was in her usual state of health until the week of ___
when she had a brief sensation of fluttering in her chest. She
returned to her baseline briefly and then again on ___ felt off
her baseline and had chest pressure and substernal "burning"
while lying in bed. She tried sublingual nitroglycerin with
partial relief. She awoke on ___ with severe exertional dyspnea
and presented to the ED at ___.
In the ED, she felt dizzy and pale, was found to have a heart
rate of 32 with EKG showing sinus bradycardia. The bradycardia
resolved her subsequent EKGs remained unconcerning for ischemia.
Cardiac enzymes were never elevated with troponin <0.01 for
three sets.
She was transferred to the floor and monitored on telemetry,
where she remained in sinus rhythm with rates in the ___ for
the duration of her hospitalization. She remained chest pain
free for the duration of the hospitalization.
She was diuresed with multiple boluses of Lasix 20mg IV until
her dyspnea on exertion resolved. She will be discharged on
chlorthalidone 25mg daily and hydrochlorothiazide will be
discontinued. She will be discharged with a prescription for
furosemide 20mg PO, which she will take if her weight increases
more than 2 pounds in a day.
Her course was complicated by hypertension with systolic BP into
the 150s-160s. Her antihypertensive regimen was increased with
the addition of hydralazine 75mg every 8 hours and
chlorthalidone 25mg daily.
During her inpatient course, she had recurrence of her anginal
symptoms with chest pressure relieved by sublingual
nitroglycerin. She had no EKG changes or troponin leak. On ___
she was taken to the cath lab. Patient found to have 70% and 60%
distal stenoses of the RCA. Two (2) drug-eluting stents were
placed.
She was discharged on aspirin, plavix, and warfarin.
==============
ACTIVE ISSUES:
==============
# Chest pain in the setting of CAD: Patient recounts symptoms of
substernal pressure and burning concerning for angina. These
symptoms occurred while she was lying in bed. Partially relieved
by nitroglycerin. Previously had substernal burning one time
with walking. Robust CAD history and PCI with stents x3 to D1,
OM1, and proximal RCA. Considered demand ischemia secondary to
CHF exacerbation and hypertension. Had recurrence of chest pain
while inpatient and went for cardiac cath which revealed 70% and
60% stenoses of RCA with the placement of 2 drug-eluting stents.
Discharged on plavix and warfarin.
# Dyspnea, diastolic CHF exacerbation: Patient with dyspnea on
exertion and now at rest, also cough. Elevated JVP. No
orthopnea. Potential triggers include pAF with palpitations and
ischemia. Patient diuresed with Lasix ___ IV boluses to a
presumed dry weight of 80.3 kg. Continued beta blocker, ACEi.
Discontinued home HCTZ and started chlorthalidone 25mg daily.
She was discharged with a prescription for lasix 20mg PO daily.
Further titration of this medication can be managed by her
outpatient providers.
# Bradycardia: Noted in ED, resolved on admission to floor. Now
in normal sinus rhythm. Consider vagal episode vs. ischemia vs.
beta blocker toxicity vs. sick sinus syndrome in the setting of
pAF. Vagal felt likely given history of suddenly feeling pale,
dizzy, and with slow HR upon arrival to the hospital. Monitored
on telemetry with rates stable in the ___.
# PVD: Bilateral disease most recently receiving a Left SFA
stent in ___. After discussion with Dr. ___ at the last
admission, her clopidogrel was discontinued (>2 months from
stent) so as to minimize her bleeding risk from being on aspirin
and warfarin. However, after cardiac cath, decision was made to
discontinue aspirin and discharge on warfarin and clopidogrel.
# Paroxysmal Atrial Fibrillation: Newly diagnosed in ___.
CHADS-VASc of 6. Had palpitations briefly ___ days prior to
admission. In sinus on admission EKGs. Continued Coumadin at
home dose for goal ___. Continued home carvedilol for rate
control.
# Hypertension: Hypertension to 160s-170s while inpatient. Home
HCTZ was increased to 25mg daily at last hospitalization due to
uncontrolled HTN to 160s. Valsartan, amlodipine, and carvedilol
doses were not changed. Discontinued HCTZ and started
chlorathalidone 25 mg daily, but chlorthalidone was poorly
tolerated and discontinued due to orthostatic symptoms.
Hydralazine was added and increased aggressively, but was also
discontinued due to poor tolerance (patient had chest pain and
orthostasis with DBP in ___ on therapeutic doses of
hydralazine). She was ultimately discharged home doses of
valsartan, carvedilol, and amlodipine with furosemide added in
place of HCTZ. Further tailoring of her antihypertensive regimen
should be completed as an outpatient.
================
CHRONIC ISSUES:
================
# DM2: HbA1c=6.2% in ___. Had been on sitagliptin, but
recently discontinued to by PCP to trial if patient really needs
it. Patient was initally left off insulin and all oral
hypoglycemics while inpatient as not to muddy this trial. Blood
sugars were only slightly above inpatient goal, until she
required premedication with methylprednisolone, which caused her
blood sugars to increase above 300. At this point, a gentle
humalog insulin sliding scale was added. She was not discharged
on insulin or oral hypoglycemics.
# Chronic Kidney Disease: Stage 3 CKD with baseline Cr=1.5-1.7.
Patient at baseline.
# Hypothyroidism: TSH wnl on ___. Continued home
levothyroxine.
# Asthma, Allergic Rhinitis: Continued home Cetirizine 10 mg PO
DAILY, Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H.
# GERD: Continued home ranitidine.
# CODE: Full
# CONTACT: ___ (daughter) ___ ___
(daughter) ___ (cell)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
2. Warfarin 2.5 mg PO 4X/WEEK (___)
3. Amlodipine 10 mg PO DAILY
4. Foltabs 800 (folic acid-vit B6-vit B12) 0.8-10-115 mg-mg-mcg
oral DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
8. Ranitidine 150 mg PO DAILY
9. Valsartan 320 mg PO DAILY
10. Carvedilol 25 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Cetirizine 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Pravastatin 40 mg PO QPM
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest
pain/pressure/burning
17. Warfarin 3.75 mg PO 3X/WEEK (___)
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest
pain/pressure/burning
6. Ranitidine 150 mg PO DAILY
7. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
8. Valsartan 320 mg PO DAILY
9. Warfarin 2.5 mg PO 4X/WEEK (___)
10. Warfarin 3.75 mg PO 3X/WEEK (___)
11. Cetirizine 10 mg PO DAILY
12. Foltabs 800 (folic acid-vit B6-vit B12) 0.8-10-115 mg-mg-mcg
oral DAILY
13. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
14. Vitamin D 1000 UNIT PO DAILY
15. Outpatient Lab Work
I48.0 Atrial fibrillation
Please draw Chem 10 panel and INR on ___. Furosemide 20 mg PO DAILY PRN weight gain
Please take if weight increases 2 lbs or more
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Pravastatin 80 mg PO QPM
RX *pravastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
18. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
- Congestive Heart Failure exacerbation
- Chest pain
- CAD s/p stenting
SECONDARY DIAGNOSIS:
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were admitted with chest pain and shortness of breath. While
you were here, we gave you diuretics, which are medications to
help you urinate. First, we did this through your IV and then we
switched you to an oral regimen.
Due to your chest pain, you underwent cardiac catheterization,
which revealed a narrowing of one of the arteries in your heart.
Two (2) stents were placed to open this artery and restore blood
flow. Unfortunately after your cardiac catheterization you had a
substantial degree of nausea, likely from the IV contrast you
received. The contrast also affected your kidneys. Fortunately
the nausea has resolved and your kidney function continues to
improve.
Please continue to take your Lasix daily. You should have your
blood drawn on ___ before you go to your cardiology
appointment. We have provided you with a prescription for this
blood draw.
At discharge, you weighed 80.0kg (176.37lbs). Weigh yourself
daily and notify your cardiology team if your weight increases
more than ___ lbs in one day. We have scheduled you with follow
up in the cardiology clinic. Please schedule a follow up
appointment with your primary care doctor this week.
It was a pleasure to be a part of your care!
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
10751641-DS-26
| 10,751,641 | 20,881,745 |
DS
| 26 |
2150-03-13 00:00:00
|
2150-03-15 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Morphine / Codeine / Keflex / Iodine-Iodine Containing /
Tetracycline / Lipitor / Ace Inhibitors / Glyburide / Metformin
/ Clonidine / Percocet / Benadryl / Flovent Diskus / Spiriva
with HandiHaler / hydralazine / chlorthalidone
Attending: ___
Chief Complaint:
Visual field cut
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ PMHx afib on warfarin s/p PPM for
tachy-brady syndrome, CAD/dCHF (EF 70% ___, HTN, HLD and PVD
who presents with an acute onset visual field cut.
The evening prior to presentation, around 20:00, pt was watching
TV when she suddenly felt lightheaded. She cannot remember if
she
had a sense of disequilibrium or room spinning sensation. She
felt like her "whole brain flipped over" [she is unable to
further elaborate]. She then realized that she could not see the
left lower quadrant of her visual field and felt that this was
just in her left eye. She denied any symptoms in her right eye.
She noticed this because her TV is on the left side of her
living
room. She got up and realized that she felt "wobbly" and
unstable
walking. She has had gait instability for years since an inner
ear injury, but this unsteadiness was much worse than baseline.
These symptoms had never happened before.
This AM, she told her daughter of her symptoms who grew
concerned
and brought pt to the ED. Daughter states pt is "tough" and
minimizes symptoms. At the time of my assessment, pt reports
visual symptoms and gait instability persist but her
lightheadedness has resolved.
Otherwise, pt also reports a dull bifrontal headache over the
past 2 days. She denies any fevers, photo/photosensitivity,
nausea or vomiting.
Of note, pt takes warfarin for her atrial fibrillation and is
compliant with this medication. She is generally in the
therapeutic range for her INRs, although value was 1.8 on ___
(dose was not changed).
On neurologic review of systems, the patient reports
intermittent
forgetfulness today (e.g. she could not find where her scale was
this AM and she weighs herself daily so this was unusual). She
also has decreased hearing bilaterally which is chronic. Pt
denies lightheadedness. Denies difficulty with producing or
comprehending speech. Denies diplopia, vertigo, tinnitus,
dysarthria, or dysphagia. Denies focal muscle weakness,
numbness,
parasthesia. Denies loss of sensation. Denies bowel or bladder
incontinence or retention.
On general review of systems, the patient reports a chronic
non-productive cough. Pt denies fevers, chest pain,
palpitations,
nausea, vomiting, diarrhea, constipation, abdominal pain,
dysuria
or rash.
Past Medical History:
- CAD: s/p D1 (___), OM1 (___), and proximal RCA (___)
stents. Pharmacologic stress test from ___ does not
demonstrate evidence of ischemia. LHC ___: Selective coronary
angiography of this right dominant system revealed no evidence
of obstructive, flow-limiting disease. The LMCA was free of
critical stenoses. The LAD had mild luminal irregularities and a
40% stenosis in the D1 branch distal to a widely patent stent.
The LCx had a 20% ISR of the OM1 stent. The RCA had 40% ISR of
the proximal stent which appeared unchanged from prior studies.
- PAD status post multiple peripheral vascular interventions in
the right superficial femoral artery. ___ peripheral
angiogram in her LLE, with subsequent two stents to L SFA. s/p R
CIA stent w/ R EIA ___ stenosis. Aorta has diffuse
atherosclerosis.
-Wet age related macular degeneration bilaterally s/p
intravitreal
-Avastin injections in both eyes and intravitreal
-Eylea injections in the left eye (last injection ___
-Moderate non proliferative diabetic retinopathy bilaterally
-Interstitial lung disease, suspected fibrotic NSIP versus
chronic HP
-Atrial fibrillation on warfarin c/b tachy-brady syndrome s/p
PPM
-dCHF (EF 70% ___
-S/P BILATERAL SHOULDER ROTATOR CUFF REPAIRS
-TYPE 2 DIABETES MELLITUS
-ALLERGIC RHINITIS
-GALLSTONES
-GASTROESOPHAGEAL REFLUX
-HYPERTENSION
-HYPOTHYROIDISM
-SQUAMOUS CELL CARCINOMA
-HEARING LOSS
-LENTEGINES
-SEBORRHEIC KERATOSIS INFLAMED
-TELANGIECTASIA, SPIDER
-Hypercholesteremia.
-Hearing loss
Social History:
SOCIAL HISTORY:
Marital status: Widowed
Children: Yes
Lives with: Alone
Lives in: House
Domestic violence: Denies
Tobacco use: Former smoker, quit ___ ago, smokes 3PPD
___ years
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: None
Exercise comments: sedentary recently - used to walk on the
treadmill daily
Diet: diabetic diet - limited portions.
Family History:
Relative Status Age Problem Comments
Mother ___ ___ ___ arthritis
Father ___ ___
Daughter LUNG CANCER
COLON CANCER
THYROID NODULE
OSTEOARTHRITIS
*No family history of stroke
+family history of CAD/DM
Mother died of MI age ___. Father lived to age ___. Daughter with
carcinoid tumor. Daughter with lung cancer, colon cancer, and OA
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 97.2 60 161/38 16 100% RA
General: NAD, resting in bed, comfortable
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
___: Sinus bradycardia
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
Immediate recall ___ and delayed recall ___ (able to name 1
additional word with category clue).
- Cranial Nerves - PERRL 3->2 brisk. +left homonymous inferior
quadrantanopia. Optic discs appear crisp bilaterally. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. No dysarthria. Palate elevation symmetric.
Trapezius
strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Take short, narrow steps in a hesitant manner and
requires my assistance. Positive Romberg.
DISCHARGE PHYSICAL EXAM:
=======================
Physical Exam:
Vitals: Tm:98.6 Tc:98.4 BP: 122/73 HR 60 RR18 94 RA
General: NAD, resting in bed, comfortable
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
___: Sinus bradycardia
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
Immediate recall ___ and delayed recall ___ (able to name 1
additional word with category clue).
- Cranial Nerves - PERRL 3->2 brisk. +left homonymous inferior
quadrantanopia. Optic discs appear crisp bilaterally. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. No dysarthria. Palate elevation symmetric.
Trapezius
strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Take short, narrow steps in a hesitant manner and
requires my assistance. Positive Romberg.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:55AM BLOOD WBC-6.5 RBC-4.12 Hgb-12.4 Hct-37.8 MCV-92
MCH-30.1 MCHC-32.8 RDW-11.9 RDWSD-39.9 Plt ___
___ 09:55AM BLOOD Neuts-69.5 Lymphs-14.3* Monos-8.5 Eos-6.9
Baso-0.5 Im ___ AbsNeut-4.51 AbsLymp-0.93* AbsMono-0.55
AbsEos-0.45 AbsBaso-0.03
___ 09:55AM BLOOD ___ PTT-40.7* ___
___ 09:55AM BLOOD Glucose-150* UreaN-85* Creat-2.2* Na-140
K-4.3 Cl-100 HCO3-25 AnGap-19
___ 09:55AM BLOOD ALT-17 AST-20 AlkPhos-75 TotBili-0.3
___ 09:55AM BLOOD Lipase-76*
___ 09:55AM BLOOD cTropnT-<0.01
___ 09:55AM BLOOD Albumin-4.0 Calcium-9.6 Phos-4.4 Mg-2.4
___ 10:30AM URINE Color-Straw Appear-Clear Sp ___
___ 10:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:30AM URINE RBC-<1 WBC-14* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
___ 10:30AM URINE CastHy-4*
___ 10:30AM URINE Mucous-RARE
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-6.5 RBC-3.89* Hgb-11.3 Hct-35.3
MCV-91 MCH-29.0 MCHC-32.0 RDW-11.5 RDWSD-38.2 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-37.1* ___
___ 06:15AM BLOOD Glucose-134* UreaN-51* Creat-1.7* Na-139
K-3.7 Cl-101 HCO3-25 AnGap-17
___ 06:15AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
___ 02:50PM BLOOD %HbA1c-6.6* eAG-143*
___ 02:50PM BLOOD Triglyc-215* HDL-38 CHOL/HD-4.6
LDLcalc-95
___ 08:00AM BLOOD TSH-1.2
___ 09:55AM BLOOD CRP-4.5
MICRO:
======
___ 10:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING:
========
___ Imaging CT HEAD W/O CONTRAST
1. Acute/subacute right occipital infarct. No intracranial
hemorrhage.
2. Old, chronic right frontal infarct.
___ Cardiovascular ECHO
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic stenosis. Mild mitral regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the degrees of aortic, mitral, and tricuspid regurgitation
appear less in the current study.
___ Imaging CHEST (PA & LAT)
No acute cardiopulmonary abnormality. Mild to moderate
cardiomegaly,
decreased from the previous exam.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a PMH notable for Afib
on warfarin s/p PPM for tachy-brady syndrome, CAD/dCHF (EF 70%
in ___, HTN, HLD, T2DM and PVD who presents with an acute
onset left lower visual field cut, with exam notable for a left
homonymous inferior quadrantanopia and NCHCT showing evidence of
an acute R occipital lobe infarct.
# R occipital lobe infarction:
Patient was noted to have a left homonymous inferior
quadrantopia with imaging showing evidence of a R occipital lobe
infarct. Etiology of pt's infarct likely cardio-embolic given
her history of paroxysmal atrial fibrillation despite warfarin
use. Patients stroke may have been due to warfarin failure (one
reading of INR 1.8 1 week prior to presentation, and patient has
been therapeutic only 50% of the time in last 3 months as
compared to being therapeutic 75% of the time in last 12 months)
vs atherosclerotic disease. With regards to an athero-embolus,
vessel imaging was deferred on this admission due to patients
chronic kidney issues (Cr 2.2 currently, baseline 2.0-2.8) which
precluded CTA imaging with contrast, and MRI/MRA was deferred
due to risk of patients pacemaker, which although was noted to
be MRI compatible was felt to not to be without risk and would
likely not change management. Due to the likely cardioembolic
nature of this clot due to warfarin failure, warfarin was held
to allow INR to correct below 2, after which time patient was
transitioned to Rivaroxaban 15mg QHS. TTE on this admission was
negative for intracardiac source of clot in the left atrial
appendage or in the left ventricle, and further no evidence of
PFO/ASD. Pts laboratory values including TSH and lipid panel
were unremarkable with only HgbA1c mildly elevated HgbA1c of
6.6. Patient was instructed to continue with Rivaroxaban 15mg
QHS, as well as continue with her home Aspirin 81mg daily and
pravastatin 80mg daily. Patient was further advised to followup
in Neurology clinic in ___ weeks. Furthermore, patient was
advised to continue to work with her primary care physician to
improve her HgbA1c and her blood glucose control.
#Pulm: on this admission, patient had no acute pulmonary issues.
Patient was continued on her home albuterol inhaler/nebulizers
prn as needed.
#Renal, known CKD: on this admission, patients BUN/Cr were at
baseline. Patients Cr was trended daily, and all meds were
renally dosed including her systemic anticoagulation
(Rivaroxaban 15mg daily).
# Endocrine:
#T2DM: on this admission, patient was maintained on QID FSG with
insulin sliding scales. She had well controlled sugars on this
regimen, however patients HgbA1c of 6.6% shows that patient may
benefit from further optimization of her diabetes regimen.
Patient is currently controlling her home blood sugars with diet
and exercise, and is not currently on any diabetes medications.
# Hypothyroidism: on this admission, patient was continued on
her home levothyroxine
#FEN/GI: on this admission, patient was evaluated with bedside
swallow eval and was noted to have no deficits with
swallowing/protecting airway. Patient was maintained on a
regular diet.
#Heme
#DVT prophylaxis: on this admission, patient was maintained on
pneumoboots, and patient was maintained on systemic
anticoagulation as noted above.
#Ophtho: on this admission, patient was continued on home
Preservision
#MSK: patient was evaluated by ___ on this admission, who
recommended home ___ vs outpatient ___, with placement at an acute
rehab facility not required. Patient was noted to be walking
well on her own with regards to navigating her hospital room and
ambulating on the ward independently, however, patient may
benefit from ___ as an outpatient to learn adaptive skills to
help compensate for her left visual field cut and to prevent
falls in the future.
TRANSITIONAL ISSUES:
====================
[] Please ensure patient is compliant with anticoagulation
regimen of Rivaroxaban 15mg QHS. Patient was discharged on
Rivaroxaban due to the significantly higher cost of Apixaban,
which family stated would be difficult for them to afford on a
monthly basis due to its prohibitive cost. Patient will remain
on systemic anticoagulation in order to prevent further
cardioembolic strokes in the setting of her known Afib, however,
patient was informed that although systemic anticoagulation can
reduce the risk of stroke her risk is not zero. Patient was
understanding of this.
[] Please continue to monitor patients Creatinine on
Rivaroxaban. Pateint may require further adjustment of systemic
anticoagulation if patients CrCl worsens or if patient has signs
of acute renal failure.
[] Please monitor patients visual field deficits. Patient was
admitted with left homonymous inferior quadrantanopia due to
right occipital lobe infarct. Patient was referred to outpatient
___ to help with ambulation in the setting of her known visual
field deficit.
[] Please monitor patients glycemic control. Patient had an
elevated HgbA1c of 6.6. Patient may benefit from further
titration of her diabetes medication regimen.
[] Please consider high-dose statin therapy when out of acute
setting. Patient was maintained on home pravastatin 80mg daily
during this admission due to significant medication allergy
history, but patient may benefit from switching to high-dose
statin therapy (atorva 40-80mg daily or rosuvastatin ___
daily) with target LDL <70.
[] Please ensure compliance with outpatient/home ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
3. amLODIPine 10 mg PO DAILY
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. benzonatate 100-200 mg oral QHS:PRN
6. Carvedilol 25 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Pravastatin 80 mg PO QPM
12. Ranitidine 150 mg PO DAILY
13. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
14. Triderm (triamcinolone acetonide) 0.1 % topical BID
15. Valsartan 320 mg PO DAILY
16. Warfarin 2.5 mg PO DAILY16
17. Aspirin 81 mg PO DAILY
18. Cetirizine 10 mg PO DAILY:PRN seasonal allergies
19. Vitamin D 1000 UNIT PO DAILY
20. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit-5 mg-0.8 mg capsule oral BID
Discharge Medications:
1. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily at
night with dinner Disp #*30 Tablet Refills:*11
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. azelastine 0.15 % (205.5 mcg) nasal BID
7. benzonatate 100-200 mg oral QHS:PRN
8. Carvedilol 25 mg PO BID
9. Cetirizine 10 mg PO DAILY:PRN seasonal allergies
10. Furosemide 40 mg PO DAILY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pravastatin 80 mg PO QPM
15. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit-5 mg-0.8 mg capsule oral BID
16. Ranitidine 150 mg PO DAILY
17. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
18. Triderm (triamcinolone acetonide) 0.1 % topical BID
19. Valsartan 320 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21.Outpatient Physical Therapy
Please evaluate and progress impaired balance consistent with
field cut due to right occipital stroke.
ICD10 I48.2, I63.40
Discharge Disposition:
Home
Discharge Diagnosis:
R occipital lobe infarct
Left homonymous inferior quadrantanopia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were hospitalized due to left-sided vision loss and unsteady
gait resulting from an ACUTE ISCHEMIC STROKE, a condition where
a blood vessel providing oxygen and nutrients to the brain was
blocked by a clot. Specifically, ___ had a stroke in the right
occipital lobe, the area of your brain that is involved in
vision. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Atrial Fibrillation
Coronary artery disease
Diabetes
Hyperlipidemia
Hypertension
We are changing your medications as follows:
- START Rivaroxaban 15mg at night with dinner
- STOP Warfarin 2.5mg daily
Please continue all your other medications as prescribed and as
indicated below.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10751641-DS-27
| 10,751,641 | 22,347,408 |
DS
| 27 |
2151-04-08 00:00:00
|
2151-04-08 15:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Keflex / Iodine-Iodine Containing /
Tetracycline / Lipitor / Ace Inhibitors / Glyburide / Metformin
/ Clonidine / Percocet / Benadryl / Flovent Diskus / Spiriva
with HandiHaler / hydralazine / chlorthalidone
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with PMH of HFpEF, CAD s/p
PCI ×3 with multiple stents placed, peripheral vascular disease,
DMII, COPD, HTN, h/o CVA, and HLD who presents with left sided
substernal chest pain radiating to the left arm and back x1 day.
The patient was seen by Dr. ___ in clinic on ___ and
shortly after returning home, she developed left sided
substernal
burning that progressed into a shooting pain that radiated into
her left arm and back. Had associated nausea, diaphoresis and
SOB. She took NTG x3 with resolution of her symptoms and
presented to ___ ED for further management.
Of note, the patient had a dobutamine stress echo from ___
which did not show any evidence of inducible ischemia. She has
had multiple discussions with Dr. ___ coronary
angiography, but the patient and her family have been hesitant
given pain with the procedure (she does not tolerate
sedation/pain medication ___ allergies) as well as her
underlying
renal disease.
Past Medical History:
-CAD: s/p D1 (___), OM1 (___), and proximal RCA (___) stents.
-PAD status post multiple peripheral vascular interventions in
the right superficial femoral artery. ___ peripheral
angiogram in her LLE, with subsequent two stents to L SFA. s/p R
-CIA stent w/ R EIA ___ stenosis. Aorta has diffuse
atherosclerosis.
-Moderate non proliferative diabetic retinopathy bilaterally
-Interstitial lung disease, suspected fibrotic NSIP versus
chronic HP
-Atrial fibrillation on warfarin c/b tachy-brady syndrome s/p
PPM
-dCHF (EF 70% ___
-DMII
-HTN
-Hypothyroidism
-Allergic rhinitis
-Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.6PO 169/55 61 16 96% RA
GENERAL: Sitting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, JVD approximately 10cm at 45 degree angle
HEART: RR, ___ systolic murmur heard throughout the precordium.
No rubs or gallops
LUNGS: Inspiratory crackles at the lung bases with L>R. No
rhonchi or wheezes
ABDOMEN: Soft, ND, NTTP, +BS
EXTREMITIES: WWP, trace pedal edema
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 519)
Temp: 98.5 (Tm 98.5), BP: 156/63 (143-163/49-72), HR: 60
(59-63), RR: 18 (___), O2 sat: 96% (95-98), O2 delivery: Ra
I/Os: -520mL
DRY WEIGHT: 174 LBS
GENERAL: sitting comfortably on edge of the bed, NAD
HEENT: AT/NC, MMM
HEART: regular, ___ systolic murmur
LUNGS: soft bibasilar crackles
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: 1+ nonpitting edema in compression stockings
NEURO: alert, responding to questions appropriately, moving all
4
extremities with purpose
Pertinent Results:
ADMISSION LABS
================
___ 10:28PM BLOOD WBC-8.9 RBC-3.53* Hgb-10.9* Hct-33.1*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.4 RDWSD-45.7 Plt ___
___ 10:28PM BLOOD Neuts-70.2 Lymphs-12.9* Monos-10.4
Eos-5.7 Baso-0.6 Im ___ AbsNeut-6.28* AbsLymp-1.15*
AbsMono-0.93* AbsEos-0.51 AbsBaso-0.05
___ 10:28PM BLOOD Plt ___
___ 11:54PM BLOOD ___ PTT-32.0 ___
___ 10:28PM BLOOD Glucose-173* UreaN-51* Creat-1.6* Na-144
K-4.9 Cl-107 HCO3-20* AnGap-17
___ 10:28PM BLOOD cTropnT-0.02*
___ 04:00AM BLOOD CK-MB-2 cTropnT-0.02* proBNP-2852*
___ 10:28PM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
IMAGING
================
___ CXR
IMPRESSION:
No evidence of pneumonia.
Stable chronic interstitial abnormality most likely represents
age related
fibrosis.
Left-sided pacemaker.
DISCHARGE LABS
=================
___ 07:50AM BLOOD WBC-6.6 RBC-3.58* Hgb-11.0* Hct-33.8*
MCV-94 MCH-30.7 MCHC-32.5 RDW-12.9 RDWSD-45.0 Plt ___
___ 07:50AM BLOOD ___ PTT-32.8 ___
___ 07:50AM BLOOD Glucose-139* UreaN-44* Creat-1.7* Na-142
K-4.2 Cl-103 HCO3-24 AnGap-15
___ 07:50AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of CAD s/p
multiple stents, HFpEF, PVD, CKD, DMII, HTN, and HLD who
presents with substernal chest pressure found to have mild
troponin elevation without EKG changes iso CKD concerning for
unstable angina vs. NSTEMI. Patient remained chest pain free
while in house. She was diuresed due to volume overload and had
uptitration of coreg and losartan due to hypertension. She was
discharged on a diuretic regimen of furosemide 40mg daily.
ACUTE ISSUES:
==============
# ?Unstable Angina
# Known Coronary Artery Disease
# Chest pain
Patient presents with substernal chest pressure radiating to her
left arm and back that occurred while ambulating to her house.
Pain resolved after 3 doses of NG with symptoms concerning for
angina. Troponin on admission mildly elevated to 0.02 in the
setting of CKD, but EKG reassuringly without STE or depressions
and patient was without chest pain on arrival to ER. She has a
known history of significant coronary artery disease with
multiple stents.
Recent dobutamine stress in ___ without evidence of
inducible ischemia. Suspect pain was secondary to volume
overload and hypertension. Per patient, she would not like to
undergo cath due to risk of kidney injury in the setting of
contrast. She was monitored on telemetry and continued on home
Aspirin 81mg daily and pravastatin 80mg daily. Her carvedilol
was increased to 25mg BID for antianginal effects and blood
pressure control. Her home losartan was increased to 50mg BID
for blood pressure control. She also continued on her home
ranexa.
#HFpEF:
#LVOT obstruction
LVEF >55% on last TTE. Appeareded volume overloaded with
elevated JVP and 2+ pedal edema to knees on admission. Not on
daily diurectics at home due to worsening renal function. Due to
an inducible LVOT gradient on her ___ stress test, careful
diuresis was done to avoid detrimental preload reduction. She
was diuresed with lasix 20mg IV daily or BID. When euvolemic,
she was switched to 40mg daily. She was continued on home
losartan. Her coreg was increased as above. Her losartan was
also increased.
#HTN:
Patient continued to have elevated SBPs while in house with SBP
values of 150-180s. Her coreg was increased and her home
losartan was increased. Her home amlodipine 10mg was continued.
#Normocytic Anemia: Likely anemia of chronic disease. No current
signs or symptoms of bleeding. Will require further follow-up
with out-patient provider
CHRONIC ISSUES:
=================
#Atrial fibrillation:
___ ___. S/p PPM placement for tachy-brady. On apixaban
for anticoagulation.
#CKD: Baseline Cr 1.6-2.0. Stayed stable with diuresis.
#PVD:
-Continued home ASA/statin
#History of CVA:
-Continued home ASA, statin as above
#HLD:
-Continued pravastatin
#DMII:
-ISS while in hospital
#COPD:
-Continued home Anoro Ellipta
TRANSITIONAL ISSUES
===================
- Discharge weight 174lbs.
- Discharge Cr 1.7
[ ] Patient started on Lasix 40mg PO daily this admission.
Please check electrolytes and volume status at next appointment.
[ ] Patient's home Carvedilol was increased to 25mg BID and home
losartan was increased to 50mg BID due to hypertension. Please
monitor patient's blood pressure at next visit.
[ ] Patient noted to have a normocytic anemia during her
hospitalization. Please consider further work-up as an
outpatient.
NEW MEDICATIONS
===================
Lasix 40mg PO daily
DISCONTINUED MEDICATIONS
===================
None
CHANGED MEDICATIONS
===================
Carvedilol increased to 25mg BID
Losartan increased to 50mg BID
#CODE: Full (presumed)
#CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Carvedilol 18.75 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
5. Ranexa (ranolazine) 500 mg oral BID
6. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
7. Ranitidine 150 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Losartan Potassium 50 mg PO DAILY
13. Pravastatin 80 mg PO QPM
14. Gabapentin 100 mg PO QHS
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Losartan Potassium 50 mg PO BID
RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Pravastatin 80 mg PO QPM
13. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
14. Ranexa (ranolazine) 500 mg oral BID
15. Ranitidine 150 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Unstable angina, acute on chronic heart
failure with preserved ejection fraction
SECONDARY DIAGNOSES: Hypertension, Atrial fibrillation, Chronic
kidney disease, Peripheral vascular disease, history of CVA,
Hyperlipidemia, Type 2 diabetes mellitus, Chronic obstructive
pulmonary 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 of taking care of you at ___!
You were here because you were having left chest pain and arm
pain.
While you were here, you were given medications in your IV to
help get extra fluid off. This was changed to a pill prior to
leaving the hospital. You also had your blood pressure
medication increased because your blood pressure was elevated.
When you leave, make sure to take your medications as
prescribed. Also you should attend all of your follow-up
appointments as listed below. Weigh yourself every morning, call
MD if weight goes up more than 3 lbs in 1 day or 5 lbs in 3
days. Your weight on discharge is 174 lbs.
If you have anymore chest pain, shortness of breath, or
palpitations, please seek medical care immediately.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10751887-DS-16
| 10,751,887 | 24,758,681 |
DS
| 16 |
2143-08-29 00:00:00
|
2143-08-29 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Trauma: stab wound to left flank
Major Surgical or Invasive Procedure:
___ renal angiogram and embolization
History of Present Illness:
___ yo M w/ PMH of IVDA, endocarditis, recieved stab wound to
left flank with CTA at OSH showing left renal grade ___
laceration with active extravasation and RP hematoma. Recieved
pRBC at OSH per report and had an asystolic event requiring
chest compressions and resuscitations. Transferred to ___, S/p
R T12-L3 lumbar arteriogram with no evidence of active
extravasation, pseudoaneurysm. Upper pole parenchymal defect
consistent with known laceration.
Past Medical History:
endocarditis
Social History:
___
Family History:
NC
Physical Exam:
Physical examination upon admission: ___:
examination taken from Trauma note ___, no narrative note
seen
vital signs: bp= 126/87, hr= 75, rr=223, oxygen saturation:
99% room air
HEENT: normal
CV: normal
LUNGS: normal
ABDOMEN: no mass, no tenderness, 2 cm laceration 5 cm of
midline
NEURO: cranial nerves WNL
MENTATION: alert and oriented
Physical examination upon discharge: ___:
vital signs: 98.1, hr=70, bp=138/87, rr=18, oxygen
saturation=98% room air
HEENT: sclera anicteric
CV: Ns1, s2, -s3, -s3
LUNGS: clear
ABDOMEN: soft, hypoactive BS
EXT: no pedal edema bil., + dp bil., left groin site with DSD,
no calf tenderness bil. 2 sutures lower back with DSD, left
middle finger, PIP swollen, tender with limited flexion
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 04:51AM BLOOD WBC-6.3 RBC-3.58* Hgb-12.7* Hct-36.1*
MCV-101* MCH-35.4* MCHC-35.1* RDW-15.6* Plt ___
___ 07:45PM BLOOD Hct-37.4*
___ 01:00PM BLOOD Hct-37.6*
___ 09:59AM BLOOD Hct-36.4*
___ 02:22AM BLOOD WBC-8.5 RBC-3.71* Hgb-13.3* Hct-37.2*
MCV-100* MCH-35.8* MCHC-35.6* RDW-16.2* Plt ___
___ 09:00PM BLOOD WBC-8.7 RBC-4.00* Hgb-14.4 Hct-41.4
MCV-104* MCH-36.1* MCHC-34.9 RDW-16.2* Plt ___
___ 04:51AM BLOOD Plt ___
___ 02:22AM BLOOD ___ PTT-29.3 ___
___ 04:51AM BLOOD Glucose-95 UreaN-10 Creat-1.0 Na-134
K-4.4 Cl-100 HCO3-28 AnGap-10
___ 04:51AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.7
___ 09:12PM BLOOD freeCa-1.03*
___: chest x-ray:
Possible minimal right upper lobe atelectasis/scarring.
Otherwise, no acute cardiopulmonary process
___: x-ray of left hand:
Possible tiny avulsion fracture at the volar base of the third
digit middle phalanx.
___: renal artery embolizaton:
Successful left renal, lumbar and renal capsular arteriogram
with no evidence of extravasation, pseudoaneurysm or AV fistula.
Brief Hospital Course:
The patient was admitted to the hospital after a stab wound to
the left flank. Imaging taken at an outside hospital showed a
left renal grade ___ laceration with active extravasation and
retro-peritoneal hematoma. He received packed red blood cells at
the outside hospital. Of note, he was reported to have an
asystolic event requiring chest compressions and resuscitations.
He as transferred here where his vital signs remained stable.
Because of his injury, there was concern for ongoing
extravasation. The patient was taken to ___ where he underwent a
lumbar arteriogram. No active extravasation was seen from left
renal or lumbar arteries. An upper pole parenchymal defect was
consistent with known laceration. The patient was monitored in
the intensive care unit where serial hematocrits were cycled.
His vital signs remained stable and he was started on a dilaudid
PCA for pain management.
He was transferred to the surgical floor on HD #2. He was
transitioned from intravenous pain medication to oral agents.
His vital signs remained stable and he was afebrile. He was
seen by the social worker who provided him with support. During
the patient's work-up he was reported to have right middle
finger pain. He underwent an x-ray of his hand and was found to
have a possible tiny avulsion fracture at the volar base of the
third digit middle phalanx. The Orthopedic service was consulted
and recommended taping the finger and a 2 week follow-up with
the hand clinic. The patient was discharged home on HD # 3 in
stable condition with a hematocrit of 36. Appointment for
follow-up was made with the acute care service and with his
primary care provider.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every ___ hours Disp #*35 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal laceration and retroperitoneal hematoma
left ___ finger avulsion fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You may shower normally. Please pat wound dry afterwards.
Please do not immerse wound in bath, swimming, or sauna for ___
weeks or until wound completely healed/closed.
-No strenuous exercise or heavy lifting for at least two weeks.
Avoid aspirin, motrin, ibuprofen until after your follow-up
visit with the acute surgery service
-Resume all of your home medications unless advised otherwise.
- Occurrence of bloody urine
-Do not drive or drink alcohol if taking narcotic pain
medication.
-Please go to your schedule appointments (details below).
-Call the ___ clinic at ___ if you have any questions.
-Call the ___ clinic or go to the nearest emergency room if you
have fevers > ___ F, if your wound appears red, hot, painful or
swollen, if your wound opens, or for anything else that is
troubling you.
You were also noted to have an avulsion fracture of your ___
right middle finger. Please report:
*increased pain right middle finger
*increased numbness in right middle finger
Please follow up in Hand clinic in ___ weeks. You can schedule
your appointment by calling # ___.
Followup Instructions:
___
|
10751923-DS-20
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| 20 |
2191-09-13 00:00:00
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2191-09-13 14:40:00
|
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, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o transgender male to female, with hx HIV
and DM, who came to the ED after experiencing two days of
nausea, vomiting, abdominal pain and inability to keep anything
down. She also has not been taking insulin or checking
fingersticks regularly. She is not sure which meds she is
taking, but does confirm that she's taking her HAART medications
(sustiva, truvada). She denies diarrhea or constipation, but has
had diffuse myalgias. Denies fevers, chills, sweats, dyspnea,
chest pain, palpitations. She was seen at ___ ___
months ago, where she was diagnosed with pneumonia; she was
prescribed inhalers and oral antibiotics, but does not know
which medications were used. In terms of her foot, she has not
had increased pain, tingling or numbness around her toe ulcer.
She had a podiatry appointment scheduled for today, but missed
it because she was in the ED.
.
In the ED, initial VS: 100 98 113/79 16 100%. Exam notable for
benign abdomen, with mild RUQ/LUQ tenderness. She was guaiac
negative on rectal exam. Labs revealed hgb/hct mildly decreased
from baseline, WBC count 9K, glucose 470, creatinine 1.3 (b/l
0.8-1.0), corrected sodium ~135, and elevated anion gap. U/a
showed ketones and large glucose. Lactate 1.1. Plain film of
foot was highly concerning for osteomyelitis, and CXR was
negative for acute processes. Podiatry was consulted, and
recommended wet to dry dressings daily, and IV antibiotics while
in house --> augmentin to complete two week course. Pt was given
2L IVF, ondansetron, 14 units of humalog, vancomycin 1g, and
unasyn 1.5g. Subsequent fingersticks was 242, no additional
insulin given. VS prior to transfer were 99 °F, 101, 16, 103/65,
100%, ra.
.
Currently, her main complaint is that she is hungry, and asking
for food "with taste." Denies ongoing abdominal pain, nausea,
foot pain, fevers, chills, or sweats.
.
REVIEW OF SYSTEMS: As per HPI. Otherwise, denies headache,
vision changes, sore throat, cough, shortness of breath, chest
pain, diarrhea, constipation, dysuria, hematuria, arthralgia or
rash.
Past Medical History:
HIV, hepatitis C, hepatitis B, NIDDM, HTN, Hyperlipidemia
Social History:
___
Family History:
Family psychiatric history: father with "drug problems"
otherwise
declines to talk about family, no hx suicide
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - Temp 98.6F, BP 106/72, HR 102, R 16, O2-sat 100% RA
GENERAL - Restricted affect, but awake, interactive, in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD/LAD, no carotid bruits
HEART - Tachycardic, regular, PMI non-displaced, nl S1-S2, no
MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - +mild epigastric and RUQ tenderness, non-radiating. No
rebound tenderness or guarding. NABS, soft, non-distended, no
masses or HSM
EXTREMITIES - thin, WWP, Trace edema in RLE to ankle, no edema
in LLE. No cyanosis/clubbing, symmetric 2+ ___ pulses.
R large toe with malodorous plantar ulcer 2 cm in diameter, no
surrounding erythema or fluctuance. Consistent granular base
without probing to deeper tissues. No proximal lymphangitis or
subcutaneous crepitus.
LYMPH - no inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
.
DISCHARGE PHYSICAL EXAM
VS: Temp 98.1, Tmax 98.4, BP 110/70, HR 92, RR 18, O2 sat 98% on
RA
GEN: A & O X3, NAD
HEENT: PERRL, MMM, OP Clear
NECK: supple, JVP flat, no LAD
HEART: RRR, good S1,S2, no m/r/g
LUNG: CTA bilaterally
ABD: soft, ND, mild RUQ and epigastric tenderness
EXT: right toe amputation, would clean, dry, intact with
appropriate dressing
peripheral pulse ___ 2+ X2, no pitting edema
Pertinent Results:
ADMISSION LABS
___ 04:00PM BLOOD WBC-9.0# RBC-3.30* Hgb-9.8* Hct-29.6*
MCV-90 MCH-29.8 MCHC-33.2 RDW-14.4 Plt ___
___ 04:00PM BLOOD Neuts-79.9* Lymphs-17.8* Monos-1.1*
Eos-0.6 Baso-0.6
___ 04:00PM BLOOD ___ PTT-33.4 ___
___ 04:00PM BLOOD Glucose-470* UreaN-28* Creat-1.3* Na-127*
K-5.5* Cl-91* HCO3-25 AnGap-17
___ 04:00PM BLOOD ALT-21 AST-19 AlkPhos-159* TotBili-0.2
___ 04:00PM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.1 Mg-2.4
___ 04:17PM BLOOD Lactate-1.1
.
DISCHARGE LABS
___ 08:34AM BLOOD WBC-3.9* RBC-3.29* Hgb-9.8* Hct-29.5*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.7 Plt ___
___ 08:34AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-139 K-4.3
Cl-107 HCO3-28 AnGap-8
.
URINE
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 06:00PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 06:00PM URINE Color-Straw Appear-Clear Sp ___
.
PERTINENT LABS
.
MICROBIOLOGY
Blood culture ___ X2 no growth to date
Wound Swab ___
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Urine culture ___ no growth to date
TISSUE ___
___ 3:10 pm TISSUE Site: FOOT
RIGHT HALLUX PROXIMAL MARGIN.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Reported to and read back by ___ @ 12:58 ___ ON
___.
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
BETA STREPTOCOCCI, NOT GROUP A. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
TISSUE ___ 3:10 pm TISSUE Site: BONE RIGHT GREAT TOE.
___ 3:10 pm TISSUE Site: FOOT
RIGHT HALLUX PROXIMAL MARGIN.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Reported to and read back by ___ @ 12:58 ___ ON
___.
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
BETA STREPTOCOCCI, NOT GROUP A. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
RADIOLOGY
CXR PA/LAB ___
FINDINGS: PA and lateral radiographs of the chest were acquired.
The lungs
are clear. The cardiac and mediastinal contours are normal.
There are no
pleural effusions. Mild biapical pleural thickening is
unchanged. There is
no pneumothorax.
IMPRESSION: No acute cardiac or pulmonary process.
.
Foot PA/LAT/OB ___
IMPRESSION: Loss of definition of the cortex at the level of the
distal
phalanx of the first toe, plantar aspect might represent early
bony
destruction and is concerning for osteomyelitis.
.
Foot PA/LAT/OB ___
IMPRESSION: S/p amputation of first toe, at the mid-proximal
phalanx. No
residual focus of osteolysis detected.
.
PATHOLOGY
Right toe pathology pending
Brief Hospital Course:
___ y/o transgender male-to-female with DM, chronic toe ulcer,
hep B/C, HIV on HAART, admitted for nausea, vomiting,
hyperglycemia, and was found to have nonhealing toe ulcer with
radiologic evidence of osteomyelitis.
.
ACTIVE ISSUES
# Toe ulcer: Pt was found to have chronic nonhealing ulcer over
the right toe, likely in the setting of poorly controlled
diabetes. On the X-ray, there is radiographic evidence for
osteomyelitis. Pt was evaluated by podiatry, who felt that
amputation was the best treatment. Pt underwent uncomplicated
distal ___ toe amputation. The preliminary culture of the
tissue grew gram positive cocci with dirty margin. Pathology is
still pending at the time of discharge. Pt therefore will need
six weeks of iv antibiotics. He is currently covered with
Vancomycin and unasyn, which could potentially narrowed upon
speciation of microbiology.
.
# Hyperglycemic crisis: On admission, pt was found to have serum
glucose over 400. Pt has known history of poorly controlled
type 2 diabetes, with recent A1c over 12. On the metabolic
panel, there was also a anion gap, which closed shortly after IV
fluids and insulin. This hyperglycemic crisis was likely a
result of poor medication compliance and dehydration. We held
her metformin and started her on fixed and sliding scale
insulin. Her blood sugar was relatively well controlled
otherwise during this admission.
.
# Nausea/vomiting/epigastric pain: Pt presented with nausea,
vomiting and mild right upper guardrant pain. We felt her
symptoms were largely a result of metabolic derangement in the
setting of ketoacidosis. There were mild elevation of ALP, but
otherwise unremarkable LFT. Her RUQ could also result from
viral hepatitis. Overall, her physical exam remained stable.
.
CHRONIC ISSUES.
# HIV: Pt has known history of HIV. Her last CD4 count on
record 458 in ___, but has hx CMV retinitis. We continued her
Sustiva, Truvada and Isentress. We STOPPED her valtrex given
...
.
# Hep B/Hep C: Pt's LFTs and lipase were generally normal, with
mildly elevated alk phos. Pt does have mild RUQ tenderness but
no jaundice. She had liver biopsy in ___, which was consistent
with chronic viral hepatitis with Grade ___ inflammation and
Stage 0 fibrosis. She will be followed in the liver clinic
shortly after discharge.
.
# Hypertension: Pt has well controlled BP. We continued her
home blood pressure regimen.
.
# Hyperlipidemia: Most recent lipid panel in OMR in ___, LDL
114. We continued her lipitor.
.
# Depression: Denies HI/SI. She appeared to have flat affect
and periodic sadness. Pt was visited by his brother and mother
during this hospitalization, which appeared to have eased much
of her depression. We asked consult from social worker for
coping and diabetes medication at home. We continued her
citalopram and buspirone.
.
# Anemia: Hct mildly below baseline. No signs or symptoms of
active bleeding other than small blood around toe ulcer. Likely
etiology include HIV, CMV, hepatitis, or iatrogenic. Her Hct
was stable during this hospitalization.
.
TRANSITIONAL ISSUES
# PENDING STUDIES AT DISCHARGE
- Blood culture on ___ X2 no growth to date
- wound swab ___ final speciation
- Tissue culture (big toe) ___ final speciation and resistance
- Tissue culture (big toe proximal) ___ final speciation and
resistance
# MEDICATION CHANGES:
- STARTED Vancomycin 1000 mg iv q12h for 5 weeks and 5 days
- STARTED unasyn 3 g q6h for 5 weeks and 5 days
- DECREASED Valtrex to 900 mg qd (from bid)
# FOLLOW UP PLAN
- Please check Vancomycin trough (goal ___ and adjust dose
accordingly
- ___ need antibiotics change upon speciation of culture
- Will need PCP followup arrangement at the time of discharge
- Pt may not need Valtex given her HIV has been well
controlled
Medications on Admission:
aspirin 81 mg qd
Amlodipine 5 mg qd
metformin 500 mg bid
Atorvastatin 10 mg qd
gabapentin 900 mg Q12
bupropion SR 150 mg daily
citalopram 40 mg QHS
Sustiva (Efavirenz) 600 mg daily
Truvada (Emtricitabine-Tenofovir) 200-300 mg daily
Isentress (Raltegravir) 400 mg bid
Valganciclovir 900 mg bid
insulin (glargine 17u QHS, humalog SS)
Proair 2 puffs q4-6h prn
Chlorhexidine rinse qid
OTC
multiviatmin daily
glucerna shake BID
Discharge Medications:
1. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
9. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
10. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
13. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
14. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze, SOB.
16. Vancomycin 1000 mg IV Q 12H
17. Ampicillin-Sulbactam 3 g IV Q6H
18. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
19. Humalog 100 unit/mL Solution Sig: see attached sliding scale
units Subcutaneous four times a day.
20. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Chronic osteomyelitis
Secondary Diagnosis
- HIV
- Hepatitis C
- Hepatitis B
- Diabetes Mellitus Type II
- Depression
- Anemia
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to our hospital for nausea and vomiting. You were
found dehydrated with very high blood sugar. We treated you
with fluids and insulin. We also found that your have a
nonhealing foot ulcer that likely has infected the toe bone.
You underwent an uncomplicated toe amputation. You will need iv
antibiotics treatment for 6 weeks for this condition. You are
otherwise doing well, and can go to the rehab today.
.
Please note the following changes to your medication:
- Please START Vancomycin 1 g every 12 hours for six weeks
- Please START Unasyn 3 g iv every 3 hours for six weeks
.
Please continue the follow appointments as previously scheduled.
Please make sure that you have a followup appointment with your
___ PCP after discharge.
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Followup Instructions:
___
|
10751923-DS-21
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DS
| 21 |
2193-12-28 00:00:00
|
2193-12-30 17:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right leg pain, redness
Major Surgical or Invasive Procedure:
___ Bedside debridement of RLE in ED
History of Present Illness:
___ y/o F with PMH of DM2 and HIV/HCV coinfection (on ARV with
CD4 unknown and VL believed to be undetectable) p/w right lower
extremity pain and redness. Patient reports ___ days of right
lower extremity pain and increased swelling. She reports redness
and warmth of the shin starting yesterday. She saw here PCP
where she started on keflex and bactrim as an outpatient.
However, her symptoms have worsened and the redness has spread
as well as drainage from her previously amputated R great toe.
She has been able to ambulate but has been limited to shorter
distances because of pain. She has not noticed and fevers or
chills at home. Given her worsening symptoms she represented to
___ where she was referred to the ED for management.
In the ED, initial vitals were: 99.7 102 116/75 18 100% RA. She
had blood cultures drawn and was given Vanc/Unasyn. Podiatry
was consulted who did a bedside debridement in the ED. XRAYs
were obtained with reads still pending.
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 ongonig nausea, vomiting
(last ___ days ago), diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
-HIV, good compliance with ARV, unknown VL and CD4
-H/o CMV retinitis, blind in R eye
-HCV without cirrhosis, followed in ___
-DM2 c/b neuropathy, on metformin + insulin
-HTN
-HL
-Depression
-S/p R great toe partial amputation (___)
Social History:
___
Family History:
Father - died of throat cancer
Mother - patient not close to her mother
Physical ___:
ADMISSION EXAM:
=============================
Vitals: T 99.3 BP 102/68 HR 101 RR 18 SO2 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Slightly decreased BS throughout
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. LLE normal with 2+ pulses. RLE
wrapped in curlex bandage. R great toe s/p amputation with open
ulceration. There is erythema, tenderness, and mild swelling
extending up to the mid shin. R ___ pulse is 1+.
Neuro: CNII-XII intact with decreased vision in her right eye,
___ strength upper/lower extremities, grossly normal sensation,
gait deferred.
DISCHARGE EXAM:
Vitals: T 98.7 (Tm 99.1) BP 138/92 HR 100 RR 18 SO2 98% RA
General: Alert, oriented, visible anxious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. LLE normal with 2+ pulses. R great
toe s/p amputation with open ulceration. No purulent discharge.
There is erythema, tenderness, and mild swelling extending up to
the mid shin. Warmth present overal whole anterior tibia.
Erythema decreased within circumscribed pen marking. R ___ pulse
is 1+.
Neuro: CNII-XII grossly intact. Full range of motion in upper
extremities bilaterally. Movement of right foot limited by pain,
+4 strength RLE, limited by pain.
=============================
Pertinent Results:
ADMISSION LABS:
=============================
___ 01:50PM WBC-10.6 RBC-3.22* HGB-9.4* HCT-31.1* MCV-97
MCH-29.3 MCHC-30.4* RDW-14.8
___ 01:50PM NEUTS-84.0* LYMPHS-12.0* MONOS-3.2 EOS-0.5
BASOS-0.3
___ 01:31PM LACTATE-2.0 K+-6.5*
___ 01:50PM GLUCOSE-245* UREA N-12 CREAT-1.2* SODIUM-133
POTASSIUM-8.7* CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
___ 01:55PM ___ PTT-26.3 ___
___ 03:30PM K+-4.6
DISCHARGE LABS:
=============================
___ 07:35AM BLOOD WBC-6.2 RBC-2.86* Hgb-8.4* Hct-27.8*
MCV-97 MCH-29.4 MCHC-30.2* RDW-15.2 Plt ___
___ 07:35AM BLOOD Glucose-162* UreaN-7 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-28 AnGap-12
___ 06:50AM BLOOD calTIBC-204* VitB12-546 Folate-9.5
Ferritn-119 TRF-157*
MICRO:
=============================
IMAGING:
=============================
Foot/Ankle/TibFib XR - No radiographic findings of acute
osteomyelitis; however, please note that MRI or nuclear medicine
bone scan are more sensitive.
Brief Hospital Course:
___ with PMH of HIV (per pt well controlled on ARVs) and DM2 p/w
diabetic foot ulcer and surrounding cellulitis and potentially
osteomyelitis.
# Cellulitis: Patient with diabetic foot ulcer and initally
started on outpatient therapy with bactrim and keflex. However,
patient appeared to be failing this regimen. She underwent
debridement in the ED. XRAY did not suggest osteomyelitis.
Started on IV Vanc/Unasyn given she failed bactrim/keflex as an
outpatient in order to cover MRSA, Strep, anerobic, and GNR
coverage. Her cellulitis was likely precipitated by her diabetic
foot ulcer and cleaning her feet with a sharp object. In
addition, she is likely largely immunocompetent given her
reports of her HIV labs. Cellulitis clinically improved
throughout hospitalization, with decreasing edema and erythema.
Warmth persisted over anterior tibia. Podiatry suggested patient
was improved enough to be discharged on 14 day course of
Augmentin 875mg BID.
- Discharge on Augmentin 875mg BID
- f/u appointments made with Dr. ___ and PCP.
# DM2: Patient had elevated FSBG levels throughout
hospitalization and was treated with insulin.
- resume home insulin management on discharge
- suggest regular follow up with podiatry for foot care
maintanence
# Anemia: On admission, pt was found to have Hb of 9.4. Hb
remained stable. Iron studies ___ TIBC, low Transferritin,
normal Ferritin, Iron, B12, folate. Possible for anemia of
chronic disease. However, Per ___ records, anemia is new.
Etiology unclear, and likely mixed picture.
- Ranitidine BID
- Consider further workup outpatient
CHRONIC ISSUES:
# HIV - continued home medications
# HTN - lisinopril held in ED given due to hyperkalemia in the
setting of acute infection.
- held on discharge, restart as outpatient with repeat labs
TRANSITIONAL ISSUES:
- f/u with podiatry
- education on foot hygiene
- education on diabetes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 1000 mg PO Q12H
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN
breakthrough pain
4. MetFORMIN (Glucophage) 850 mg PO BID
5. Estradiol 3 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
7. Efavirenz 600 mg PO DAILY
8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Gabapentin 900 mg PO BID
12. Citalopram 40 mg PO DAILY
13. ValGANCIclovir 900 mg PO Q12H
14. BuPROPion (Sustained Release) 150 mg PO DAILY
15. Raltegravir 400 mg PO BID
16. Lisinopril 5 mg PO DAILY
17. Atorvastatin 20 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Aspirin 81 mg PO DAILY
20. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
4. Citalopram 40 mg PO DAILY
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Estradiol 3 mg PO DAILY
8. Gabapentin 900 mg PO BID
9. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Raltegravir 400 mg PO BID
13. ValGANCIclovir 900 mg PO Q12H
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Docusate Sodium 100 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 8.6 mg PO BID:PRN constipation
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
19. Aspirin 81 mg PO DAILY
20. MetFORMIN (Glucophage) 850 mg PO BID
21. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Suggest taking medication with food to prevent stomach upset.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
22. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Cellulitis
SECONDARY:
- diabetes, type II, insulin dependent with nephropathy and
neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Ambulatory. Instructed to wear boot on right foot when talking.
PE: R great toe s/p amputation with open ulceration. No purulent
discharge. There is erythema, tenderness, and mild swelling
extending up to the mid shin. Warmth present over whole anterior
tibia. Erythema decreased within circumscribed pen marking.
Currently covering roughly 5 inches up anterior tibia and 3
inches wide.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to treat you while you were at ___. You were
admitted with pain and redness in your right leg which was
diagnosed as a cellulitis without osteomyelitis. You were given
strong antibiotics through the IV to help fight the infection
and your infection improved on this treatment. We are
discharging you on oral antibiotics for 14 days and have made
appointments for you to follow up with your PCP and Dr. ___
podiatry.
Please remember to follow up with podiatry often for regular
cleaning of feet. Do not use any sharp objects to clean feet at
home. You can discuss with Dr. ___ your PCP about how this
infection will affect your job.
Best wishes,
Your ___ medical team
Followup Instructions:
___
|
10751923-DS-24
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| 24 |
2195-11-10 00:00:00
|
2195-11-12 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
Upper GI Series
Gastric emptying study
History of Present Illness:
___ year old male to female transgender patient PMHx HCV s/p
Harvoni, HIV on HAART (undetectable viral load ___, and
insulin dependent diabetes mellitus who presented with nausea,
vomiting.
Patient reports nausea, vomiting ongoing since completion of
Harvoni treatment 6 months prior. Nausea and vomiting waxes and
wanes. During episodes is unable to tolerate po. Associated with
mild abdominal cramping in lower abdomen and fatigue.
Has presented to ED multiple times for symptoms. Per patient,
attributed to DKA previously. Seen in ED ___ for these symptoms
and found to have ___ to 1.4, BG 269, UA neg ketones, and
hyperkalemia. Was treated with IVF. Symptoms attributed to
gastroparesis. Few days ago fell due to dizziness after standing
up from bathroom. No head strike or injuries. Patient noted
brief reprieve from symptoms until ___ morning when n/v
recurred.
In the ED, initial VS were 97 100 95/60 16 100% RA.
Labs showed WBC 6.5, Hgb 9.2, mildly elevated LFts, mild
acidosis, mild ___ that resolved with fluids, BS 312 -> 70, and
no ketonuria.
Imaging showed CT wet read:
1. The bladder is significantly distended. Recommend correlation
with UA.
2. 3 mm pleural-based nodule new since prior study. Recommend 12
month follow-up chest CT if patient is high risk per ___
guidelines.
Received 4 L fluids (NSx2L, D5NSx2L), morphine, 10U insulin,
Zofran
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports headache. Pressure at
top of head. Slight improvement with morphine in ED. No neck
pain or pain with eye movements. Slight photophobia. No prior
h/o migraines.
ROS: [+] sweats, R toe ulcer
[-] cp, sob, cough, diarrhea, dysuria, hematuria, hematochezia,
melena
Past Medical History:
-Hepatitis C for which she is genotype 1A. Her baseline viral
load prior to starting therapy was about 5.6 million. She was
treatment naive prior to this therapy. Liver by biopsy in ___
showed stage 0 fibrosis. She had a Fibroscan in ___ that
showed a score of 4.5 kilopascals indicative of stage ___
disease. s/p 12wk course of Harvoni
-Hepatitis B, cleared
-HIV
-Remote history of CMV retinitis.
-T2DM c/b by neuropathy
-HTN
-HLD
-Depression
-S/P right great toe partial amputation in ___
-Male to female transgender
Social History:
___
Family History:
DM, HTN
Physical Exam:
Admission Physical Exam:
========================
VS - 99.3 145/86 104 18 100%RA
GENERAL: NAD
HEENT: EOMI, PERRL.
NECK: Flexion/extension without pain.
CARDIAC: RRR
LUNG: CTAB
ABDOMEN: nondistended, +BS, mild TTP across lower abdomen
EXTREMITIES: no edema. R foot ___ digit with shallow erosion, no
purulence or drainage or increased erythema/warmth of
surrounding skin.
NEURO: CN II-XII intact, ___ strength UE and ___ bilaterally. FTN
intact. No tremor/flapping tremor.
SKIN: per above
Discharge Physical Exam:
========================
Vitals: 97.8 92/60 (87-115/70s) 85 18 100RA
General: Alert, oriented, pleasant
HEENT: Sclera anicteric, MMM, PERRL.
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, R shin with lidocaine patch, slight
increased warmth but no overlying erythema or marked edema. R
calf no TTP. R foot ___ digit with dry dressing in place,
clean/dry/intact.
Skin: per above
Neuro: ___ strength UE ___ and ___ ___. CN2-12 grossly intact
Pertinent Results:
Admission Labs:
===============
___ 08:30AM BLOOD WBC-6.5 RBC-3.39* Hgb-9.2* Hct-30.1*
MCV-89 MCH-27.1 MCHC-30.6* RDW-15.3 RDWSD-48.7* Plt ___
___ 08:30AM BLOOD Neuts-77.2* Lymphs-14.1* Monos-7.2
Eos-0.8* Baso-0.2 Im ___ AbsNeut-5.06 AbsLymp-0.92*
AbsMono-0.47 AbsEos-0.05 AbsBaso-0.01
___ 08:30AM BLOOD Plt ___
___ 08:30AM BLOOD Glucose-312* UreaN-27* Creat-1.4* Na-128*
K-7.9* Cl-96 HCO3-22 AnGap-18
___ 08:30AM BLOOD ALT-91* AST-106* AlkPhos-181* TotBili-0.2
___ 12:00PM BLOOD Glucose-70 UreaN-22* Creat-1.1 Na-137
K-4.9 Cl-108 HCO3-21* AnGap-13
___ 08:30AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.9 Mg-2.0
___ 08:48AM BLOOD ___ pO2-28* pCO2-49* pH-7.31*
calTCO2-26 Base XS--3 Comment-ADDED ON-
___ 08:48AM BLOOD Lactate-2.1* K-6.1*
___ 05:14PM BLOOD Lactate-1.1
Urine:
======
___ 05:02PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:02PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:02PM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE Epi-3
___ 05:02PM URINE CastHy-1*
___ 02:01PM URINE Hours-RANDOM TotProt-83
___ 02:01PM URINE U-PEP-PND
Microbiology:
=============
___ 8:30 am URINE SPECIMEN NOT PROCESSED DUE TO:. .
**NOT PROCESSED**
URINE CULTURE:
___ 5:02 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
EKG
====
ECGStudy Date of ___ 8:47:22 AM
Clinical indication for EKG: R10. 84 - Generalized abdominal
pain
Sinus rhythm at upper limits of normal rate. The QRS complex is
narrow.
Compared to the previous tracing of ___ the rate is now
slightly slower.
Otherwise, no change.
Rate 96 PR 167 QRS 75 QT350 QTc 413/443
Imaging:
========
CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 12:26 ___
IMPRESSION:
1. Bladder distention with wall thickening, correlate with
urinalysis or
symptoms of bladder outlet obstruction.
2. Moderate fecal loading, may contribute to symptoms of
abdominal discomfort.
3. 3 mm pleural-based nodule, new since prior study.
RECOMMENDATION(S): 12 month follow-up chest CT if patient is
high risk per
___ guidelines.
CHEST (PA & LAT)Study Date of ___ 5:25 ___
IMPRESSION:
No acute cardiopulmonary process.
GASTRIC EMPTYING STUDYStudy Date of ___
IMPRESSION: Delayed gastric emptying study. Patient was
symptomatic during
study, reporting nausea at the time of meal ingestion. No
symptoms were
reported after that time.
UGI AIR W/KUBStudy Date of ___ 8:51 AM
IMPRESSION:
No evidence of obstruction. No stomach mucosal abnormalities
identified.
Discharge Labs:
===============
___ 06:25AM BLOOD WBC-4.6 RBC-2.93* Hgb-7.9* Hct-25.8*
MCV-88 MCH-27.0 MCHC-30.6* RDW-15.0 RDWSD-48.7* Plt ___
___ 06:25AM BLOOD Plt ___
___ 05:34AM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 06:25AM BLOOD Glucose-255* UreaN-13 Creat-0.8 Na-136
K-4.7 Cl-104 HCO3-24 AnGap-13
___ 10:45AM BLOOD ALT-51* AST-38 AlkPhos-164* TotBili-0.1
___ 06:25AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
Brief Hospital Course:
Summary:
========
___ year old male to female transgender patient PMHx HCV s/p
Harvoni, HIV on HAART (undetectable viral load ___, and
insulin dependent diabetes mellitus who presented with nausea,
vomiting. Symptoms occurring for months and resulting in poor po
intake, hyperglycemia, hypoglycemia, and multiple ED and
hospital presentations including recent ICU admission in ___ for ___.
Acute Issues:
==========
#Nausea, vomiting:
CTAP demonstrated distended bladder but no other acute finding
(bladder scan ~400ccs and patient voiding on own without
difficulty). GI consulted. Upper GI series performed
demonstrating no evidence of obstruction and no stomach mucosal
abnormalities identified. Gastric emptying study performed
demonstrating delayed gastric emptying and patient was trialed
on Metoclopramide 10 mg PO/NG QIDACHS. QTc checked and was 414.
Patient tolerating po intake at time of discharge without nausea
or vomiting.
#Diabetes:
Initially hyperglycemic in ED to 300s but down to 70 with 10u
insulin regular. Two episodes of symptomatic hypoglycemia while
NPO for imaging above (dizziness) that improved with D50 and
D51/2NS. ___ consulted during hospital stay and was seen by
diabetes educator. Tested for adrenal insufficiency with ACTH
stimulation test and did not show insufficiency. Reinforced
importance of checking FSGs TID even when not eating and to use
bedtime ISS while NPO.
#R shin pain:
Patient with localized tenderness to palpation over R shin.
Burning sensation. No skin changes, overlying erythema, mild
increased warmth. Improved with lidocaine patch; no change with
capscaicin cream.
#RLE Ulcer:
Patient with shallow erosion on ___ lateral digit of foot. No
evidence of surrounding cellulitis and no drainage. Covered in
dry dressing.
#Anemia:
Stable. Prior labs not consistent with iron deficiency anemia.
Reticulocyte production index 0.5%, thus inadequate bone marrow
response to anemia. SPEP and UPEP pending at time of discharge.
Bone marrow suppression may be secondary to HIV, HCV.
#Acute kidney injury:
Creatinine on admission 1.1, up from baseline of 0.8. Likely
pre-renal due to dehydration given low po intake and
nausea/vomiting. Improved to baseline with IVF and po intake.
#Fall:
Patient reporting falls at home and one fall in bathroom while
inpatient. Denies injuries, neck pain, back pain, urine or
bladder incontinence. Usually occur while active and without
preceeding symptoms including chest pain. Vision limited in R
eye due to CMV retinitis and with diabetic neuropathy in feet.
Also contribution potentially from hypoglycemia or orthostasis
given history of low po intake. ___ evaluated patient and
___ felt falls due to poor po intake; recommend f/u
outpatient ___ for weakness prn; no acute ___ needs identified.
Chronic Issues:
============
#Peripheral neuropathy:
Continued on home gabapentin.
#Mood:
Continued home buproprion and citalopram. On ___ demonstrated
abrupt change in demeanor and began to refuse care. Psychiatry
was consulted but patient refused to engage in discussion or
evaluation. After continued discussion and rapport building with
primary inpatient team, patient amenable to receiving care.
Transitional Issues:
====================
-Patient reporting falls as outpatient, attributing to low po
intake. Seen by ___ and felt to have no acute ___ needs. Please
provide Rx for outpatient ___ prn for weakness. Please follow up
and further address as clinically warranted.
-Please follow up SPEP and UPEP pending at time of discharge
-Patient with RLE shallow erosion on lateral aspect ___ digit.
No evidence of infection at this time. Covered with dry
dressing. Please monitor.
-R shin pain burning in nature, improved with lidocaine patch.
No cellulitis skin changes. Please monitor.
-Discharged on sliding scale and lantus 5 units at noon,
metformin BID per prior to admission. Recommend close ___
follow up this week. Please ensure follow up.
-Started on Metoclopramide 10 mg PO/NG QIDACHS for
gastroparesis. Please monitor nausea and vomiting for
improvement.
-Patient started on metoclopramide during hospital stay;
concurrently on prior citalopram. Tolerating well. Please
monitor for serotonin syndrome.
-Follow up tissue transglutaminase Ab
-CTAP during this hospital stay with 3 mm pleural-based nodule
new since prior study. ***12 month follow-up chest CT if patient
is high risk per ___ guidelines.****
-___ follow up scheduled on THURS ___ at 1:30 ___. Patient
called on ___, left voicemail regarding this appointment time.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Citalopram 40 mg PO DAILY
5. Dronabinol 7.5 mg PO BID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
8. Estradiol 5 mg PO DAILY
9. Gabapentin 600 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Raltegravir 400 mg PO BID
12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
13. Nystatin Oral Suspension 5 mL PO QID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Citalopram 40 mg PO DAILY
5. Efavirenz 600 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Estradiol 5 mg PO DAILY
8. Gabapentin 600 mg PO BID
9. Nystatin Oral Suspension 5 mL PO QID
10. Raltegravir 400 mg PO BID
11. Glargine 5 Units Lunch
Insulin SC Sliding Scale using HUM Insulin
12. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*56
Tablet Refills:*0
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidoderm] 5 % 1 patch once a day Disp #*30 Patch
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- gastroparesis
Secondary diagnoses
- type 2 diabetes mellitus
- acute kidney injury
- human immunodeficiency virus
- peripheral neuropathy
- anxiety/depression
- anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for nausea and vomiting.
We performed lab tests and imaging to help find out the cause of
these symptoms. We did not see anything obstructing your
esophagus (or food pipe). One of the imaging tests we performed
was a gastric emptying study that showed delayed gastric
emptying that is indicative of a condition called
"Gastroparesis". This is likely due to your diabetes. We started
you on a new medication called "reglan" that can help with this
condition.
It is also important that you check your blood sugars three
times a day even when you are not eating and to give yourself
insulin per the bedtime insulin sliding scale when not eating.
Blood sugar control will also help keep your gastroparesis under
control and help you avoid more nausea and vomiting.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10751923-DS-28
| 10,751,923 | 24,156,001 |
DS
| 28 |
2197-09-17 00:00:00
|
2197-09-22 16:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ year old male to female transgender who presents with
nausea and vomiting for the past 3 days after eating/drinking
with occasional episodes in between meals. She thought this
vomiting was due to hyperkalemia. She notes headache and
constipation that she attributes to ___. She has ongoing
weakness since diagnosis of hyperkalemia about a month ago. She
had a similar episode of nausea/vomiting in the past but this
was in setting of diabetes. She denies sick contacts. She
denies blood in her vomit or stool.
Past Medical History:
Chronic kidney disease stage 1
Cortical cataract right
Cytomegalovirus infection
Type 1 diabetes
Diabetic foot ulcer associated with type 2 diabetes mellitus
Diabetic oculopathy associated with type 2 diabetes mellitus
Essential hypertension
Human immunodeficiency virus infection
Hyperkalemia
Hyperlipidemia
Iron deficiency
Osteomyelitis
CMV retinitis
Peripheral chorioretinal scars
PTSD
Impulse control disorder
Severe recurrent major depression
Viral hepatitis C s/p Harvoni
Visual impairment
Social History:
___
Family History:
DM, HTN
Physical Exam:
Admission exam
-VS: reviewed
-General Appearance: pleasant, comfortable, no acute distress
-Eyes: PERLL, EOMI, no conjuctival injection, anicteric
-HENT: moist mucus membranes, atraumatic, normocephalic
-Respiratory: clear b/l, no wheeze
-Cardiovascular: RRR, no murmur
-Gastrointestinal: nontender, nondistended, bowel sounds present
-GU: no foley, no CVA/suprapubic tenderness
-Musculoskeletal: no pedal edema, no joint swelling
-Skin: no rash, ulceration, or jaundice noted
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Discharge PHYSICAL EXAM:
VITALS: 97.9 PO 157 / 93 L Lying 92 18 99 Ra
GENERAL: Alert, appears uncomfortable
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, NT on palpation. Bowel sounds
present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout, gait wnl, minimal to no ataxia on FTN,
Romberg neg
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
=================
___ 07:23AM URINE HOURS-RANDOM
___ 07:23AM URINE UHOLD-HOLD
___ 07:23AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:36AM K+-4.9
___ 02:05AM ___ PO2-25* PCO2-47* PH-7.34* TOTAL
CO2-26 BASE XS--1
___ 01:20AM GLUCOSE-102* UREA N-27* CREAT-1.4* SODIUM-138
POTASSIUM-5.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-15
___ 01:20AM estGFR-Using this
___ 01:20AM WBC-5.4 RBC-3.52* HGB-10.3* HCT-33.1* MCV-94
MCH-29.3 MCHC-31.1* RDW-14.4 RDWSD-50.0*
___ 01:20AM NEUTS-50.4 ___ MONOS-6.3 EOS-2.4
BASOS-0.6 IM ___ AbsNeut-2.73 AbsLymp-2.16 AbsMono-0.34
AbsEos-0.13 AbsBaso-0.03
___ 01:20AM PLT COUNT-196
NOTABLE LABS:
==============
___ 06:55AM BLOOD WBC-4.0 RBC-2.92* Hgb-8.4* Hct-26.0*
MCV-89 MCH-28.8 MCHC-32.3 RDW-13.7 RDWSD-45.0 Plt ___
___ 07:40AM BLOOD ___ PTT-37.4* ___
___ 06:55AM BLOOD ___ PTT-39.3* ___
___ 07:35AM BLOOD WBC-4.0 Lymph-48 Abs ___ CD3%-79
Abs CD3-1520 CD4%-30 Abs CD4-581 CD8%-46 Abs CD8-874*
CD4/CD8-0.67*
___ 06:55AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-145
K-4.3 Cl-110* HCO3-24 AnGap-11
___ 06:55AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8
___ 08:00AM BLOOD VitB12-833 Folate-9
___ 08:26AM BLOOD %HbA1c-5.7 eAG-117
___ 08:00AM BLOOD TSH-3.7
___ 08:00AM BLOOD Cortsol-28.8*
___ 08:00AM BLOOD PEP-NO SPECIFI IgG-1189 IgA-272 IgM-36*
IFE-PND
___ 10:25PM BLOOD CMV VL-NOT DETECT
___ 02:05AM BLOOD ___ pO2-25* pCO2-47* pH-7.34*
calTCO2-26 Base XS--1
___ 02:36AM BLOOD K-4.9
MICROBIOLOGY:
================
__________________________________________________________
___ 8:00 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 7:23 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___: Chlamydia trachomatis/Neisseria gonorrhoeae RNA, TMA,
Rectal. NEGATIVE.
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL : NEGTIVE
___ 10:25PM BLOOD CMV VL-NOT DETECT
OTHER NOTALBE TEST:
====================
___BD & PELVIS WITH CO
1. There is wall thickening, submucosal edema, and a segment of
narrowing
measuring approximately 4 cm involving the distal sigmoid colon
and proximal rectum (series 2: image 61) compatible with
colitis. This could be secondary to inflammation or infection.
Ischemia is less likely. No evidence of obstruction.
2. Borderline bladder wall thickening which is unchanged as
compared to CT
abdomen and pelvis ___. Clinical correlation with
signs and
symptoms of cystitis is recommended.
___ Imaging MR HEAD W & W/O CONTRAS
1. No evidence for acute intracranial hemorrhage or infarction.
No abnormal enhancement.
2. Global parenchymal volume loss and minimal chronic small
vessel ischemic disease.
3. Additional unchanged findings, as above.
Brief Hospital Course:
___ year old male to female transgender who presents with nausea
and vomiting for the past 3 days after eating/drinking with
occasional episodes in between meals, being treated for
infectious colitis
ACUTE/ACTIVE PROBLEMS:
======================
# Colitis: First episode concerning for infectious process. She
does not
have personal/family history of autoimmune disease and lower
clinical suspicion for inflammatory bowel disease. She is
compliant with HAART with low clinical suspicion that this is a
complication of HIV. She was started on IVF and cipro/flagyl
intravenously with significant improvement. Therefore she was
switched to Flagyl and ciprofloxacin orally and continued for a
total of 7 days which concluded during her hospital stay. Her
diet was gradually advanced and her diarrhea resolved. Nutrition
was consulted to help manage her diet.
# Hyperkalemia - Patient being managed by nephrology for
hyperkalemia who feel
this may be due to CKD w/ frequent episodes ___ but question
type 4 tubular acidosis. Patient was continued on sodium bicarb
and fludrocortisone (dose increased). On discharge her
potassium was within normal range and creatinine normal at the
time of discharge.
# orthostatic hypotension:
# Gait instability: found during admission and likely explaining
her fatigue when standing up. After aggressive IVF and improved
PO intake as well as uptitration of fludrocortisone, this
resolved essentially by the time of discharge. Neuro exam was
notable for possible mild ataxia and + mild Romberg sign, so
underwent MRI (without lesion), B12, TSH, RPR, am cortisol
testing (all normal). It is likely that her orthostasis is due
to a combination of hypovolemia chronically due to poor PO,
possible intermittent hypoglycemia, and autonomic neuropathy
from her DM and HIV. On the day of discharge, the patient was
only mildly orthostatic SBP:
157(lying)->136(sitting)->144(standing).
# Jaw pain/lock: Complained of jaw pain and lock after opening
her mouth, which is likely from a muscle spasm that resolved
with warm massage. We discussed with oral surgery and they
recommended that should this recur, a dental appointment would
be required to evaluated for any jaw disease.
# ___ (resolved) - Likely prerenal in setting of vomiting and
poor PO intake,
improved s/p IV fluids. During her admission her creatinine
level improved and her discharge creatinine was normal.
# Malnutrition: ongoing and was evaluated by nutrition who
recommended either tube feeding prior to discharge or very close
monitoring of her nutritional intake. Multifactorial, likely
from depression, possible component of disordered eating/food
fear, confusion about dietary restrictions (K, DM),
gastroparesis, and depression. She was started on 5 mg
Dronabinol for appetite stimulation which was doubled on the day
of discharge. We started the patient on Reglan for treating
nausea from her gastroparesis during meals. The patient had mild
improvement in her intake and will require further assessment of
her nutritional status as a outpt with a dietician.
# Idiopathic Diabetes: Patient was found to have markedly
reduced A1c from previous, likely ___ poor PO and continued use
of To___ as an outpatient. When her PO intake increased even
slightly, she had significant hyperglycemia. She was found to be
very sensitive to insulin. Given her history of DKA, she was
therefore presumed to have idiopathic/type ___
diabetes. She was managed with low dose lantus and discharged on
this regimen to rehab (where her intake will be monitored
carefully and she has 3 meals/day) but per the ___ diabetes
service, we recommend on discharge home (where she is most
likely going to be eating very small meals frequently during the
day) that she resume her home ___ but at a lower dose
(5U/day) than on admission. Her home metformin was held while
inpatient but resumed on discharge.
CHRONIC MEDICAL PROBLEMS
# Depression: continue bupropion and citalopram
# HIV on HAART: continue dolutegravir, efavirenz, and descovy.
Her PCP ___ CD4 and viral load.
# Acute on chronic normocytic anemia: stable
# Constipation: continue bowel regimen
# Male to female transgender status: continued estrogen po (was
on lower dose while in house but discharged on home dose)
Transitional issues:
- The patient was treated for colitis with completion of her Abx
course in house. Recommend colonoscopy for follow up as an
outpatient.
- we increased her fludrocortisone dose to 0.3 mg daily. may
increase by 0.1 mg weekly if orthostasis is persistent despite
fluid therapy and good hydration. ___ consider Midodrine as
another option for treating orthostatic hypotension.
- check creatinine and monitor K in 1 week.
- Continued to encourage the patient to improve her PO intake.
If her nutritional intake falls consider addressing tube feeds
and placing a NG feeding tube.
- ensure close follow up with nutrition.
- Patient will follow up with ___ diabetes service and will
see a nursing specialist in diabetes with concomitant disordered
eating as outpatient.
- She was started on Dronabinol for apatite stimulation which
was doubled on the day of discharge. Consider continuing this
medication based on the result on her appetite.
On discharge the patient was stably anemic with Hb=8.4. Please
repeat CBC after 1 week.
- The patient suffered from 2 episodes of Jaw lock and pain
associated with muscle spasm of the right face. Per oral surgery
team, if this is a recurrent symptom, we would recommend an
evaluation with her dentist.
- After discharge from the rehab facility we would recommend
switching back to her home ___ but to decrease dose to 5
units daily. Please assess for assess need for 'tighter' Humalog
coverage if BG trends up significantly after Breakfast.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 10 mg PO QPM
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Citalopram 40 mg PO QHS
4. dolutegravir 50 mg oral DAILY
5. Dronabinol 5 mg PO BID
6. Efavirenz 600 mg PO DAILY
7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
8. Estradiol 2 mg PO DAILY
9. Fludrocortisone Acetate 0.2 mg PO DAILY
10. Gabapentin 600 mg PO BID
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Toujeo SoloStar U-300 Insulin (insulin glargine) 6 units
subcutaneous DAILY
14. Aspirin 81 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Ferrous GLUCONATE Dose is Unknown PO DAILY
17. sodium bicarbonate 650 mg oral BID
Discharge Medications:
1. Glargine 2 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
2. Metoclopramide 10 mg PO QIDACHS
3. Fludrocortisone Acetate 0.3 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Citalopram 40 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. dolutegravir 50 mg oral DAILY
12. Dronabinol 5 mg PO BID
13. Efavirenz 600 mg PO DAILY
14. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
15. Estradiol 6 mg PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. sodium bicarbonate 650 mg oral BID
18. HELD- Ferrous GLUCONATE Dose is Unknown PO DAILY This
medication was held. Do not restart Ferrous GLUCONATE until ___
follow up with your primary care doctor
19. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until untill ___
follow upw with ___ primary care doctor
20. HELD- ___ SoloStar U-300 Insulin (insulin glargine) 6
units subcutaneous DAILY This medication was held. Do not
restart ___ SoloStar U-300 Insulin until ___ are discharged
from rehab. ___ will restart this medication at a lower dose
than ___ used to be on
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Infectious colitis
HIV
orthostatic hypotension
Idiopathic Diabetes
Jaw locking
___
hypokalemia
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___
___ were admitted for abdominal pain, nausea, and vomiting. ___
were found to have an inflammation of the colon related to
infection. ___ improved with antibiotics. ___ were also noted to
have low blood pressure which was treated with fluids and
increasing your fludrocortisone. ___ were also found to have low
blood sugar and we consulted the ___. We kept
___ on a different type of insulin during ___ hospital stay.
However, once your discharged from rehab ___ will likely be on a
lower dose of your Toujeo. ___ were noted to have nausea not
eating well. Therefore, we started ___ on Reglan and started a
apatite stimulant. Please follow the recommendation from the
nutritionist and increase ___ oral intake. If unfortunately ___
caloric intake is not enough, ___ might need a tube placed
though the nose to the stomach through which ___ can receive
food. With regards to your jaw pain, we recommend simple massage
and warm compression when ___ jaw hurt and seeing ___ dentist if
the symptoms recur.
Please follow up with ___ doctors as listed below and take ___
medication as prescribed.
It was a pleasure taking care of ___ at the ___. We wish ___
all the best.
Your ___ team
Followup Instructions:
___
|
10752010-DS-6
| 10,752,010 | 25,468,617 |
DS
| 6 |
2136-12-14 00:00:00
|
2136-12-21 08:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, diarrhea
Major Surgical or Invasive Procedure:
Sigmoidoscopy with biopsy
History of Present Illness:
___ with history of NSAID colitis and two prior episodes of H.
pylori s/p treatment presents with abdominal pain, found to have
leukocytosis with bandemia, and CT with diffuse pancolitis.
Visit was conducted with ___ interpreter over the phone.
He states that he has been having constant abdominal pain since
___. He had a positive H. Pylori breath test on ___ and was
started on treatment on ___ by his GI Dr. ___ with plan for
EGD in ___. His abdominal pain has been getting worse,
associated with some nausea. He has had no fevers or vomiting.
He has had some diarrhea 3x/day -> 5x/day for the past month,
pink and watery, although with some dark red initially. No
clots. He also complains of some joint aches which are not new.
In the ED, initial vital signs were: 99.0 100 114/65 20 100% RA.
Exam notable for diffuse abdominal pain. Labs notable for WBC
15.1 with 28% bands, CBC, LFTs, lipase otherwise unremarkable
with lactate 1.0.
CT with Diffuse colonic wall thickening and hyperemia with mild
surrounding fat stranding is consistent with colitis, which may
be infectious or inflammatory in etiology. CXR negative.
Patient was given:
___ 17:32 IVF 1000 mL NS 1000 mL
___ 17:32 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 17:32 PO Donnatal 10 mL
___ 17:32 PO Lidocaine Viscous 2% 10 mL
___ 18:58 PO Oxycodone-Acetaminophen (5mg-325mg) 1 TAB
___ 19:55 IV Morphine Sulfate 4 mg
___ 19:55 PO Acetaminophen 1000 mg
___ 22:28 IV Ciprofloxacin 400 mg
On transfer, vitals were T100.5 96 ___ 95% RA
On the floor, he continues to have ___ abdominal pain. He has
lost 10 lbs in past two weeks. He has poor PO intake. He states
he only took 1 out of the 2 week H Pylori treatment course due
to abdominal pain. He denies taking any meds for his recent
symptoms.
ROS: Abdominal pain, nausea, diarrhea. No fever, chest pain,
dyspnea, dysuria, frequency, discharge, melena, hematochezia.
Past Medical History:
PAST MEDICAL HISTORY:
1. H. pylori, ___, treated with Pylera.
2. H. pylori, persistent, treated with ___.
3. Colitis due to NSAIDs.
4. History of gout
PRIOR STUDIES:
1. Colonoscopy ___, colitis- cecal inflammation- NSAIDs.
2. Sigmoidoscopy ___, biopsies negative.
Social History:
___
Family History:
There is no gastric cancer or colon cancer. Father has diabetes.
No IBD or other GI disorders in the family.
Physical Exam:
ADMISSION
VS: T97.8 86/53 76 14 95RA
GEN: Middle aged man in mild distress from abdominal pain
HEENT: No scleral icterus, OP clear
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes or rales
ABD: Soft, diffusely tender, nondistended, normal bowel sounds,
positive ___ sign, no rebound or guarding
EXT: No ___ edema, 2+ DP pulses
MSK: No joint erythema or effusion
NEURO: Alert, oriented, interactive
Pertinent Results:
ADMISSION
___ 04:45PM BLOOD WBC-15.1*# RBC-4.18* Hgb-12.8* Hct-37.4*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.0 RDWSD-42.4 Plt ___
___ 04:45PM BLOOD Neuts-58 Bands-28* Lymphs-3* Monos-10
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-12.99*
AbsLymp-0.45* AbsMono-1.51* AbsEos-0.15 AbsBaso-0.00*
___ 04:45PM BLOOD Glucose-126* UreaN-23* Creat-1.0 Na-135
K-3.5 Cl-100 HCO3-21* AnGap-18
___ 04:45PM BLOOD ALT-14 AST-30 AlkPhos-36* TotBili-0.4
___ 04:45PM BLOOD Lipase-24
___ 04:45PM BLOOD Albumin-3.3* Calcium-8.8 Phos-2.7 Mg-2.3
___ 07:37PM BLOOD Lactate-1.1
___ 06:05AM BLOOD WBC-15.5* RBC-4.03* Hgb-12.1* Hct-36.6*
MCV-91 MCH-30.0 MCHC-33.1 RDW-13.5 RDWSD-43.9 Plt ___
___ 06:05AM BLOOD Glucose-79 UreaN-17 Creat-0.9 Na-132*
K-4.3 Cl-99 HCO3-23 AnGap-14
___ 06:05AM BLOOD ALT-25 AST-77* AlkPhos-34* TotBili-0.3
___ 06:00AM BLOOD CRP-35.8*
Stool culture
. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ CXR-
The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The aorta is tortuous. The
cardiac silhouette is not enlarged. No evidence of free air is
seen beneath the diaphragms.
IMPRESSION:
No findings to suggest free air beneath the diaphragms.
___ CT A/P-
Diffuse colonic wall thickening and hyperemia with mild
surrounding fat stranding is consistent with pancolitis, which
may be infectious or inflammatory in etiology.
SIGMOIDOSCOPY:
Moderately severe ulceration and friability from the mid-sigmoid
to the extent of the exam in the proximal descending colon. The
rectum was relatively spared but had mild erythema.
Otherwise normal sigmoidoscopy to proximal descending colon
PATHOLOGIC DIAGNOSIS:
Colonic biopsies, three:
1. (descending): Chronic severely active colitis with
ulceration. 2. (sigmoid): Chronic severely active colitis with
ulceration.
3. (rectum): Chronic inactive colitis.
Test Result Reference
Range/Units
HISTOPLASMA GALACTOMANNAN <0.5 ng/mL
ANTIGEN, URINE
REFERENCE RANGE: <0.5 ng/mL
STRONGYLOIDES AB IGG NEGATIVE NEGATIVE
Test Result Reference
Range/Units
SCHISTOSOMA IGG ANTIBODY, <1.00 <1.00
FMI (SERUM)
INTERPRETIVE CRITERIA:
<1.00 Antibody Not Detected
> or = 1.00 Antibody Detected
ENTAMOEBA HISTOLYTICA IGG NEGATIVE
___
REFERENCE RANGE: NEGATIVE
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD INDETERMINATE A NEGATIVE
Results are indeterminate for
response to ESAT-6,TB7.7 and/or
CFP-10 test antigens.
Test Result Reference
Range/Units
NIL 0.04 IU/mL
MITOGEN-NIL 0.09 IU/mL
TB-NIL 0.01 IU/mL
Brief Hospital Course:
___ with history of NSAID colitis and two prior episodes of H.
pylori s/p treatment presents with abdominal pain, found to have
leukocytosis with bandemia, and CT with diffuse pancolitis found
to have ulcerative colitis
Ulcerative colitis: Abdominal pain with bloody diarrhea for
several weeks. First infection was excluded. C diff and
bacterial colitis was negative. GI consulted and flex sig
performed showing acute colitis. Biopsy returned with
ulcerative colitis. He was initiated on IV steroids starting
___, as well as tenofovir given his HBcag+ and risk for
reactivation. His symptoms improved somewhat but did not
completely resolve so he was given one dose of remicaid while
hospitalized and he tolerated it well at a dose of 10 mg/kg. GI
team was arranging for him to receive outpatient remicaid
infusions at 2 and 6 weeks. By the time of discharge, he was
only having ___ bm daily, pink colored, and was tolerating food
and drink well.
He was discharged on a dose of prednisone 60 mg daily with plans
to taper by 5 mg every week. He will followup with GI in
outpatient followup. He as also started on asacol prior to
discharge.
Indeterminate Quantiferon Gold: Seen by the ID service; they
advised INH and B6 for 9 months.
H. pylori: He was initiated on therapy as an outpatient. This
was continued to complete his 2 week course which completed on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain,fever
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
3. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
4. Mesalamine ___ 1600 mg PO TID
RX *mesalamine [Asacol HD] 800 mg 2 tablet(s) by mouth three
times a day Disp #*180 Tablet Refills:*1
5. Pyridoxine 50 mg PO DAILY
RX *pyridoxine 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
RX *tenofovir disoproxil fumarate [Viread] 300 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*1
7. PredniSONE 60 mg PO DAILY
RX *prednisone 5 mg 12 tablet(s) by mouth a day for one week,
and then taper by 5 mg each week Disp #*300 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis
H. pylori
Latent TB
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and bloody diarrhea.
After several tests, including a sigmoidoscopy and biopsy, we
have made the diagnosis of ulcerative colitis. You were treated
with steroids and also a dose of remicaid. You will decrease
the dose of prednisone by 5 mg every week. Our
gastroenterologists will be in touch with you regarding your
next dose of remicaid in two weeks. You have also been started
on a medication called mesalamine for your ulcerative colitis.
Please take the medication isoniazid and vitamin B6 to prevent a
reactivation of tuberculosis. You will followup with the
infectious disease doctors.
Followup Instructions:
___
|
10752477-DS-7
| 10,752,477 | 26,109,154 |
DS
| 7 |
2150-05-30 00:00:00
|
2150-05-30 23:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever, rigors, RUQ pain, transaminitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with prior HCV, DM2, obesity, depression,
tobacco use, who presented with 1 week of intermittent fevers,
rigors, RUQ pain, and transaminitis.
She was in her usual state of fairly good health until about 1
week ago when she began to note flu like symptoms with some body
aches and low grade fever. She became concerned that she could
have a problem with her tooth, which had been chipped for quite
some time (she was not having acute pain or swelling). She went
to the dentist and had it extracted. She was given some
unspecified antibiotic to take thereafter. On getting home that
night, she experienced fever and rigors. This continued into the
next day, and she ultimately sought care at a local ED. There
she
was given yet more antibiotics, seemingly for some presumed
odontogenic source. She says that the physician had ordered ___
RUQUS due to elevated LFTs but she left the hospital prior to
obtaining the result.
She says that she had been experiencing abdominal pain for some
time, about a month, vague, gas-like in the RUQ. However, on
returning home she began to notice worsening RUQ pain, sharp,
moderate to severe, some radiation to epigastrum. Pain
progressively worsened, with some associated nausea.
Symptoms progressively worsened and she presented again to her
local ED. Labs showed worsening transaminitis. She was referred
to ___ ED. Here, she had stable vital signs. She had repeat
labs confirming transaminitis. She underwent imaging with CTAP
and RUQUS that were relatively unrevealing. Admission was
requested.
REVIEW OF SYSTEMS
She noted a transient rash that she had difficulty further
characterizing, described almost as a flushing episode but
accompanied by itchiness. A full 10 point review of systems was
performed and is otherwise negative except as noted above.
Past Medical History:
HCV, DM2, obesity, depression, tobacco use
Surgeries: thigh abscess I&D, tonsillectomy
Social History:
___
Family History:
Family history was reviewed and is thought impertinent to
current
presentation. Mother with DM1, brothers with DM2. No family
history of gallstones.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.4 147/90 92 20 96 RA
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: mildly distended, tender in RUQ with voluntary guarding,
hyperactive BS. HSM deferred due to tenderness.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, minimal TTP in the RUQ to
palpation.
Bowel sounds present. No HSM
SKIN: (during episode on ___, none on day of discharge) -
raised erythematous papules over the torso and arms and inner
things (no mucosal involvement, no
involvement of soles or palms). No jaundice
Pertinent Results:
ADMISSION LABS:
___ 10:15PM BLOOD WBC-5.5 RBC-4.32 Hgb-13.4 Hct-39.4 MCV-91
MCH-31.0 MCHC-34.0 RDW-13.8 RDWSD-45.8 Plt ___
___ 10:15PM BLOOD Neuts-51 Bands-0 ___ Monos-7 Eos-6
Baso-0 ___ Myelos-0 AbsNeut-2.81 AbsLymp-1.98
AbsMono-0.39 AbsEos-0.33 AbsBaso-0.00*
___ 10:15PM BLOOD ___ PTT-31.2 ___
___ 10:15PM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-142
K-3.3 Cl-101 HCO3-29 AnGap-12
___ 10:15PM BLOOD ALT-791* AST-471* AlkPhos-760*
TotBili-1.6*
___ 10:15PM BLOOD Lipase-15
HOSPITAL COURSE LABS AND IMAGING:
___ 09:30AM BLOOD WBC-4.9 RBC-3.98 Hgb-12.2 Hct-36.4 MCV-92
MCH-30.7 MCHC-33.5 RDW-14.2 RDWSD-47.0* Plt ___
___ 10:00AM BLOOD WBC-7.2 RBC-4.31 Hgb-13.3 Hct-39.5 MCV-92
MCH-30.9 MCHC-33.7 RDW-14.6 RDWSD-48.7* Plt ___
___ 09:30AM BLOOD Glucose-125* UreaN-5* Creat-0.6 Na-143
K-3.2* Cl-101 HCO3-29 AnGap-13
___ 10:00AM BLOOD Glucose-195* UreaN-5* Creat-0.7 Na-138
K-5.6* Cl-99 HCO3-26 AnGap-13
___ 12:50PM BLOOD K-4.0
___ 09:30AM BLOOD ALT-583* AST-325* AlkPhos-666*
TotBili-1.2
___ 10:00AM BLOOD ALT-495* AST-187* AlkPhos-754*
TotBili-1.2
___ 09:35AM BLOOD ALT-359* AST-111* AlkPhos-689*
TotBili-1.1
___ 09:45AM BLOOD ALT-258* AST-87* AlkPhos-569* TotBili-0.8
___ 09:30AM BLOOD Calcium-7.9* Phos-4.4 Mg-2.0
___ 10:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.1 Iron-186*
___ 10:00AM BLOOD calTIBC-458 Ferritn-631* TRF-352
___ 09:30AM BLOOD TSH-3.3
___ 09:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HAV-NEG
___ 12:50PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 09:35AM BLOOD ___
___ 12:50PM BLOOD IgG-1202
___ 09:35AM BLOOD IgA-146
___ 09:35AM BLOOD tTG-IgA-PND
___ 09:30AM BLOOD HCV Ab-POS*
___ 09:30AM BLOOD HBV VL-NOT DETECT HCV VL-PND
CMV IGG: POSITIVE, IGM: NEGATIVE
EBV PENDING
LYME ANTIBODIES NEGATIVE
ANAPLASMA NEGATIVE
HCV GENOTYPE PENDING
___ RUQ U/S:
IMPRESSION:
1. No cholelithiasis or biliary ductal dilatation.
2. Subtly coarsened echotexture of the liver likely reflects
sequela of HCV
infection.
___ CT ABD/PELVIS:
1. No evidence of intra or extrahepatic biliary ductal dilation.
No hepatic
mass lesion identified.
2. Small hiatal hernia.
___ MRCP:
1. No evidence of biliary obstruction. Normal gallbladder.
2. Heterogeneous hepatic enhancement, periportal edema, and
prominent porta
hepatic lymph nodes, while findings are nonspecific, they can be
seen in the
setting of hepatitis. No focal hepatic lesion.
Brief Hospital Course:
___ y/o woman with HCV (not treated, per patient not active, DM2,
obesity, depression, tobacco use, OUD on suboxone (completed in
___, who presented with 1 week of intermittent
fevers, rigors, RUQ pain, and transaminitis x several months.
ACUTE/ACTIVE PROBLEMS:
# Fevers, RUQ pain, transaminitis - ddx included passed
gallstone, drug-induced liver injury, viral illness or
autoimmune hepatitis. RUQ u/s, CT abdomen, MRCP all negative for
a biliary process or obstruction. CMV, Anaplasma, and Lyme were
negative. Autoimmune markers were negative ___, AMA,
anti-smooth). Hepatitis A and B were negative. Hepatitis C Ab
positive, viral load and genotype pending. Iron studies notable
for elevated iron and ferritn (600s) but not consistent with
hemachromatosis. Drug-induced from recent antibiotics is
possible, but does not fit the time course as her symptoms
pre-dated the antibiotics for the dental infection. She was seen
by our hepatologists here. Given improving LFTs throughout her
stay (700s->200s), and improvement in RUQ pain (resolved), she
is being discharged with recommendations for close follow up.
She will need LFTs checked WEEKLY until they normalize. If they
do not normalize, she will need referral for a liver biopsy.
# Urticarial rash - intermittent, comes and goes and may be
related to the underlying liver process though not classic for
DILI. Currently resolved so no areas for biopsy. She can take
Benadryl as needed.
CHRONIC/STABLE PROBLEMS:
# DM2 - metformin and glipizide held in-house for sliding scale,
restarted on discharge.
# OUD - patient on suboxone per PCP office and ___ (last
prescribed beginning of ___, she stopped this 1 week prior
to when it was supposed to end as it was the lowest dose and she
did not want it
# Tobacco use - resumed Chantix on discharge
TRANSITIONAL ISSUES:
** Needs LFTs checked next week and followed weekly until
normalization
** referral for liver biopsy if they do not normalize
** HCV VL, HCV Genotype, EBV serologies pending on discharge
** She needs to be immunized against HAV and HBV given chronic
HCV infection
Greater than 30 minutes spent on discharge related activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. GlipiZIDE 5 mg PO DAILY
3. Amphetamine-Dextroamphetamine XR 30 mg PO BID
4. Chantix (varenicline) 1 mg oral DAILY
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
2. Amphetamine-Dextroamphetamine XR 30 mg PO BID
3. Chantix (varenicline) 1 mg oral DAILY
4. GlipiZIDE 5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatitis, NOS
Abdominal pain
DM 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain and
elevated liver tests. We sent off many tests to understand why
your liver tests were elevated - the ultrasound and CT scan and
MRI showed no gallstones; your lyme test was negative; and the
other hepatitis test (hepatitis A and B) were negative. As you
know, hepatitis C was positive given the known history and the
viral load was pending on discharge. We sent several autoimmune
tests that returned negative. We sent a test for mono, this was
also pending on discharge. Your liver tests improved while here
as did your symptoms, but are still elevated so need very close
follow-up. You need to have your liver checked EVERY WEEK until
it gets back to normal. If it doesn't go back to normal, you
will need a liver biopsy.
You can take Benadryl as needed for the itching. Please avoid
any products with Tylenol until your liver becomes normal.
It was a pleasure caring for you!
Your ___ Team
Followup Instructions:
___
|
10753150-DS-2
| 10,753,150 | 22,860,698 |
DS
| 2 |
2155-07-04 00:00:00
|
2155-07-04 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided facial weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female who presented to the Emergency
Department early this morning with persistent Headache and
tongue
numbness who was found to have a left frontal meningioma. The
patient was discharged from the Emergency Room this morning on
Keppra for seizure prophylaxis and Percocet for headache with a
plan to follow up in the ___ on ___ to
discuss elective resection of meningioma.
The patient presented to the Emergency Room again this afternoon
with complaints of left facial weakness. She states that her
left eye feels like it does not close as easily as her right
eye.
The left eye has been tearing today. The left face feels weaker
and her left mouth was twitching at approximately 3 pm this
afternoon. She continues to experience toungue numbness. The
patient denies other weakness, numbness or tingling sensation,
bowel or bladder dysfunction or leg weakness.
Past Medical History:
L frontal/parasagittal meningioma
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Gen: comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
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, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength decreased strength left cheek and left
eye and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
Nonfocal other than left facial weakness
Pertinent Results:
___ CT Head
1. Stable left frontal meningioma, with mild mass effect.
2. No acute intracranial process.
___ MRI Head
1. 3 x 2.7 x 2.4-cm extra-axial left frontal mass, consistent
with
meningioma. Mild mass effect is seen on the brain, but no
evidence of brain
edema seen.
2. No evidence of acute infarcts, midline shift or
hydrocephalus.
3. Soft tissue changes in the paranasal sinuses.
Brief Hospital Course:
Pt admitted to the neurosurgery service and started on Decadron
4mg Q6. An MRI was obtained and was consistent with left frontal
meningioma with mild surrounding edema. The patient's facial
weakness was not consistent with her lesion and Neurology was
consulted. Neurology recommended some blood work such as a Lyme
titer and ACE test. She remained stable. She was discharged home
on ___ with follow-up directions.
Medications on Admission:
None
Discharge Medications:
1. Keppra 750 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Disp:*60 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, headache, fever.
3. prednisone 10 mg Tablet Sig: 6 tablets Tablets PO once a day:
Take 6 tablets daily for 2 days, then 4 tablets daily for 2
days, then 2 tablets daily for 2 days then discontinue .
Disp:*24 Tablet(s)* Refills:*0*
4. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day: Take
while on Prednisone.
Disp:*20 Tablet(s)* Refills:*0*
5. Lacri-Lube S.O.P. 56.8-42.5 % Ointment Sig: One (1)
Ophthalmic four times a day as needed for Eye dryness.
Disp:*1 tube* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Meningioma
Left facial palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been prescribed Keppra (Levetiracetam), continue to
take this medication until discontinued by your neurosurgeon.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
No driving while taking pain medications.
*** We recommend you tape your eye shut at night and continue to
use Lacrilube to keep your eye moist. Take your steroids as
prescribed
***** Prednisone Taper:
Take 6 tablets (60mg) daily for 2 days, then
4 tablets (40mg) daily for 2 days, then
2 tablets (20mg) daily for 2 days then discontinue
Followup Instructions:
___
|
10754184-DS-28
| 10,754,184 | 22,870,652 |
DS
| 28 |
2190-04-04 00:00:00
|
2190-04-04 12:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / ciprofloxacin
Attending: ___
Chief Complaint:
Ankle pain
Major Surgical or Invasive Procedure:
___: Open reduction and internal fixation of right
bimalleolar ankle fracture
History of Present Illness:
Ms. ___ is an ___ year old woman with a h/o diastolic heart
failure, TIA, atrial fibrillation on warfarin, pancreatic
cancer, AVNRT s/p ablation and pacemaker placement who presented
with ankle pain after a fall. The day prior to admission, she
reports slipping on a floor mat on her back deck, which was
slippery from fresh paint and rain. She twisted her right ankle
and fell on her left buttock. She denies head strike or loss of
consciousness. Patient reports immediate pain and swelling of
her right ankle after the fall. She reports a bruise on her
left flank. She is clear that the fall was mechanical in nature
and unrelated to her heart conditions. She denies preceding
chest pain, palpitations, shortness of breath, nausea,
lightheadedness, or diaphoresis.
An XR in the ED was notable for displaced bimalleolar fractures
of the right ankle.
Currently, patient reports ___ pain of her right ankle. A cast
is in place. She denies numbness, tingling, or loss of
sensation of the leg, foot, or toes. She otherwise fees well.
Past Medical History:
Cardiac History:
-HTN
-HOCM-unclear if outflow obstruction
-Mod MR, mild AR, TR, cardiac MRI with EF 61%
-AVNRT s/p ablation ___
-Paroxsymal Atrial Fibrillation, symptomatic
-PFO on echo
.
Pacemaker/ICD placed ___ for tachy-brady syndrome: ___
___ RF ___ ___, dual chamber pacemaker
.
Other Past History:
TIA x1
recurrent syncope prior to pacemaker
RCC s/p right nephrectomy (___)
CKD II, baseline 1.1-1.3
hyperparathyroidism s/p parathyroidectomy
macrocytosis - eval by hematology unrevealing --> vitB12 started
despite normal levels
gout
OA
wrist/rib fracture ___
diverticulosis
psoriasis behind ear
Social History:
___
Family History:
father died at ___- patient unsure of cause.
mother died of diabetic complications
Physical Exam:
ADMISSION EXAM:
VS: T 97.5, HR 75, BP 122/58, RR 18, O2 98% RA, I/O ___
Gen: well-appearing elderly female sitting in bed, thin, NAD
HEENT: EOMI, PERRL, anicteric sclerae, moist mucous membranes,
oropharynx clear
Neck: supple, +JVP to jaw midline, +HJR
CV: regular rate and rhythm, normal S1 and S2, III/VI
holosystolic
murmur heard best at apex, no rubs/gallops
Lungs: breathing comfortably without use of accessory muscles,
lungs CTAB, no wheezes, rales, rhonchi
Abdomen: +BS, soft, nontender, nondistended
Ext: cast in place over right lower leg, 1+ pitting edema of LLE
to mid-shins, sensation intact to light touch bilaterally.
Skin: no jaundice, warm and dry. +ecchymosis L elbow,
excoriation
on left flank and mild point tenderness posteriorly, petechiae
and ecchymoses over left shin
Neuro: grossly intact, sensation intact to light touch, moves
all extremities well
DISCHARGE EXAM:
VS: Tm 98.7, Tc 98.4, HR 70, BP 110/70 (110-120/50-60), RR 18,
O2 97% RA, I/O ___
Gen: Well-appearing elderly female sitting in bed, thin, NAD
Neck: Supple, JVP ~8cm with +HJR
CV: Regular rate and rhythm, normal S1 and S2, III/VI
holosystolic
murmur heard best at apex, no rubs/gallops
Lungs: Breathing comfortably without use of accessory muscles,
bibasilar crackles, no wheezes or rhonchi
Abdomen: +BS, soft, nontender, nondistended
Ext: Splint in place over right lower leg, no edema bilaterally,
sensation intact to light touch bilaterally
Skin: Skin is warm, moist. Ecchymoses over chest and b/l
antecubital fossas. Hematoma over right antecubital fossa.
Neuro: Grossly intact, sensation intact to light touch, moves
all extremities well.
Pertinent Results:
ADMISSION LABS:
___ 05:35PM BLOOD WBC-5.9 RBC-3.60* Hgb-11.3* Hct-36.8
MCV-102* MCH-31.2 MCHC-30.6* RDW-16.3* Plt Ct-79*
___ 05:35PM BLOOD Neuts-60.8 ___ Monos-7.0 Eos-4.7*
Baso-0.4
___ 05:35PM BLOOD ___ PTT-38.9* ___
___ 05:35PM BLOOD Glucose-134* UreaN-34* Creat-1.2* Na-139
K-3.8 Cl-103 HCO3-27 AnGap-13
___ 06:45AM BLOOD proBNP-1851*
___ 06:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-6.8 RBC-2.79* Hgb-9.0* Hct-29.5*
MCV-106* MCH-32.3* MCHC-30.6* RDW-17.3* Plt Ct-96*
___ 05:45AM BLOOD ___ PTT-37.6* ___
___ 05:45AM BLOOD Glucose-103* UreaN-28* Creat-1.1 Na-133
K-4.0 Cl-99 HCO3-28 AnGap-10
___ 05:45AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0
OTHER LABS:
___ 08:02AM URINE RBC-2 WBC-119* Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
___ 08:02AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:02AM URINE Color-Yellow Appear-Clear Sp ___
IMAGING:
___ CXR:
Moderate to severe cardiomegaly is chronic. There is no
pulmonary edema, vascular congestion, or pleural effusion. Lungs
are clear. Transvenous right atrial and ventricular pacer leads
follow their expected courses from the left pectoral generator.
___ R Ankle XR:
FINDINGS: Images from the operating suite show placement of
fixation devices about fractures of the distal fibula and medial
malleolus. Further information can be gathered from the
operative report.
___ CT chest w/contrast:
1. No acute intra-abdominal abnormalities identified.
2. There is no significant interval change in the appearance of
the upstream pancreatic ductal dilatation at the body and tail
as well as the pancreatic neck at the site of the fiducial
seeds. Unchanged prominent lymph nodes in the gastrohepatic
ligament.
3. Moderate cardiomegaly with enlargement of right-sided heart
chambers.
4. Unchanged 4-mm nodule in the right middle lobe, series 2,
image 35, compared to prior exams dated back to ___.
___ CT A/P w/contrast:
IMPRESSION:
1. No acute intra-abdominal abnormalities identified.
2. There is no significant interval change in the appearance of
the upstream pancreatic ductal dilatation at the body and tail
as well as the pancreatic neck at the site of the fiducial
seeds. Unchanged prominent lymph nodes in the gastrohepatic
ligament.
3. Moderate cardiomegaly with enlargement of right-sided heart
chambers.
4. Unchanged 4-mm nodule in the right middle lobe, series 2,
image 35, compared to prior exams dated back to ___.
___ Right ankle XR:
FINDINGS: There is an oblique mildly comminuted fracture
through the distal fibula above the level of the tibiotalar
joint. The medial malleolus shows a distracted avulsion
fracture with a large distal fragment. The cortex along the
posterior tibia appears irregular, although it is not clear that
this is due to recent injury; sequela of more remote injury is
possible. The talar
dome and distal medial malleolar fragment are shifted laterally.
The distal fibula fracture is also mildly displaced. Soft
tissues are swollen about both sides. There is an ankle
effusion. Percutaneous pins span a fracture site along the base
of the first metatarsal, which appears remodeled. Pins appear
intact. Vascular calcifications are present.
IMPRESSION: Displaced bimalleolar fractures.
Brief Hospital Course:
___ year old woman with a h/o diastolic heart failure, TIA,
atrial fibrillation on warfarin, pancreatic cancer, AVNRT s/p
ablation and pacemaker placement who presented with a right
ankle fracture.
# Right ankle fracture: Patient underwent successful ORIF on
___. Her leg was placed in a splint, which was changed to a
walking boot on day of discharge. Hematocrit remained stable.
Her pain was well-controlled on standing tylenol and oxycodone
prn.
# Acute on chronic diastolic heart failure: Patient was mildly
volume overloaded on admission so she was given IV lasix ___
daily until euvolemic was reached. Course was complicated by
relative hypotension (90s/50s), so diuretics were held and
patient was fluid restricted to 1L, but she self-diuresed well
and blood pressure improved. On day of discharge, we restarted
home chlorthalidone 12.5mg po daily. Please check chem10 on
___ and send results to PCP.
# Atrial fibrillation/anticoagulation: Given patient's history
of
TIA, age, and comorbidities, she is at high risk for
thromboembolism (CHADS2 4; CHA2DS2-VASc 6). Warfarin was held
on admission in preparation for surgery. She was bridged on
heparin and warfarin was restarted on post-op day 1. INR is
therapeutic. She will need her INR checked on ___.
# Hypotension: Patient became hypotensive at times during
admission, likely related to aggressive diuresis. We decreased
her metoprolol to 12.5mg daily and discontinued her amlodipine.
Her home chlorthalidone 12.5mg daily was restarted on day of
discharge.
# UTI: Patient spiked a temperature to 101.9 on post-op day 1
despite standing tylenol and U/A was suggestive of UTI. She was
asymptomatic and did not have leukocytosis, but decision was
made to start her on a 5-day course of cefpodoxime due to the
high temperature despite standing tylenol. Urine culture
pending at time of discharge. She remained afebrile after
antibiotics were started.
TRANSITIONAL ISSUES:
[ ] Amlodipine was discontinued and Metoprolol XL was decreased
from 50mg bid to 12.5mg daily due to hypotension
[ ] Patient was restarted on home chlorthalidone on day of
discharge; please recheck chem10 in ___ days to ensure stable
electrolytes
[ ] Cefpodoxime course for UTI will end on ___ urine culture
with sensitivities still pending, please follow up with results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY
4. estradiol 0.01 % (0.1 mg/gram) vaginal twice weekly
5. Omeprazole 40 mg PO DAILY
6. Warfarin 3 mg PO 3X/WEEK (___)
7. Warfarin 2 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 50 mg PO BID
9. Cyanocobalamin ___ mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral 1
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Chlorthalidone 12.5 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Warfarin 3 mg PO 3X/WEEK (___)
7. Warfarin 2 mg PO 4X/WEEK (___)
8. Omeprazole 40 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral 1
10. estradiol 0.01 % (0.1 mg/gram) vaginal twice weekly
11. Cefpodoxime Proxetil 200 mg PO Q24H
Please take through ___ then stop.
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID
Use as needed for constipation.
14. 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 #*15 Tablet Refills:*0
15. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Ankle fracture
Acute on chronic diastolic heart failure
Atrial fibrillation
Secondary diagnoses:
Chronic kidney disease
Pancreatic cancer
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted after a fall with a right ankle fracture. You had
surgery to stabilize your fracture. Your leg was placed in a
splint, which was changed to a walking boot on the day of
discharge.
You had too much fluid in your body so we gave you a higher dose
of water pill and the fluid improved. You also developed a
fever from a urinary tract infection, so we started you on
antibiotics for this and the fever resolved.
Please continue your medications as prescribed and keep your
outpatient appointments. You are scheduled to see the
orthopedic surgeon in clinic on ___.
-Your ___ Team
Followup Instructions:
___
|
10754405-DS-4
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DS
| 4 |
2167-03-09 00:00:00
|
2167-03-09 22:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
Poor PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old ___ female with a five year
history of a seizure disorder who had been treated with
carbamezapine with the recent addition of phenytoin one week ago
who presents with two days of poor PO intake. Per the daughter,
Ms ___ has been unable to tolerate food for the past two days.
Two days ago when eating, she would take her food or medications
in her mouth but was unable to swallow. The family was concerned
that this represented seizure activity especially as her eyes
deviated upward at this time which had occured during previous
seizures. As per the son, she had extension of one arm and
flexion of the other arm which is characteristic of her past
seizures (Son ___, speaks ___ and is available by phone at
___. The family was especially concerned because Ms
___ has to take a number of seizure medicaitons daily and if
she cannot swallow, she cannot take her medications.
.
Yesterday the patient was confused and unable to speak, and was
still unable to tolerate PO intake. As per the family, the
patient denies any dysphagia or mechanical difficulty
swallowing. The patient has no pain.
.
Of note, the patient was discharged from the neurology service
on ___ for decreased responsiveness, possible seizure
activity, exacerbated by a UTI. Per d/c summary, typically her
seizures involve movements such as eye deviation to the right,
extension of the RUE, flexion of LUE, plantar flexion of feet.
.
In the ED, the patient had no complaints including no chest
pain, abdominal pain, cough, fevers.
.
In the ED, initial vitals were: 97.2, 99, 192/116, 16, 98%.
Labs reveal Cr 1.2 up from 0.8 and mild acidosis. No other
electrolyte abnormalities. Infectious work up with U/A and CXR
felt to be negative, and head CT imaging negative. She was given
2 mg ativan and is being admitted for further work up.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Epilepsy - diagnosed ___, eye deviation to the right,
extension of the RUE, flexion of LUE, plantar flexion of feet -
on carbamazepine. Multiple EEGs here in the past ___ years that
typically showed encephalopathy.
- Cataracts with blindness
- Possible prior right frontal stroke
- Osteoporosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical
Vitals: T:98.0 BP:180/100 P:89 R:20 O2:96% RA
General: Per daughter, the patient is alert and orientated, at
baseline, in no discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear, eyes not
deviated, bilateral cataracts, EOMI
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, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, EOMI, tongue protrudes midline, uvula symmetrical,
facial symmetry, normal muscle bulk and tone, symmetrical
strength in upper and lower extremities, decreased reflexes but
symmetrical throughout with negative babinski.
Discharge Physical
Vitals: T:98.6 BP:148/90 P:73 R:18 O2:99% RA
General: Per daughter, the patient is alert and oriented, at
baseline, in no discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear, eyes not
deviated, bilateral cataracts, EOMI
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, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
___ 09:08PM BLOOD WBC-8.7 RBC-3.29* Hgb-10.5* Hct-32.6*
MCV-99* MCH-32.0 MCHC-32.3 RDW-12.6 Plt ___
___ 09:08PM BLOOD Neuts-46.6* Lymphs-46.3* Monos-3.2
Eos-3.2 Baso-0.6
___ 09:08PM BLOOD ___ PTT-30.1 ___
___ 09:08PM BLOOD Glucose-144* UreaN-31* Creat-1.2* Na-134
K-4.4 Cl-104 HCO3-19* AnGap-15
___ 09:08PM BLOOD ALT-15 AST-26 AlkPhos-75 TotBili-0.3
___ 09:08PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9
___ 09:15PM BLOOD Lactate-1.5
Drug monitoring:
___ 09:08PM BLOOD Phenyto-0.7*
___ 09:08PM BLOOD Carbamz-3.3*
___ 09:15PM BLOOD Lactate-1.5
Discharge labs:
___ 04:55AM BLOOD Glucose-104* UreaN-25* Creat-0.8 Na-133
K-4.4 Cl-101 HCO3-21* AnGap-15
___ 04:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.6
___ 11:10AM BLOOD WBC-8.8 RBC-3.23* Hgb-10.5* Hct-32.5*
MCV-101* MCH-32.4* MCHC-32.2 RDW-12.8 Plt ___
___ 04:55AM BLOOD Phenyto-10.4
___ 04:55AM BLOOD Carbamz-4.___:
No acute process
CXR ___:
No overt process, poor study
EKG ___:
Sinus rhythym, no change from baseline.
Microbiology:
UA negative
Urine culture/blood culture negative.
Brief Hospital Course:
Assessment and Plan: This is a ___ year old female with a five
year history of a seuzire disorder who is currently on
carbamazepine and phenytoin admitted with decreased oral intake,
and confusion, consistent with seizure and post ictal state
while subtherapeutic on anti-epileptics.
ACUTE ISSUES:
.
# Seizure: As per family, the steryotyped movements were
consistent with prior seizure activity. Since patient was
discharged one week ago on new seizure medication regimen, it
was likely that the patient needed adjustments of her medication
doses as she was likely subtheraputic. The mental status changes
were consistent with post-ictal confusion. She was unable to
tolerate PO intake including her medications so her
carbamazepine levels were low at 3.3 and tegretol levels were
0.7. Neurology was consulted and they recommended a loading dose
of dilantin 900mg. They also recommended changing to liquid
formulations of both carbamezapine 100mg Q8H and dilantin 100mg
Q8H.
# Acute encephalopathy, due to post ictal state: Patient
returned to baseline and the confusion was likely post ictal as
discussed above. A head CT did not show any pathology.
Similarly, UA and CXR were unremarkable for infetctious
etiologies.
.
# Dysphagia: We believe the dysphagia and poor PO intake is in
the context of her seizures and post-ictal confusion. We
consulted speech and swallow who thought the patient could
tolerate PO intake and they recommended nectar thick diet. She
is able to tolerate
.
# Acute renal failure: The ___ is most likely secondary to poor
PO intake and pre-renal in nature. With fluid, the creatinine
normalized to 0.8 from 1.3. We also checked urine electrolytes
which showed a FeNa of 0.21% which further supported a prerenal
etiology
.
# Hypertension: The patient was not tolerating her PO
medications for the past two days, so had hypertension on
admission, with systolic pressures 180s. She was started on her
home medications with pressures down to the 160s. She required a
few doses of metoprolol 5mg IV. At this time we recommend
outpatient titration of blood pressure medications. We continued
her hydrochlorothiazide, metoprolol, amlodipine per home regimen
once tolerating PO intake.
.
CHRONIC ISSUES:
# Subacute L caudate infarct: Seen on MRI during a prior
admission but given the patient's age and functional status,
neurology started daily aspirin. We continued this in addition
to pravastatin while in the hospital.
.
# HLD: Continued home pravastatin
.
# GERD: Continued home omeprazole
.
Transitional issues:
Seizure medication: Patient requires follow up with neurology
within the week to assess levels of anti-epileptics, and ability
to take in oral medications.
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
3. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO QHS (once a day (at bedtime)).
Disp:*60 Capsule(s)* Refills:*2*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily). Tablet(s)
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. senna 8.6 mg Tablet Sig: ___ Tablets PO at bedtime as needed
for constipation.
12. Multiple Vitamins Daily Tablet Sig: One (1) Tablet PO
once a day.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Dilantin-125 125 mg/5 mL Suspension Sig: Four (4) mL PO
every eight (8) hours.
Disp:*1 bottle* Refills:*0*
12. Tegretol 100 mg/5 mL Suspension Sig: Five (5) mL PO every
eight (8) hours.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms ___,
You were admitted to the hospital after two days of poor oral
intake. We believe that you had a seizure two days ago and were
unable to take your anti-epileptic medication. We measured the
levels of your anti-seizure medication and found that they were
low. The confusion you had yesterday is most likely confusion
that occurs following a seizure known as post-ictal confusion.
While in the hospital, we consulted the neurology service and
they recommended increasing the dose of your medication. We have
changed your anti-seizure medications to be a liquid formulation
since it may be easier to swallow but you will have to take this
every eight hours. We have arranged close follow-up and they
will recheck your levels as an outpatient. At this point we
believe you are safe to return back home.
We spoke with the speech and swallow team while in the hospital.
They recommend that your have a nectar thick diet and are
concerned that you may have trouble swallowing regular food. We
recommend continuing a nectar thick diet once you are
discharged. You are able to tolerate thin liquids as long as you
take small sips. If you take large swallows of thin liquids,
there is a risk of aspiration and pneumonia.
While in the hospital you were noted to have an elevated blood
pressure. We recommend discussing increasing your blood pressure
medications with your primary care physician.
Medication Changes
START Tegretol 100mg, liquid formulation (changed from Tegretol
100mg tablet) every 8 hours
START Dilantin 100mg, liquid formulation (increased from 200mg
QHS) every 8 hours
Thank you for the opportunity to participate in your care.
Followup Instructions:
___
|
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2167-03-23 00:00:00
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2167-03-25 20:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure.
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
Ms. ___ is unable provide any history as she is not answering
any questions (her son was speaking to her in her native
language). History obtained from her son, who is at bedside and
from review of OMR.
Ms. ___ is a ___ year-old woman with PMH significant for HTN,
HLD, and seizure disorder who presents with seizures in the
setting of taking nothing by mouth since yesterday evening. Her
son says her last PO intake was yesterday afternoon and since
last night, she has taken nothing by mouth, including her AEDs
(Tegretol 100mg, liquid formulation q8h and Dilantin 100mg,
liquid formulation q8h). This afternoon, around 12PM her son
reports that she began having seizure activity, which involves
unresponsiveness and plantar flexion of her feet. She was
initially ___ to ___, where seizure activity reportedly
briefly stopped and son notes she was briefly close to her
baseline and able to respond. She was then transferred to ___
as this is where she usually receives her care, but her son
notes
she began seizing again (he says he is able to tell when she
seizes by plantar flexion of her feet and diminished
responsiveness). At this time, he believes she is still seizing
as her feet are plantar flexed and though she is awake, she is
not responding to any questions he is asking her. In the ___
ED, she was given Ativan 0.5 mg and EEG monitoring was performed
to ensure she was not in status epilepticus.
Of note, she was admitted to ___ from ___ for
confusion, which was believed to be due to a post-ictal state as
she was subtherapeutic on her AEDs in the setting of poor PO
intake. During her recent admission, she was seen by neurology
and her AEDs were adjusted and switched to liquid formulation;
she was discharged on Tegretol 100mg, liquid formulation q8h and
Dilantin 100mg, liquid formulation q8h. She was also recently
admitted to the Neurology service from ___ for seizures in
the setting of UTI and ___ during that admission she had EEG
monitoring, which showed moderate encephalopathy, frequent sharp
wave discharges seen diffusely over the left frontal temporal
and
central region as well as the right central region, indicative
of
independent areas of cortical irritability, but no clear
electrographic seizures. Her exact seizure frequency is unclear,
but according to her son, he believes she has not had any
seizures (until today) since her discharge on ___.
Regarding her seizures, she was diagnosed with a seizure
disorder about ___ years ago. Her seizure semiology has previously
been described as eye deviation to the right, extension of the
RUE flexion of the LUE and plantar flexion of the feet. Her son
reports that her seizures involves unresponsivess and plantar
flexion of her feet. She had previously been on ___ for her
seizures, but this was stopped due to sedation.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Epilepsy - diagnosed ___, eye deviation to the right,
extension of the RUE, flexion of LUE, plantar flexion of feet -
on carbamazepine. Multiple EEGs here in the past ___ years that
typically showed encephalopathy.
- Cataracts with blindness
- Possible prior right frontal stroke
- Osteoporosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
At admission:
Vitals: T: 97 P: 65 R: 12 BP: 155/74 SaO2: 100%
General: laying in bed, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: +meningismus
Pulmonary: lcta b/l
Cardiac: RRR, S1S2
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic Exam:
Mental Status: She is somnolent, no eye opening to voice or
light
touch; she does open eyes to noxious stimulation. Says "hi"
initially, but otherwise no speech. When asked by her son in her
native language, she will open and close eyes to command, but
otherwise did not follow any commands.
Cranial Nerves: Pupils are in midline. There appears to be
cataract of left eye, but both are 3 mm and briskly reactive to
light. She blinks to threat b/l. She would not track and would
also resist head turning attempted with Doll's maneuver. Face
appears symmetric,
Motor: Increased tone in ___ b/l. No spontaneous movements noted.
She hold left upper extremity antigravity for longer than right
upper extremity when both are raised for her. She briskly
withdraws all extremities to noxious stimulation.
Sensory: Grimmaces to noxious stimulation throughout.
Reflexes: 2+ and symmetric at biceps, triceps, brachioradialis
and patellae. Unable to elicit Achilles reflex. Plantar response
extensor b/l.
Coordination: unable to perform due to patient somnolence
Gait: deffered given patient somnolence.
At discharge:
eyes closed intermittently but awake. Says "hi" and "good
morning" in ___. Speaks with family in native language -
appropriately per family report. Moving bilateral UEs more than
lowers.
Pertinent Results:
___ 12:22PM BLOOD WBC-5.9 RBC-3.26* Hgb-10.6* Hct-32.0*
MCV-98 MCH-32.5* MCHC-33.0 RDW-15.6* Plt ___
___ 04:30PM BLOOD ___ PTT-28.2 ___
___ 12:22PM BLOOD UreaN-31* Creat-0.9 Na-131* K-4.4 Cl-98
HCO3-21* AnGap-16
___ 04:30PM BLOOD Glucose-119* UreaN-39* Creat-1.2* Na-136
K-5.4* Cl-101 HCO3-20* AnGap-20
___ 10:00AM BLOOD Glucose-149* UreaN-7 Creat-0.6 Na-143
K-3.1* Cl-114* HCO3-19* AnGap-13
___ 09:04AM BLOOD ALT-15 AST-23 CK(CPK)-20* AlkPhos-75
___ 04:30PM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.5 Mg-2.2
___ 09:04AM BLOOD CRP-12.3*
___ 12:22PM BLOOD Phenyto-7.7*
___ 12:22PM BLOOD Carbamz-4.0
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Carbamz-1.6*
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:33PM BLOOD Glucose-113* K-5.5*
___ 05:31PM BLOOD K-4.3
___ 04:40PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:40PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 04:40PM URINE RBC-10* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 4:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cultures negative x 2.
CXR:
IMPRESSION: Patchy left basilar opacification, but decreased,
and accordingly
likely due to resolving atelectasis or potentially improving
infection in the
appropriate setting.
Portable Abd:
FINDINGS: Two frontal views of the abdomen demonstrate a bowel
gas pattern
within normal limits. The stomach is collapsed, which makes
assessment of
position between the stomach and colon difficult. The right
lung base is
clear. The left lung base is slightly opacified by eventration
of the left
hemidiaphragm, also seen on prior CT. S-shaped thoracolumbar
scoliosis is
noted. Vascular calcifications are incidentally noted in the
proximal lower
extremities
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with PMH significant for HTN,
HLD, and seizure disorder who presents with seizures in the
setting of taking nothing by mouth since X2 days,
including her AEDs. Treated for UTI at admission although UCx
now shows contamination. Lengthy discussion was held with family
regarding how to avoid such frequent hospital admissions. The
majority of hospital admissions in past few months are for
prolonged seizures. These seizures tend to occur after the
patient misses 1 or more doses of her anti-epileptics, typically
in the setting of lethargy (possibly post-ictal vs infection).
We discussed with the family the risks and benefits to having a
PEG tube placed for an alternative way to give medications in
such a situation. Although we discussed risks of PEG tube
placement, given this could potentially prevent many future
hospitalizations, this was deemed appropriate per the family. We
discussed at length that the PEG is not for tubefeeding as the
patient should continue to eat with her family. Likewise she can
also take medication by mouth when alert. The PEG is to be used
as an alternate method to deliver AEDs in the setting of
somnolence.
.
# Neuro:
- cont decreased dose: ___ to 500mg BID
- per discussion with outpt neurologist Dr. ___ cont
___ at home rather than previous home regimen of Dilantin and
Carbamazepine since patient has been seizure-free on this
regimen while in the hospital with good level of alertness
- PEG to be placed by ACS
.
# UTI:
-Ceftriaxone for UTI tx; Has received 6 days. UCx now shows
contamination.
-CTX stopped after 6 days
.
# PPx:
-seizure, fall, aspiration precautions
-pneumoboots for DVT proph as she has allergy to Heparin agents
.
# Code:
-DNR/DNI
Medications on Admission:
1. aspirin 325 mg daily
2. cholecalciferol (vitamin D3) 400 units daily
3. hydrochlorothiazide 25 mg daily
4. metoprolol tartrate 25 mg bid
5. docusate sodium 100 mg bid
5. amlodipine 2.5 mg daily
7. omeprazole 20 mg daily
8. pravastatin 40 mg daily
9. senna 8.6 mg Tablet, ___ Tablets PO BID prn constipation
10. multivitamin daily
11. Dilantin-125 125 mg/5 mL Suspension, take 4 mL q8h
12. Tegretol 100 mg/5 mL Suspension, take 5 mL q8h
Discharge Medications:
1. syringe (disposable) 60 mL Syringe Sig: Four (4) syringe
Miscellaneous once a week as needed.
Disp:*50 syringes* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2
times a day): 500mg po bid.
Disp:*300 ml* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
9. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
11. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizures
urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of seizures and
lethargy. It is likely these seizures are increased often by
missing doses of anti-seizure medicines due to sleepiness. A PEG
tube was placed into your stomach so that you may receive your
medicines in the case that you are too sleepy to swallow them
safely. We hope that this will help to keep you out of the
hospital and home with your family.
During your stay we had started you on a different anti-seizure
medicine, levetiracetam 500mg by mouth twice a day. Since you
did well on this medicine, please continue on this medicine and
stop taking the phenytoin and carbamazepine.
Followup Instructions:
___
|
10754405-DS-6
| 10,754,405 | 25,474,443 |
DS
| 6 |
2167-04-20 00:00:00
|
2167-05-01 18:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with PMH of HTN, HLD, and seizure
disorder s/p ___ tube (for intake of AEDs) who presents with an
episode of loss of consciousness for 45 minutes.
.
According to the patient's son (patient is non-conversant), Ms.
___ was in her usual state of health until 9 am this morning
when her daughter noticed that she was not opening her eyes, not
recognizing him, and not responding to anything she was saying.
Her daughter called her son who drove to the patient's home,
notice that her breathing was quite labored. There was no head
trauma (patient was lying down at the time). Of note, patient at
baseline is bed-bound (has not walked for ___ years), A+O x 1
(knows location only), and has severe visual deficits (cataract)
but is able to recognize family members by voice and can
converse in short sentences (per her son, yesterday was able to
say "goodbye, see you tomorrow" to him). Her son called the
ambulance and the patient was brought to the ___ ED. He did
feel that her mental status returned to baseline upon giving her
O2 on NC.
.
Of note, the patient had one episode of vomiting 4 days PTA and
had not been taking any PO since that time. She was given 3 cans
ensure / 2 bottles water through G-tube each day. She has not
had a bowel movement for the past 4 days. Ms. ___ has also had
several recent admissions for poor po intake and seizure
activity (___).
Her most recent EEG (___) showed frequent sharp wave
discharges diffusely over the L frontal temporal and central
region as well as the right central region, indicative of
independent areas of cortical irritability but without clear
evidence of electrographic seizures. Ultimately the decision was
made to place a ___ tube on ___ for an alternative way to take
AEDs and prevent frequent admissions.
.
On arrival to the ED, VS were 98.4 HR: 81 BP: 118/70 Resp: 18
O(2)Sat 100% on RA. Labs were notable for UA trace prot (neg
leuk/wbc/bact/rbc), Na 130, K 5.1, HCO3 23, BUN 30, Cr 1, Glu
133, WBC 8.7, Hct 29.8, Plt 297. CXR was negative for any acute
cardiopulmonary abnormality. An infectious work-up was started.
The patient was noted to intermittently awaken with deep labored
breathing. She was felt to have returned to her baseline mental
status.
.
Currently, the patient is non-conversant and only accompanied by
her daughter who speaks no ___.
.
ROS (per patient's son): denies fever, chills, headache, cough,
chest pain, abdominal pain, BRBPR, melena, hematochezia,
dysuria, or hematuria.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Epilepsy - diagnosed ___, has had multiple EEGs here in the
past ___ years that showed encephalopathy. Had ___ placed on
___
to give AEDs
- Cataracts resulting in blindness
- Possible prior right frontal stroke
- Osteoporosis
Social History:
___
Family History:
several family members with high blood pressures
Physical Exam:
Admission:
VS - Temp 98.5F, BP 130/60, HR 80, RR 18, O2-sat 92% RA
GENERAL - lying in bed under covers with eyes closed, R knee
flexed
HEENT - NC/AT, pupils 3-->2 b/l, brief upward nystagmus and
saccades noted, dried saliva surrounding mouth
NECK - supple, no thyromegaly, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTA anteriorly
ABDOMEN - soft, non-tender, ___ tube in place
without surrounding erythema or purulence
EXTREMITIES - WWP, RLE appears slightly more atrophied than LLE
SKIN - no rashes or lesions
NEURO - A+O x 0, unresponsive to voice (after asking "how are
you?" several times, patient groans), withdraws to nailbed
pressure, eyes are closed. Spontaneously moving all 4
extremities but increased rigidity is noted no upper extremities
bilaterally.
Discharge:
VS - Tm 97.9, Tc 97.6, BP 144/72 (136-158/56-76), HR 63 (61-84),
RR 18, O2-sat 97% RA
GENERAL - lying in bed under covers with eyes closed but in NAD
HEENT - NC/AT, pupils 3-->2 b/l
NECK - supple, no thyromegaly, JVD flat
HEART - RRR, ___ holosystolic murmur in LUSB
LUNGS - CTA anteriorly
ABDOMEN - soft, non-tender, ___ tube in place
without surrounding erythema or purulence
EXTREMITIES - WWP, RLE appears slightly more atrophied than LLE
SKIN - no rashes or lesions
NEURO - A+O x 0, with son translating in ___, was able to
follow commands (open eyes, grip with hands). Appears to nod in
recognition of daughter and son. Spontaneously moving all
extremities. R ___ appears weaker compared to L.
Pertinent Results:
___ 12:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:50PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 12:50PM URINE GRANULAR-1* HYALINE-1*
___ 12:30PM GLUCOSE-133* UREA N-30* CREAT-1.0 SODIUM-130*
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-14
___ 12:30PM estGFR-Using this
___ 12:30PM ALT(SGPT)-12 AST(SGOT)-23 ALK PHOS-76 TOT
BILI-0.2
___ 12:30PM CALCIUM-8.0* PHOSPHATE-3.5# MAGNESIUM-2.0
___ 12:30PM WBC-8.7 RBC-3.02* HGB-9.7* HCT-29.8* MCV-99*
MCH-32.1* MCHC-32.5 RDW-12.9
___ 12:30PM NEUTS-76.6* LYMPHS-15.9* MONOS-5.0 EOS-2.0
BASOS-0.5
___ 12:30PM PLT COUNT-297#
Brief Hospital Course:
___ year old female with PMH of HTN, HLD, and seizure disorder
s/p ___ tube (for intake of AEDs) who presents with altered
mental status.
.
Active Issues:
#Encephalopathy, metabolic
On arrival to the floor, the patient was non-responsive to
voice, only withdrawing to painful stimuli. We considered
several different etiologies of the patient's altered mental
status and thought the most likely were hyponatremia (Na+ 130 on
admission, baseline ~136) and seizure activity. Neurology
evaluated her and felt that her presentation was different from
prior seizure episodes. An EEG was done which did not show any
evidence of clear seizure activity. However, neurology was
nevertheless worried that her Keppra dose may be too low and and
suggested increasing from 500 to 750 mg BID. Her neurological
status was checked every 4 hours during her stay. On discharge,
her mental status had improved to baseline, per her family
members. She was able to follow simple commands (open eyes,
gripping with hands) and able to recognize her children.
.
#) Hyponatremia:
On arrival, Na+ was 130. The patient's baseline Na+ is ~136,
with a few dips into the low 130s recently. We thought the most
likely cause of her hyponatremia was poor po intake. We treated
her with 1L of D5NS. We rechecked her electrolytes prior to
discharge and her Na+ was 133.
.
#) Constipation:
The patient's son reported that the patient had not had a bowel
movement for ___ days prior to admission. She had 1 hard bowel
movement while in the hospital. On exam, she was found to have
hard stool in the rectum which was manually disempacted. We
spoke to her son about the need to continue her bowel regmimen
after discharge.
.
Chronic Issues:
#) Macrocytic Anemia:
The patient was found to have a macrocytic anemia of (Hct 29.8,
MCV 99). Her most recent B12 and folate have been within normal
limits and prior CT imaging did not reveal liver disease or
splenomegaly. Other etiologies include primary bone marrow
process. AEDs are also associated with anemia's, though keppra
has not specifically been associated with macrocytic anemia.
Would recommend continued follow-up for this on an outpatient
basis.
.
#HTN: stable, BP on admission 130/60. The patient was continued
on home metoprolol, and amlodipine. HCTZ was held given low Na+
on admission.
.
#HLD: stable. Patient was continued on home statin
.
#Sub-acute L caudate infarct: seen on MRI in ___. Patient
was continued on home aspirin and statin.
Transitional issues:
1) F/u appointments with PCP and neurology
___ on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 325 mg PO/NG DAILY stroke
2. Vitamin D 400 UNIT PO/NG DAILY
3. LeVETiracetam Oral Solution 500 mg PO/NG BID
4. Metoprolol Tartrate 25 mg PO/NG BID
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Amlodipine 2.5 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Nutrition
Disp: Fibersource HN
1 can four times a day to supplement PO intake
Disp: 120
Refills: 11
ICD9 code ___
2. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Aspirin 325 mg PO DAILY stroke
RX *aspirin 325 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 Tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *Chewable Multi Vitamin 1 Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Pravastatin 40 mg PO DAILY
RX *pravastatin 40 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Senna 2 TAB PO HS
RX *senna 8.6 mg 1 capsule by mouth daily Disp #*30 Capsule
Refills:*0
9. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 Tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. LeVETiracetam Oral Solution 750 mg PO/NG BID seizure
RX *Keppra 100 mg/mL 7.5 ml(s) by mouth twice daily Disp #*1
Bottle Refills:*0
12. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyponatremia
Encephalopathy, metabolic
Constipation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your recent
admission at the ___. You came to the hospital after your
daughter found you unresponsive, unable to recognize any of your
family members, and also breathing very heavily. Out of concern
for your change in mental status, your son called the ambulance
and you were brought to the ___ emergency department. You
were found to have a low sodium level on admission. A chest
x-ray was done which was normal. You came up to the medicine
floor on the night of ___. Given that you had not eaten for
several days and that your sodium was low, you were started on
intravenous fluids. We checked your sodium twice during your
stay and it rose to close to your baseline by the time you were
discharged. We ordered an EEG which was unchanged from your
last EEG and showed no seizure activity. However, we consulted
the neurology team how and they were concerned that your Keppra
dose may be too low thus they recommended that you increase your
dose to 750 mg twice daily. The nutrition team also came to see
you and recommended that you should supplement food eaten orally
with 4 cans Fibersource on days when you are not able to eat.
Given that you had been constipated for several days and passed
1 hard stool during your stay here, we manually removed some of
the residual stool and also ordered an X-ray of your abdomen
which showed no signs of obstruction.
MEDICATION CHANGES:
1) Please increase your dose of Keppra to 750 mg twice daily.
FOLLOW-UP APPOINTMENTS:
Please see below
Followup Instructions:
___
|
10754405-DS-7
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| 7 |
2167-05-24 00:00:00
|
2167-06-26 23:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ bed-bound woman with PMH of HTN, HLD, and
seizure disorder s/p PEG tube (for intake of AEDs) who presents
with fevers to 102 at home with oral thermometer, cough, and
constipation x 2 days. The patient is fed and cared for by
family, who report feeding the patient ___ cans of fibersource
daily with ___ aquafina bottles for water (all via PEG tube).
Past Medical History:
- Hypertension
- Hyperlipidemia
- Epilepsy - diagnosed ___, has had multiple EEGs here in the
past ___ years that showed encephalopathy. Had PEG-tube placed on
___
to give AEDs
- Cataracts resulting in blindness
- Possible prior right frontal stroke
- Osteoporosis
Social History:
___
Family History:
several family members with high blood pressures
Physical Exam:
ADMISSION:
VS - Temp 98.3 BP 113/61, HR 101, R 14, O2-sat 95% RA
I/O:
BM x 1 large this AM
Foley in place with clear urine
GENERAL - elderly thin ___ female who is accompanied by
her daughter. NAD, laying in bed with hips and knees bent, with
her eyes closed. Arousable to say good morning and hello. Does
not respond to questions from her daughter consistently. Per
daughter this is her baseline functional capacity.
HEENT - Does not open eyes for me. Patient has poor eyesight ___
b/l catarcts and does not follow commands when eyes open. Did
not open mouth for me.
NECK - supple, no thyromegaly, no JVD.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG
ABDOMEN - PEG tube in place with new bandage, no erythema, some
exudate at entrance, Per daughter this has been there since the
PEG tube was first inserted.
Soft, NT, ND. No guarding or rebound.
EXTREMITIES - Axilla slightly moist. Warm, non edematous. 2+
peripheral pulses.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - laying with eyes closed, A&Ox1 to location when answers
question, Moves all extremities spontaneously. No facial
asymmetry, no facial droop. Slight rigidtiy of upper
extremities. Pt able to lower/raise arms on her own against
gravity.
DISCHARGE:
GENERAL - elderly thin ___ female who is accompanied by
her daughter. NAD, laying in bed. Arousable to say good morning
and hello. Does not respond to questions from her daughter
consistently. Per daughter this is her baseline functional
capacity.
HEENT - Opens eyes sporadically. Patient has poor eyesight ___
b/l catarcts and does not follow commands when eyes open.
NECK - supple, no thyromegaly, no JVD.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG
ABDOMEN - PEG tube in place, no erythema, some exudate at
entrance, Per daughter this has been there since the PEG tube
was first inserted.
Soft, NT, ND. No guarding or rebound.
EXTREMITIES - Warm, non edematous. 2+ peripheral pulses.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - laying with eyes closed, A&Ox1-2. Moves all extremities
spontaneously. No facial asymmetry, no facial droop.
Pertinent Results:
ADMISSION:
___ 07:40PM BLOOD WBC-11.7* RBC-3.06* Hgb-9.7* Hct-28.8*
MCV-94 MCH-31.7 MCHC-33.6 RDW-12.8 Plt ___
___ 07:40PM BLOOD Neuts-63.7 Lymphs-14.3* Monos-4.4
Eos-17.4* Baso-0.3
___ 05:35AM BLOOD ___ PTT-30.0 ___
___ 07:40PM BLOOD Glucose-121* UreaN-49* Creat-1.2* Na-121*
K-5.1 Cl-88* HCO3-27 AnGap-11
___ 10:00AM BLOOD Albumin-3.2* Calcium-7.5* Phos-3.2 Mg-2.0
DISCHARGE:
___ 06:30AM BLOOD WBC-8.1 RBC-2.78* Hgb-8.8* Hct-26.7*
MCV-96 MCH-31.7 MCHC-33.0 RDW-13.5 Plt ___
___ 06:30AM BLOOD ___ PTT-29.2 ___
___ 06:30AM BLOOD Glucose-145* UreaN-39* Creat-0.9 Na-135
K-4.5 Cl-101 HCO3-25 AnGap-14
___ 06:30AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.8
URINE:
___ 01:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-NEG
___ 01:00AM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:33PM URINE RBC-2 WBC-11* Bacteri-NONE Yeast-NONE
Epi-0 TransE-1
___ 12:33PM URINE Eos-POSITIVE
___ 12:33PM URINE Hours-RANDOM UreaN-554 Creat-37 Na-29
K-29 Cl-11
___ 12:33PM URINE Osmolal-___
MICRO:
BCx negative x3
Urine Cx negative
C diff negative
Stool O and P negative x3
Legionella negative
Strongyloides Antibody: Pending
IMAGING:
___
1. Mild congestive heart failure.
2. Retrocardiac opacity consistent with fat-containing
Bochdalek hernia.
Concurrent pneumonia in this location would be obscured. If
there is clinical concern for infection, consider lateral view.
___: CT A and P:
IMPRESSION:
1. No evidence of abscess subjacent to the gastrostomy tube.
2. Probable right hepatic liver cyst.
3. Left Bochdalek fat-containing hernia.
4. 1.3-cm left adnexal cyst.
5. Diffuse severe atherosclerotic disease.
6. Rectal fecal impaction.
___: CT CHEST:
IMPRESSION:
1. No evidence of pneumonia. Small bilateral pleural
effusions, but no
evidence of pulmonary edema at the time of scanning.
2. Stable aortic caliber with ectasia of the ascending aorta.
Severe
atherosclerotic calcifications of the thoracic aorta with
ulcerative plaque or
mural thrombus.
3. 1.8 cm hypodense liver lesion is indeterminate, but probably
not
significantly changed compared to ___.
4. Biatrial enlargement.
Brief Hospital Course:
Ms. ___ is a ___ year old ___ bed-bound female with PMH
of HTN, HLD, and seizure disorder s/p PEG tube on ___ (for
intake of AEDs) who presents with poor PO intake and especially
poor free water intake with cough, fevers, purulence of PEG
tube, hyponatremia, constipation and slight leukocytosis with
eosinophilia.
ACTIVE ISSUES:
Fever and cough: Patient with leukocytosis as well and an
eosinophilia. Treated empirically for pneumonia however still
had temperature spikes and leukocytosis on this treatment. No
cause was ascertained (negative stool, urine, and blood
cultures), but in a lady of ___ nationality with
eosinophilia, and no recent travel, Stronyloides was considered
as a possible parasitic infection that can be dormant for long
periods (even decades) of time. Also, after the patient was in
the hospital for many days, one of her sons mentioned that
"worms" were seen in this stool 2 weeks prior. Strongyloides IgG
was sent (and still pending), however, due to the likelihood of
some parasitic infection and her lack of improvement on
antibiotics that covered bacterial infections, she was sent out
on empiric coverage with Ivermectin. She received 2 doses in the
hospital, with her 3rd dose to be 2 weeks later.
Hyponatremia: Likely due to the patient's poor po intake. This
was likely due to the patient's families lack of understanding
of the appropriate feeding protocol. The patient's family was
educated by Nutritionists who determined the patient was lacking
in sodium and water intake. The family was instructed to give
their mom salt tabs in addition to their current feeding
regimen. During the admission, the patient was repleted with
fibersource at 45cc/hr x 24hours/day. The patient was also
repleted with NS. The patient's Na improved from 121 to 135 on
discharge.
Constipation and diarrhea: Patient was constipated on admission,
and then with stool softeners added to her regimen, began to
have diarrhea. We discharged her with stool softeners on a prn
basis for constipation.
CHRONIC ISSUES:
HTN: Patient was continued on her anti-hypertensives of
Amlodipine and Metoprolol.
TRANSITIONAL ISSUES:
-Finish Ivermectin course
-Follow up Strongyloides antibody
-Recheck Na as outpatient
-Follow to ensure fevers are improving
Medications on Admission:
1. Metoprolol Tartrate 25 mg PO/NG BID
2. Aspirin 325 mg PO DAILY
3. Mineral Oil ___ mL PO/NG BID
4. Amlodipine 2.5 mg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Guaifenesin ___ mL PO/NG Q6H:PRN cough
7. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
8. Hydrochlorothiazide 25 mg PO/NG DAILY
9. Senna 2 TAB PO/NG BID constipation
10.Levetiracetam Oral Solution 750 mg PO/NG BID
11.Sodium Chloride 1 gm PO BID
___ 1 TAB PO/NG DAILY
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID
2. LeVETiracetam Oral Solution 750 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
4. Vitamin D 400 UNIT PO DAILY
5. Senna 2 TAB PO HS constipation
6. Pravastatin 40 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Aspirin 325 mg PO DAILY
11. Amlodipine 2.5 mg PO DAILY
12. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
13. Ivermectin 12 mg PO ONCE Duration: 1 Doses
RX *Stromectol 3 mg 4 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Suspected Parasitic Infection, likely Strongyloides
Secondary diagnosis:
Hyponatremia
Constipation
Discharge Condition:
Mental Status: Confused - always. Nonverbal.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for high fevers and a cough.
We initially had a high suscpicion for a pneumonia (infection of
the lung), however, we did not see any signs of it on imaging
and anti-biotic therapy did not completely treat your signs of
infection. You also had no signs of infection in your blood,
urine, stool or on your skin. We removed anti-biotics because we
did not find a source of infection that we were treating; you
did not have increased fevers, just the intermittent temperature
spikes that you had on the medication as well. Your "White blood
count" (another sign of infection) was elevated and you had a
predominence of a certain cell type called "eosinophils"
(parasite fighting cells). With the help of the Infectious
Disease specialists, as well as the new information that you may
have had worms in your stool a few weeks ago, we concluded that
your infection was parasitic, and most likely called
"Strongyloides" (a parasite found in ___ and other areas of
the world). A test was sent for this parasite but is not
currently back yet. The Infectious Disease doctors ___ that ___
were doing well enough to send home. We felt that given your
likely infection, we should treat you, regardless of the fact
that it was not yet confirmed on laboratory testing. Today, you
received the 1st dose of this medication: Ivermectin 12mg and
tomorrow you should take another dose as well. You can then STOP
taking it for 2 weeks and take your 3rd dose on ___ which
will be your final dose. This should help with your fevers, and
hopefully, your cough as well.
When you were admitted, we noticed that you had very low levels
of salt in your body. After talking to nutrition, we recommend a
slight change in your tube feedings at home. In addition to what
you are already getting, you should receive 3 bottles of ___
spring water gradually over each day, as well as a Sodium tablet
(1gram) twice a day.
You also came in with constipation. After giving you medications
to help you have a bowel movement, you started having diarrhea.
Because of this, we decreased your stool softeners to only take
if you need it. When you go home, you should only take your
stool softeners if you haven't had a bowel movement that day.
Followup Instructions:
___
|
10754405-DS-8
| 10,754,405 | 21,931,096 |
DS
| 8 |
2168-01-02 00:00:00
|
2168-01-04 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ ___, mute woman with history of
HTN, HLD, and seizure disorder, s/p PEG tube (for intake of
AEDs) who presents from home, reporting left thigh, flank
swelling since yesterday. History was obtained from her son, as
pt is nonverbal.
___ (her son) stated that family found a R sided swelling and
redness over her thigh. This all started in the past two days.
There were no reported pain, fever, chill, diaphoresis. There
were absolutely no trauma involved. Ms. ___ reportedly became
___ about ___ years ago. She had a PEG tube placement last
year for poor PO intake and anti-epileptic medication intake. Pt
stopped talking after the PEG tube placement. Her son however
stated that she can talk if she wants to. There has been
witnessed communication with her daughter, and she was felt to
be "well oriented".
In the ED, initial VS were 98.6 90 171/90 16 100% RA. Her lab
was unremarkable. ___ showed no evidence of DVT. Pt was
admitted for further workup.
REVIEW OF SYSTEMS:
Per HPI. Unable to obtain from pt.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Epilepsy - diagnosed ___, has had multiple EEGs here in the
past ___ years that showed encephalopathy. Had PEG-tube placed on
___ to give AEDs
- Cataracts resulting in blindness
- Possible prior right frontal stroke
- Osteoporosis
Social History:
___
Family History:
several family members with high blood pressures
Physical Exam:
Admission:
VS: 98.0 92 138/80 22 98% on RA
GENERAL: not cooperating with exam, nonverbal,
HEENT: NC/AT,
NECK: supple, no LAD, JVD not visualized
LUNGS: crackles over left base, good air movement, resp
unlabored, no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-distended, no guarding,
no masses
EXTREMITIES: trace pitting edema over left thigh, mild erythema
over left inner thigh, not withdrawing to deep palpation. No
inguinal lymphadenopathy bilaterally
SKIN: multiple stage 2 ulcer over buttock and sacrum
PULSE: 2+ pulses radial and dp
NEURO: good musle tone bilaterally, otherwise cannot assess
Discharge:
VS: 98.2, 126/80-160/86, 79-97, 16, 100% RA
GENERAL: nonverbal, opens her eyes and shakes head yes and no
when daughter asks her to
HEENT: NC/AT
NECK: supple, no LAD, JVD not visualized
LUNGS: CTAB anteriorly, good air movement, resp unlabored, no
accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-distended, no guarding,
no masses
EXTREMITIES:no erythema over left inner thigh, not withdrawing
to deep palpation, but there is a 7-8cm area of swelling. No
inguinal lymphadenopathy bilaterally.
SKIN: multiple stage 2 ulcer over buttock and sacrum
PULSE: 2+ pulses radial and dp
NEURO: good musle tone bilaterally, otherwise cannot assess
Pertinent Results:
___ 06:20PM BLOOD WBC-9.5 RBC-2.85* Hgb-9.3* Hct-27.8*
MCV-98 MCH-32.5* MCHC-33.3 RDW-13.3 Plt ___
___ 06:20PM BLOOD Neuts-73.5* Lymphs-16.1* Monos-7.0
Eos-2.7 Baso-0.7
___ 09:10AM BLOOD WBC-9.6 RBC-2.63* Hgb-8.4* Hct-25.0*
MCV-95 MCH-31.9 MCHC-33.6 RDW-13.5 Plt ___
___ 06:50AM BLOOD WBC-9.4 RBC-2.80* Hgb-9.1* Hct-27.0*
MCV-96 MCH-32.5* MCHC-33.7 RDW-14.1 Plt ___
___ 09:20PM BLOOD ___ PTT-25.7 ___
___ 06:20PM BLOOD Glucose-156* UreaN-45* Creat-0.9 Na-130*
K-5.5* Cl-94* HCO3-24 AnGap-18
___ 09:10AM BLOOD Glucose-112* UreaN-39* Creat-0.7 Na-129*
K-4.3 Cl-96 HCO3-24 AnGap-13
___ 06:50AM BLOOD Glucose-154* UreaN-30* Creat-0.7 Na-128*
K-4.4 Cl-95* HCO3-21* AnGap-16
___ 01:15PM BLOOD UreaN-32* Creat-0.7 Na-128* K-4.1 Cl-97
HCO3-20* AnGap-15
___ 06:20PM BLOOD ALT-16 AST-38 AlkPhos-70 TotBili-0.1
___ 09:10AM BLOOD CK(CPK)-25*
___ 06:20PM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.4 Mg-2.2
___ 09:10AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0
___ 06:50AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
___ 09:10AM BLOOD Osmolal-283
___ 01:15PM BLOOD Osmolal-282
___ 06:50AM BLOOD TSH-4.6*
___ 06:50AM BLOOD Free T4-1.1
___ 03:00PM URINE Color-Straw Appear-Clear Sp ___
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 03:00PM URINE RBC-<1 WBC-0 Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:15PM URINE Hours-RANDOM Na-46 K-49 Cl-48
___ 01:15PM URINE Osmolal-452
___ 03:00PM URINE Hours-RANDOM UreaN-293 Creat-11 Na-125
K-17 Cl-106
___ 03:00PM URINE Osmolal-373
.
U/S LLE:
1) No evidence of DVT.
2) New left inguinal region hypoechoic avascular structure new
since ___ of unclear etiology and may represent a
hematoma. Differential diagnosis would also include abnormal
large lymph node/conglomerate, however, this structure was not
present on CT from ___.
Brief Hospital Course:
___ ___ ___, mute woman with history of
HTN, HLD, and seizure disorder, s/p PEG tube (for intake of
AEDs) who presents from home, reporting left thigh, flank
swelling since yesterday. There was no flank swelling on exam.
# L thigh swelling: Ms ___ was hospitalized in the setting of
focal left thigh swelling incidentally noted by her daughter. US
demonstrated a non-discrete inguinal mass likely resembling a
hematoma without evidence of clot, mass or lymphadenopathy. CK
and WBC were wnl with no infectious signs or symptoms. Patient
completely asymptomatic with no evidence of pain; neuro exam
limited at baseline as patient bedbound. HCT was stable during
hospital course and mass did not change in size. Radiology said
MRI could be done to further characterize but felt lesion was
benign so also recommended clinically monitoring if
asymptomatic. We did not feel this was a clinically significant
lesion since there was no associated pain, no other changes in
physical exam, and no significant lab changes. Her daughter will
continue to monitor and MRI can be pursued if enlarging or
causing symptoms as an outpatient.
# Hyponatremia: Was initially thought to be due to hypovolemia,
but SIADH more likely based on labs (urine Na 125, urine osm
383) and lack of response to fluids. Patient's HCTZ was stopped,
free water flushes were minimized and salt tabs were started
(patient was previously on salt tabs for treatment of
hyponatremia in the past). Hyponatremia was stable at discharge
with values similar to prior. TSH was also checked and was
mildly elevated with anormal free T4
# Nutrition: Tube feeds were continued via PEG.
# Pressure Ulcer: Patient was seen by wound care due to concern
for pressure ulcers; no discrete ulcers were found but several
areas of hypo/hyperpigmentation visualized with recommendation
for miconazole powder prn and possible outpatient derm
follow-up.
# HTN: Metoprolol continued. Stopped HCTZ.
# Seizure: Levetiracetam continued.
# HLD: Simvastatin continued.
# Anemia: Appears to be baseline.
# Prior to discharge several non-essential medications such as
vitamin C were stopped.
Transitional Issues:
- DNR/DNI
- Outpatient follow up of serum Na
- Outpatient derm follow up can be arranged if PCP thinks this
is necessary
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 500 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Alendronate Sodium 70 mg PO Frequency is Unknown
qweek, unknown day
4. Simvastatin 40 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Calcium Carbonate 500 mg PO Frequency is Unknown
7. Vitamin D 400 UNIT PO Frequency is Unknown
8. magnesium gluconate *NF* 27 mg (500 mg) Oral tid
9. Aspirin 81 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Ascorbic Acid ___ mg PO Frequency is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. Miconazole Powder 2% 1 Appl TP QID:PRN rash
RX *miconazole nitrate [Anti-Fungal] 2 % apply thin layer to
affected area up to four times a day Disp #*1 Bottle Refills:*0
7. magnesium gluconate *NF* 27 mg (500 mg) Oral tid
8. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyponatremia due to SIADH
Left thigh swelling
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted to ___ in the setting of left thigh
swelling. An ultrasound was negative for clot or mass. You
remained without appreciable pain, fever, or bruising to suggest
untreated infection or ongoing bleeding. Decision was made to
monitor clinically rather than pursue additional imaging as
likely no intervention would be warranted.
Additionally your sodium was found to be low. Your
hydrochlorothizide was stopped and your labs remained stable.
You were also started on salt tabs which you should take twice
daily.
Please follow-up with your primary doctors as ___.
Followup Instructions:
___
|
10754501-DS-4
| 10,754,501 | 21,145,771 |
DS
| 4 |
2170-03-10 00:00:00
|
2170-03-10 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:
hematoma
Major Surgical or Invasive Procedure:
___ Evacuation of hematoma
History of Present Illness:
Patient presented to ___ for sudden onset worsening back
pain. He was transferred to ___ for neurosurgical evaluation.
He is POD 5 from a T7-T9 Exploration for Tumor. Patient had
restarted Lovenox for hx of PE upon discharge
Past Medical History:
PAST MEDICAL HISTORY: Allergic rhinitis, and esophagitis.
PAST SURGICAL HISTORY: Thoracic surgery for a noncancerous
tumor.
Social History:
___
Family History:
NC
Physical Exam:
Upon discharge:
Neurologically intact.
Incisional hematoma was vastly decreased in size, improving,
staples intact.
Pertinent Results:
CT OF THE THORACIC SPINE: ___
Soft tissue stranding and 12.8 cm complex fluid collection at
the surgical site described above. Punctate nonobstructive right
renal calculus.
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgical service for
observation of a hematoma underlying incision from ___ T7-T9
Exploration for Tumor. It was noted that hematoma was growing in
size and patient was in severe pain. Aspiration with needle was
attempted at the bedside. It was determined patient should be
taken to OR for evacuation of hematoma.
On ___, the patient remained stable however, continued with
excruciating pain requiring IV pain medication. His Hemovac
remained in place with moderate drainage.
On ___, The patient remained stable, His Hemovac drain and
dressing were removed, no drainage noted. The patient complained
of pain and muscle spasms, requiring IV pain medication and he
was started on his home Valium.
On ___, the patient remained neurologically intact. He was
encouraged to mobilize. His pain was improving and did not
require IV pain med. Plan to discharge home tomorrow. He was
started on SQH TID.
On ___, the patient's hematoma appeared to be re-accumulating,
his SQH was stopped. However, the patient was stable from a
neurosugical perspective and pain continued to improve. A
hematology consult was obtained for further evaluation of
re-accumulation of hematoma at the surgical site. Hematology
evaluated the patient and recommended a CT of the thoracic spine
to evaluate hematoma and for a baseline image, may start the
lovenox once hematoma stops expanding, and check a factor Xa for
4hrs after starting lovenox.
On ___ Neuro exam stable. Hematoma outlined and appears stable
from yesterday. Will continue to monitor and reassess tomorrow.
On ___, the patient was doing well neurologically. His wound
hematoma was stable with no appreciable increase in size.
Lovenox was restarted at 4pm and a factor Xa was ordered at 8pm
which was WNL.
On ___, the patient was stable neurologically and had minimal
complaints. His hematoma appears to have resolved to some
degree. Hematology recommended that another LMWH lab be drawn
after he received the 3rd dose of lovenox to check for dosing
efficacy. Discharge planning was for ___.
On ___, the patient was stable neurologically. His hematoma
was stable. He had no complaints. His factor Xa lab test came
back at 0.92.
He was discharged to home in improved condition.
Medications on Admission:
nexium, lovenox, percocet, ambien
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Diazepam 5 mg PO Q6H:PRN muscle spasm
hold for sedation.
RX *diazepam 5 mg 1 tablet by mouth q6h prn Disp #*50 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL ___very twelve (12) hours
Disp #*60 Syringe Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
decrease dose as soon as possible.
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3h prn Disp #*60
Tablet Refills:*0
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
suture/staple removal. Please keep your incision dry until
suture/staple removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture/staple
removal.
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. ___ 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.
Medications
Continue as lovenox, as was cleared by the neurosurgeon.
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.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10754727-DS-14
| 10,754,727 | 20,895,038 |
DS
| 14 |
2158-04-22 00:00:00
|
2158-04-28 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Erythromycin Base / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dizziness, blurry vision, headache, neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with PMH
significany for shingles (affecting his legs) who presents with
constellation of symptoms including vertigo, blrury vision and
neck pain/headache. He says that he woke up in his usual state
of
health at 6AM to go for a run (not a common activity for him).
He
ran for less than a mile, when he started feeling lightheaded
and
noticed that his vision (in each eye) was blurry. He went home
and lay in bed for about an hour, but his symptoms persisted. He
went to take a shower, during which time he noted blurred
vision,
but was otherwise ok. However, when getting out of the shower,
he
developed a severe room spinning sensation. He had to hold on
when walking to prevent himself from falling. He is unsure if he
was falling in any particular direction. He went back to bed and
was able to sleep for a few hours. Upon awakening, between 10:30
and 11 AM, the vertigo was improved but he still had blurry
vision in each eye and he noted onset of neck pain (he describes
as neck stiffness but also pain) than radiated up to the base of
his skull and then to the vertex and behind his eyes. He
described the pain as a constast pain, which felt "tight" but
was
nonthrobbing. No positional component. He says at its worst, the
pain is ___ in intensity. With regards to his neck pain, he
says
that his neck has felt stiff at times prior to today, but
without
pain usually and with no headaches. He has had no recent neck
trauma or whiplash injuries and does not get any neck
manipulations done. He saw his PCP this afternoon, he referred
him to the ED for further evaluation. He says that now his
vision
has largely improved, though he notes that it appears like he is
looking through a prism in the upper and lower corners (but not
the remainder) of his right visual field.
Neuro ROS: Positive for vertigo and lightheadeness today as per
HPI as well as blurry vision, neck pain and headache. He also
notes tinnitus b/l earlier today. No diplopia, dysarthria,
dysphagia, or hearing loss. No difficulties producing or
comprehending speech. No focal weakness, numbness,
parasthesiae.
No bowel or bladder incontinence or retention. Difficulty with
ambulating earlier today as per HPI.
General ROS: He does note nausea earlier today associated with
vertigo. no fever or chills. No night sweats or recent weight
loss or gain. He did have virual URI about 6 weeks ago but no
current sequelae. No cough, shortness of breath, chest pain or
tightness, palpitations. No vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. No rash.
Past Medical History:
-Shingles
-s/p appendectomy
Social History:
___
Family History:
Father with history of vertigo. Maternal GF with history of
stroke.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.9 P: 89 R: 18 BP: 145/95 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. Tympanic membranes clear.
Neck: Supple, no carotid bruits appreciated.
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. 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 ___ with
prompting). No evidence of apraxia or neglect.
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: Visual acuity ___ OS and ___ OS. PERRL 4 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: 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 IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch, pinprick, proprioception
throughout. Vibratory sense 10 seconds at right great toe and 14
seconds at left great toe. No extinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor on the left and mute on the right.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally. No dysmetria with toe to finger. Normal
rebound b/l. Normal mirroring b/l. No dysdiadokinesia. RAMs
intact b/l.
Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Able to walk in tandem without difficulty. Romberg absent.
Physical Exam on Discharge:
Mental status, cranial nerves, motor, sensory, coordination exam
normal. Sees small, white dots in his field of vision b/l
Pertinent Results:
Labs on Admission:
___ 04:15PM WBC-8.3 RBC-4.74 HGB-14.5 HCT-42.6 MCV-90
MCH-30.5 MCHC-34.0 RDW-13.3
___ 04:15PM NEUTS-70.9* ___ MONOS-6.6 EOS-1.1
BASOS-0.4
___ 04:15PM ___ PTT-25.6 ___
___ 04:15PM GLUCOSE-119* UREA N-15 CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
___ 05:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Relevant Labs:
___ 04:50PM BLOOD ACA IgG-2.7 ACA IgM-6.7
___ 07:30AM BLOOD Triglyc-98 HDL-62 CHOL/HD-3.2 LDLcalc-116
___ 04:50PM BLOOD Homocys-8.6
Beta-2-Glycoprotein 1 Antibodies IgG: wnl
Imaging:
CTA head/neck:
1. Diminished caliber, with a linear intraluminal filling
defect
of the right V3 segment of the vertebral artery. These
findings,
raise concern for arterial dissection and/or intraluminal
thromboembolus.
2. No other evidence of thromboembolic filling defect or
aneurysm.
3. No acute intracranial hemorrhage.
MR head/MRA neck w/ and w/o contrast:
1. Punctate foci of restricted diffusion within the right
greater
than left cerebellar hemispheres and the left greater than right
occipital lobes, compatible with acute to subacute foci of
ischemia, likely from embolic source.
2. Focal filling defect within the V3 segment of the right
vertebral artery likely secondary to thrombus and focal
dissection.
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%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Mildly dilated aortic root. No clinically
significant valvular regurgitation or stenosis. Indeterminate
pulmonary artery systolic pressure.
Labs on Discharge:
___ 01:40PM BLOOD ___ PTT-35.1 ___
Brief Hospital Course:
Mr. ___ is a ___ RHM with PMH of shingles on his legs who
presented with blurry vision, dizziness, headache, neck pain
found to have a R vertebral dissection and thrombus.
# Neuro: Pt denied anyrecent trauma or over exertion of the
neck, no chiropracter
manipulation of neck. However, did recently move to new house,
so trauma from lifting heavy objects may have caused dissection.
Neuro exam was nonfocal. Does have some joint laxity in both
elbows and on finger extension bilaterally. Imaging c/w
dissection causing thrombus rather than thrombus alone.
However, will still initiated with hypercoag w/u, although much
of it could not be obtained as pt was already on heparin. Also
on differential is a collagen disorder such as one of the ___
Danlos types (especially type IV Vascular) which can predispose
to dissection. Marfan's disease is also on the differential but
he does not have a typical Marfanoid appearance. Suspicion for
for a collagen vascular disorder is higher given the mildly
dilated aortic root as seen on TTE. In house, patient was
started on heparin bridge to coumadin. On d/c, he will continue
Lovenox bridge to coumadin. Communicated with PCP's office who
has agreed to manage anticoagulation. Will need to continue
anti coagulation for at least 3 months. He will need to
complete hypercoag w/u once off anticoagulation as well. He
will have an MRA head and neck with fat sats in 2.5mo prior to
f/u in stroke clinic with Dr. ___. He will also have skin
testing for laxity as well as a repeat TTE to re-evaluate aortic
root.
TRANSITIONS OF CARE:
-anti coagulate with coumadin x3 months
-MRA head and neck with fat sats in 2.5 months prior to f/u in
stroke clinic with Dr. ___ testing for ? ___
-TTE to evaluate for aortic root dilation (?Marfan's)
-Complete hypercoag w/u as outpt once off anticoagulation
(Protein C,S, Factor V, prothromin, Anti thrombin III)
Medications on Admission:
none
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC BID
Please continue this medication until your doctor tells you that
you may stop it
RX *enoxaparin 80 mg/0.8 mL twice a day Disp #*14 Syringe
Refills:*1
2. Warfarin 5 mg PO DAILY16
Please adjust dose as instructed by your doctor
RX *Coumadin 2.5 mg 2 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*2
3. Outpatient Lab Work
Please check ___ on ___ and fax results to:
___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Right vertebral artery dissection
Discharge Condition:
Mental status, cranial nerves, motor, sensory, coordination exam
normal. Sees small, white dots in his field of vision b/l
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital when you came in with
dizziness and blurry vision as well as neck pain and headache.
You were found to have a small tear and clot in the vertebral
artery (a small artery running from your neck into your head).
The tear was most likely due to lifting heavy objects while
moving. As we discussed, you may have a collagen disorderwhich
makes your blood vessels more susceptible to tearing. We
obtained a cardiac ultrasound to evaluate for blood vessel
abnormalities. One portion of a blood vessel, the "aortic
root," was mildly larger than normal. You will need to have a
repeat heart ultrasound as an outpatient to re-assess in the
future.
On discharge, we have started you on blood thinner medications,
Lovenox and Coumadin as below. You will need a repeat MRI in
2.5 months to re-assess the artery with the dissection. Please
call ___ to schedule it (it is ordered in the system,
you just need to book the appointment).
We have made the following changes to your medications:
-START Lovenox 80mg twice daily until your doctor tells you to
stop
-START Coumadin 5mg daily; your doctor ___ adjust your dose as
needed.
Please have your blood work checked on ___. Prescription is
included below.
On discharge, please call your primary care doctor to schedule a
follow up appointment. Also, follow up with Dr. ___ in
stroke clinic as scheduled before.
Before your appointment with Dr. ___ call
REGISTRATION at ___ as we do not have all of your
pertinent insurance information in the computer system at this
time.
Followup Instructions:
___
|
10754875-DS-2
| 10,754,875 | 26,020,576 |
DS
| 2 |
2148-12-24 00:00:00
|
2148-12-24 22:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pneumococal vaccine
Attending: ___.
Chief Complaint:
Right hand redness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ presents with hx of DVTs on coumadin presents with right
hand cellulitis. Patient was seen at a medical clinic 2 days ago
with mild cellulitis of the right hand and was started on
Keflex, however, she return to the clinic today with worsening
symptoms, severe pain and fever to 101. She was then sent to the
emergency department for further evaluation. Patient denies any
injury to the affected extremity. Denies any shaking chills.
Denies any numbness or weakness in the affected extremity.
She denies any bites, lacerations or exposures. Patient states
she was in her usual state of health until late last week when
she started to have right hand swelling, pain and erythema. She
was seen at an outside urgent care who gave her Keflex. She
returned to the urgent care today with worsening of her right
hand swelling and erythema tracking to the volar wrist despit
Keflex and was subsequently transferred to ___. On exam she
has swelling and erythema over the dorsal and palmar aspect of
the thumb and index finger tracking proximally over the dorsum
of the hand and to the volar aspect of the wrist. No drainable
fluid collections. Neurovascularly intact on exam. Obtaining
basic labs and starting vancomycin. Hand surgery has been
consulted and has evaluated the patient to evaluate for possible
flexor tenosynovitis which they do not feel the patient
currently has. Given the patient's failure of outpatient Keflex
with rapidly expanding cellulitis will plan to admit to medicine
for further management and observation. Hand surgery has stated
they will be following along inpatient.
-In the ED, initial VS were: ___ 90 143/84 16 96% RA
-Exam notable for: notable for significant swelling of the
patient's hand with erythema extending one quarter of the way up
the forearm. Based on the outpatient notes this is a rapidly
progressing cellulitis.
On arrival to the floor, patient reports above history, with sx
for about 3 days, no triggers, no injury, no fevers/chills, no
URI, abdominal pain, no travel, no pets. She has never had other
skin infections that required admission.
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-DVTs on Coumadin since 1990s, no hx of hypercoagulation, no PE
-HLD
-Thrombophlebitis
-Osteoarthritis
Social History:
___
Family History:
COPD in her mother, also thinks mother was on coumadin, possible
stroke in her father,
Physical Exam:
ADMISSION:
VS: 99.7 148/85 89 16 97 RA
GENERAL: NAD, well appearing
HEENT: PERRL, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD , no axillary LAD
HEART: RRR, S1/S2, no murmurs
LUNGS: CTA bilaterally aside from decreased breath sounds at
left base
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: no ___ edema, right hand and arm without any
lesions although prominent PIP and DIP. right hand with cast on,
swelling and erythema over dorsal thumb and index finger, no
fluctuance, full painless ROM, pain with flexion of thumb and
index finger, minimal erythema over palmar surface, slight
bullae like appearance over dosrsal area, good 2+ radial pulse
b/l
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3
DISCHARGE:
VITALS: 98.9 PO 129 / 79 L Lying 65 18 97 Ra
GENERAL: NAD, well appearing
HEENT: PERRL, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD, no axillary LAD
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes, rales or rhonchi
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: Right hand and forearm in cast. Shiny quality to
exposed area of proximal thumb. Prominent prominent PIP and DIP,
with swelling to dorsal thumb and index finger. no fluctuance,
painless passive ROM to thumb and forefinger, improved from
prior flexion of thumb and index finger
LYMPH: no LAD
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, memory intact to distant medical events but not to
recent ones, asking how many days she has been in the hospital
Pertinent Results:
ADMISSION LABS:
===============
___ 10:15PM BLOOD WBC-9.3 RBC-4.42 Hgb-12.3 Hct-36.0
MCV-81* MCH-27.8 MCHC-34.2 RDW-13.2 RDWSD-39.2 Plt ___
___ 10:15PM BLOOD Neuts-64.8 ___ Monos-15.0*
Eos-0.1* Baso-0.5 Im ___ AbsNeut-5.98 AbsLymp-1.78
AbsMono-1.39* AbsEos-0.01* AbsBaso-0.05
___ 10:15PM BLOOD ___ PTT-40.0* ___
___ 10:15PM BLOOD Glucose-104* UreaN-22* Creat-0.9 Na-137
K-3.1* Cl-95* HCO3-22 AnGap-20*
___ 07:20AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0
___ 10:15PM BLOOD CRP-170.6*
___ 10:15PM BLOOD SED RATE-Test 48 H
PERTINENT LABS:
===============
___ 07:20AM BLOOD ___
___ 07:20AM BLOOD ___ PTT-32.0 ___
___ 08:40AM BLOOD ___ PTT-30.9 ___
___ 07:19AM BLOOD ___ PTT-29.5 ___
___ 07:10AM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-142
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 10:15PM BLOOD CRP-170.6*
___ 10:15PM BLOOD SED RATE-Test ___ H
IMAGING:
========
___ Hand Xray:
No fracture or dislocation is seen. Moderate degenerative
changes of the ___ CMC joint. Severe degenerative changes at
the index finger and long finger DIP joints.. No bone erosion
or periostitis is identified. There is diffuse
demineralization. A nonaggressive appearing 8 mm sclerotic
lesion in the distal radius likely represents a bone island.
No radiopaque foreign body is identified. There is vascular
calcifications.
IMPRESSION:
1. No fracture or dislocation. No radiopaque foreign bodies.
2. Moderate to severe degenerative changes as described.
Brief Hospital Course:
___ year old female with history of DVTs, Factor V Leiden
heterozeigosity on Coumadin, HLD presenting with persistent
right hand swelling/erythema consistent with cellulitis.
#Hand cellulitis:
#Osteoarthritis:
Rapidly worsening cellulitis per documentation, along with
fevers, elevated inflammatory markers despite ___ days of
Keflex. Xray without fracture or joint erosion. Hand was
consulted, recommended no surgical intervention. No classical
risk factors for MRSA, however empiric treatment with vancomycin
resulted in marked improvement(resolved erythema, reduced edema,
pain.) She was treated with vancomycin/Ceftriaxone (___)
with improvement in swelling and range of motion. Underlying
osteoarthritis considered possible contributing to welling,
however this unusual to be sole cause given multiple joints
involved, extension from DIP to wrist. Pain was controlled with
Tylenol. Discharged with plan to complete for 7 day course to
cover MRSA. Amoxicillin/doxycycline were chosen for ease of
dosing (___) Activity recommendations were as followed:
strict elevation in volar resting slab splint. Discharged with
___.
#MCI
Patient was noted to be poor historian for recent events with
neurocognitive testing suggesting MCI in ___. On presentation
had supratherapeutic INR raising concern for medication
nonadherence. ___ (daughter, HCP) noted forgetfulness over the
last months, prompts to take medication. She noticed her mom
does best with routine at home. Recommend continued follow up
with PCP and reassessment by neuro-psych. ___ can also help
assess home situation.
#Hx of DVT/ Factor V Leiden heterozygosity:
Per atrius records; on lifelong AC. Perhaps suspicion of APLS,
as heterozygosity FVL is not in itself indication. INR
supratherapeutic on admission. Downtrended. Discharged with plan
for close interval follow up.
#Relative hypotension:
#HTN:
Presented normotensive. Had relative hypotension to 88 SBP
(asymptomatic, no fever or emerging sepsis) after administration
of antihypertensives. In this patient with likely advancing MCI,
thought to be due to giving home doses in the hospital with
concern that she was not taking these at home. Home Lisinopril,
amlodipine, were held. ___ can assist with blood pressure
monitoring and medication assistance.
#HLD:
Continued simvastatin
Transitional Issues:
====================
[] Follow up INR ___
[] Monitor BP, reintroduce antihypertensives as indicated
[] Recommend repeat neurocognitive testing given above
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Warfarin 5 mg PO DAILY16
6. Cephalexin 500 mg PO Q12H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 4 Days RX
*doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 40 mg PO QPM
5. Warfarin 5 mg PO DAILY16
6. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do
not restart amLODIPine until you see your primary care doctor
7. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
Secondary:
H/O DVT, Factor V leiden heterozygosity on Coumadin
HTN
HLD
MCI
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 ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You had swelling and redness of your hand because of an
infection that did not get better with a few days of oral
antibiotics.
WHAT HAPPENED IN THE HOSPITAL?
You had an xray which showed no broken bones or unexpected
changes to your joints.
You were seen by the hand orthopedic surgery team. They wrapped
your hand and followed you closely.
You were given intravenous antibiotics to treat your infection.
Your swelling improved.
Your blood pressures were low when we gave you your home
medication for blood pressure (amlodipine and lisinopril) so we
held these medications. They should not be restarted until you
see your primary care doctor.
WHAT SHOULD I DO WHEN I GO HOME?
Take your medication as prescribed.
Use your resting splint and elevate your hand when possible.
Follow up with your primary care doctor, and the hand surgery
team (see appointments below.)
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
10754911-DS-9
| 10,754,911 | 24,174,704 |
DS
| 9 |
2166-03-28 00:00:00
|
2166-03-28 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Symptomatic hepatic cysts.
Major Surgical or Invasive Procedure:
___: Laparoscopic unroofing of hepatic cysts.
History of Present Illness:
___ otherwise healthy reports sharp right sided abdominal
pain for one day. The pain started last night at 11 ___, was
severe and diffuse over the right side of her abdomen and has
since remitted but is sharp and severe with movement but she is
comfortable at rest. She denies previous abdominal pain.
Past Medical History:
PMH: none
PSH: tonsillectomy in childhood
Social History:
___
Family History:
FH: no history of liver cysts or liver, GI disease
Physical Exam:
Discharge Physical
NAD, AVSS
rrr
ctab
abd soft, non distend, aprop tender over laproscopic incisions.
incision c/d/i
no ___ edema
Pertinent Results:
___ ___:
1. MANY CYSTS ARE SEEN WITHIN THE LIVER, WITH THE LARGEST AT THE
INFERIOR ASPECT OF THE LIVER SIGNIFICANTLY DISTORTING THE
LIVER
CAPSULE AND DISPLACING ABDOMINAL/PERITONEAL STRUCTURES.
ALTHOUGH
THERE IS NO OVERT HEMORRHAGE WITHIN ANY OF THE CYSTS, THERE
IS SLIGHT
STRANDING ADJACENT TO THE LIVER CAPSULE AND A TRACE OF
PERIHEPATIC
FLUID OF UNCERTAIN SIGNIFICANCE. THE PRESENCE OF THESE
LARGE CYSTS
COULD BE THE CAUSE OF THE PATIENT'S PAIN.
___ 09:05AM BLOOD WBC-8.8 RBC-3.79* Hgb-12.3 Hct-36.2
MCV-95 MCH-32.3* MCHC-33.9 RDW-12.1 Plt ___
___ 09:05AM BLOOD Plt ___
___ 05:15AM BLOOD Glucose-131* UreaN-8 Creat-0.5 Na-136
K-5.0 Cl-102 HCO3-25 AnGap-14
___ 05:15AM BLOOD ALT-16 AST-30 AlkPhos-66 TotBili-0.3
___ 05:15AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.7 Mg-2.0
Brief Hospital Course:
Pt originally presented to ___ w/ RUQ pain, found to
have multiple large liver cysts, and transferred to medical
service at ___ for further evaluation. HB surgery evaluated
patient, and recommended laparoscopic unroofing procedure for
symptomatic relief. After informed consent obtained pt taken to
operating room for laparoscopic unroofing of hepatic cysts. See
operative dictation for details. Tolerated procedure well.
Advanced to clears and then regular diet on POD#1, as well as to
oral pain medications. Discharged POD#2 tolerated diet,
ambulating, pain controlled with oral pain meds.
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic hepatic cysts.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call if you experience fever, chills, nausea, vomiting,
abdominal pain, inability to tolerate a diet.
Do not drive while taking narcotic pain medications.
___ shower. Pat incisions dry. Record drain output, per hospital
teaching.
Followup Instructions:
___
|
10754991-DS-13
| 10,754,991 | 26,940,500 |
DS
| 13 |
2135-04-02 00:00:00
|
2135-04-03 21:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Glucophage / Avandia / Lisinopril / Lyrica / Allegra / clonidine
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ T2DM, fibromyalgia, GERD, hypothyroidism p/w palpitation.
On night prior to admission, around 6pm. pt reports onset of
palpitation, diaphoresis, substernal chest pain w/o radiation,
SOB. She also complained of sig. dizziness. The symptoms would
not go away, so pt eventually seek care at the ED.
In the ED, initial vitals were:
98.6 181 88/56 28 100% RA
pt triggered for tachycardia and hypotension
- EKG showed SVT 174, NANI
- pt was given fluid bolus and adenosine and returned to sinus
rhythm.
- Labs subsequently were significant for ALT 491 AST 1412 AP182
serum tox, including Tylenol, was negative. lactate 3.9
- Imaging revealed:
RUQ: No ductal dilation or other hepatic abnormality. Trace
perihepatic fluid.
CXR: no sig abnormality on ___
Upon further questioning. Pt reports that she has not had fever,
cough, abd pain, jaundice. She used Tylenol w/ Codeine ___
in the past few days. She endorses ___ drinks (wine, beer) per
week. No hx of liver disease. no unusual food recently. She
reports that her neice has a cold recently, but no additional
sick contact. no d/c. no changes in stool or urine color. denies
illicit drug use.
On floor: CP, palpitation, SOB, dizziness have all resolved.
denies RUQ pain.
REVIEW OF SYSTEMS:
(+) Per HPI, otherwise negative
Past Medical History:
Type 2 diabetes
Fibromyalgia
GERD
Depression
Hypothyroidism
Chronic pain
Pulmonary nodule
Urinary incontinence
h/o hepatitis B, resolved
s/p hysterectomy
Social History:
___
Family History:
DM2
Breast cancer in mother at ___, maternal GM
Aunt w/ "rare nerve disease"
No family history of liver disease
Physical Exam:
=================
ADMISSION EXAM:
=================
Vitals: 97.6 119/74 80 16 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
=================
DISCHARGE EXAM:
=================
Vitals: T 97.7 BP 132/68 HR 79 RR 18 97% RA
Telemetry: No events
General: AOx3, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: No LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no RUQ tenderness, no ascites
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, no asterixis.
Pertinent Results:
================
ADMISSION LABS:
================
___ 02:40AM BLOOD WBC-6.7 RBC-4.26 Hgb-13.5 Hct-41.4 MCV-97
MCH-31.7 MCHC-32.6 RDW-13.1 RDWSD-46.5* Plt ___
___ 02:40AM BLOOD Neuts-36.5 Lymphs-58.2* Monos-3.4*
Eos-1.0 Baso-0.6 Im ___ AbsNeut-2.45 AbsLymp-3.91*
AbsMono-0.23 AbsEos-0.07 AbsBaso-0.04
___ 02:40AM BLOOD ___ PTT-34.4 ___
___ 02:40AM BLOOD Glucose-297* UreaN-18 Creat-0.8 Na-139
K-4.5 Cl-98 HCO3-23 AnGap-23
___ 02:40AM BLOOD ALT-491* AST-1412* AlkPhos-182*
TotBili-0.7
___ 02:40AM BLOOD Albumin-4.7 Calcium-9.9 Phos-3.2 Mg-2.0
___ 02:47AM BLOOD Lactate-3.9*
___ 10:51AM BLOOD Lactate-2.8*
====================
PERTINENT RESULTS:
====================
LABS:
====================
___ 02:40AM BLOOD ALT-491* AST-1412* AlkPhos-182*
TotBili-0.7
___ 09:45AM BLOOD ALT-537* AST-1271* AlkPhos-156*
TotBili-0.7
___ 04:56AM BLOOD ALT-349* AST-330* LD(LDH)-280*
AlkPhos-151* TotBili-0.3
___ 02:40AM BLOOD cTropnT-<0.01
___ 02:40AM BLOOD Lipase-30
___ 04:56AM BLOOD Free T4-1.3
___ 09:45AM BLOOD TSH-0.080*
___ 02:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 02:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:40AM BLOOD HCV Ab-NEGATIVE
===
ECG (___): Narrow complex tachycardia. Supraventricular
tachycardia is suggested.
Intervals ___
RatePRQRSQTQTc (___) ___
___
===
CXR (___): Mild vascular congestion without frank pulmonary
edema. No focal consolidation to suggest bacterial pneumonia.
===
RUQ US (___): No ductal dilation or other hepatic
abnormality. Trace perihepatic fluid.
================
DISCHARGE LABS:
================
___ 04:56AM BLOOD WBC-3.9* RBC-3.40* Hgb-10.5* Hct-32.1*
MCV-94 MCH-30.9 MCHC-32.7 RDW-12.5 RDWSD-43.5 Plt ___
___ 04:56AM BLOOD ___ PTT-31.2 ___
___ 04:56AM BLOOD Glucose-51* UreaN-9 Creat-0.5 Na-136
K-3.5 Cl-103 HCO3-27 AnGap-10
___ 04:56AM BLOOD ALT-349* AST-330* LD(LDH)-280*
AlkPhos-151* TotBili-0.3
___ 04:56AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with T2DM, fibromyalgia, GERD,
hypothyroidism who p/w palpitations, found to have unstable
AVNRT. On presentation the patient's heart rates were found to
be in the 170s-180s with associated hypotension to the ___.
Given persistent SVT, she was given adenosine with return to
normal sinus rhythm. Her labs were notable for a hepatocellular
injury with ALT/AST: ___ likely secondary to hypotension.
The patient was evaluated by the electrophysiology cardiology
team, who recommended an AVNRT ablation. The patient's LFTs
improved, and her heart rate remained in normal sinus rhythm.
She was discharged home with plan to follow up with outpatient
EP for an AVNRT ablation.
==============
ACTIVE ISSUES:
==============
# AV Nodal Reentry Tachycardia: The patient presented with
palpitations and her heart rates were found to be in the
170s-180s with associated hypotension to the ___. Given
persistent SVT, she was given adenosine with return to normal
sinus rhythm. The patient was evaluated by the electrophysiology
cardiology team, who recommended an AVNRT ablation. The patient
was scheduled for an ablation on ___. Amlodipine and
losartan were held in the setting of hypotension. Amlodipine was
restarted upon discharge.
# Hepatitis: Her labs on admission were notable for a
hepatocellular injury with ALT/AST: ___ likely secondary to
hypotension due to AVNRT as above. ALT/AST improved to 349/330
on day of discharge.
# Hyperthyroidism: The patient was found to have a TSH of 0.08.
She has had difficulty with her levothyroxine dosing as an
outpatient due to need for frequent adjustments. Her does was
decreased to levothyroxine 112mcg daily, and her TSH should be
followed-up as an outpatient.
==============
CHRONIC ISSUES:
==============
# Diabetes Mellitus: Levemir was decreased from 30 units to 28
units due to hypoglycemia in the morning.
==================
TRANSITIONAL ISSUES:
==================
- Patient should follow-up with EP as an outpatient for AVNRT
ablation on ___
- Levemir was decreased from 30 units to 28 units due to
hypoglycemia in the morning. ___ require further titration as an
outpatient.
- TSH low to 0.08. Home levothyroxine decreased to 112mcg daily.
Please follow-up repeat TSH in ___ months to assess for
improvement of hyperthyroidism.
- Amlodipine and losartan held in the setting of hypotension.
Amlodipine restarted upon discharge. Please check BP and
re-start losartan as needed.
- Code: Full
- Contact: ___ ___ (fiancé)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 1 PUFF IH BID
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyclobenzaprine 5 mg PO BID:PRN muscle spasm
6. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___)
7. Levothyroxine Sodium 225 mcg PO 1X/WEEK (___)
8. Losartan Potassium 100 mg PO DAILY
9. Nortriptyline 10 mg PO QHS
10. levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Omeprazole 20 mg PO DAILY
12. Tolterodine 2 mg PO BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Cyclobenzaprine 5 mg PO BID:PRN muscle spasm
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. levemir 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 112 mcg PO DAILY
RX *levothyroxine 112 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
7. Nortriptyline 10 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Tolterodine 2 mg PO BID
10. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=======================
Primary Diagnosis:
=======================
- AV Nodal Reentry Tachycardia
- Hepatitis
===========================
Secondary Diagnosis:
===========================
- Hyperthyroidism
- Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you developed a very fast heart rate called SVT that
caused your blood pressure to drop to low values. This improved
with a medication called adenosine. Due to your low blood
pressure your liver also was temporarily injured, although this
improved as your blood pressures improved. You were evaluated by
the cardiology team (Electrophysiology) who recommended an
ablation procedure as an outpatient to prevent this from
happening again.
We also found on your labs that your thyroid hormone was too
high. This possibly contributed to your fast heart rates. We
reduced the dose of your levothyroxine.
Please follow-up at your appointments as listed below.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10754991-DS-15
| 10,754,991 | 20,976,196 |
DS
| 15 |
2137-11-28 00:00:00
|
2137-11-28 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Glucophage / Avandia / Lisinopril / Lyrica / latex
Attending: ___.
Chief Complaint:
fatigue and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of type 2
diabetes on insulin and reportedly brittle, complicated by
peripheral neuropathy, who presented with nausea, vomiting,
weakness and found to have HHS, in the setting of missing two
days of insulin. She was in her normal state of health until
last
week. She was preparing a massive feast for her ___ anniversary
to her fiancé ___. The last two days were especially hectic
(making a large number of salads), and she missed her insulin
for
two days. Prior to this had been taking it as normal. She began
to feel increasingly fatigued, then developed nausea and
vomiting. She continued to give herself insulin again, but did
not improve. She finally presented to the emergency room. In
this
period, she denied any diarrhea or constipation, urinary
symptoms, respiratory symptoms, or fevers or chills. She did
lose
~10 lbs due to not eating. No other recent changes to her
health.
No new medications. No sick contacts.
In the ED, AVSS. She had an elevated lactic acid (~10) and an
anion gap of 24, and was bolused 4 liters of NS with improvement
in her lactic acid. She received 20 u glargine and a SS. Her
anion gap closed, and she became hypoglycemic. She had a CXR and
CT torso, both negative for signs of infection. In the AM, it
was
noted that her lactic acid increased from ~2 to 4.7, so she was
admitted to medicine.
Past Medical History:
1. Type 2 diabetes, followed at ___, c/b peripheral neuropathy
2. Fibromyalgia
3. Hypothyroidism
4. HTN
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Geographic tongue with longitudinal furrows. Otherwise, OP
clear.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Patient examined on day of discharge. AVSS/ FSBGs 107-224.
Otherwise exam unchanged.
Pertinent Results:
LABORATORY RESULTS:
___ 11:40AM BLOOD WBC-4.0 RBC-3.24* Hgb-10.1* Hct-30.5*
MCV-94 MCH-31.2 MCHC-33.1 RDW-12.6 RDWSD-43.8 Plt ___
___ 06:18AM BLOOD WBC-4.3 RBC-2.89* Hgb-9.1* Hct-28.1*
MCV-97 MCH-31.5 MCHC-32.4 RDW-12.9 RDWSD-45.6 Plt ___
___ 08:33PM BLOOD WBC-6.3 RBC-4.05 Hgb-12.9 Hct-38.0 MCV-94
MCH-31.9 MCHC-33.9 RDW-12.8 RDWSD-43.4 Plt ___
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-238* UreaN-8 Creat-0.6 Na-135
K-4.3 Cl-95* HCO3-25 AnGap-15
___ 06:18AM BLOOD Glucose-142* UreaN-7 Creat-0.7 Na-135
K-4.7 Cl-105 HCO3-18* AnGap-12
___ 01:23AM BLOOD Glucose-49* UreaN-9 Creat-0.6 Na-135
K-4.1 Cl-100 HCO3-21* AnGap-14
___ 08:33PM BLOOD Glucose-404* UreaN-14 Creat-0.9 Na-129*
K-5.2 Cl-89* HCO3-16* AnGap-24*
___ 09:26PM BLOOD %HbA1c-11.6* eAG-286*
___ 08:33PM BLOOD Calcium-10.5* Phos-2.0* Mg-1.5*
___ 01:23AM BLOOD Calcium-9.3 Phos-1.8* Mg-1.4*
___ 06:18AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.3*
___ 08:37PM BLOOD ___ pO2-45* pCO2-28* pH-7.40
calTCO2-18* Base XS--5
___ 06:21AM BLOOD ___ pO2-165* pCO2-29* pH-7.41
calTCO2-19* Base XS--4 Comment-GREEN TOP
___ 12:02PM BLOOD ___ pO2-97 pCO2-47* pH-7.33*
calTCO2-26 Base XS--1 Comment-GREEN TOP
___ 08:53PM BLOOD Lactate-10.4*
___ 11:04PM BLOOD Lactate-4.7*
___ 01:35AM BLOOD Glucose-45* Na-134 K-3.7 Cl-101
calHCO3-22
___ 02:30AM BLOOD Lactate-2.4*
___ 06:21AM BLOOD Lactate-4.6*
___ 12:02PM BLOOD Lactate-6.7*
Brief Hospital Course:
Ms. ___ was admitted to the hospital with hyperglycemic
hyperosmolar state, and received a total of six liters of NS and
LR, as well as subcutaneous insulin. With her levemir and
sliding scale, her blood sugars returned to ~110-210. Her gap
closed, and her lactic acid downtrended. Her symptoms completely
resolved. However, follow up labs showed her anion gap increase
from 12 to 15, and her lactic acid increased from 4 to 6. I
discussed the case with the ___ Diabetes Service -- given
signs that her HHS was worsening, we both recommended continued
admission and IV fluids. However, Ms. ___ strongly desired
immediate discharge. She stated that she understood the risks,
including becoming ill, and potentially death. She stated that
if she felt worse, she would immediately come back to the
hospital. This is certainly not an ideal discharge plan, and I
would like her to remain an inpatient given the considerable
risks. However, because she clearly has capacity to make her own
medical decisions, I made her a follow up appointment with her
endocrinologist Dr. ___, and a PCP follow up
appointment the next day. She has been instructed (and repeated
back to me) the warning signs that would make her come back to
the emergency room. I am not making any changes to her insulin
regimen at this time; I will defer to Dr. ___.
> 35 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Tolterodine 2 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Aspirin 81 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tolterodine 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemic hyperosmoloer nonketotic state
Type 2 DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with HHS (hyperosmotic
hyperglycemic non-ketotic state) caused by missing your insulin.
You were treated with insulin and fluids. Your blood sugars
returned to normal, and the ___ Diabetes Service recommended
several changes to your regimen. However, your acidosis started
to worsen. Ideally we would want to keep you in the hospital for
more fluids and insulin. However, you strongly desired to leave.
Therefore, I have made a close follow up appointment with both
your primary care doctor and your endocrinologist Dr. ___
___ tomorrow. Because of this, do not make any changes to your
insulin for now -- continue your levemir and sliding scale at
your previous doses, and allow Dr. ___ to make the necessary
changes tomorrow.
If you start to develop nausea, vomiting, fevers, or chills,
PLEASE return to the emergency room immediately. I am concerned
that you could easily slip back into an acidosis.
It was a pleasure taking care of you.
Followup Instructions:
___
|
10755700-DS-16
| 10,755,700 | 24,566,836 |
DS
| 16 |
2155-04-17 00:00:00
|
2155-04-17 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, ___ with HIV (VL undetectable, CD4 492 in ___ and
asthma here with shortness of breath since ___. Noted at that
time development of URI with congestion and stuffiness. Over
___ and ___ cold moved into chest leading to increased
dyspnea and wheeze. Patient was using his inhaler every four
hours but by ___ felt this was not enough to relieve his
symptoms. Endorses fevers, non-productive cough. Denies any sick
contacts, nocturnal cough, pleuritic chest pain, leg swelling,
calf pain. Patient's asthma is mild, only flaring with viral
illnesses. Presented to PCP office on day of admission where
noted to be tachycardic to 111, with temperature of 39.1, and
hypoxic to 92%RA. CXR performed there was negative but patient
was sent to ED for further eval.
.
In ED, repeat CXR showed small left-sided effusion and low lung
volumes, no focal opacity. Patient received duoneb, solumedrol
125mg IV, and Bactrim 500mg IV. On transfer O2 sat had improved
to 95% RA.
.
Currently, pt feels his SOB has improved somewhat with the nebs.
He is breathing comfortably.
.
ROS: denies headache, chest pain, abdominal pain, nausea,
diarrhea, dysuria
Past Medical History:
- CONDYLOMA ACUMINATUM
- HYPERTENSION - ESSENTIAL
- ASTHMA
- HIV INFECTION - last CD4 492 on ___ and VL Undectable
___
- ACQUIRED IMMUNE DEFICIENCY SYNDROME
- RETINITIS
Social History:
___
Family History:
Father ___ at ___, Mother ___ at ___ Cancer - Ovarian
Sister Alive ___ Sickle Cell Trait
Physical Exam:
VS 98.3 134/94 80 18 94%RA
Gen - well-appearing, lying comfortably in bed
CV - RRR, no mrg, hyperdynamic precordium
Lungs - + end-expiratory wheezes anteriorly and posteriorly R>L,
some decreased BS over left base but no egophony or dullness to
percussion, no accessory muscle use, able to speak in full
sentences
Abd - S/NT/ND, no HSM, normal bowel sounds
Ext - no edema, no calf tenderness, no palpable cords, 2+DPs b/l
Skin - no rashes
On discharge, lung exam was much improved with good air movement
and only a few scattered expiratory wheezes
Pertinent Results:
___ 11:35PM BLOOD WBC-5.4 RBC-5.33 Hgb-16.0 Hct-49.4 MCV-93
MCH-30.0 MCHC-32.4 RDW-13.6 Plt ___
___ 11:35PM BLOOD Neuts-57.9 ___ Monos-11.3*
Eos-5.1* Baso-0.8
___ 08:45AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 11:35PM BLOOD Glucose-108* UreaN-16 Creat-1.3* Na-138
K-3.9 Cl-100 HCO3-25 AnGap-17
___ 11:35PM BLOOD ALT-39 AST-34 LD(LDH)-220 AlkPhos-81
TotBili-1.3
___ 11:35PM BLOOD Calcium-10.1 Phos-4.2 Mg-1.9
___ 11:35PM BLOOD D-Dimer-<150
___ 07:54PM BLOOD Type-ART pO2-70* pCO2-38 pH-7.49*
calTCO2-30 Base XS-5
___ 11:48PM BLOOD Lactate-1.5
___ NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
.
CXR ___ Extremely low lung volumes, limiting evaluation of
pulmonary
pathology. PA and lateral radiograph is recommended, when
feasible.
.
Attending Addendum ___
A subtle nodular opacity is seen overlying the right anterior
third rib,
unclear if this represents anterior end of the rib or a
pulmonary nodule,
recommended follow-up chest PA and shallow oblique chest
radiographs with
better inspiration.
The above findings were e-mailed to the ED QA nurses on ___.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___: FRI ___ 4:33 ___
Brief Hospital Course:
___ with HIV on HAART, mild asthma here with fever, shortness of
breath, and relative hypoxia admitted for further work-up.
.
# Dyspnea/hypoxia: Patient's history and presentation seemed
most consistent with viral versus atypical bacterial infection
leading to asthma exacerbation. CXR shows some interstitial
changes consistent with this though the imaging was limited by
low lung volumes. Though patient was febrile, he had no
significant sputum production and no focal consolidation on CXR
so true pneumonia seems unlikely. In the ER patient received
nebs, iv bactrim and iv methylprednisolone. Though there was
initial concern for PCP on presentation, patient's last CD4
count was ~500 in ___, his hypoxia improved with nebulizer
treatments, and his CXR was not suggestive of PCP. On arrival to
the floor, patient appeared well and exam was notable for
end-expiratory wheezes. Patient was started on standing
albuterol nebulizers with improvement in his symptoms. His
ambulatory sat was 94-95% and his peak flow on discharge was
320. He was discharged on a five-day course of azithromycin for
possible atypical PNA and five-day steroid taper for asthma
exacerbation. He will follow-up with his PCP on ___ to
monitor for resolution of his symptoms.
.
CHRONIC ISSUES
# HIV: Last viral load was undetectable and CD4 was 494 in
___. Patient states he continues to be compliant with his
HAART therapy. Repeat CD4 count was sent and was pending at the
time of discharge. He was continued on HAART therapy during his
stay.
.
# HYPERTENSION: Coninued on HCTZ
.
TRANSITIONAL ISSUES
- CD4 count was pending at the time of discharge
Medications on Admission:
- Hydrochlorothiazide 25 mg PO Once Daily
- Truvada 200 mg-300 mg PO Once Daily
- Ritonavir 100 mg PO Once Daily
- Atazanavir 300 mg PO Once Daily
- Acyclovir 800 mg PO Three times daily (only during outbreaks)
- Albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler
Inhalation ___ puffs HFA Aerosol Inhaler(s) Every ___ hrs, as
needed
- Imiquimod 5 % Topical Cream Packet apply topically 3 times
weekly (not currently using, plans to F/U with dermatology)
- Sildenafil 100 mg PO before sex
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. acyclovir 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for outbreak.
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
7. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed for sexual activity.
8. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. prednisone 10 mg Tablet Sig: per taper Tablet PO once a day
for 5 days: Take 5 tabs on ___, 4 tabs on ___, 3 tabs on ___,
2 tabs on ___, 1 tab on ___, and STOP on ___.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Asthma exacerbation
.
SECONDARY
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were feeling short of
breath and not oxygenating well. Your chest x-ray and symptoms
suggested you were likely suffering from a viral infection or
atypical bacterial infection that led to an exacerbation of your
underlying asthma. We treated you with steroids and nebulizer
treatments and your symptoms improved.
.
The following medications were changed or added during this
stay:
START azithromycin 250mg daily for four days to end on ___
START prednisone for the next five days. Take 50mg today, then
decrease by 10mg (1 tablet) each day until you stop on ___
.
Please take all your other medications as previously prescribed.
Followup Instructions:
___
|
10755736-DS-21
| 10,755,736 | 26,138,855 |
DS
| 21 |
2174-10-14 00:00:00
|
2174-10-16 13:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PCP: ___ MD
CC: ___
MICU CC: acute hypoxemic respiratory failure
Major Surgical or Invasive Procedure:
___ Port-a-cath removal by ___
___ PICC line placement on right arm
___ Swan-Ganz catheter placement
___ Elective intubation and bronchoscopy by ___ Consult
team
___ Bronchoscopy by Interventional Pulmonary
History of Present Illness:
___ YOM with PMH of Stage 4B rectal cancer (C5D12 FOLFOX), Type 1
diabetes c/b diabetic nephropathy s/p kidney/pancreas
transplant, chronic abdominal pain on opiate therapy, recent
admissions for pain crisis (___), ___ (___)
who presents with weakness, confusion. Patient initially
presented to ___ with reports of nausea,
vomiting and decreased PO intake x 1 week. Labs there were
notable for WBC 20.7, Hgb 8.9, Cr 1.1, UA neg nitrite/leuko.
CXR reported to show a pneumonia. Patient transferred to ___
for further management.
In ED, initial VS 101.6, 95, 122/74, 14, 97% Nasal Cannula.
Labs were notable for WBC 19.5 (N84%), Hgb 8.9, Plt 229, K 3.5,
Cr 1, Mg 1. He was given IV cefepime, IV vancomycin, IV normal
saline x 1L, Oxycontin 40mg x 1, IV ketorolac 30mg x 1, PO
Tylenol ___ x1. He was admitted to medicine for further
management. VS prior to transfer were 100.3, 106, 125/56, 18,
97% Nasal Cannula.
On arrival to the floor, he reported feeling tired with poor
appetite x 1 week. He was otherwise a poor historian and unable
to tell much about the prior week. Additional corroborative
evidence from his mother ___ ___ reports
patient has not been eating, frequently lying about
eating/drinking; also sleeping most of the day; has been
managing his own medications, but she is not sure of his
compliance, suspects he is missing many doses. Per her, he
constantly minimizes all symptoms. Given increasing lethargy,
poor PO intake, she became worried and called ambulance.
Full 10 point review of systems positive where noted, otherwise
negative per the best of my interview.
Past Medical History:
PAST MEDICAL HISTORY (per patient and OMR)
- Stage 4B rectal cancer
- Type I diabetes mellitus
- Diabetic nephropathy c/b ESRD (followed by Dr. ___ s/p L
radiocephalic AVF ___, s/p simultaneous kidney & pancreas
transplant in ___
- HTN
- HLD
- Diabetic retinopathy (s/p surgery ___
- Chronic idiopathic diarrhea
PAST ONCOLOGIC HISTORY (per patient and OMR)
Rectal cancer stage IV KRAS w/t MSI stable
- ___ Increasing fatigue after work.
- ___ Developed new abdominal pain, fevers and weight loss
- ___ Presented to the ED with these symptoms. CT torso
showed a dominant large heterogeneous mass in the left lobe of
the liver with associated satellite lesions. Concerning for
either metastatic disease (with possible rectal source) or
primary malignancy such as cholangiocarcinoma or
lymphoproliferative disease. Associated with the hepatic lesion
is moderate IHBD dilation, likely due to obstruction. Hyperemia
around the dilated biliary ducts in the left lobe of the liver
could represent cholangitis, especially given the history of
fever. Occlusion of the left portal vein by the hepatic lesion.
Numerous pulmonary nodules, which are likely metastatic. Mild
wall thickening at the rectosigmoid junction, which is of
uncertain clinical significance, though may represent a mass,
and the primary malignancy. The finding appears suspicious
including possible extramural extension.
- ___ Colonoscopy showed a fungating and ulcerated 8 cm
mass of malignant appearance in the mid rectum. Biopsy showed
microinvasive adenocarcinoma. Liver biopsy that same day showed
metastatic adenocarcinoma.
- ___ C1D1 FOLFOX6
- ___ Held C1D15 for diarrhea, mild ___.
- ___ C1D15 FOLFOX6 given at full dose - diarrhea
resolved with dietary changes
- ___ C2D1 dose held for anemia with Hb 6.9 of unclear
cause, transfused 2 units pRBC, guaiac negative, hemolytic w/u
negative.
- ___ C2D1 modified FOLFOX (ci5Fu 1800 mg/m2)
- ___ CT torso showed stable pulmonary nodules and
interval decrease in size of the largest liver lesion replacing
much of the left lobe of the liver. Mild interval improvement
in left IHBD dilation. Persistent occlusion of the left portal
vein. Improved wall thickening at the rectosigmoid junction.
- ___ C3D1 modified FOLFOX (ci5Fu 1800 mg/m2)
- ___ Presented with worsening diarrhea. Admitted. Some
evidence of subacute pancreatic rejection. Improved clinically.
- ___ C3D1 FOLFOX (oxali 65 mg/m2) dose reduced for CKD
- ___ C4D1 FOLFOX (oxali 65 mg/m2)
- ___ C4D15 FOLFOX held due to ___, hypotension,
hypomagnesemia
- ___ C5D1 FOLFOX
Social History:
___
Family History:
(per patient and OMR)
No history of cancer. Mother has type ___ diabetes. His father
passed away from liver failure at the age of ___ years. This was
thought to be secondary to hepatitis. Sister died due to
complications of drug use.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 97.6, 53, 119/58, 78, 16, 100%2L
Gen - supine in bed, sleeping, awaking to voice;
comfortable-appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender; transplant site nontender; well-healed
scars; NABS
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3 (full name, ___, BID), moving all
extremities; able to do MOYB
Psych - appropriate
DISCHARGE EXAM
Vitals- 97.5, 125/72, 75, 18, 94% on 2L
Wt: 57.5->57.6->56.3->57.4-> 57.3
General- Sitting edge of bed, alert and NAD.
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- CTAB posterior
CV- RRR, ___ holosystolic murmur best heard over the axilla.
Abdomen- soft, mild tenderness around umbilicus, ND, no rebound
tenderness or guarding
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- A&Ox3, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 07:00AM WBC-19.5*# RBC-3.40* HGB-8.9* HCT-28.3*
MCV-83 MCH-26.2 MCHC-31.4* RDW-19.9* RDWSD-55.8*
___ 07:00AM NEUTS-84* BANDS-5 LYMPHS-4* MONOS-6 EOS-0
BASOS-1 ___ MYELOS-0 AbsNeut-17.36* AbsLymp-0.78*
AbsMono-1.17* AbsEos-0.00* AbsBaso-0.20*
___ 07:00AM GLUCOSE-108* UREA N-21* CREAT-1.0 SODIUM-137
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
___ 07:08AM LACTATE-1.2
___ 09:40PM URINE GRANULAR-9* CELL-4*
___ 09:40PM URINE RBC-8* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
DISCHARGE LABS:
___ 07:30AM BLOOD Hgb-7.9* Hct-25.6*
___ 06:20AM BLOOD Glucose-83 UreaN-47* Creat-0.8 Na-134
K-3.4 Cl-96 HCO3-27 AnGap-14
___ 06:20AM BLOOD LD(LDH)-576* TotBili-0.4
___ 06:17AM BLOOD Lipase-55
___ 06:20AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7
IMAGING
====================
___ PANOREX - READ PENDING
___ CARDIAC CT
IMPRESSION:
Suboptimal examination of the mitral valve, due to limited
opacification of the left heart due to poor cardiac function and
significant patient arrhythmia despite intravenous and oral
beta-blockers. Repeat imaging should be considered
Interval increase in size and number of numerous pulmonary
nodules, morphologic characteristics most suggestive of
progressive metastatic disease.
The differential includes atypical infection less likely, given
imaging appearance.
Further interval improvement of the peribronchial consolidation
can be improving organizing pneumonia.
Mild pulmonary edema.
Small bilateral pleural effusions, substantially decreased since
the prior.
Sub optimal assessment of the liver, however the degree of
metastatic infiltration and biliary ductal dilatation appears to
progressed since ___.
___ PCXR
IMPRESSION:
In comparison to previous radiograph of ___,
multifocal bilateral pulmonary opacities are relatively similar
to the prior exam except for worsening in the left retrocardiac
region. No other relevant change.
___ PCXR
IMPRESSION:
Comparison to ___. Mild improvement of the
pre-existing pulmonary edema. The widespread bilateral
parenchymal opacities, however, still clearly visible. Mild
cardiomegaly persists. No pleural effusions
___ PCXR
IMPRESSION:
Compared to prior chest radiographs since ___, most
recently ___.
It is hard to tell whether there is some clearing at the
periphery of the severe cicatricial consolidative pulmonary
abnormality or whether the patient is developing subpleural
pneumatoceles, for example in the left upper lobe laterally.
Heart size is normal. No pleural effusion.
Right PIC line ends in the low SVC.
___ PCXR
IMPRESSION:
Compared to prior chest radiographs, ___ through
___ at 10:01.
No change since earlier in the day in severe residual
cicatricial pulmonary infiltration. No pneumothorax or
appreciable pleural effusion. Borderline cardiomegaly
unchanged. Gaseous distention of the stomach has worsened.
Right PIC line ends in the right atrium, approximately 4 cm
below the estimated location of the superior cavoatrial
junction.
___ PCXR
IMPRESSION:
Compared to prior chest radiographs ___ through ___.
Previous hyperinflation has improved following tracheal
extubation. Severe infiltrative pulmonary abnormality,
including accelerated scarring scarring and pneumatoceles,
persists.
Heart size is normal. Pleural effusion small if any. No
pneumothorax.
Right PIC line ends close to the superior cavoatrial junction.
___ PCXR
IMPRESSION:
As compared to ___ chest radiograph, endotracheal
tube has been advanced, now terminating 5.1 cm above the carina.
Allowing for differences in technique, there has otherwise not
been a substantial change in the appearance of the chest.
___ TTE
IMPRESSION:
Severe mitral regurgitation with thickened leaflets, but no
discrete vegetation. Mild symmetric left ventricular hypertrophy
with preserved regional and global biventricular systolic
function. Moderate pulmonary artery systolic hypertension.
Aortic valve sclerosis.
Compared with the prior study (images reviewed) of ___, the
severity of mitral regurgitation is slightly greate and the
estimated PA sytolic pressure is much higher. The mitral leaflet
morphology is similar.
The change in mitral regurgitation and PASP could be partially
attributable to the higher systolic pressure as was present on
___.
___ PCXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lower lungs excluded from the examination.
ET tube tip at the thoracic inlet, approximately 7 cm from the
carina, could be advanced 2 cm for more secure positioning. No
pneumothorax. Right PIC line ends in the mid SVC. Esophageal
drainage tube passes into the stomach and out of view.
Heavy calcification in the neck is probably in the left internal
carotid artery.
___ PCXR
IMPRESSION:
There is no pneumothorax, pleural effusion, or appreciable
pulmonary hemorrhage if any. Right lung volume is larger now
and aeration has improved at the left lung base, compared to
earlier today. These developments could be due to either
pneumatocele formation, air trapping, or increase positive
pressure ventilation, perhaps even improvement in the diffuse
pulmonary abnormality.
Heart size is normal.
ET tube and esophageal drainage tube are in standard placements.
___ PCXR
IMPRESSION:
ET tube tip is 6.5 cm above the carinal. NG tube tip is in the
stomach. Heart size and mediastinum are stable. Widespread
parenchymal consolidations are present, extensive, unchanged in
the prior study.
___ Bronchoscopy (by IP)
Findings:
No endobronchial lesions
___ Bilateral Lower Extremity Ultrasound
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Note is made of sluggish flow identified within the left
common femoral vein and left popliteal vein.
___ PCXR
IMPRESSION:
Extensive bilateral consolidations larger on the right lung are
unchanged. Cardiac size is normal. Lines and tubes are in
unchanged standard position. There is no pneumothorax
___ CT CHEST
IMPRESSION:
Improvement of pre-existing consolidations that giving the a
distribution are unlikely to represent pulmonary edema but small
likely to represent organizing pneumonia or ARDS. Left upper
lobe more discrete pulmonary nodule, series 4, image 98 might
potentially represent partial resolution since not seen on the
previous study.
New bibasal opacity, potentially representing infection or
aspiration as described.
Unchanged bilateral moderate pleural effusions.
___ PCXR
IMPRESSION:
There no prior chest radiographs ___ through ___.
There has been no change over several days in the persistent
severe symmetric perihilar infiltrative and consolidative
pulmonary abnormality. Heart is normal size. There is no
pleural effusion or pneumothorax.
Lines and tubes in standard placements.
___ PCXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
___-___ catheter is been removed. Right jugular introducer
remains, tip at the thoracic inlet. Right PIC line ends close
to the superior cavoatrial junction. Esophageal drainage tube
ends in the mid stomach. ET tube in standard placement.
Recent, severe infiltrative pulmonary abnormality not changed
appreciably since ___. Heart size normal. No
pneumothorax or appreciable pleural effusion.
___ Portable KUB
IMPRESSION:
1. No evidence of obstruction.
2. Severe calcified atherosclerotic disease.
___ PCXR
IMPRESSION:
Right ___ catheter tip is in the left main pulmonary
artery. Extensive bilateral lung consolidations right greater
than left are unchanged. There is no pneumothorax or effusion.
Cardiomediastinal contours are unchanged. Retrocardiac
atelectasis has minimally increased. ET tube is in standard
position. NG tube tip is out of view below the diaphragm.
Right PICC tip is in the cavoatrial junction.
___ PCXR
IMPRESSION:
After diuresis extensive bilateral opacities improved. Still
there are remain dense peribronchial bilateral consolidations
larger in the right lung. Lines and tubes are in unchanged
standard position. There is no pneumothorax or enlarging
pleural effusions
___ PCXR
IMPRESSION:
After diuresis there has been mild improvement of extensive
bilateral peribronchial consolidations right greater than left.
There is a small left pleural effusion. No other interval
change from prior study.
___ PCXR
IMPRESSION:
1. Bilateral opacities are progressed since ___.
2. Lucency at the tip of the ___ catheter is suspicious
for balloon dilation.
___ TEE
IMPRESSION:
Small vegetation originating from posterior mitral annular
calcification with possible leaflet perforation and
moderate-severe mitral regurgitation. Preserved biventricular
systolic function.
___ PCXR
IMPRESSION:
OG tube is seen in the stomach. Otherwise, little interval
change since earlier same day radiograph.
___ PCXR
IMPRESSION:
In comparison with the study of ___, there has been
placement of an endotracheal tube with its tip approximately 4
cm above the carina.
Nasogastric tube extends to the stomach, with the side port
close to the esophagogastric junction. It could be pushed
forward about 5 cm for more optimal positioning. The ___
catheter has been pulled back so that the tip is in the most
proximal portion of the right pulmonary artery.
Diffuse bilateral pulmonary opacifications persist, appearing
somewhat more prominent in the right lower and left upper zones.
___ Bilateral Lower Extremity Ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ CT ABD/PELVIS
IMPRESSION:
1. Extensive hepatic metastatic disease, similar to prior.
Persistent left greater than right intrahepatic biliary ductal
dilatation.
2. Stable pancreatic and renal transplants.
___ CT CHEST
IMPRESSION:
Substantial progression of the peribronchial infiltration with
slight upper lobe and central predominance, distortion of the
lung and bronchiectasis, can be worsening and/or new atypical
infection including subacute PJP, alternatively scarring due to
ARDS.
Bilateral pleural effusions have slightly decreased and prior
pulmonary edema has resolved.
___ PCXR
IMPRESSION:
In comparison with the study of ___, there little change
in the diffuse bilateral pulmonary opacifications. ___
catheter tip remains in the right pulmonary artery.
___ PCXR
IMPRESSION:
In comparison with the earlier study of this date, the ___
catheter is been pulled back so that it is with in the
mediastinum. Diffuse bilateral pulmonary opacifications are
essentially unchanged.
___ TTE
IMPRESSION: No PFO seen.
___ PCXR
IMPRESSION:
In comparison with the study of ___, there is little
change in the severe and symmetric bilateral opacifications that
shows some improvement since the study of ___. Again,
this could reflect severe pulmonary edema, though in the
appropriate setting widespread pneumonia, pulmonary hemorrhage,
or even ARDS would have to be considered. The right IJ ___
catheter tip again is in the right pulmonary artery,
slightly beyond the mediastinal confines.
___ AVF U/S
IMPRESSION:
Patent left upper extremity radiocephalic AV fistula with access
volume flow means as measured above
___ PCXR
IMPRESSION:
Compared to prior chest radiographs ___ through ___. Severe symmetric, predominantly perihilar infiltrative
pulmonary abnormality improving slowly. No pneumothorax. Small
pleural effusions unchanged. Heart size normal. ___
catheter ends in the right pulmonary artery.
___ PCXR
IMPRESSION:
Right subclavian PICC line and right internal jugular ___
catheter unchanged in position. There has been no interval
change in the diffuse bilateral parenchymal process which could
represent severe pulmonary edema, although pulmonary hemorrhage
or a diffuse infectious process could have a similar appearance.
Clinical correlation is recommended. There is likely a small
layering left effusion. Given the diffuse airspace process,
assessment of cardiac and mediastinal contours is difficult. No
obvious pneumothorax.
___ PCXR
IMPRESSION:
In comparison to ___ chest radiograph, when
consideration is given to differences in technique, there has
not been appreciable change in the appearance of the chest.
___ PCXR
IMPRESSION:
Clear to prior chest radiographs ___ through ___
at 07:37.
New right transjugular ___ catheter ends in the right
pulmonary artery.
No pneumothorax pleural effusion or mediastinal widening.
Severe global infiltrative pulmonary abnormality, moderate
cardiomegaly common small left pleural effusion are stable. No
pneumothorax. Right PIC line ends close to the superior
cavoatrial junction.
___ Pancreas U/S
IMPRESSION:
Limited exam of the right lower quadrant pancreas transplant,
with poor assessment of the pancreas transplant vasculature
secondary to limited visibility related to surrounding bowel
gas. The pancreas transplant is well visualized on prior CT on
___, and is unchanged compared priors. If there is
a change in clinical status and imaging is needed, repeat CTA
would likely be most helpful although pancreas transplant
vasculature size is noted to appear diminutive in size.
___ Renal Transplant U/S
IMPRESSION:
Normal renal transplant ultrasound with mildly elevated
resistive indices. No hydronephrosis.
___ PCXR
IMPRESSION:
Allowing for differences in technique and projection, there has
been little change the appearance of the chest since the recent
radiograph of 1 day earlier with the exception of apparent
slight worsening of extent of diffuse airspace disease in the
right mid and lower lung.
___ PCXR
IMPRESSION:
Comparison ___. Minimal improvement of the
pre-existing extensive bilateral parenchymal opacities. No
pleural effusions. Unchanged borderline size of the cardiac
silhouette. Right PICC line is in unchanged position.
___ TTE
IMPRESSION:
Irregular calcified mass on the posteromedial aspect of the
mitral valve annulus which may represent vegetation, thrombus,
or exophytic extension of mitral annular calcification into the
left atrial cavity. Liver parenchyma appears nodular and may be
due to cirrhosis or metastatic rectal cancer.
If clinically indicated, a TEE may better define the
characteristics of the mass.
___ PCXR
IMPRESSION:
1. The tip of the right PICC line is seen in the low SVC.
2. Unchanged diffuse multifocal opacities and small bilateral
pleural effusions since earlier same day chest radiograph.
___ PCXR
IMPRESSION:
Slight improvement of right upper lobe opacity, remaining
multifocal opacities have not substantially changed, likely a
combination of multifocal pneumonia and edema.
___ PCXR
IMPRESSION:
Worsening confluent bilateral airspace opacities, which may be
due to progressive multifocal pneumonia with or without
superimposed secondary process such as noncardiogenic pulmonary
edema, aspiration or hemorrhage.
___ TTE
IMPRESSION: no vegetations seen
___ Bilateral ___ ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Left greater than right leg soft tissue edema.
___ CT CHEST
IMPRESSION:
New multifocal pneumonia
New bilateral pleural effusion
Known metastatic hepatic lesions are partially imaged
___ PA/LAT CXR
IMPRESSION:
Multi focal opacification in the left upper lobe, right middle,
and right upper lobe are consistent with multi focal pneumonia.
___ ___ Port removal
IMPRESSION:
Successful removal of a left upper chest port.
___ CT ABD/PELVIS
IMPRESSION:
1. Continued improvement in extensive hepatic metastatic disease
with persistent left greater than right intrahepatic biliary
duct dilatation. No new metastases identified.
2. Persistent occlusion of left portal vein.
3. Slight decrease in size of rectosigmoid junction mural
thickening/ mass.
4. Stable right lower quadrant pancreatic transplant and left
iliac fossa kidney transplant.
5. Please refer to separate CT chest for additional findings
regarding the thorax.
___ CT CHEST
IMPRESSION:
1. Multiple stable pulmonary nodules, unchanged since ___ and consistent with metastatic disease.
2. Please refer to separate report on CT abdomen/pelvis for
additional findings.
___ TTE
IMPRESSION:
Posterior mitral annular mass likely represents MAC but cannot
exclude vegetation or other mass. Moderate to severe MR.
___ pulmonary hypertension.
___ PA/LAT CXR
IMPRESSION:
Compare to prior chest radiographs since ___, most
recently ___.
Lung volumes have increased substantially, now hyperinflated
suggesting emphysema. Previous pulmonary edema has cleared.
Heart size is normal. There is no focal pulmonary abnormality.
Nipple shadow should not be mistaken for lung nodules, but CT
scanning would be required to detect or assess pulmonary
metastases.
Central venous infusion catheter ends in the low SVC. Pleural
effusion minimal if any. No pneumothorax.
MICROBIOLOGY
====================
___ Blood culture: POSITIVE for MSSA
___ Urine culture: No growth (FINAL)
___ Blood culture x 2 sets: No growth (FINAL)
___ Blood culture x 2 sets: No growth (FINAL)
___ Blood culture x 2 sets: No growth (FINAL)
___ Blood culture x 2 sets: No growth (FINAL)
___ Blood culture x 2 sets: No growth (FINAL)
___ Port tip culture: No growth (FINAL)
___ MRSA screen: NEGATIVE
___ Sputum culture: Sparse growth of commensal respiratory
flora
___ Blood culture x 2 sets: No growth (FINAL)
___ Blood culture: No growth (FINAL)
___ Sputum culture: Sparse growth of commensal respiratory
flora
___ Urine culture: No growth
___ CMV viral load: Not detected
___ Urine legionella Ag: Not detected
___ MRSA screen: NEGATIVE
___ BAL culture: Negative CMV Ag, No CMV, mycobacteria
(prelim), Legionella, fungus, Nocardia or bacteria. Negative
AFB smear. Negative PJP stain.
___ Viral screen and culture: Negative influenza,
parainfluenza, adenovirus and RSV
___ MRSA screen: NEGATIVE
___ BAL: No bacterial growth. + Yeast growth. AFB smear
NEGATIVE. No mycobacteria (preliminary, final PENDING).
___ Tissue (lung) culture: No bacteria or fungal growth.
AFB smear NEGATIVE. No mycobacteria (preliminary, final
PENDING).
___ Sputum culture: Rare commensal growth. Moderate yeast
growth.
___ C. diff: NEGATIVE
___ Urine culture: No growth (FINAL)
___ C. diff: NEGATIVE
PATHOLOGY
====================
___ BAL CYTOLOGY
DIAGNOSIS:
BRONCHIAL LAVAGE:
NEGATIVE FOR MALIGNANT CELLS.
Reactive bronchial epithelial cells, pulmonary macrophages,
inflammatory cells.
Special stain on cell block preparation for fungi (GMS) is
negative for organisms. Also see
concurrent microbiological studies (lab ___.
___ Right Lower Lobe Biopsy
- Scant fragments of alveolated lung parenchyma with organizing
pneumonia.
- Fragment of airway tissue and detached bronchial epithelial
cells with no specific pathologic changes.
- Gram, GMS, and ___ (modified AFB) stains are negative for
microorganisms.
- No malignancy, granulomas, viral cytopathic effects, or
increased numbers of eosinophils are identified.
Note: See associated microbiologic culture results ___
___ ___ for further characterization. Clinical and
radiologic correlation is advised to ensure the specimen is
representative of the targeted lesion.
Brief Hospital Course:
___ YOM with a PMH of Stage 4B rectal cancer (C5D12 FOLFOX), type
1 DM c/b diabetic nephropathy s/p kidney/pancreas transplant,
chronic abdominal pain on opiate therapy, admitted ___ w
sepsis, pneumonia and MSSA bacteremia with mitral valve
infectious endocarditis, also found to have cryptogenic
organizing pneumonia.
ACTIVE ISSUES:
====================
# Acute hypoxemic respiratory failure
# Acute heart failure (diastolic) / severe mitral regurgitation
# Cryptogenic organizing pneumonia (COP)
Likely a combination of possible PNA and pulmonary edema from
severe valvular endocarditis of the MV. Alveolar hemorrhage was
initially a concern given ongoing scant hemoptysis, but this is
thought to be mostly pulmonary edema/pneumonia. Given severity
of pulmonary infiltrates and history of immune suppression, PCP
PNA was considered but thought to be unlikely given negative
beta-glucan and improvement with diuresis. Patient was treated
for heart failure and HCAP pneumonia as described below. In the
CCU, the patient underwent aggressive diuresis, with Lasix drip
and bolus, and was negative 16 liters by ___. However, despite
significant fluid reduction, and a pulmonary wedge of 19, AA
gradient remained notably to be elevated. Given concern for
cryptogenic pneumonia, patient was transferred to MICU service
with plan for bronchoscopy and further management. The patient
was intubated with the intention to obtain biopsy, however due
to his significant pressure requirement this was deferred
briefly. He had initial BAL on ___, followed by repeat
bronchoscopy on ___ by Interventional Pulmonary with biopsy.
Biopsy confirmed COP and he was started on systemic steroids,
and was started on empiric antifungal and PCP ___ 6 days
prior to the initiation of steroids. Steroids were continued as
the patient's respiratory status improved. The patient was
extubated on ___. He was changed from IV to PO steroids on
___ and is now takeing 60mg prednisone daily. Plan is for
slow taper and follow up with Pulmonary Clinic. His diuretic was
changed to PO torsemide and titrated to 60mg daily. On
atovaquone for PCP ___.
# Infective MSSA endocarditis with severe MR: Patient fulfilled
Duke's criteria [organism MSSA, new/worsening valvular
problem(4+MR)]. Treated initially with cefazolin initially but
broadened to vancomycin and cefepime for 8 day treatment of HCAP
pneumonia as well. Cultures negative since ___. On ___ was
transitioned to cefazolin for narrowed coverage. Most likely
source was port vs excoriations/sores vs pneumonia. Port was
removed by ___ and was culture negative. Initial TTE had shown
mitral mass 1.2cm, likely mitral annular calcification, and
repeat TTE subsequently excluded mass. While TEE was the desired
study for further evaluation, it had to be postponed due the
patients inability to lie flat. Patient was aggressively
diuresed, with Lasix drip and bolus, and was negative 16 liters
with a wedge of 19. However, despite significant fluid
reduction, AA gradient remained elevated. A CT chest indicated
pulmonary edema improved, but was notable for peribronchial
consolidation with slight upper lobe and central predominance
can be worsening and/or new atypical infection including
subacute PJP or less likely ARDS. It was determined the
patient's MR was optimized and that a TEE would be performed.
TEE on ___ showed slightly increased mitral regurgitation
from prior. Patient will complete a 6 week course of IV
antibiotics (cefazolin) via ___ as above and may in the future
be re-evaluated for mitral clip by Interventional Cardiology.
He was followed by the ID consult team during hospitalization,
and they will continue to follow him in the ___ clinic (for
outpatient IV antibiotics). He obtained a CT Cardiac and
Panorex films per request of the Interventional Cardiology team
in anticipation of possible transcatheter MV repair in the
future.
# Multifocal Pneumonia: Patient had recurrent ICU transfers
during admission. CT on initial admission on ___ showed
multifocal pneumonia, not thought to be from septic pulmonary
emboli. He was transitioned from cefazolin to
vancomycin/cefepime for HCAP coverage. Given severity of
pulmonary infiltrates and history of immune suppression, PCP PNA
was considered but thought to be unlikely given negative
beta-glucan and initial improvement with diuresis. However, AA
gradient remained significantly elevated and O2 requirements
stably high. CT Chest showed peribronchial consolidation with
slight upper lobe and central predominance concerning for a
worsening infection. A Bronch was performed ___ and showed
bloody aspirates with cytology negative for malignant cells. A
lung biopsy was obtained prior to transfer from the MICU with
repeat bronch on ___ by IP, which showed:
- Scant fragments of alveolated lung parenchyma with organizing
pneumonia.
- Fragment of airway tissue and detached bronchial epithelial
cells with no specific pathologic
changes.
- Gram, GMS, and ___ (modified AFB) stains are negative for
microorganisms.
- No malignancy, granulomas, viral cytopathic effects, or
increased numbers of eosinophils are
identified.
# Anemia: Likely multifactorial in setting of sepsis, rectal
cancer with slow bleeding from tumor and new hemolysis (hapto
<5, was normal on ___. Per Oncologist Dr. ___
___ may be from tacrolimus or cancer-induced however
process appears to be more acute. Hgb was stable during
admission.
CHRONIC ISSUES:
# Stage IV Rectal Cancer / Chronic Abdominal Pain - Metastasis
to abdomen. CT torso shows ongoing response to FOLFOX. He was
due for cycle 5 day 15 dose on ___ but currently on hold due
to MSSA bacteremia and suspected port infection.
- followup with Dr. ___ discharge for discussion of
timing of resuming FOLFOX.
- per d/w Dr. ___ not be able to tolerate the volume
of FOLFOX given his severe MR, so chemotherapy will have to be
deferred till MV can be intervened on by Interventional
Cardiology
# Severe Protein Calorie Malnutrition - Albumin 2.5; suspect
related to cancer and recent poor PO intake (as reported by
patient's mom).
# Hypertension / CAD: blood pressure medications held during
admission in setting of sepsis and decompensated heart failure.
He was continued on aspirin.
- restart home meds (as outpatient)
# s/p renal-kdiney transplant: Continue tacrolimus (with goal
levels ___, prednisone 5mg daily.
# pancreatic insufficiency: Continued home Creon.
# Chronic Diarrhea: Continued home cholestyramine. Was C. diff
NEGATIVE.
TRANSITIONAL ISSUES:
==========================
#Patient has cataracts which are greatly affecting his eye sight
and quality of life, consider cataract surgery in the future,
should follow-up BID Ophthalmology, Dr. ___,
tentative booking for ___
#Patient will need follow up with Interventional Cardiology for
when medically stable for evaluation. They are working to
schedule an appointment but if ___ do not hear from them please
contact for appointments: ___
#Patient has severe Protein Calorie Malnutrition please continue
to monitor PO intake and supplement as needed
#Torsemide changed to 60mg PO on ___, please follow
electrolytes and adjust as needed to maintain net even
#Please check Cr in ___ days as patient as patient has kidney
transplant and was exposed to contrast on ___ for cardiac CT.
Fax to Dr. ___ at ___.
#On ___ Patient had a rising leukocytosis which increased
from 16.8 to 19.5 however this was thought to be due to steroid
use as patient is afebrile and asymptomatic. Given his immune
suppression please continue to monitor for signs of infection.
#Please monitor FSBG and adjust insulin PRN
#Patient currently on prednisone PO 60mg, recommendations for
taper is decrease to 40 mg PO on ___ and then after two weeks
decrease to 30mg PO daily. If questions or concerns please
contact pulmonologist: ___ ___
#Patient needs tacrolimus level checked in 3 days, please send
to transplant coordinator: ___
___ and fax to Dr. ___ at
___: ___
#Antibiotics: needs to finish 6 week course of antibiotics with
CefazoLIN 2 g IV Q8H, last day ___
#Weight on discharge: 57.3 kilos
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
MONITORING: WEEKLY: CBC with diff, BUN, Cr, LFT's
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.
# Communication: ___ (mother, HCP) ___
# Code: Full confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Cholestyramine 4 gm PO BID
5. Creon 12 3 CAP PO TID W/MEALS
6. Creon 12 1 CAP PO WITH SNACKS
7. LOPERamide 4 mg PO BID diarrhea w/o fever
8. nystatin 100,000 unit/mL oral TID
9. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q4H:PRN diarrhea
10. OxycoDONE (Immediate Release) 30 mg PO Q6H:PRN pain
11. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
12. PredniSONE 5 mg PO DAILY
13. Prochlorperazine 10 mg PO Q6H:PRN mild nausea
14. Tacrolimus 5 mg PO Q12H
15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
16. nalOXone 1 mg/mL intranasal PRN opioid overdose
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cholestyramine 4 gm PO BID
3. Creon 12 3 CAP PO TID W/MEALS
4. nystatin 100,000 unit/mL oral TID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every 8
hours Disp #*10 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
10. Atovaquone Suspension 1500 mg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. CefazoLIN 2 g IV Q8H
13. HydrALAzine 100 mg PO Q8H
14. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth every 3 hours as
needed for pain Disp #*15 Tablet Refills:*0
15. PredniSONE 60 mg PO DAILY
16. Tacrolimus 3 mg PO Q12H
17. Allopurinol ___ mg PO DAILY
18. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
20. Isosorbide Dinitrate 80 mg PO TID
21. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
22. Lorazepam 0.5-1 mg PO DAILY: PRN nausea/anxiety
23. Metoprolol Tartrate 25 mg PO Q6H
24. Multivitamins 1 TAB PO DAILY
25. Ondansetron 4 mg IV Q8H:PRN nausea
26. Pantoprazole 40 mg PO Q12H
27. Sodium Chloride Nasal ___ SPRY NU QID:PRN Nasal irritation
28. Vitamin D 400 UNIT PO DAILY
29. Creon 12 1 CAP PO WITH SNACKS
30. Torsemide 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
1. Infective MSSA endocarditis
2. Severe Mitral regurgitation
3. Acute hypoxic respiratory failure
4. Organizing PNA
Secondary:
1. DM
2. Stage 4B Rectal Carcinoma
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. ___ were admitted to ___ on ___. ___ had a bad infection
in your blood stream which caused your heart valves to
malfunction, this in combination with a pneumonia made it
difficult for ___ to breath. We removed fluid with diuretic
medication and treated your infection with antibiotics. We
treated your pneumonia with antibiotics and steroids and your
symptoms improved. ___ are being discharged to rehab to get
stronger and finish your antibiotics. When ___ are done ___ will
follow up with your cancer and lung doctors. ___ may eventually
have further imaging and a procedure to improve your heart valve
function. It was a pleasure taking part in your care. Please
take all of your medications as prescribed and attend all of
your follow up appointments.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10755736-DS-22
| 10,755,736 | 26,615,766 |
DS
| 22 |
2174-11-01 00:00:00
|
2174-11-01 18:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with stage IV rectal cancer, s/p pancreas/kidney transplant
with a two month long hospital admission for MSSA bacteremia,
moderate-severe MR with vegetation, representing from his SNF
for hypoxic respiratory failure.
His prior ___ hospital stay was complicated by multiple
ICU transfers for persistent hypoxic respiratory failure. He was
initially treated in the CCU, on a Lasix drip, with initial
improvement. He was also treated for HCAP and continued on
cefazolin for treatment of his MSSA bacteremia and endocarditis.
His persistent respiratory failure and CXR with bilateral hazy
opacities was worked up extensively on his recent admission:
- Cardiac CT (done for further evaluation for MV replacement)
showed peribronchilar consolidation.
- Biopsy significant for crytogenic organizing pneumonia,
without organisms.
- PCP was considered given his history of immunosuppression on
tacrolimus (for his kidney/pancreas transplant), however,
thought to be less likely given a negative BD glucan.
- He was ultimately initiated on prednisone 60 mg daily, with a
plan for a prolonged course for COP. He was discharged on
atovaquone for PCP ___.
Per the patient's report, he did not do well in the two days
following his discharge. He felt progressively short of breath,
with worsening shortness of breath the day of admission. He
endorsed a new gurgling wet cough. He denies fevers or chills.
At the ___, the patient was thought to have worsening fluid
overload. 250 mg of furosemide was hung and subsequently
disappeared, and it is unclear whether he received the full 250
mg. Documentation from the ___ suggests he may have received
anywhere between ___ mg of furosemide. He was subsequently
transferred to ___ for hypoxemia.
In the ED, initial vitals: 98.8 93 106/57 22 96% RA
He received 5 units of insulin and 40 meQ of potassium.
CXR with increase in bilateral pulmonary opacities may be due to
increased pulmonary edema and/or infection overlying chronic
pulmonary opacities
Labs notable for a leukocytosis of 20.9 (up from 14), H/H of
8.2/26.7. BMP significant for Na 122, K 3.1, Cl 89, Bicarb 25,
BUN/Cr 54, 1.0, glucose of 580. ProBNP 3347. Initial lactate of
1.7.
On transfer, vitals were: 97.9 91 104/59 22 95% Non-Rebreather
On arrival to the MICU, the patient reports feeling well. He
states that he was not treated well at the other facility. He
reports feeling progressively more short of breath over the
last few days, and more acutely so this morning. He endorses a
new wet cough, without sputum, which began this morning. He
otherwise denies fevers or chills. He endorses abdominal pain
and diarrhea which are chronic and unchanged from his baseline.
He denies chest pain.
Per his family reports, the diet he was given at the SNF was
high in sodium. He also reports worsening lower extremity edema.
Past Medical History:
PAST MEDICAL HISTORY (per patient and OMR)
- Stage 4B rectal cancer
- Type I diabetes mellitus
- Diabetic nephropathy c/b ESRD (resolved s/p SPK ___, followed
by Dr. ___ s/p L radiocephalic AVF ___ s/p simultaneous
kidney & pancreas transplant in ___
- HTN
- HLD
- Diabetic retinopathy (s/p surgery ___
- Chronic idiopathic diarrhea
PAST ONCOLOGIC HISTORY (per patient and OMR)
Rectal cancer stage IV KRAS w/t MSI stable
- ___ Increasing fatigue after work.
- ___ Developed new abdominal pain and subsequently fevers.
Also began to lose weight.
- ___ Presented to the ED with these symptoms. CT torso
showed a dominant large heterogeneous mass in the left lobe of
the liver with associated satellite lesions. This is concerning
for either metastatic disease (with possible rectal source) or
primary malignancy such as cholangiocarcinoma or
lymphoproliferative disease. Associated with the hepatic lesion
is moderate intrahepatic biliary duct dilation, likely due to
obstruction. Hyperemia around the dilated biliary ducts in the
left lobe of the liver could represent cholangitis, especially
given the history of fever. Occlusion of the left portal vein by
the hepatic lesion. Numerous pulmonary nodules, which are
likely
metastatic. Mild wall thickening at the rectosigmoid junction,
which is of uncertain clinical significance, though may
represent
a mass, and the primary malignancy. The finding appears
suspicious including possible extramural extension.
- ___ Colonoscopy showed a fungating and ulcerated 8 cm
mass of malignant appearance was found in the mid rectum. Biopsy
showed microinvasive adenocarcinoma. Liver biopsy that same day
showed metastatic adenocarcinoma.
- ___ C1D1 FOLFOX6
- ___ Held C1D15 for diarrhea, mild ___.
- ___ C1D15 FOLFOX6 given at full dose - diarrhea
resolved
with dietary changes
- ___ C2D1 dose held for anemia with Hb 6.9 of unclear
cause, transfused 2 units pRBC, guaiac negative, hemolytic w/u
negative.
- ___ C2D1 modified FOLFOX (ci5Fu 1800 mg/m2)
- ___ CT torso showed stable pulmonary nodules and
interval decrease in size of the largest liver lesion replacing
much of the left lobe of the liver. Mild interval improvement
in
left intrahepatic biliary duct dilation. Persistent occlusion of
the left portal vein. Improved wall thickening at the
rectosigmoid junction.
- ___ C3D1 modified FOLFOX (ci5Fu 1800 mg/m2)
- ___ Presented with worsening diarrhea. Admitted. Some
evidence of subacute pancreatic rejection. Improved clinically.
- ___ C3D1 FOLFOX (oxali 65 mg/m2) dose reduced for renal
insufficiency
- ___ C4D1 FOLFOX (oxali 65 mg/m2)
- ___ C4D15 FOLFOX held due to ___, hypotension,
hypomagnesemia
- ___ C5D1 FOLFOX
Social History:
___
Family History:
FAMILY HISTORY (per patient and OMR)
No history of cancer. Mother has type ___ diabetes. His father
passed away from liver failure at the age of ___ years. This was
thought to be secondary to hepatitis. Sister died due to
complications of drug use.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Recent Discharge weight: 57.3 kg
Admission weight: 60.9 (bed weight)
Vitals: 97. 88 127/69 19 95% on NRB
GENERAL: Alert, oriented, conversant in full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to the jawline, but bounding
LUNGS: diffuse crackles in posterior lung fields ___ of the way
up
CV: Regular rate and rhythm, systolic murmur
ABD: soft, mild diffuse tenderness, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, thin legs, 2+ pitting edema
NEURO: alert, oriented, moves all extremities
DISCHARGE PHYSICAL EXAM:
========================
VS: No longer checking given CMO
General: Awake and alert, jaundiced appearance, NAD.
HEENT: Pinpoint pupils, PERRLA, EOMI, sclera icteric, MMM
Neck: Supple
Lungs: Soft crackles b/l to mid-lung fields
CV: RRR, ___ holosystolic murmur best heard over the axilla
Abdomen: Soft, diffuse tenderness to palpation, distended,
rebound tenderness in ___, ___ sign negative, +BS
GU: No Foley
Ext: WWP, no clubbing or cyanosis, ___ pitting edema in b/l ___
Neuro: A&Ox3, CN ___ grossly intact, motor function grossly
normal
Psych: Calm, cooperative, answering questions appropriately
Pertinent Results:
ADMISSION LABS:
===============
___ 06:35PM BLOOD WBC-20.9* RBC-3.07* Hgb-8.2* Hct-26.7*
MCV-87 MCH-26.7 MCHC-30.7* RDW-20.8* RDWSD-65.2* Plt ___
___ 06:35PM BLOOD Neuts-95.3* Lymphs-1.6* Monos-2.4*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.87* AbsLymp-0.34*
AbsMono-0.50 AbsEos-0.00* AbsBaso-0.02
___ 11:11PM BLOOD ___ PTT-34.4 ___
___ 06:35PM BLOOD Glucose-580* UreaN-54* Creat-1.0 Na-122*
K-3.1* Cl-89* HCO3-25 AnGap-11
___ 11:11PM BLOOD ALT-8 AST-48* LD(LDH)-587* AlkPhos-290*
TotBili-0.5
___ 06:35PM BLOOD cTropnT-<0.01 proBNP-3347*
___ 07:48AM BLOOD Lipase-35
___ 11:11PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.5*
___ 03:42AM BLOOD calTIBC-161* ___ Ferritn-230
TRF-124*
___ 03:42AM BLOOD tacroFK-3.3*
___ 11:28PM BLOOD ___ Temp-37.0 pO2-37* pCO2-44
pH-7.41 calTCO2-29 Base XS-2
___ 06:46PM BLOOD Lactate-1.7
DISCHARGE LABS:
===============
No longer checking given CMO status
SIGNIFICANT IMAGING:
====================
CXR ___:
Increase in bilateral pulmonary opacities may be due to
increased pulmonary edema and/or infection overlying chronic
pulmonary opacities.
CHEST CT ___:
Extensive bilateral abnormalities with diffuse ground-glass
opacities,
scattered nodules, ranging from 1-5 cm, in a primarily
peribronchial and
subpleural distribution and bronchial thickening, are findings
consistent with patient's given history of cryptogenic
organizing pneumonia.
RENAL TRANSPLANT US ___:
1. Mild increase in peak systolic velocity, previously 141 cm/s
to 160 cm/s currently, with moderately elevated resistive
indices since prior exam, ranging from 0.7 to 0.9 on current
exam, previously 0.79 to 0.82.
2. Small amount of pelvic ascites.
3. Trabeculated bladder is incidentally noted.
4. Stable appearance of 1.1 cm renal cyst.
RUQ US ___:
LIVER/BILE DUCTS: The hepatic parenchyma, particular within the
left lobe, is predominantly replaced by metastatic disease,
similar to multiple prior studies. There is associated mild
intrahepatic biliary ductal dilatation, likely obstructive in
etiology. The CBD measures 7 mm.
GALLBLADDER: The gallbladder is entirely filled with sludge,
however there is no significant distention, wall thickening, or
wall edema.
MRCP ___:
Innumerable metatastic lesions replacing most of the liver.
Severe dilation
of the right anterior, right posterior, left superior and left
inferior
intrahepatic bile ducts. The right anterior and posterior bile
ducts do not
merge and are obstructed separately. The left superior and
inferior bile
ducts do not merge and are obstructed separately.
MICRO:
======
- Blood cx ___ negative
- Sputum cx ___ SPARSE GROWTH Commensal Respiratory Flora
- Urine culture ___ negative
Brief Hospital Course:
___ male with a past medical history of Stage 4B rectal cancer
(s/p 5 cycles FOLFOX), type 1 diabetes c/b diabetic nephropathy
s/p kidney/pancreas transplant, and chronic abdominal pain on
opiate
therapy who was admitted ___ for sepsis, pneumonia, COP,
and MSSA bacteremia and presumed mitral valve infectious
endocarditis who re-presented on ___ with hypoxemic respiratory
failure felt to be multifactorial: COP, MR/volume overload, and
PNA. Now with worsening biliary obstruction ___ malignancy.
ACTIVE ISSUES:
==============
# Goals of care:
Patient with hx of Stage IV Rectal Cancer, endocarditis, tenuous
volume status, now with worsening biliary obstruction in setting
of progression of underlying rectal cancer. MRCP showed diffuse
obstruction of intrahepatic bile ducts ___ mets. There were
limited interventions possible with no definitive management of
the issues below. Given this, patient elected to pursue comfort
measures only. DNR/DNI; comfort-focused care order placed.
Antibiotics for potential intraabdominal infection from biliary
duct obstruction d/c'ed. Dilaudid PCA basal 0.25mg/hr + bolus
0.5mg q10min (max hourly dose 2.5mg); uptitrate basal rate
(0.25-1.0mg/hr) as necessary. Continue oxycodone PRN while
taking PO. No plans to reverse INR with Vit K, as pt declined ___
procedures. Continue Zofran 4mg IV q8h PRN for nausea. Continue
Protonix 40mg BID. Continue calcium carbonate 500mg BID.
Continue simethicone 80mg QID PRN for bloating.
# Stage IV Rectal Cancer/Chronic Abdominal Pain/Liver
Metastases/Acute on Chronic Liver Failure:
Chemotherapy contraindicated i/s/o severe MR without operative
or endovascular option. Has chronic abdominal pain due to
metastases to the abdomen and liver. Developed acute on chronic
liver failure from biliary obstruction (Tbili increased 1.4 on
___ -> 8.6 on ___ Dbili 7.4; INR increased from 2.0 on ___
-> 2.9 on ___. RUQ US showed gallbladder sludge but no e/o
cholecystitis and diffuse hepatic metastases with intrahepatic
biliary obstruction but no CBD dilation (7mm). ERCP determined
that there was no distal obstruction amenable to stent. MRCP
showed diffuse mets obstructing the L superior/inferior bile
ducts, and the R anterior/posterior bile ducts. Per ___,
percutaneous drainage would first require correction of INR but
that given the underlying malignancy it would be at most a
temporizing measure. Patient opted for comfort-centered care
(above).
# ___:
Baseline Cr 0.7-0.8. 1.4 ___ -> 2.0 ___ -> 2.5 ___. Most
likely prerenal i/s/o diuresis, afterload reduction, and ACEi
combined with component from worsening liver failure. Spun urine
showed hyaline casts c/w prerenal etiology and no e/o ATN.
FeUrea 25.09%, which is suggestive of prerenal etiology. UA
unremarkable, urine culture negative. Renal US showed mildly
increased resistive indices, but no c/f rejection or
obstruction. Continued diuresis (with Torsemide 40-60mg BID and
then with Lasix 120mg IV BID) despite ___ given hyponatremia,
severe MR, and risk for pulmonary edema/hypoxemic respiratory
failure if diuresis stopped. Lisinopril held given worsening
___.
# Severe MR/acute on chronic diastolic CHF leading to acute on
chronic hypoxic respitory failure:
Diuresed with 160mg IV Lasix and 5mg metolazone daily in MICU.
Switched to PO diuresis with Torsemide 60mg daily on ___ when
Cr increased 0.8 -> 1.4. Torsemide was increased to 60mg BID on
___ due to hyponatremia (126), which indicated continued volume
overload, but was decreased to 40mg BID on ___ when Cr bumped
to 2.0. Torsemide was d/c'ed and Lasix 120mg IV BID started on
___ when pt was feeling more SOB. Patient was started on
hydralazine 100mg PO q6h, isosorbide dinitrate 60mg TID, and
captopril 37.5mg TID for afterload reduction in the MICU.
Captopril was downtitrated to 12.5mg TID on ___ due to ___, and
was converted to lisinopril 10mg daily on ___. However,
lisinopril was held on ___ due to worsening ___. ASA 81mg and
metoprolol continued for heart failure treatment. Albumin 2.8 on
___, which could be contributing to volume overload/anasarca.
Pt given nutritional supplementation with Glucerna shakes and
Magic Cup.
# Hyponatremia:
Likely ___ volume overload. Patient was started on a 1.5L fluid
restriction on ___, and Na uptrended. Patient was diuresed with
Torsemide 60mg BID until Cr bumped to 2.0 on ___, when it was
decreased to 40mg BID. Torsemide d/c'ed and pt started on 120mg
IV Lasix BID on ___ due to feeling more SOB.
# COP leading to acute on chronic hypoxic respitory failure:
Diagnosed with lung biopsy on ___. CT ___ showed
improvement in COP. Continued on Prednisone 60mg during
admission. Continued atovaquone 1500mg daily for PCP
___. Given albuterol neb q6h PRN and ipratropium neb q6h
PRN for SOB.
# PNA:
S/p treatment with 7 days of Zosyn (last day ___. No
infectious symptoms after treatment (afebrile, WBC count
downtrending, no productive cough).
# MSSA Bacteremia/Endocarditis:
Diagnosed during admission ___, started on 6-week course of
cefazolin 2g IV q8h, which transitioned to Zosyn for 7 days for
PNA treatment, restarted on ___, and completed on ___. Blood
cultures NG this admission.
# Iron Deficiency Anemia:
Likely due to slow ooze from GI malignancy. Transfused ___ and
___. Hgb 6.6 on ___, but decided not to give blood transfusion
due to minimal potential benefit i/s/o CMO status and risk of
causing flash pulmonary edema. Given Protonix 40mg BID for GI
bleed prophylaxis.
# T1DM:
Maintained on Lantus 10U qAM and ISS.
# S/p Renal and Pancreatic Transplant:
Renal transplant following. Tacrolimus dose adjusted PRN to
maintain goal level of ___. Tacro dose on discharge 2mg BID.
Cholestyramine 4g BID was continued for chronic diarrhea.
Continued Creon 12 3 caps TID with meals and 1 cap TID PRN with
snacks for pancreatic insufficiency.
Transitional Issues:
[] Comfort-focused care.
[] Home with hospice.
[] Uptitrate dilaudid PCA as necessary for pain control.
[] Home O2 for CHF/COP.
[] Consider Rifaximin if becoming encephalopathic.
# CODE: DNR/DNI, comfort-focused care
# CONTACT: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Cholestyramine 4 gm PO BID
3. Creon 12 3 CAP PO TID W/MEALS
4. nystatin 100,000 unit/mL oral TID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
10. Atovaquone Suspension 1500 mg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. CefazoLIN 2 g IV Q8H
13. HydrALAzine 100 mg PO Q8H
14. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
15. PredniSONE 60 mg PO DAILY
16. Tacrolimus 3 mg PO Q12H
17. Allopurinol ___ mg PO DAILY
18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
19. Isosorbide Dinitrate 40 mg PO QID
20. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
21. Lorazepam 0.5-1 mg PO DAILY: PRN nausea/anxiety
22. Metoprolol Tartrate 25 mg PO Q6H
23. Multivitamins 1 TAB PO DAILY
24. Ondansetron 4 mg IV Q8H:PRN nausea
25. Pantoprazole 40 mg PO Q12H
26. Sodium Chloride Nasal ___ SPRY NU QID:PRN Nasal irritation
27. Vitamin D 1000 UNIT PO DAILY
28. Creon 12 1 CAP PO WITH SNACKS
29. Torsemide 60 mg PO DAILY
30. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Home Oxygen
ICD 10:
Cryptogenic organizing pneumonia, J84.116
Heart failure, unspecified, I50.9
Oxygen ___
2. Atovaquone Suspension 1500 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Cholestyramine 4 gm PO BID
5. Creon 12 3 CAP PO TID W/MEALS
6. Creon 12 1 CAP PO TID:PRN with snacks
7. HydrALAzine 100 mg PO Q6H
8. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
10. Isosorbide Dinitrate 60 mg PO TID
11. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
12. Lorazepam 0.5-1 mg PO DAILY: PRN nausea/anxiety
13. Metoprolol Tartrate 25 mg PO QID
14. Nystatin Oral Suspension 5 mL PO QID
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth every six hours Disp
#*15 Tablet Refills:*0
17. Pantoprazole 40 mg PO Q12H
18. PredniSONE 60 mg PO DAILY
19. Tacrolimus 2 mg PO Q12H
20. Sodium Chloride Nasal ___ SPRY NU QID:PRN Nasal irritation
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
22. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
23. Furosemide 120 mg IV BID
24. Lidocaine 5% Patch 1 PTCH TD QPM
25. Simethicone 80 mg PO QID:PRN bloating
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypoxemic respiratory failure
Stage IVB rectal cancer with liver metastases
Mitral valve regurgitation
Congestive heart failure
Hyponatremia
Acute kidney injury
Acute liver failure
Cryptogenic organizing pneumonia
Pneumonia
Secondary:
Endocarditis
Chronic lower back pain
Iron deficiency anemia
Type 1 Diabetes mellitus
S/p renal transplant
S/p pancreas transplant
Gout
Thrush
Anxiety
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You came to ___ with
respiratory failure. You were admitted to the ICU and given
medication to remove excess fluid from your lungs, antibiotics
for pneumonia, and steroids for your lung disease. You will
continue to receive a medication called Lasix twice daily to
prevent fluid from building up in your lungs again. You should
continue taking steroids for your lung disease.
While you were in the hospital, you finished the course of
antibiotics that you were taking for the infection on one of the
valves in your heart. You were seen by cardiologists, who
determined that your heart valve cannot be replaced.
You began having worsening abdominal pain while you were in the
hospital. Blood and imaging tests showed that the cancer
metastases in your liver have gotten worse and are causing your
liver to fail. You can no longer undergo chemotherapy due to
your failing heart valve, and you are at high risk of bleeding
from the liver failure. Thus after discussion with the
palliative care team, you asked that your medical care focus on
comfort and to work to get you home. You were discharged home
with hospice.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10755791-DS-19
| 10,755,791 | 20,113,485 |
DS
| 19 |
2154-02-27 00:00:00
|
2154-02-28 09:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with history of
Alzheimer's dementia, recent hip fracture s/p left hip repair
who
presents with weakness and recurrent falls.
Patient returned from ___ yesterday and is being cared for
by family. Family reports they have been struggling to maneuver
her from chair to bed etc. Patient was being placed in car today
by daughters and they accidentally dropped her. Patient reports
left hip pain. Patient has been telling her children "the bone
is
sticking out". Her children report they are unsure what to
believe with her dementia. Patient had a hip procedure end of
___ in ___. No LOC or head strike, and not on blood
thinners.
She had a fall 2 months ago while in ___ (visiting) and
ended up staying for longer than planned to recuperate after
left
hip repair surgery. Per daughter, she has had minimal ___ since
the surgery because rehabs in ___ don't do a ton of ___ and
so she's been essentially bed bound for the past 2 months with
progressive muscle atrophy and weakness and has been in a
wheelchair since.
Yesterday she went to ___ at ___. After PCP visit, patient
had the fall upon transferring so family brought her to the ED
for further eval. They were concerned about acute fracture, but
also they feel that they are unable to care for her at home due
to her weakness currently and feel that she would benefit from
___ rehab stay before she can safely return home.
Currently
she lives with sister on ___ floor.
Per daughters/grandson, likely dementia ongoing for years with
intermittent agitation. They were in the process of exploring
possible return to ___ permanently but started with a
visit
first, which is when she had the fall and ended up requiring
surgical hip repair as above. Have called her PCP for further
info, patient is a new patient for them and they only saw her
once, yesterday to establish care. She was started newly on
Seroquel, donepezil, and clonazepam.
In the ED:
VS: 98.6 P 80 BP 125/76 RR 20 pOx 97% on RA
ECG:
PE:
Labs: unremarkable CBC/ CMP except for elevated LDH and +UA
Imaging: CXR showed RUL opacification concerning for infection
versus atelectasis versus mass, CT chest showed ___
nodularity with airway mucous plugging in RUL but no evidence of
mass. xray of hip and pelvis negative for acute process
Impression: UA c/f UTI. CXR c/f PNa. Given overall weakness will
admit on ceftri/azithro to medicine for further eval.
Interventions: CTX 1g, Azithro 500mg, home clonazepam seroquel
and donepezil
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Alzheimer's Dementia with behavioral disturbance
History of cholecystectomy
History of biliary obstruction status post sphincterotomy
History of Left hip fracture status post repair
Social History:
___
Family History:
___ and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: reviewed in POE
GENERAL: Asleep arouses to voice, cachectic
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: limited by poor participation in exam, +ronchi R > L.
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
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: asleep, minimally interactive, noncompliant with exam,
pain on ROM of left hip without point tenderness, gait testing
deferred
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS
--------------
___ 06:15AM BLOOD WBC-5.3 RBC-4.08 Hgb-11.2 Hct-35.6 MCV-87
MCH-27.5 MCHC-31.5* RDW-14.8 RDWSD-47.6* Plt ___
___ 06:15AM BLOOD Neuts-60.7 ___ Monos-6.3 Eos-1.0
Baso-0.6 Im ___ AbsNeut-3.19 AbsLymp-1.64 AbsMono-0.33
AbsEos-0.05 AbsBaso-0.03
___ 06:15AM BLOOD Glucose-90 UreaN-14 Creat-0.7 Na-143
K-3.7 Cl-104 HCO3-26 AnGap-13
___ 06:15AM BLOOD ALT-10 AST-17 LD(LDH)-214 AlkPhos-104
TotBili-0.7
___ 06:15AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.2 Mg-2.1
IMAGING
-------
CT Chest
1. Right paratracheal opacification seen on prior chest
radiograph corresponds to overlapping vascular structures.
2. ___ nodularity with airway mucous plugging in the
anterior right upper lobe likely reflects infectious
bronchiolitis. Aspiration is also a possibility, but less likely
given location.
3. Dilatation of the partially imaged common bile duct up to 1.5
cm. This can represent a normal sequela of prior
cholecystectomy.
Otherwise, please correlate with LFTs for possible biliary
obstruction.
4. Pneumobilia, which may be seen with prior sphincterotomy.
CXR - Opacification at the right apex, which could represent
focal right upper lobe collapse, focal consolidation or mass.
Recommend correlation with prior imaging, if available or chest
CT for further evaluation.
Pelvis Ap ___ Views
Hip Unilat Min 2 Views Left
1. No acute displaced fractures visualized.
2. Left hip prosthesis in overall anatomic alignment.
Discharge Labs:
===============
Brief Hospital Course:
___ female with history of Alzheimer's dementia, recent
hip fracture s/p left hip repair who presents with weakness and
recurrent falls, found to have pneumonia and possible UTI.
# Weakness
# Recurrent falls
# RUL pneumonia versus infectious bronchiolitis
# Presumed UTI:
Likely weak with recurrent falls given recent hip repair and
immobility. There was no evidence of acute fracture or bony
tenderness. She is recently s/p hip repair with significant
muscle atrophy and loss of function since. Plain films of hip
and pelvis were reassuring. However, given agitation and
underlying dementia, infectious workup was pursued since
infection could be contributing to delirium and overall
weakness. CXR revealed possible RUL pneumonia vs. infectious
bronchiolitis. She received 5 days of azithromycin. Urine
culture grew MDR E. coli - initial plan for meropenem given
concern for limited in ___ susceptibility to Zosyn, though ID
antibiotic approval felt Zosyn would be sufficient given overall
clinical stability and high urinary penetration of Zosyn
compared to plasma. Bacteriuria was thought to possibly
represent colonization, though given inability to determine if
patient was symptomatic she was started on 7 day course of Zosyn
(day ___ = ___. Pain was managed with lidocaine patch and
Tylenol.
# Pneumobilia
# CBD dilation:
Incidentally noted. This was reviewed with Radiology and
daughter. Patient is s/p remote cholecystectomy and ERCP with
sphincterotomy. LFTs are wnl and abdominal exam is benign. These
are chronic post chole and post sphincterotomy changes. No
further workup indicated.
# ___'s dementia with behavioral disturbance: she was
evaluated by geriatrics team. They recommended stopping
donepezil, as this medication is no longer helpful in the
setting of advanced dementia. She was started on trazodone and
ramelteon to treat insomnia. Home Seroquel was decreased to
12.5mg QHS. She was also started on sertraline to address
possible underlying depression and anxiety. Home clonazepam was
stopped due to the concern that benzodiazepines were worsening
delirium.
Expected length of stay < 30 days
Transitional Issues:
====================
- discharged on Zosyn for ___ay 7 = ___
- if recurrent MDR E. coli in urine, would consider this
colonization rather than true infection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. QUEtiapine Fumarate 50 mg PO QHS
3. Donepezil 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever NOT
relieved by Ibuprofen
2. Bisacodyl ___AILY
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Piperacillin-Tazobactam 2.25 g IV Q6H Duration: 5 Days
6. Ramelteon 8 mg PO QHS
7. Senna 8.6 mg PO BID
8. Sertraline 12.5 mg PO DAILY
9. TraZODone 25 mg PO QHS
10. QUEtiapine Fumarate 12.5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Dementia
Toxic metabolic encephalopathy
Pneumonia
UTI
Recurrent falls
Sacral ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with confusion. You
were treated for a pneumonia and urinary tract infection, as
these can sometimes cause confusion.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Followup Instructions:
___
|
10755897-DS-12
| 10,755,897 | 20,854,750 |
DS
| 12 |
2190-01-01 00:00:00
|
2190-01-02 13:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ketamine / Aloe
Attending: ___
Chief Complaint:
Nausea/vomiting/abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of diabetes, cystic fibrosis heterozygosity s/p
pancreatectomy, splenectomy, CCY, DM among other conditions
presenting with nausea, frequent heaving, and non-bilious
vomiting associated with loose yellow stool since ___ similar
to his prior episodes of pancreatitis.
He states that he has chronic abdominal pain from pancreatitis.
He awoke yesterday vomiting with increase in abdominal pain from
baseline. He tried to manage at home, but stated that the amount
of pain become overwhelming and decided to report to the
hospital.
His abdominal pain is characterized as "whole abdominal" and
"pain". Intensity on the floor was ___. He states associated
symptoms of dizziness and respiratory splinting as the pain can
get so bad. He had a bowel movement today that was yellowish,
non-bloody. He also endorses having flatus still.
He states that this is similar to prior episodes except that the
level of pain makes him think this will take awhile to recover.
He also states that the pain is "fanning" out more. In addition,
he reports loose,watery diarrhea today x 3 bowel movements.
He denies any sick contacts, recent travel or recent
antibiotics. He has not been able to tolerate any liquid or
solid food today.
Patient was admitted from ___ to ___ for similar
compliants.
.
In the ED, initial VS: 15:40 8 97.4 93 132/64 18 98%
Physical exam was significant for pain, tender RUQ pain and
epigastrium with mild dull tenderness overall. Bowel sounds
present.
He was given insulin regular IV 10 units x 1 for hyperglycemia,
dilaudid 1 mg IV x 3, zofran 4 mg IV x 2,
He was given 3 L NS IVF total. Patient was kept NPO.
Chemistry panel was significant for hyperglycemia to 525 with AG
of 22 (including K in measurement). LFTs were within normal
limits.
CBC showed WBC 15.7, Hgb 13.3, Plt 663 with Diff N85.1, L10.8.
Patient was admitted for nausea,vomiting, and diarrhea - ?
gastroenteritis.
VS on transfer: T 98.6, HR 98, BP 127/69, RR 18, Sat 95% RA,
pain ___ from ___ (7:30 pm), BG 274 (7 pm)
Most recent vitals on transfer: 98.6,131/63,93,98% rm air.
.
Currently, the patient confirms the above story. Abdominal pain
was ___ on arrival to floor. Blood glucose was ~ 400.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-Chronic pancreatitis with heterozygous CF delta 508 mutation
s/p Roux-en-Y/distal pancreatectomy/splenectomy in ___
completion pancreatectomy in ___
-Secondary diabetes, on insulin
-Herniated disc s/p microdiscectomy X ___
-s/p cholecystectomy in ___
-Nicotine use
-RAD
-GERD
-Paresthesias (L)thigh, leg due to lumbar disc disease
Social History:
___
Family History:
Father with dementia and CHF, sister with CF, GM with breast Ca,
GF with CVA and CAD, M with liver/lung cancer
Physical Exam:
VS - T 96.3, BP 118/66, HR 84, RR 18 pOx 98 RA
GENERAL - appears like in pain, non-toxic, speaking in complete
sentences, able to navigate the hospital bed without much
difficulty HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, mucous
membranes extremly dry. Poor dentition
NECK - supple, ? pain on lateral left portion of neck, ? mild
posterior cervical LAD on left.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - appears distended, several post-surgical scars noted
that well-healed, prior J-tube site. Soft, tender diffusely, no
peritoneal signs (able to move, cough), no rebound/guarding.
EXTREMITIES - WWP, no c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout.
Pertinent Results:
Admission Labs:
___ 03:59PM BLOOD WBC-15.7* RBC-4.43* Hgb-13.3* Hct-41.2
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.0 Plt ___
___ 03:59PM BLOOD Neuts-85.1* Lymphs-10.8* Monos-2.5
Eos-1.0 Baso-0.5
___ 03:59PM BLOOD Glucose-525* UreaN-10 Creat-0.8 Na-136
K-5.4* Cl-96 HCO3-23 AnGap-22
___ 03:59PM BLOOD ALT-18 AST-28 AlkPhos-178* TotBili-0.4
___ 03:59PM BLOOD Lipase-5
___ 01:54AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.5*
Discharge Labs:
___ 10:50AM BLOOD WBC-12.2* RBC-3.79* Hgb-11.4* Hct-34.6*
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.0 Plt ___
___ 08:56AM BLOOD Neuts-55.0 ___ Monos-4.9 Eos-3.0
Baso-0.8
___ 11:00AM BLOOD Glucose-76 UreaN-8 Creat-0.8 Na-140 K-3.9
Cl-107 HCO3-25 AnGap-12
___ 11:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9
MICRO:
Blood cx x2 ___: No growth to date
IMAGING:
PORTABLE ABDOMEN RADIOGRAPH OF ___
COMPARISON: ___ radiograph.
FINDINGS: A non-obstructive bowel gas pattern is visualized, and
there is no evidence of free intraperitoneal air. Surgical clips
are present in the left upper quadrant and mid abdomen. No acute
skeletal abnormalities are detected.
IMPRESSION: No evidence of obstruction or perforation.
Brief Hospital Course:
Primary reason for hospitalization:
___ with cystic fibrosis heterozygosity s/p pancreatectomy,
splenectomy, and cholecystectomy with chronic abdominal pain
presenting with acute on chronic abdominal pain
Active issues:
# N/V/Abdominal pain: Likely viral gastroenteritis given short
duration of symptoms. He was managed with supportive care
including IV fluids, IV dilaudid for pain management and IV
zofran for nausea/vomiting. His symptoms quickly improved and
he was transitioned to PO diet and his home PO pain medications.
He was discharged home on his home medications and PO zofran as
needed for nausea.
# Elevated anion gap: Anion gap on admission was 18, likely
elevated ___ ketosis in setting of hyperglycemia and missing
home insulin doses due to N/V. His AG resolved by HD#2 with IV
fluids and his home insulin regimen.
Chronic issues:
# IDDM: Pt was hyperglycemic on admission ___ 400s), was treated
with IV fluids and ISS. His home lantus and humalog SS were
resumed.
Transitional issues:
-No medication changes during this admission. He was given
3-day supply of PO zofran as needed for nausea.
-He is scheduled to follow up with his PCP and outpatient
gastroenterologist after discharge.
Medications on Admission:
1. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q8H (every 8 hours).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Lantus 100 unit/mL Solution Sig: Eighteen (18) units
Subcutaneous at bedtime: if not eating well, use ___ dose (12
units).
4. Humalog 100 unit/mL Cartridge Sig: One (1) injection
Subcutaneous per usual sliding scale.
5. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO with snacks (up to 4
times a day).
6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO three times a day
with meals.
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Medications:
1. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*9 Tablet Extended Release(s)* Refills:*0*
2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
5. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QID W/ SNACKS ().
6. Lantus 100 unit/mL Solution Sig: Eighteen (18) units
Subcutaneous at bedtime: if not eating well, use ___ dose (12
units).
7. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous per sliding scale.
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 3 days.
Disp:*9 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:
Dear Mr. ___,
You were admitted to ___ because you were having
nausea/vomiting and abdominal pain. You were given IV fluids
and medication to help your pain and nausea, and your symptoms
improved. It is not clear what caused your symptoms but most
likely you had a viral gastroenteritis.
We made no changes to your medications while you were here.
Please continue taking all of your home medications as
prescribed by your outpatient providers.
We have scheduled an appointment for you to follow up with your
primary care physician. You also have an appointment to follow
up with Dr. ___. Please see below for your currently
scheduled appointments.
It has been a pleasure taking care of you at ___.
Followup Instructions:
___
|
10756520-DS-4
| 10,756,520 | 29,991,754 |
DS
| 4 |
2164-10-12 00:00:00
|
2164-10-12 17:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion, elevated INR
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is an ___ woman with a h/o COPD (on home ___, OSA
(on CPAP with imperfect adherence), PE (___) on warfarin,
HFpEF, hypothyroidism, and T2DM presenting from rehab for
slurred speech and INR >10. She was given 5mg vitamin K PO and
INR was unchanged on recheck. She had a nosebleed 2 hours later
and was sent to the ED. Per ___ records, she was alert, verbally
responsive, and confused at times. EMS activated a code stroke
en route; on arrival, they noted dysarthria, word-finding
difficulty, and RUE weakness of unclear onset. Of note, UA
collected on ___ at ___ showed +nitrite, 2+ ___, 3+ bacteria, 41
WBCs. Na was 149, WBC 10.5. She was also diagnosed with PNA on
___ and treated with azithromycin and acidophilus.
In the ED, initial vitals: 97.0 82 142/80 18 100% RA
- Labs notable for: INR 11.1, K 5.2
- Imaging notable for: CXR showing RML atelectasis vs scarring
seen on multiple previous CXRs (my read); CTA Head/Neck showing
no acute hemorrhage and no major vessel abnormality
- Patient given: Vanc and Zosyn
- Code Stroke called for slurred speech. Neurology did not find
any focal findings and recommended admission to medicine.
On the floor, pt had slurred, incomprehensible speech and was
unable to given any history, although she denied headache, chest
pain, difficulty breathing, nausea. (Per ___ aide, pt has slow
speech at baseline, worsening in past 2 weeks; she is also more
confused and not as fully oriented as before. Baseline ___ and
L>R weakness of unclear etiology. She gets help with all ADLs.)
Warfarin was held. She was found to have non-gap acidosis (HCO3
17, pH on VBG 7.16, pCO2 51) and was started on 150mEq HCO3/D5W.
Of note, she was also found to have K 5.2 and UA with +nitrite,
TR ___, 7 RBC, 3 WBC, and few bacteria. Tox was positive for
opiates despite none on her PAML.
Past Medical History:
COPD (on ___ home O2 via oxygen concentrator)
OSA (on CPAP with imperfect adherence)
PE in ___ (on warfarin)
HFpEF
Obesity
Type 2 diabetes on insulin
HLD
HTN
MGUS
Hypothyroidism
Spinal stenosis
DJD s/p L knee replacement
IPMN
Anemia
Hemorrhoids
Uterus leiomyoma
Diverticulosis
Depression and anxiety
Recurrent falls
Lumbar spine surgery
Coronary calcifications
Known R renal mass (negative Bx in ___
Stress incontinence
Venous insufficiency
Social History:
___
Family History:
Patient unable to recall any contributory family history.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: Tm98.9, 130s/60s-80, 72, 24, 95%1L
Weight: 81.9kg
General: Awake and relatively alert, responsive to questioning
with continued improved speech; interval improvement in work of
breathing
HEENT: Teary eyes, MMM, neck supple, JVP not elevated
Lungs: CTAB other than faint, diffuse crackles, although limited
by poor inspiratory effort
CV: Regular rate and rhythm, normal S1 + S2, no rubs, murmurs,
or gallops
Abdomen: Soft, non-tender, bowel sounds present
GU: No foley
Ext: Warm, in compression stockings, no edema
Neuro: Oriented to person, place, date
DISCHARGE EXAM
==============
Vital Signs: Tm98.4, 110-30s/70-80s, 94, 22, 97%1L
General: Somnolent but responsive to questioning
HEENT: Teary eyes, MMM, neck supple, JVP not elevated
Lungs: Poor air movement at the bases, occasional wheezes
bilaterally, faint crackles at bases, although limited by pt
difficulty with taking deep breath
CV: Irregular rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, non-tender, bowel sounds present
GU: No foley
Ext: Warm, well-perfused, trace pitting edema on ankles
Neuro: Oriented to person, place, year with probing
Pertinent Results:
LABS ON ADMISSION:
===================
___ 10:04PM BLOOD WBC-10.0 RBC-4.20# Hgb-11.3# Hct-38.9#
MCV-93 MCH-26.9 MCHC-29.0* RDW-18.7* RDWSD-63.4* Plt ___
___ 10:04PM BLOOD ___ PTT-68.2* ___
___ 10:04PM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-142
K-5.6* Cl-111* HCO3-19* AnGap-18
___ 10:04PM BLOOD ALT-9 AST-19 AlkPhos-66 TotBili-<0.2
___ 10:04PM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.6 Mg-1.9
Cholest-160
___ 10:04PM BLOOD Triglyc-114 HDL-35 CHOL/HD-4.6
LDLcalc-102
___ 10:04PM BLOOD TSH-0.07*
___ 10:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:25AM BLOOD ___ pO2-200* pCO2-51* pH-7.16*
calTCO2-19* Base XS--10
LABS ON DISCHARGE:
=====================
___ 06:02AM BLOOD WBC-9.2 RBC-3.97 Hgb-10.8* Hct-35.5
MCV-89 MCH-27.2 MCHC-30.4* RDW-17.2* RDWSD-55.3* Plt ___
___ 06:02AM BLOOD Plt ___
___ 06:02AM BLOOD Glucose-92 UreaN-7 Creat-0.8 Na-143 K-3.6
Cl-103 HCO3-32 AnGap-12
___ 06:02AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.6
IMAGING:
=========
CTA Head Neck ___:
1. No acute intracranial abnormalities identified.
2. Severe atherosclerotic disease is seen along the cavernous
segments of the bilateral intra carotid arteries however the
middle cerebral arteries
bilaterally are patent distally. No evidence of aneurysm on the
CTA of the
head.
3. Note is made ___ at termination of the left vertebral
artery.
Otherwise, the internal carotid arteries bilaterally are normal
without
evidence of stenosis by NASCET criteria.
4. Stable bilateral partial upper lobe atelectasis compared to
the prior chest CT from ___. Stable 1 cm ground-glass
lesion within the right middle lobe. New 3 mm nodule within the
lingula. A dedicated chest CT in 3 months is recommended for
further evaluation.
RECOMMENDATION(S): 3 months dedicated chest CT is recommended
for further
evaluation.
CXR AP ___:
Lung volumes are low. A right mid lung opacity obscures the
right heart
border, not significantly changed from prior studies, most
likely representing aged between in atelectasis and prominent
right pulmonary artery. If clinically warranted, correlation
with chest CT in the non emergency basis is to be considered.
Linear opacity left lower lung is unchanged from ___,
consistent with
scarring. The mediastinal contour and cardiac silhouette are
stable from
___. No pneumothorax or pleural effusion.
IMPRESSION:
No pneumonia.
EKG ___: The rhythm is most likely atrial fibrillation with a
controlled ventricular response, although sinus rhythm with
atrial ectopy cannot be excluded. There is a late transition
that is probably normal. Non-specific ST-T wave changes.
Compared to the previous tracing of ___ the rhythm may have
changed. If clinically indicated, a repeat tracing may better
clarify the rhythm.
CXR ___ PA/Lateral:
No acute cardiopulmonary abnormalities. No evidence of
pneumonia or pulmonary edema
Chronic right middle lobe collapse, volume loss in the right
upper lobe, and a smaller atelectasis in the lingula are better
seen on prior CT
MICROBIOLOGY:
==============
Blood culture ___: Negative
Urine culture ___:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
THIS PATIENT HAS AN EXPECTED STAY AT ___ OF LESS THAN 30
DAYS.
Ms. ___ is an ___ woman with h/o COPD, OSA, PE, HFpEF,
hypothyroidism, and T2DM who presented from rehab for dysarthria
and elevated INR.
# Encephalopathy: Pt presented with dysarthria and could not
relay a history. Possible contributing factors included stroke
(seen by neuro; CT negative, no focal neurologic signs), UTI (E.
coli on urine culture, treated with ceftriaxone 3-day course),
medications (ativan, ? opiates), hypercarbia, and electrolyte
abnormalities. Utox was also positive for opiates although no
pain meds were listed in rehab records. Pt was placed on
delirium precautions. Ultimately, suspect that symptoms related
to ativan use as well as metabolic acidosis likely secondary to
acetazolamide use without torsemide which was discontinued. Her
metal status improved throughout admission with holding of
ativan and acetazolamide and correction of her metabolic
acidosis. Initial concern for stroke and she underwent CTA head
and neck without evidence of bleed or subacute stroke. Per
neurology, initial plan was for MRI of the head for further
evaluation of stroke however given improvement in mental status
and initial supratherapeutic INR, stroke was felt very unlikely
on further discussion with neurology and MRI was deferred. She
was alert and oriented to person, place, and time on discharge.
# ACUTE-ON-CHRONIC HFpEF: Pt presented with hypervolemia
(bibasilar crackles, severely edematous lower extremities). It
appears that her home torsemide was not restarted at rehab, and
that she had been on acetazolamide since previous discharge at
end of ___. She was diuresed with IV furosemide 120mg x3
with aggressive electrolyte repletion as needed. On discharge,
patient appeared near euvolemia with much improved crackles and
no pitting edema. She is discharged on torsemide 100mg BID and
KCl 30meq BID. She will need ongoing monitoring of her
electrolytes and daily weights for monitoring of her volume
status and diuresis.
# COPD/INCREASED WORK OF BREATHING: Pt was initially using
accessory muscles and had clear increased work of breathing.
However, her sats remained in the mid-90s on the same or
decreased O2 requirement compared to at home. Most likely due to
combination of HF exacerbation combined with baseline COPD.
Treated HF as above and given prednisone 15mg daily per prior
dosing, and continued other home meds, with Spiriva replacing
Symbicort per formulary. The patient refused Spiriva as she it
had not worked for her in the past. An episode on the floor of
dyspnea a/w wheezing supports under-treatment of COPD. During
this episode of dyspnea a CXR was obtained that showed
prominence of R hilar region. On subsequent PA/Lat CXR to
evaluate there were no acute changes from prior imaging. Patient
will need ongoing evaluation of her prednisone dose as
outpatient and titration per her PCP.
# Failure to Thrive at rehab: Reports of possible mistreatment,
negligence at ___. Pt reports being handled "roughly," pushed to
bed causing lip laceration, and possibly being slapped. Though
the patient used similar language describing nurses on our floor
at ___ when the nurses were not clearly being aggressive or
physical. Meds had possibly not been given appropriately, and
urine tox showed positive opiates though this was not on her MAR
from ___. Social work was consulted and investigated SNF
situation. Seen by ___, who recommended discharge to rehab. Pt
will be discharged to ___ at ___ (transition from prior
placement).
# Supratherapeutic INR: Pt presented with INR 11.1 and recent
epistaxis. Per discussion without ___ outpatient NP, her
dosing of warfarin at rehab was likely too high contributing to
supratherapeutic INR. She was given 5mg vitamin K at rehab and
___ with drop in INR to 1.2 and restarted on home warfarin at
2.5mg daily (initially at 3mg daily). Her INR at discharge was
1.9. Unclear if she is on anticoagulation for history of
provoked DVT/PE vs related to underlying afib as one EKG at
___ concerning for atrial fibrillation. Outpatient PCP
notified of possible atrial fibrillation (rate controlled with
home metoprolol).
# HYPOTHYROIDISM: Pt presented with TSH 0.07, likely due to
inappropriately high doses of levothyroxine (home dose 150mcg
daily). Possible euthyroid sick syndrome was considered,
although pt did not appear clinically sick enough to cause such
low TSH. Levothyroxine decreased to 125mcg daily. She will need
repeat TSH in 6 weeks with adjustment of levothyroxine dose prn.
# UTI/ASYMPTOMATIC BACTERIURIA: Never complained of symptoms of
UTI, but positive UA on admission with encephalopathy as above
thus initially treated with 3 days of ceftriaxone. UCx returned
positive for Ecoli resistant to ceftriaxone. Given improvement
in mental status despite inappropriate coverage of her Ecoli
without symptoms of UTI when mental status normalized, decision
was made to hold off on further treatment as she met criteria
for asymptomatic bacteruria. Should she develop new symptoms of
UTI, would have low threshold for treatment of UTI.
# NON-GAP METABOLIC ACIDOSIS/RESPIRATORY ACIDOSIS: Presented
with severe acidosis to 7.16. Primary respiratory acidosis due
to hypoventilation in context of chronic COPD retainer, and
non-gap metabolic acidosis possibly related to acetazolamide on
admission. Acetazolamide was dc'd and acidosis resolved. pCO2
was within baseline.
#HEMATURIA: Had red-tinged urine on admission. Likely traumatic
from foley placement in setting of elevated INR. Resolved soon
after admission. Should receive follow-up UA at ___.
# HYPERNATREMIA: Up to 150 at its highest, improved with IVF and
water intake. Likely related to impaired thirst response in
context of AMS, improved with improved PO intake.
CHRONIC STABLE ISSUES
=====================
# HTN: Continued metoprolol 12.5 BID.
# DEPRESSION: Continued home Lexapro.
# HLD: Continued home Lipitor.
# DM: Held home glipizide, started ISS while inpatient
TRANSITIONAL ISSUES
===================
[]Medication changes
- stopped acetazolamide
- started torsemide 100mg BID
- Decreased levothyroxine to 125mcg daily
[]Measure potassium every other day for 1 week, and titrate PO
KCl repletion as needed
[]Hematuria: obtain UA at ___ within 1 week
[]Pulmonary nodules: f/u CT 3 in months to evaluate
[]Please repeat TSH in 6 weeks given adjustment in levothyroxine
dose
[]Had R hilar prominence on portable CXR c/f PNA. On PA/Lat to
evaluate there were no acute changes seen to suggest PNA. ___
want to consider evaluating in future if clinically warranted.
FULL CODE
HCP is ___, ___
___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. GlipiZIDE 2.5 mg PO 4X/WEEK (___)
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. PredniSONE 15 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Escitalopram Oxalate 20 mg PO DAILY
11. Potassium Chloride 30 mEq PO BID
12. Omeprazole 20 mg PO BID
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. Senna 8.6 mg PO BID:PRN constipation
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Warfarin 1.25 mg PO 1X/WEEK (___)
17. Warfarin 2.5 mg PO 6X/WEEK (___)
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Moderate
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL ___
puffs IH q6h PRN Disp #*1 Ampule Refills:*0
3. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 1 tablet by mouth four times daily PRN
Disp #*30 Tablet Refills:*0
4. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Warfarin 2.5 mg PO DAILY16
7. Atorvastatin 40 mg PO QPM
8. Docusate Sodium 100 mg PO BID
9. Escitalopram Oxalate 20 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. GlipiZIDE 2.5 mg PO 4X/WEEK (___)
12. Metoprolol Tartrate 12.5 mg PO BID
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Potassium Chloride 30 mEq PO BID
17. PredniSONE 15 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
20. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Altered mental status
Acute-on-chronic heart failure
Urinary tract infection
SECONDARY DIAGNOSIS:
COPD
Type 2 diabetes mellitus
Hypothyroidism
HTN
HLD
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ from your SNF because you were having
trouble speaking and were confused. We think this was because of
some of the medications you were on. You were seen by
neurologists and had a CT scan of your head, which showed no
concerning findings. You also had trouble breathing, which was
likely due to fluid in your lungs caused by heart failure. We
treated you with a diuretic, and the fluid in your lungs and
legs decreased. Your breathing also got better. We stopped one
of the medications you were on for heart failure because this
was not the optimal medication for you.
The number that we measure to tell how thin the blood is, the
INR, was also high when you came in. Soon after you got here
though, it had normalized and you were started back on your
regular warfarin dose.
Here are the medication changes we made:
- Started torsemide 100mg twice daily
- Stopped the acetazolamide
It was a true pleasure taking care of you!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10756675-DS-7
| 10,756,675 | 23,600,101 |
DS
| 7 |
2207-09-11 00:00:00
|
2207-09-13 22:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R shin ulcer
Major Surgical or Invasive Procedure:
R Tibia Incision & Drainage with biopsy
PICC insertion
History of Present Illness:
___ with history of HIV (last CD4 315, VL 2.6 on ___ c/b
___'s sarcoma who presents from home for RLE pain and
osteomyelitis.
For the past 6 months, patient states that he has been dealing
with a non-healing ulcer on R shin. He has been seen several
times at ___ and by PCP ___. Says he has always
been treated with Keflex pill of varying duration.
Most recently he saw Dr. ___ on ___ where xrays of R
tibia were done due to concern for osteomyelitis; xrays findings
were indeed c/f osteo so patient was advised to present for
admission. Patient lives in ___ so went closeby to ___ for admission on ___. Hospital course there significant
for:
-MRI right lower leg: Ill-defined and stippled areas of
intramedullary and cortical signal abnormality and enhancement
within the intramedullary right tibia and fibula with
cortical/periosteal thickening. Findings suggestive of mild
osteomyelitis or sequela of osteo-myelitis. Skin thickening and
subcutaneous edema/enhancement within the right calf, greatest
posteriorly suggestive of cellulitis. Right tibiotalar
osteoarthritis. Osteochondral lesion at right medial talar dome.
-ESR 44, CRP 8.9
-Patient given IV Vanc/CTX x 2 days
-Told that he likely needs surgical intervention but due to
comorbidities, ___ was not comfortable performing this;
he
was discharged without antibiotics and told to present to either
___ ___
Transportation is an issue for the patient and it took him quite
a while to get to the point where he was ready for admission.
Finally secured a ride to ___ on ___ and presented to our
ED.
In the ED, initial VS were: 97.6 87 137/82 16 98% RA
Exam notable for:
Erythema of right calf with 1 cm opening in the skin, yellow
purulent material underneath opening; palpable distal pulses,
sensation consistent with prior according to patient, distal
strength intact
Labs showed:
CRP 2.4
Lactate 1.7
Imaging showed:
R Tib/Fib xray
There is generalized edema without gas. Vascular calcifications
are present. No fracture or dislocation seen. Numerous
hyperdense
foci along the mid and distal shaft of the right tibia, also
seen
previously could reflect periosteal reaction. There is relative
demineralization through the proximal to mid shaft of the right
fibula which is nonspecific. No focal bony erosions are present.
Patient received:
___ 20:42 IV Morphine Sulfate 4 mg
___ 22:28 IV Vancomycin 1000 mg
___ 01:05 PO OxyCODONE (Immediate Release) 5 mg
___ 01:05 PO Acetaminophen 1000 mg
Ortho was consulted
ESR/CRP
Repeat MRI to evaluate disease progression
WBAT RLE
Wound care consult for RLE anterior leg wound
ID consult for IV abx
Agree with Medicine admission for IV abx
Transfer VS were: 97.7 78 127/84 15 99% RA
On arrival to the floor, patient reports he feels well.
Endorses
the above story. No fevers or chills. No chest pain or SOB.
He says that he is unaware of any cultures obtained of his
wound/bone.
Past Medical History:
GERD
HTN
HIV
H/o Anal dysplasia
CAD, MI with stents
Social History:
___
Family History:
Mother with breast cancer
Father with MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 132/75 56 19 96 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1.5 cm size open lesion on RLE shin; surrounding
erythema, no purulence
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
==============
VITALS: 97.9F 155/79 73 18 96%ra
GENERAL: No acute distress
HEENT: MMM
NECK: No lymphadenopathy.
LUNGS: CTAB
CV: RRR, no murmurs
ABD: soft, NTND.
EXTREMITIES: R. shin with dressing clean, Wound C/D/I without
purulence.
NEURO: A&O, face symmetric, normal gait.
Pertinent Results:
ADMISSION LABS
==============
___ 07:25PM BLOOD WBC-7.4 RBC-5.00 Hgb-15.7 Hct-45.0 MCV-90
MCH-31.4 MCHC-34.9 RDW-13.9 RDWSD-45.9 Plt ___
___ 07:25PM BLOOD Neuts-45.4 ___ Monos-6.1 Eos-6.5
Baso-0.4 Im ___ AbsNeut-3.36 AbsLymp-3.05 AbsMono-0.45
AbsEos-0.48 AbsBaso-0.03
___ 07:25PM BLOOD Glucose-78 UreaN-21* Creat-1.1 Na-143
K-3.9 Cl-102 HCO3-28 AnGap-13
___ 07:10AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.2
___ 07:25PM BLOOD CRP-2.4
___ 07:28PM BLOOD Lactate-1.7
DISCHARGE LABS
==============
___ 05:45AM BLOOD WBC-6.2 RBC-4.21* Hgb-12.9* Hct-39.0*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.1 RDWSD-47.9* Plt ___
___ 05:45AM BLOOD Glucose-109* UreaN-21* Creat-1.0 Na-143
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 05:40AM BLOOD Calcium-8.9 Phos-5.6* Mg-2.1
___ 05:45AM BLOOD CRP-12.1*
MICROBIOLOGY
============
___ BLOOD CULTURES - Negative
___ 07:31PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
Time Taken Not Noted Log-In Date/Time: ___ 4:33 pm
TISSUE BONE RIGHT TIBIA.
ACID FAST CULTURE AND SMEAR, FUNGAL CULTURE AND SMEAR
ADDED ON PER
___ (___) AT 22:03 ON ___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
___ M with non-healing right shin ulcer presenting after OSH
visit 1 month ago with MRI consistent with chronic
osteomyelitis. Received a biopsy and was started on vancomycin
and ceftriaxone for culture-negative osteomyelitis.
ACUTE ISSUES
#NON-HEALING SHIN ULCER concerning for
#CHRONIC CULTURE NEGATIVE OSTEOMYELITIS
Patient presented with non-healing ulcer of the right shin at
site of prior radiation therapy for ___'s sarcoma. He noted
over a month of recurrent purulent drainage and periodic sharp
electric pains. He was evaluated by MRI at ___ a month
PTA, which revealed findings concerning for osteomyelitis.
Differential also included squamous cell carcinoma or recurrent
Kaposi's sarcoma. He had been discharged with instructions to
follow up at ___, which was delayed by a month. Repeat MRI at
___ revealed unchanged findings, consistent with chronic
indolent osteomyelitis. Bone biopsy was performed ___ and
vancomycin and ceftriaxone were started for culture negative
osteomyelitis. Plan for 6 week antibiotic course with
vanc/ceftriaxone (D1 = ___, last day ___
#POST-OPERATIVE PAIN
After the bone biopsy he had throbbing pain on the shin at the
biopsy site. He was given tylenol and oxycodone, with a short
term course of ibuprofen for inflammation. His pain was
controlled at time of discharge. Ibuprofen ___, instructed
to use sparingly given renal function and HIV meds and for no
longer than ___ days.
CHRONIC ISSUES
#HIV/AIDS: Dx by ___ Sarcoma. Adherent to medications.
Continued on home regimen of Truvada, Maraviroc, Etravirine and
raltegravir.
#GERD: Home pantoprazole
#CAD: History of MI requiring stents ___ years ago. Continued on
ASA, statin, Plavix
TRANSITIONAL ISSUES
===================
NEW MEDICATIONS:
- IV Vancomycin 1500 mg q12h (discharge vanc trough 19.4)
- IV ceftriaxone 2 g q24h
Start Date: ___
Projected End Date: ___
- ibuprofen 400mg PO Q8H PRN pain (no more than 5 days without
talking to MD given risk ___ and HIV meds)
FOLLOW-UP
[ ] follow up pathology, cultures and universal PCR from bone
biopsy
[ ] Weekly OPAT labs: First by ___. CBC with diff, BUN, Cr,
AST, ALT, Total Bili, ALK PHOS, Vanc trough, CRP
[ ] At 2 weeks will need ID follow up (preferably close to him)
but will start with ___ OPAT. Will need additional ID follow
up, preferably closer to home.
[ ] At 2 weeks: Orthopedics follow up
[ ] MRI right tibia at week 4 (Approx ___.
OTHER ISSUES:
- Hemoglobin prior to discharge: 12.9
- Cr at discharge: 1.0
- Antibiotic course at discharge: vancomycin and ceftriaxodne
for 6 weeks as below
- Discharged with instructions for no more than 5 days ibuprofen
for inflammatory pain at biopsy site.
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.
LAB MONITORING RECOMMENDATIONS:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
CEFTRIAXONE: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS
*PLEASE OBTAIN WEEKLY CRP
Essential Dates for OPAT therapy:
- biopsy R tibia ___
- UNIVERSAL PCR BACTERIAL ___ SENT OUT - PENDING
- f/u bone biopsy pathology to rule out non-infectious causes of
MRI findings and ulceration
- PICC placed ___
# CONTACT: ___ (partner) ___
# CODE: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Etravirine 200 mg PO BID
5. Gabapentin 300 mg PO QID
6. Maraviroc 600 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Raltegravir 400 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV daily
Disp #*42 Intravenous Bag Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Can take 1 breakthrough dose daily. Do not take past ___ w/o
consulting your doctor.
RX *ibuprofen [Advil Liqui-Gel] 200 mg 2 capsule(s) by mouth up
to q8h Disp #*15 Capsule Refills:*0
4. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 500 mg 3 bags IV every 12 hours Disp #*84 Vial
Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. Etravirine 200 mg PO BID
11. Gabapentin 300 mg PO QID
12. Maraviroc 600 mg PO BID
13. Metoprolol Tartrate 25 mg PO BID
14. Pantoprazole 40 mg PO Q24H
15. Raltegravir 400 mg PO BID
16. Vitamin D 1000 UNIT PO DAILY
17.Outpatient Lab Work
*WEEKLY* - First by ___. Draw before AM vanc dose.
ATTN: ___ CLINIC - FAX: ___
ICD M86.9: CBC with diff , BUN, Cr, AST, ALT, Total Bili, ALK
PHOS, Vanc trough, CRP
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Ulcer of the right shin concerning for chronic osteomyelitis
Secondary Diagnosis
===================
HIV/AIDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
- You were admitted for a possible bone infection in your right
shin.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- A sample of the bone was taken to test for infection.
- You were started on antibiotics to treat your infection.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You need to continue taking your antibiotics as prescribed.
- You need to get WEEKLY labs faxed to ___ Infectious Disease
(___) clinic. These labs should be drawn ___ hours before a
vancomycin dose so we can make sure the level is safe in your
blood.
- Please schedule an appointment with the orthopedic doctors to
remove your stitches. The appointment will be in 2 weeks. You
can reach them at ___.
- You should also see the Infectious Disease doctors ___ 2 weeks;
you can schedule the appointment for the same day. You can call
them with any questions and to schedule your appointment at
___.
- Your PCP or the ___ Infectious Disease Doctors ___
to arrange for you to follow up closer to home, but you need to
see the ___ Infection doctors at least once.
- All questions regarding antibiotics should be directed to the
___ R.N.s at ___ or to the on-call ID
fellow when the clinic is closed.
We wish you the best in your recovery!
Your ___ Care Team!
Followup Instructions:
___
|
10757032-DS-23
| 10,757,032 | 27,301,624 |
DS
| 23 |
2162-11-30 00:00:00
|
2162-12-01 00:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Levofloxacin
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
___ with h/o anemia, asthma, dCHF (EF 50-55%), t2DM, ESRD,
afib on coumadin, who p/w 10 days cough productive of white
sputum, and SOB. Denies fevers or chills. Has chronic cough, but
worse in last few days, sounds more junky. More SOB than usual,
and wheezing more. Has recently been exposed to others who have
been coughing. Also diarrhea x3 days, watery w/o blood; no
recent abx exposure. Of note, he is currently on prednisone 5mg
daily for gout.
He notes that he has doe at baseline, but came in because of
increased mucous and coughing. NO blood in phlegm, just white.
Non smoker. exercise tolerance one block, used to be perhaps one
city block. No fevers, chills, nor night sweats. Doesnt have a
baseline peak flow known. No home o2. No orthopnea, no pnd.
Denies any CP, n/v/diaphoresis.
In the ED, initial VS were: 99.2 81 150/91 22 93%. He received
ctx/azith for possible pna, prednisone 60 mg po, as well as neb
alb/ipratropium. Labs reveal an elevated Trop at 0.6, CKMB at
15, normal MBI, and a conversation with the ED team is notable
that they do not suspect ACS, and as such do not feel the need
to heparinize or further treat. Peak flow in the ED after
steroids was 175. VS on transfer: 87 112/48 19 94%
Past Medical History:
ANEMIA
ASTHMA
ATRIAL FIBRILLATION on coumadin
BPH
CONGESTIVE HEART FAILURE s/p BiV Ppm (last EF in ___
DIABETES MELLITUS
DIARRHEA
END STAGE RENAL DISEASE on HD ___
ESOPHAGEAL HERNIA REPAIR
GOUT
HBP
HEMOPTYSIS
Social History:
___
Family History:
His mother and father lived well into their ___
Physical Exam:
VS: T98.4, 100/48, 97, 22, 95RA
GENERAL: chronically ill appearing
HEENT: NC/At, EOMI, sclerae anicteric, MMM
NECK: supple, JVP at 10 cm
LUNGS: rhoncorous breath sounds throughout noted; very faint
crackles in the bases, slightly decreased air mvmt, slight belly
breathing.
HEART: difficult to ascultate, no obvious MRG
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: 1+ edema ___, Right leg cooler to touch than left
NEURO: awake, A&Ox3, MAE, grossly wnl
SKIN: senile purpura extensively on extremities, with darkening
of the acral surfaces, and fragile skin
Pertinent Results:
On admission:
___ 11:50PM BLOOD WBC-7.2 RBC-3.17* Hgb-11.1* Hct-33.4*
MCV-105* MCH-34.9* MCHC-33.1 RDW-16.0* Plt ___
___ 11:50PM BLOOD ___ PTT-30.7 ___
___ 11:50PM BLOOD Glucose-95 UreaN-50* Creat-4.8* Na-141
K-4.4 Cl-91* HCO3-29 AnGap-25
___ 12:02AM BLOOD Lactate-3.3*
___ 06:13PM BLOOD freeCa-0.82*
CXR:
IMPRESSION:
Small bilateral pleural effusions and cardiomegaly.
Brief Hospital Course:
Please review the Medicine NF Admission note for additional
information. In brief, this is a ___ with h/o asthma, CAD, and
ERSD on HD originally presented with ___ days of worsening DOE
and cough productive of whitish sputum. Pt treated for presumed
COPD flare with steroids, azithromycin and nebs. His breathing
began to improve, but not back to baseline.
Around noon, patient was noted to have BRBPR x3-4 episodes. He
denied pain but it appeared to be large volume. He was not
noting any SOB, dizziness, or lightheadedness. No T&S available
and unmatched blood and FFP were ordered. He was transiently
hypotensive with BPs in the ___, which improved when fluids were
started. Additional access was in the process of being obtained
and he was transferred to the MICU.
A central line was placed and transfusions of PRBCs were
started. He was also given FFP to help reverse his
coagulopathy. Unfortunately, he continued to have BRBPR, and
his blood pressures began to drop. Pressors were started and
his family confirmed that he was DNR. He went for CTA of the
abdomen to see if there was a source for possible ___
intervention, but he continued to bleed and ultimately expired.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4-6H prn sob
2. Nephrocaps 1 CAP PO DAILY
3. budesonide *NF* 0.5 mg/2 mL Inhalation BID
4. ipratropium bromide *NF* 0.02 % Inhalation Q6hprn sob
5. Levalbuterol Neb *NF* 0.63 mg/3 mL Inhalation q6hprn sob
6. PredniSONE 5 mg PO DAILY
7. Saline Mist *NF* (sodium chloride) nebs ih qidprn dryness
8. sevelamer HYDROCHLORIDE *NF* 800 mg OTHER QDAILY
at breakfast
9. Warfarin 4 mg PO QOD
10. Acetaminophen Dose is Unknown PO Frequency is Unknown
11. Guaifenesin ER ___ mg PO Q12H
Two tablets in AM, 1 tablet at night
12. Warfarin 2 mg PO QOD
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Gastrointestinal bleeding
COPD Exacerbation
Congestive Heart Failure
ESRD on dialysis
Atrial fibrillation on coumadin
Discharge Condition:
Expired
Discharge Instructions:
Mr. ___ was admitted with SOB and treated for a presumed COPD
exacerbation. On the morning after admission, he developed large
volume bright red blood per rectum. He was transferred to the
ICU where aggressive blood and fluid resuscitation was
attempted. While in the radiology suite undergoing a CT-A to try
and localize the bleeding, he expired. His code status was
DNR/DNI.
Followup Instructions:
___
|
10757372-DS-20
| 10,757,372 | 26,957,341 |
DS
| 20 |
2116-02-11 00:00:00
|
2116-02-15 18:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transient left arm weakness and transient visual complaints
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: ___ is a ___ yo RH AAF with h/o HTN, IDDM, HLD and
PVD w claudication who presents as CODE STROKE for transient
left arm weakness.
She was in her usual state of health prior to today. In the late
afternoon, she was walking around her house when she experienced
severe leg pain, as she always does ___ claudication. This time
the pain was bilateral, which is unusual for her (usually just
in left leg). Because of the pain, she decided to go to bed and
attempt to nap. Between 1730 - 1800hrs, she lay in bed but did
not sleep. The leg pain gradually improved. At 1800hrs, she got
OOB to check her blood sugar (which was 125) and then take her
dinnertime insulin. As she walked to the kitchen toward the
fridge, she had transient "blurring" of her vision. Did not try
closing one eye or the other to see which was affected. This
resolved after a few seconds to a minute, possibly after she
blinked.
When she reached the fridge, she opened it and tried to grab her
insulin bottle with her left hand. When she grabbed it, the
bottle dropped out of her hand and onto the floor. She tried
picking it up again, but every time she did the bottle would
slip out of her hand and fall to the floor. This lasted for a
couple of minutes, then resolved. There were no associated
sensory symptoms: no numbness, no parasthesias. Her daughter was
with her throughout this episode, and states there was no facial
droop or dysarthria, no speech difficulties. She was standing up
at the time and had no leg weakness or gait problems. They
called ___, and EMS transported them to ___ ED. On arrival to
ED, a CODE STROKE was called. FSBS 200s.
Currently all of her symptoms are resolved. She complains only
of severe R calf pain and cramping.
Neuro ROS: denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal 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:
PMHx:
- HTN
- IDDM
- HLD
- Hyperaldosteronism
- Iron deficiency anemia
- Asthma
- GERD
- Gout
- Hemorrhoids
- Senile nuclear cataract
- Cystocele
Social History:
___
Family History:
+FHx aneurysm. Otherwise no family history of neurologic issues.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL EXAM:
- Vitals: 98.4 89 188/59 16 98% 0
- General: Overweight AAF in NAD, sitting upright in bed talking
comfortably with examiner. Appears uncomfortable ___ calf pain.
- 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.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Able to register
3 objects and recall ___ at 5 minutes. Good knowledge of current
events. No evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
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.
- 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: decreased pinprick in feet bilaterally. Otherwise
intact to all modalities. No No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 0
R 1 1 1 1 0
Plantar response was MUTE 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:
Notable for full visual fields and in tact EOM. Continued full
strength in left hand. Slowness in left hand on rapid
alternating movements.
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-8.4 RBC-4.62 Hgb-11.6* Hct-35.5*
MCV-77* MCH-25.1* MCHC-32.7 RDW-17.3* Plt ___
___ 08:00PM BLOOD ___ PTT-31.1 ___
___ 08:00PM BLOOD Glucose-161* UreaN-11 Creat-0.9 Na-144
K-4.4 Cl-105 HCO3-21* AnGap-22*
___ 08:00PM BLOOD %HbA1c-7.0* eAG-154*
___ 06:45AM BLOOD Triglyc-91 HDL-46 CHOL/HD-3.0 LDLcalc-72
___ 06:45AM BLOOD ALT-20 AST-24 CK(CPK)-466* AlkPhos-91
TotBili-0.2
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-6.0 RBC-4.49 Hgb-11.2* Hct-34.1*
MCV-76* MCH-24.9* MCHC-32.8 RDW-17.6* Plt ___
___ 06:45AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-145
K-4.1 Cl-108 HCO3-27 AnGap-14
UA:
___ 08:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:40PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:40PM URINE MUCOUS-RARE
___ 08:00PM CREAT-0.8
___ ECG: Artifact is present. Sinus tachycardia. Left axis
deviation. Right bundle-branch block with left anterior
fascicular block. Left ventricular hypertrophy with associated
ST-T wave changes, although ischemia or myocardial infarction
cannot be excluded. No previous tracing available for
comparison.
IMAGING:
___: CT HEAD w/o CONTRAST: IMPRESSION: No acute
intracranial abnormality. If there is high clinical suspicion
for acute stroke, MRI is more sensitive.
___: UNILAT LOWER EXT VEINS: IMPRESSION: No evidence of deep
venous thrombosis in the right lower extremity.
___: CTA HEAD/NECK w/ and w/o RECONSTRUCTION:
___: MR HEAD w/o CONTRAST:
IMPRESSION: Multiple T2/FLAIR hyperintensities in the right
frontal lobe and right parietal lobe, some of which demonstrate
faint slowness on ADC mapping most compatible with subacute
infarctions that are beginning to be visible on FLAIR and likely
related to embolic infarcts.
___: CAROTID SERIES: IMPRESSION: Findings as stated above
which indicate:
1. Approximately 40% right ICA stenosis.
2. No significant left ICA stenosis.
Please note, review of the CT angiogram was performed. The
calcific plaque in question on the right is at the skull base
and beyond the cervical carotid, which is an area not
accessible for ultrasound
___: CHEST (PA+LAT): IMPRESSION: Normal chest radiograph.
No pneumonia.
___: ECHO:Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF = 65%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Ms. ___ is a ___ right handed female with HTN, IDDM,
HLD, and PVD with claudication who presented as CODE STROKE for
transient left arm weakness and transient vision changes who was
found to have strokes in the frontal and parietal lobes on MR
concerning for emboli vs. watershed infarction.
#Ischemic stroke: Ms. ___ was found to have multiple strokes
on MR which correlated well with her symptoms of left hand
weakness. Throughout the course of her stay, she denied further
left handed weakness although maintained that her hand did not
feel entirely normal. The transient vision changes reported on
admission did not recur throughout the visit. Carotid ultrasound
and TTE with bubble were performed to identify potential embolic
source (see studies). Carotid ultrasound showed 40% right ICA
stenosis. Vascular surgery was consulted and determined that
intervention to the right ICA was not indicated based on 40%
stenosis. Patient was monitored throughout her admission on
telemetry without concering rhythm. Prior to admission, patient
took 81mg of aspirin daily. She will be transitioned to
clopidogrel going forward. She was assessed by OT who endorsed
discharge to home.
#Hypertension: Due to ischemic insult to the brain, amlodipine,
spironolactone, and losartan were held while Ms. ___ was in
house. Her blood pressure remained well controlled on labetalol
throughout her visit.
#Insulin Dependent Diabetes Mellitus: Patient's HbA1c was 7.1 on
admission. Ms. ___ was maintained on an insulin sliding
scale throughout her visit. Her metformin was held on admission.
Her blood sugars remained well controlled.
#Hypercholesterolemia: Patient's LDL was 72 on admission. Ms.
___ was maintained on her home dose of simvastatin 40mg
daily throughout her admission and she should continue in the
future for stroke prevention.
TRANSITIONAL ISSUES:
- Follow up with Dr. ___ in stroke clinic
- Consider restarting amlodipine at previous home dose (10 mg
daily) at outpatient appointment, Goal systolic BP 120-140
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 72 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lantus (insulin glargine) 100 unit/mL Subcutaneous HS
2. NovoLOG (insulin aspart) 100 unit/mL Subcutaneous BID
3. Simvastatin 40 mg PO DAILY
4. Spironolactone 100 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Labetalol 100 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Losartan Potassium 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Omeprazole Dose is Unknown PO DAILY
11. Vitamin D Dose is Unknown PO DAILY
12. Cyanocobalamin Dose is Unknown PO DAILY
13. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Labetalol 100 mg PO BID
2. Lantus (insulin glargine) 60 unit/mL SUBCUTANEOUS HS
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. NovoLOG (insulin aspart) 0 unit/mL SUBCUTANEOUS BID
6. Omeprazole 0 mg PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. Cyanocobalamin 50 mcg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. ischemic stroke
Secondary diagnosis
1. hypertension
2. diabetes
3. hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurology: mild L hand weakness and mild L hand clumsiness
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for left arm weakness and
transient blurred vision. You were found to have had several
small strokes. Your aspirin was stopped and you should take
plavix in the future for stroke prevention.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10757372-DS-22
| 10,757,372 | 29,075,794 |
DS
| 22 |
2119-01-10 00:00:00
|
2119-01-20 19:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
erythromycin base / hydrochlorothiazide / lisinopril
Attending: ___
Chief Complaint:
left-sided numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ woman with h/o R MCA
stroke, R carotid stenosis, HTN, HLD, PVD, DM2 who presents with
acute onset left sided numbness.
Around lunch time today, her left arm felt funny, but she could
still feel things. This has happened before in the past. Around
___, however, her left foot buckled. Her left foot "felt
funny" like it was hot and numb. Only the bottom of her foot was
affected, but her toes now feel stiff. She has neuropathy at
baseline, but she thought it was odd that she was unable to get
up and walk.
She denies any focal motor weakness. Denies speech difficulties,
vision changes, or headaches. Endorses increase in urinary
frequency, denies pain with urination. Denies fever, cough,
rhinorrhea, diarrhea.
She currently complains of a cramping leg pain in R quad similar
to a ___ horse."
Of note, she was seen in ___ for transient left arm
tingling without numbness or weakness. Her exam at that time
showed no deficits to light touch and reduced sensation to
pinprick in stocking distribution to mid-ankle bilaterally.
Her initial presentation to ___ was in ___ for a code stroke
where she had severe leg pain worse than baseline ___
claudication. Pain improved but then had blurry vision. Unable
to
hold things in her hand. MRI at that time showed small strokes
in
the R hemisphere in the MCA/ACA territory.
Past Medical History:
DM2, HTN, PVD, HLD, R MCA stroke, R carotid stenosis,
pancreatic cyst, asthma, gout, vaginal and rectal prolapse, has
a
stent in her L leg
Social History:
___
Family History:
father with stroke at age ___, no history of miscarriages or
blood clots
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.6F HR: 74 BP: 127/90 RR: 18 SaO2: 99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history with mild difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response mute bilaterally
- Sensory: Decreased sensation to light touch in LUE, 50%
compared to 100%. Intact to pin prick in bilateral upper
extremities, decreased in bilateral stocking-glove distribution
in lower extremities to shins. No exinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
DISCHARGE EXAMINATION:
Pertinent Results:
ADMISSION LABS: ___
WBC-5.9 Hgb-11.6 Hct-38.5 Plt ___
Glucose-113* UreaN-19 Creat-1.0 Na-141 K-4.3 Cl-106 HCO3-23
AnGap-16
Calcium-9.4 Phos-4.3 Mg-1.7
ALT-21 AST-32 AlkPhos-96 TotBili-0.2 Albumin-5.1
STox/UTox: negative
UA: bland
STROKE RISK FACTORS:
Cholest-142 Triglyc-119 HDL-39 CHOL/HD-3.6 LDLcalc-79
%HbA1c-6.2* eAG-131*
TSH-2.5
IMAGING:
MRI Brain ___
IMPRESSION:
1. There is no evidence of acute or subacute intracranial
process. No diffusion abnormalities are detected to indicate
acute or subacute ischemic changes.
2. Grossly unchanged scatter foci of T2/FLAIR high-signal
intensity identified in the subcortical and periventricular
white matter, which are nonspecific and may reflect changes due
to small vessel disease.
CAROTID DOPPLERS ___
IMPRESSION:
Less than 40% stenosis of the bilateral ICAs.
EEG ___:
IMPRESSION: This is a normal waking EEG, though the background
frequency is at the lower limit of what would be considered
acceptable in a patient of this age. No focal abnormalities or
epileptiform discharges are present. If clinically indicated,
repeat EEG with sleep recording may provide additional
information.
Brief Hospital Course:
Ms. ___ was admitted with transient inability to walk and
with unclear left lower extremity sensory vs motor deficit. MRI
showed no acute ischemic stroke nor other abnormalities. Carotid
dopplers showed <40% stenosis bilaterally, which was an
improvement from her previous study in ___. EEG was performed
which was normal with no focality or epileptiform discharges.
Her A1c and LDL were at goal on her current home medication
regimen. Her presenting symptoms are most likely due to an
exacerbation in her peripheral neuropathy symptoms. An
alternative possibility is a TIA; however her stroke risk
factors are optimized and no change to her regimen is necessary
at this time. Seizure is unlikely given the time course of the
event and there is no evidence of underlying predisposition to
seizure. She was discharged home to complete her scheduled
follow up in Stroke Neurology clinic.
==================================================
Transitional Issues:
-A 4 mm right upper lobe pulmonary nodule and a 3 mm left upper
lobe
pulmonary nodule are identified incidentally on CTA neck.
Recommend follow-up at 12 months and if no change, no further
imaging needed.
-Metformin held for 3 days after CTA; patient should resume on
___
==================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 7.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN sinus
problems
5. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
6. Labetalol 100 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Pantoprazole 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. amLODIPine 7.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN sinus
problems
7. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
8. Labetalol 100 mg PO BID
9. Losartan Potassium 100 mg PO DAILY
10. Pantoprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until ___, then restart your home dose.
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral neuropathy
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of transient inability to
walk. We are not sure why this happened, but we believe that
this was due to a brief worsening of your symptoms from
peripheral neuropathy.
Another possibility is a transient ischemic attack, a condition
where a blood vessel providing oxygen and nutrients to the brain
is temporarily blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Because you have a history of narrowing of the arteries feeding
your brain, we were worried that your symptoms could be due to a
worsening of this atherosclerosis. For this reason we looked at
the blood vessels in your neck with two different imaging tests.
We saw that the blockage was stable and the flow of blood in the
vessels was actually improved. In addition, we did an MRI and we
do not see any sign of a new stroke. This is good news!
We also looked at an EEG, looking at your brain waves to see if
there was any abnormal signal. The final report is still
pending, but this test does not show any sign concerning for
ongoing or predisposition to seizure activity. We do not think
that you had a seizure.
Stroke, such as the one you had in the past, can have many
different causes, so we re-assessed you for medical conditions
that might raise your risk of having stroke. In order to prevent
future strokes, we plan to modify those risk factors. Your risk
factors are:
high blood pressure
high cholesterol
atherosclerosis (hardening of the arteries)
We are changing your medications as follows:
No changes
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10757372-DS-24
| 10,757,372 | 26,499,597 |
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| 24 |
2122-04-19 00:00:00
|
2122-04-19 15:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
erythromycin base / hydrochlorothiazide / lisinopril
Attending: ___.
Chief Complaint:
right hand clumsiness and dysarthria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old woman with medical history
notable for hypertension, hyperlipidemia, insulin-dependent
diabetes, CKD, PVD S/P left SFA stent, prior right MCA stroke on
aspirin and Plavix who presents to the ED with acute onset of
right hand clumsiness, right leg clumsiness, and dysarthria.
Ms.
___ said she woke up feeling normal and was going about her
day in her usual state of health until approximately 10 or ___
where she noticed that she had difficulty controlling her right
hand "clumsy" as well and has difficulty walking to the
bathroom.
She called out for her daughter and she noticed that her voice
did not sound quite like herself. She had no problem thinking
of
words or understanding conversation just producing speech. Her
daughter was concerned for stroke and called an ambulance to
bring her to ___ ED.
In the ED she was found to be hypertensive to 203/71, afebrile
initial lab work was notable for negative troponin, ALP 140,
creatinine 1.4, lipase 63, lactate 3.2. NCHCT, CTA head and
neck
were ordered and are still pending at this time. She was given
1
L fluid bolus and neurology was consulted for guidance on
further
management. She was also noted to have a first-degree AV block,
left anterior fascicular block, and right bundle branch block
which according to her atrius cardiologist was similar to her
___ EKG and required no intervention. At baseline she is
completely independent in her ADLs and IADLs. She does note a
slight baseline right grip strength weakness from a prior
stroke.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties comprehending speech.
Denies focal 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. She
denies any missed doses of her medications.
Past Medical History:
- IDDM
- HTN
- PVD, stent in her L leg
- HLD
- R MCA stroke (___)
- pancreatic cyst
- asthma
- gout
- vaginal and rectal prolapse
- CKD, stage III
- Hyperaldosteronism
- R carotid stenosis,
Social History:
___
Family History:
father with stroke at age ___, no history of miscarriages or
blood clots
Physical Exam:
Physical Exam:
Vitals: T97.8, HR77, BP 203/71, RR 18 O299%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Language
is
fluent with intact repetition and comprehension. Normal prosody.
There were sparse paraphasic errors (on NIHSS card saw hammock
and said "the thing you lay in on a tree, a hamper"). Pt was
able
to name both high and low frequency objects. Able to read
without difficulty. Speech was moderately dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation. Fundoscopic
exam performed, was limited, but revealed crisp disc margins
with
no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. mild left sided intention tremor noted, chronic as
per patient and daughter. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: mild left sided intention tremor, there was right
sided slow finger tapping, right sided dysmetria on FNF testing,
mild orbiting around right arm, no HKS deficit although pain and
flexibility limited (chronic knee arthritis)
-Gait: deferred for safety
DISCHARGE EXAM
=-=-=-=-=-=-=-=-=-=-=-
Neurologic:
-Mental Status: Awake, alert, oriented. Able to relate the
history without difficulty. Able to name high and low frequency
objects.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. Some
question of limited lateral gaze to the right.
V: Facial sensation intact to light touch, cold.
VII: Right facial droop involving the forehead
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. mild left sided intention tremor noted, chronic as
per patient and daughter. No asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5 5
R 2 ___ 0 4- 5 4- 4+ 5
-Sensory: No deficits to light touch, cold
-DTRs:
Not tested
Plantar response was flexor bilaterally.
-Coordination: unable to test
-Gait: deferred for safety
Pertinent Results:
Admission Labs
=============
___ 02:00PM BLOOD WBC-7.2 RBC-4.55 Hgb-12.3 Hct-40.7 MCV-90
MCH-27.0 MCHC-30.2* RDW-15.4 RDWSD-49.8* Plt ___
___ 02:00PM BLOOD Neuts-77.3* Lymphs-15.6* Monos-4.6*
Eos-1.3 Baso-0.4 Im ___ AbsNeut-5.54 AbsLymp-1.12*
AbsMono-0.33 AbsEos-0.09 AbsBaso-0.03
___ 02:00PM BLOOD ___ PTT-32.6 ___
___ 02:00PM BLOOD Glucose-178* UreaN-17 Creat-1.4* Na-143
K-5.6* Cl-107 HCO3-17* AnGap-19*
___ 02:00PM BLOOD ALT-16 AST-17 AlkPhos-140* TotBili-0.3
___ 02:00PM BLOOD Lipase-63*
___ 02:00PM BLOOD cTropnT-<0.01
___ 02:00PM BLOOD Albumin-5.5* Calcium-10.0 Phos-3.4 Mg-1.6
___ 05:55AM BLOOD %HbA1c-8.2* eAG-189*
___ 06:38AM BLOOD Triglyc-PND HDL-PND
___ 09:40PM BLOOD TSH-2.1
___ 02:20PM BLOOD Lactate-3.2*
___ 07:09PM BLOOD Lactate-2.5*
___ 06:06AM BLOOD Lactate-1.2
Pertinent Labs
=================
___ 02:20PM BLOOD Lactate-3.2*
___ 07:09PM BLOOD Lactate-2.5*
___ 06:06AM BLOOD Lactate-1.2
___ 02:00PM BLOOD cTropnT-<0.01
___ 09:40PM BLOOD cTropnT-0.03*
___ 11:20AM BLOOD CK-MB-4 cTropnT-0.03*
___ 07:30PM BLOOD CK-MB-5 cTropnT-0.02*
___ 05:55AM BLOOD %HbA1c-8.2* eAG-189*
Imaging
=============
CTA HEAD W&W/O C & RECONS Study Date of ___ 5:50 ___
IMPRESSION:
1. Right parietal subcortical hypodensity of indeterminate age
with no
associated mass effect or intracranial hemorrhage, correlation
with MRI of the
head is recommended for further characterization.
2. Patent circle of ___ without evidence of severe
stenosis,occlusion,or
more than 3 mm aneurysm.
3. There is a calcification at right vertebral artery origin
with underlying
moderate stenosis.
4. Atherosclerotic disease and the right carotid cervical
bifurcation causing
approximately 30% of stenosis at the origin of the right
internal carotid
artery by NASCET criteria.
5. There are multiple bilateral biapical lung ground-glass
nodules.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
7:07 ___
1. No evidence of acute large territorial infarction or
intracranial
hemorrhage. Please note MRI is more sensitive for detection of
acute infarct.
2. Focus of encephalomalacia in the right parietal lobe, likely
secondary to
chronic infarct.
3. Chronic microangiopathic and involutional changes.
Radiology Report MR HEAD W/O CONTRAST Study Date of ___
5:12 ___
IMPRESSION:
1. Acute infarction of the posterior limb of the left internal
capsule.
2. Encephalomalacia in the right parietal lobe, likely sequelae
of chronic
infarction.
3. Stable chronic microangiopathic changes.
Transthoracic Echocardiogram Report
Name: ___ ___ MRN: ___ Date: ___ 24:00
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. Mild mitral and
tricuspid regurgitation. Mild pulmonary artery
systolic hypertension. No definite structural cardiac source of
embolism identified.
\
DISCHARGE LABS
===================
___ 06:38AM BLOOD WBC-9.1 RBC-4.08 Hgb-10.9* Hct-36.0
MCV-88 MCH-26.7 MCHC-30.3* RDW-15.7* RDWSD-50.2* Plt ___
___ 06:38AM BLOOD Plt ___
___ 06:38AM BLOOD ___ PTT-30.7 ___
___ 06:38AM BLOOD Glucose-244* UreaN-16 Creat-1.3* Na-145
K-4.8 Cl-109* HCO3-21* AnGap-15
___ 09:40PM BLOOD ALT-13 AST-13 CK(CPK)-200 AlkPhos-138*
TotBili-0.3
Brief Hospital Course:
Information for Outpatient Providers: Ms. ___ is an
___ woman with a
medical history notable for multiple prior strokes in various
territories on aspirin and Plavix without missed doses,
hypertension, hyperlipidemia, peripheral vascular disease S/P
stent to left SFA, insulin-dependent diabetes, CKD stage III who
presented to the ED with acute onset of clumsiness of the right
hand > right leg, as well as dysarthria. In the ED, exam notable
for moderate dysarthria, right hand dysmetria on FNF, slow right
finger taps, but no other focal weakness. On the night of
admission, her exam worsened to dense RUE paresis and
significant right facial weakness with proximal> RLE weakness.
MRI revealed with left thalamocapsular
infarct involving the genu, interestingly with minimal leg
involvement. Etiology of her stroke most certainly secondary to
her underlying chronic medical conditions and small vessel
disease leading to a small lacunar infarct. Her a1c was noted to
be 8.2. Her LDL was <70. She was able to tolerate pureed diet
with nectar thick liquids and was evaluated by ___ for rehab. She
was enrolled in the Sleep Smart Trial and was randomized to the
arm with CPAP.
TI
=========
[] A1c 8.2, she should revisit with her endocrinologist for
consideration of improvement in her blood sugar management
[] Patient continues on asa/clopidogrel
[] Patient is not entirely sure of her medication list, consider
formal med recc in the outpatient setting
[] Patient is on spironolactone and an ___, in the setting of
CKD, recommend close monitoring of her potassium. Repeat K
within one week of discharge
[] Patient discharged on nectar thick liquids diet, may require
additional IVF supplementation. Please re-evaluate swallowing at
rehab.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Labetalol 100 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Gabapentin 300 mg PO DAILY
10. amLODIPine 10 mg PO DAILY
11. Pantoprazole 20 mg PO Q24H
12. Allopurinol ___ mg PO DAILY
13. Metoprolol Tartrate 50 mg PO BID
14. Clopidogrel 75 mg PO DAILY
15. Atorvastatin 80 mg PO QPM
16. 70/30 80 Units Breakfast
70/30 55 Units Dinner
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gabapentin 300 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Tartrate 50 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Spironolactone 100 mg PO DAILY
14. HELD- 70/30 80 Units Breakfast
70/30 55 Units Dinner This medication was held. Do not restart
Insulin until you consult with your doctor
15. HELD- Labetalol 100 mg PO BID This medication was held. Do
not restart Labetalol until you talk to your doctor
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnoses
Acute ischemic stroke
Secondary diagnoses
Hypertension
Diabetes
Hyperlipidemia
Chronic kidney disease
Stroke
PAD
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 hospitalized due to symptoms of left arm weakness and
slurred speech resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms. Your stroke occurred on
the left side of your brain and a small area that controls the
muscles of your right arm and face.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
Diabetes
Hyperlipidemia
We are changing your medications as follows:
He will need to follow-up with your primary care doctor and
endocrinologist to discuss improving her diabetic control. You
are also noted to be quite hypertensive and he will need to be
monitored for possible improvement in your blood pressure
management.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10757533-DS-5
| 10,757,533 | 26,357,640 |
DS
| 5 |
2152-10-04 00:00:00
|
2152-10-05 15:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atorvastatin / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of dementia,
HTN, CKD III, pulmonary HTN, tricuspid regurgitation, and
osteoarthritis who presents to the ED s/p syncope and fall.
Patient
does not clearly remember the event, and her granddaughter is no
longer available to interview. Per EMS report and ED report,
patient's granddaughter reported that she heard the patient fall
in the bathroom and yell out. She went into the bathroom where
the patient was unresponsive and noted that she was having
irregular breathing for approximately ___ minutes. When EMS
arrived the patient was alert and responsive. However, the
granddaughter reports that she seems at her mental baseline but
seems more tired than normal. Family denies any new medications.
The patient denies any headache, blurry vision, chest pain, SOB,
N&V, abdominal pain, back pain, or dysuria.
In the ED, initial VS were: T 96.0, HR 84, BP 144/65, RR 18, 95%
RA
ECG: STE aVR, III, diffuse STD (new)
Labs showed:
CBC: WBC 13.1, Hgb 13.4, Hct 41.9, Plt 194
Lytes:
146 / 103 / 18
---------------- 142
3.6 \ 25 \ 1.2
Trop-T: <0.01 -> 0.32
Lactate:3.0 -> 1.9
Imaging showed:
- CXR with no acute cardiopulmonary process.
- CT head and c-spine with no acute changes
- CTA with pulmonary emboli involving the main pulmonary
arteries
bilaterally. Findings could suggest right heart strain which
could be further evaluated with echocardiography. No evidence of
infarct.
Following the CTA, patient was placed on heparin gtt and MASCOT
was consulted.
Transfer VS were: T 98.6, HR 103, BP 132/69, RR 18, 96%RA
On arrival to the floor, patient reports that she is feeling
very
well, and well taken care of. She reports no pain, including no
chest pain, and no difficulty breathing. Has not noticed any leg
swelling. Reports that she has never had a blood clot before.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- hypertension
- tricuspid regurgitation
- pulmonary hypertension
- CKD III
- osteoarthritis
- abnormal LFTs
- Alzheimer's disease
Social History:
___
Family History:
- Mother - chronic kidney disease
- Father - ___ artery disease
- Son - passed away around ___
- Sister - anxiety, possibly bipolar disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4, HR 104, BP 119/60, RR 18, 96%RA
GENERAL: lying in bed, well appearing, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: tachycardic with regular rhythm, S1/S2, no murmurs,
gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Temp: 97.8 (Tm 99.1), BP: 137/79 (133-154/62-84), HR: 70
(70-94), RR: 18 (___), O2 sat: 100% (94-100), O2 delivery: Ra
GENERAL: Sitting up in chair, well appearing, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, +S1/S2, ___ systolic murmur, no gallops or rubs
LUNGS: Mild inspiratory crackles at bases, Breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
ECG: STE aVR, III, diffuse STD (new)
Labs showed:
CBC: WBC 13.1, Hgb 13.4, Hct 41.9, Plt 194
Lytes:
146 / 103 / 18
---------------- 142
3.6 \ 25 \ 1.2
Trop-T: <0.01 -> 0.32--> 0.23
Lactate:3.0 -> 1.9
IMAGING:
========
- CXR with no acute cardiopulmonary process.
- CT head and c-spine with no acute changes
- CTA on ___:
FINDINGS:
HEART AND VASCULATURE: Filling defects in the distal main
pulmonary arteries bilaterally (02:32, 02:38), with extensive
involvement of the lobar pulmonary arteries of the bilateral
lower lobes (02:46). There is slight flattening of the
interventricular septum and enlargement of right heart with
contrast refluxing back into IVC and hepatic veins which could
suggest right heart strain. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma.
There is mild atherosclerotic calcifications in the aortic arch
and great vessels. 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: Other than minimal dependent atelectasis, the
lungs are clear without masses or areas of parenchymal
opacification. In the left lower lobe there is a 4 mm fissural
based pulmonary nodule (02:43), likely a lymph node. 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: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture. Degenerative changes are present in the thoracic
spine.
IMPRESSION:
1. Pulmonary emboli involving the main pulmonary arteries
bilaterally.
2. Findings could suggest right heart strain which could be
further evaluated with echocardiography. No evidence of
infarct.
- TTE on ___:
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Normal LA volume index.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease
with sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
regional/global systolic function (biplane LVEF>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 57 %). The right ventricular chamber size is mildly dilated
with mild free wall hypokinesis. 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. The mitral valve leaflets appear structurally normal
with trivial mitral regurgitation. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Mild right ventricular cavity size with mild free wall
hypokinesis. Normal left ventricular cavity size with preserved
regional and global biventricular systolic function. Moderate
tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is now greater butr the
severity of tricuspid regurgitation is now slightly reduced.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
DISCHARGE LABS:
===============
___ 07:43AM BLOOD WBC-11.4* RBC-3.43* Hgb-10.4* Hct-33.5*
MCV-98 MCH-30.3 MCHC-31.0* RDW-13.8 RDWSD-49.1* Plt ___
___ 07:43AM BLOOD ___ PTT-63.4* ___
___ 12:55PM BLOOD Glucose-157* UreaN-17 Creat-1.1 Na-141
K-4.1 Cl-100 HCO3-28 AnGap-13
___ 07:43AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.6 Mg-2.0
Iron-39
___ 07:43AM BLOOD calTIBC-241* Ferritn-126 TRF-185*
Brief Hospital Course:
Ms. ___ is a lovely ___ woman with a history of
Alzheimer's dementia, hypertension, CKD, and pulmonary
hypertension who presents after a fall at home. She was found to
have submassive bilateral pulmonary embolisms treated with
heparin gtt. She was then started on a warfarin with heparin gtt
bridge as her CKD prevented initiation of another agent. She had
bilateral LENIs that were negative for clots and TTE without
evidence of RV strain. Patient was discharged home with services
once she was therapeutic on warfarin for 2 days.
ACUTE ISSUES:
==============
#Syncope: Most likely due to PE. Trigger of PE is unclear, but
is possibly due to sedentary lifestyle at home. Echo without RV
strain, although PA pressure was notably increased. Non-contrast
head CT was negative.
# Bilateral submassive pulmonary emboli
# Elevated troponin
# ST depressions
Patient presented with a syncopal event and was found to have
bilateral PEs in main pulmonary arteries associated with ST
depressions and a trop leak. Bilateral LENIs were negative. The
trop trended down. TTE was notable for higher pulmonary
pressures but decreased TR. MASCOT was consulted, and
recommended continuing heparin gtt with transition to Apixaban.
Unfortunately, per pharmacy, Apixaban could not be started given
her renal failure. She was started on warfarin instead on ___
with heparin bridge. Her home aspirin was held given new
anticoagulation (with vascular service in agreement). Her INR
was 2.3 for two consecutive days after which IV heparin was
stopped.
#Hypernatremia (highest 150)
Patient with intermittent hypernatremia most likely in setting
of dehydration and poor PO intake as it resolved with IV fluids.
Na repeated on the day of discharge, down to 141 (from 150). No
neurologic symptoms and mentating well. The 150 thought to be
spurious since it resolved so quickly. Advised to have a repeat
BMP the day after discharge at rehab (along with INR) to ensure
Na stable.
# Hypertension
Since irbesartan (300mg) was not on formulary, patient was
started on the equivalent dose of losartan (100mg) with good
control of blood pressures. Her hydrochlorothiazide (12.5mg) was
held given patient's poor kidney function.
# Anemia
Patient's hemoglobin has slowly been trending down on heparin
gtt and warfarin. Stool guaiac was negative on ___. Most
likely downtrending in setting of frequent lab draws. Iron
studies c/w AoCD.
# Osteoarthritis
- Tylenol prn pain
- Continued home lidocaine patch
# Alzheimers
- Continued home donepezil
- Continued home olanzapine
- Continued on home lorazepam prn (as per daughter, she
tolerates it well).
#CODE: Full (confirmed)
#CONTACT:
Name of health care proxy: ___
___: Daughter
Phone number: ___
TRANSITIONAL ISSUES:
====================
[] HCTZ was held given CKD and normotension without it.
[] Losartan was started (in place of irbesartan as the latter
not on hospital formulary), additionally her irbesartan had been
in a combination pill with HCTZ so overall it was switched to
Losartan for ease of administration.
[] Patient needs close follow-up of INR (Goal INR ___. The
results should be faxed to Dr. ___. (Fax number is
(___.)
[] Patient has a scheduled follow-up with MASCOT (see above).
[] Follow-up pulmonary hypertension (measured on TTE).
[] Encourage good intake of liquids/hydration.
***[] Please re-draw basic metabolic panel on ___ and
ensure that the patient's sodium levels are stable. ___ AM was
150, rechecked a few hours later without major intervention and
was 141, with the 150 felt to be a spurious lab value in this
setting.
[] Please redraw hemoglobin within 1 week to make sure
hemoglobin does not continue to trend down. Discharge Hb: 10.4
(___).
Time spent: 50 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild
2. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. OLANZapine 2.5 mg PO DAILY
5. LORazepam 0.25 mg PO DAILY:PRN severe anxiety
6. Hydrocortisone Cream 2.5% 1 Appl TP DAILY PRN itchiness
7. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
8. Ibuprofen 400 mg PO DAILY:PRN Pain - Moderate
9. Donepezil 5 mg PO QHS
10. Aspirin 81 mg PO DAILY
11. Loratadine 10 mg PO DAILY:PRN allergies
12. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Losartan Potassium 100 mg PO DAILY
3. Senna 17.2 mg PO QHS:PRN Constipation - First Line
4. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
5. Acetaminophen 500 mg PO BID:PRN Pain - Mild
6. Donepezil 5 mg PO QHS
7. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
8. Hydrocortisone Cream 2.5% 1 Appl TP DAILY PRN itchiness
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Loratadine 10 mg PO DAILY:PRN allergies
11. LORazepam 0.25 mg PO DAILY:PRN severe anxiety
12. OLANZapine 2.5 mg PO DAILY
13. Vitamin D 5000 UNIT PO DAILY
14.Outpatient Physical Therapy
15.rolling walker
Dx: 728.87
Px: good
___: 13 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Bilateral main pulmonary artery PE
# Troponemia
# ST depressions
# Syncopal Event
# HTN
# OA
# Alzheimer's
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you!
WHY WERE YOU HERE?
==================
You were admitted to the hospital after a fall.
WHAT HAPPENED WHILE YOU WERE HERE?
==================================
You had imaging of your chest that showed blood clots in your
lungs. We started you on a medication to help prevent more clots
from forming.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
==================================
Please continue to take your new medication and follow-up with
your doctors as ___ below.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10757533-DS-6
| 10,757,533 | 22,106,172 |
DS
| 6 |
2152-10-20 00:00:00
|
2152-10-20 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atorvastatin / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Anxiety
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo F with Hx of dementia, HTN, CKD3,
Pulmonary HTN, and recent b/l PE on Coumadin who has been
admitted for anxiety. Patient recently admitted 1 month ago with
PE found after a fall. Due to CKD patient placed on heparin gtt
and bridged to Coumadin, and then sent to rehab.
Recently admitted for submassive pulmonary embolism with
troponin leak and right heart strain from ___. She was
discharged from rehab to home on ___.
After discharge home from rehab 8 days ago patient's daughter
noted she has been more "withdrawn." She has had decreasing PO
intake, whereas she used to have an excellent appetite. Has been
waking up in the middle of the night very anxious, unable to
fall back to sleep, unable to describe what is bothering her to
her daughter except to say that she feels anxious and like she
needs to walk around. This is not usual for her, usually she
falls to sleep around 7 ___, wakes up in the middle of the night
to urinate, but is able to get herself to the bathroom and back
to bed without issue, and goes back to sleep until the morning.
Notably, olanzapine, previously a home med, was stopped about 6
months ago due to family concerns it was making patient too "out
of it" but it seems to have been restarted recently and the
patient was discharged on this medication from ___. It was
then discontinued at ___ and seemed to have been doing
OK, per my review of WebOMR notes.
Daughter notes that since coming home from rehab, she has had
the patient "take it easy" and didn't send her back to the adult
daycare that the patient seems to enjoy so much. Only started
working with home ___ yesterday (7 days after discharge from
rehab), and that session went "well."
The anxiety, which has definitely been worse at night, now seems
to be increasing in the day time as well. Patient has Lorazepam
0.25 mg PO PRN once daily for anxiety, daughter reports this
helps for a few hours, but patient has recurrent anxiety
afterwards.
Of note, denies RLQ pain and daughter says that ___ been an
issue. No n/v. No abdominal pain. No diarrhea.
Past Medical History:
- hypertension
- tricuspid regurgitation
- pulmonary hypertension
- CKD III
- osteoarthritis
- abnormal LFTs
- Alzheimer dementia
- Pulmonary embolism: diagnosed with bilateral main pulmonary
artery PE and hospitalized at ___ from ___ to ___, is
currently on on systemic anticoagulation with coumadin
Social History:
___
Family History:
- Mother - chronic kidney disease
- Father - ___ artery disease
- Son - passed away around ___
- Sister - anxiety, possibly bipolar disorder
Physical Exam:
DISCHARGE EXAM
VS: afebrile during stay
Gen: NAD
HEENT: EOMI, OP clear, tongue midline, anicteric sclera
Neck: no JVD, +elevated JVP to tragus
Chest: CTAB with limited inspiratory effort
Cardiovasc: RR, ___ systolic murmur heard best at LLSB
Abd: S, NT, ND, BS+
GU: no SP tenderness or CVA tenderness to percussion
Extr: WWP, no edema, cyanosis, 2+ distal pulses, strength is
grossly normal on limited testing
Skin: no jaundice; + rash in inguinal/abdominal fold b/l
Neuro: awake, alert, oriented to person, place, and time,
conversant, poor recall
Psych: pleasant, cooperative, calm
Pertinent Results:
UA: negative for evidence of inflammation, mild proteinuria (not
new), +trace blood & 4 RBCs
Micro:
-___ BCx: no growth one day
-___ BCx: no growth one day
CXR ___ (portable)
The lungs are clear besides minimal left basilar atelectasis.
There is no effusion or edema. Cardiomediastinal silhouette is
stable. No acute osseous abnormalities.
DISCHARGE LABS
___ 07:42AM BLOOD WBC-10.2* RBC-4.14 Hgb-12.4 Hct-40.0
MCV-97 MCH-30.0 MCHC-31.0* RDW-13.2 RDWSD-47.1* Plt ___
___ 07:42AM BLOOD Glucose-112* UreaN-14 Creat-1.0 Na-146
K-3.5 Cl-103 HCO3-31 AnGap-12
___ 07:42AM BLOOD ALT-13 AST-19 AlkPhos-80 TotBili-0.9
___ 07:42AM BLOOD Albumin-4.3 Calcium-9.6 Phos-2.8 Mg-1.9
___ 07:42AM BLOOD TSH-1.8
Brief Hospital Course:
Ms. ___ is a ___ y/o female with w/ mild Alzheimer dementia,
HTN, CKD3, pulmonary HTN, and recent Dx of b/l PE on Coumadin
who presents with worsening nocturnal anxiety and insomnia, as
well as decreased PO intake and perhaps increased
lethargy/weakness in the daytime. It was suspected that she may
be having a depressive episode in the setting of
hospitalization, rehab, and then being at home without her usual
social interaction.
# Anxiety
# Insomnia
# Poor PO intake
# Fine hand tremor
# Subjective weakness
Based on history and lack of obvious infectious/metabolic
abnormalities, all of these disparate complaints were suspected
to be due to depression and anxiety. She was started on
mirtazapine 7.5 mg qHS and citalopram 10 mg daily. She tolerated
both of these well, and endorsed improved sleep and appetite
after the mirtazapine. She was seen by ___ who felt she was not
physically weaker than her reported baseline.
# Pulmonary embolism
Continue home Coumadin (2 mg daily). ___ have to decrease
Coumadin dose with initiating Mirtazipine.
TRANSITIONAL ISSUES:
- Assess tolerability of mirtazapine and citalopram. After a few
weeks, consider either increasing or stopping the low dose
citalopram, as indicated.
- Check an INR on ___ at her PCP follow up to ensure new meds
are not potentiating warfarin.
- Noted to have microscopic hematuria; consider referral for
outpatient cystoscopy if within patient's goals of care.
- Noted to have baseline leukocytosis. Please follow ___ and
consider hematology referral if it continues to rise.
Medications on Admission:
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild
2. Vitamin D 5000 UNIT PO DAILY
3. LORazepam 0.25 mg PO DAILY:PRN severe anxiety
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Donepezil 5 mg PO QHS
6. Warfarin 2 mg PO DAILY16
7. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
8. Hydrocortisone Cream 2.5% 1 Appl TP DAILY PRN itchiness
9. Losartan Potassium 100 mg PO DAILY
10. Senna 17.2 mg PO QHS:PRN Constipation - First Line
11. Docusate Sodium 100 mg PO BID
12. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Acetaminophen 500 mg PO BID:PRN Pain - Mild
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO QHS
6. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
7. Hydrocortisone Cream 2.5% 1 Appl TP DAILY PRN itchiness
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Loratadine 10 mg PO DAILY:PRN allergies
10. LORazepam 0.25 mg PO DAILY:PRN severe anxiety
11. Losartan Potassium 100 mg PO DAILY
12. Senna 17.2 mg PO QHS:PRN Constipation - First Line
13. Vitamin D 5000 UNIT PO DAILY
14. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Generalized anxiety disorder
Major depressive episode
Discharge Condition:
Mental Status: Confused - sometimes.
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 variety of issues (weak, shaky,
poor appetite, poor sleep, worrying excessively). These are
symptoms that are often seen with depression or anxiety.
We started you on MIRTAZAPINE (a gentle antidepressant that
helps also with sleep and appetite) and CITALOPRAM (a gentle
medication for anxiety and depression).
You did OK walking with the physical therapist and your labs
showed no obvious new medical problems. We think you are safe to
go home.
Followup Instructions:
___
|
10757533-DS-7
| 10,757,533 | 24,217,010 |
DS
| 7 |
2152-12-09 00:00:00
|
2152-12-09 13:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atorvastatin / Statins-Hmg-Coa Reductase Inhibitors / citalopram
/ mirtazapine
Attending: ___.
Chief Complaint:
back pain, knee pain, right hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a PMH notable for
Alzheimer's disease, CKD stage 3, and osteoarthritis who
presents
from home with worsening musculoskeletal pain.
Per ___ records, she's had a series of ED visits and
hospitalizations recently in the past few months. She was first
admitted from ___ to ___ with bilateral pulmonary emboli
leading to syncope. She was admitted from ___ to ___ after
presenting with anxiety, insomnia, and fatigue. She was seen in
the ED on ___, and ___ for evaluation of hip pain, low
back pain, and pelvic pain, which were evaluated by combination
of x-ray and CT with no positive findings. After ___ visit, she
was sent to ___ for rehabilitation. She was discharged
home on ___.
Because of the patient's advanced dementia, she wasn't able to
provide any history. I spoke with her daughter, who told me that
the patient had been doing well in terms of pain since getting
home. While at home, she's been able to get up and ambulate
independently with the aid of a cane. She's been good about
calling for help. This morning, she suddenly started complaining
of more severe pain in her back, hip, and knee after getting
back
into bed. She was in such severe pain that her daughter became
worried about her safety and brought her to the ED.
In the ED, the patient was evaluated by physical therapy, who
recommended discharge to rehab. She's now admitted for
placement.
ROS: Aside from the pains above, reported no additional
symptoms.
Notably, no chest pain, dyspnea, abdominal pain, dysuria, rash.
All other reviews of systems negative.
Past Medical History:
- hypertension
- tricuspid regurgitation
- pulmonary hypertension
- CKD III
- osteoarthritis
- abnormal LFTs
- Alzheimer dementia
- Pulmonary embolism: diagnosed with bilateral main pulmonary
artery PE and hospitalized at ___ from ___ to ___, is
currently on on systemic anticoagulation with coumadin
Social History:
___
Family History:
- Mother - chronic kidney disease
- Father - ___ artery disease
- Son - passed away around ___
- Sister - anxiety, possibly bipolar disorder
Physical Exam:
Admission Exam:
GENERAL: Alert and in mild distress.
EYES: Anicteric, normal conjunctivae. Pupils equally round.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate.
CV: Heart regular, no murmur, no S3, no S4. No peripheral edema.
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 hepatomegaly or splenomegaly.
MSK: Neck supple, moves all extremities, strength at least
antigravity and symmetric bilaterally in all limbs.
SKIN: No rashes or ulcerations noted.
NEURO: Face symmetric, gaze conjugate with EOMI, speech fluent.
Sensation to light touch grossly intact throughout.
PSYCH: Oriented to "hospital" and ___. Poor memory. Pleasant
affect.
Discharge Exam:
98.2 145 / 70 79 16 94 Ra
Gen: Thin, elderly female, appearing the most calm I have seen
her
Lung: CTA B
CV RRR
Abd: Nabs, soft, nt/nd
Neuro: Oriented to person, hospital. Cannot tell me the year,
or who the president is.
Pertinent Results:
___ 12:00PM BLOOD WBC-9.6 RBC-4.04 Hgb-12.2 Hct-39.4 MCV-98
MCH-30.2 MCHC-31.0* RDW-13.5 RDWSD-47.8* Plt ___
___ 12:00PM BLOOD Glucose-91 UreaN-19 Creat-1.4* Na-146
K-3.6 Cl-106 HCO3-27 AnGap-13
___ 07:05AM BLOOD Glucose-92 UreaN-10 Creat-1.0 Na-148*
K-3.6 Cl-103 HCO3-31 AnGap-14
___ 12:00PM BLOOD ALT-14 AST-19 AlkPhos-63 TotBili-0.7
___ 07:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.6
CXR
No acute cardiopulmonary process.
KUB: Wet read: Non specific bowel gas pattern. No fecal
loading.
Brief Hospital Course:
Ms. ___ is a ___ female with Alzheimer's disease,
CKD stage 3, and osteoarthritis who presents with worsening
chronic musculoskeletal pain.
ACUTE/ACTIVE PROBLEMS:
# Acute on Chronic Low Back, Right Hip, and Left Knee Pain
# Osteoarthritis
Symptoms appear to exacerbation of chronic MSK pain, likely
related to osteoarthritis. Will benefit from rehab placement for
strengthening. She is able to ambulate with supervision, she
felt that pain overall well controlled on present regimen to
Tylenol, low dose gabapentin and prn tramadol.
# Abdominal pain and Diarrhea: on ___ had several bms,
and then this stopped. C/o of abdominal pain on day of having
diarrhea. Unclear cause, c diff not tested as diarrhea
resolved. ___ KUB WNL and did not show fecal loading.
Abdominal pain now resolved and Abdominal exam reveals soft
abdomen.
# Dementia with ? of sundowning, difficulty sleeping,
superimposed delirium
Anxiety:
Prior notes reviewed, and patient also seen by geriatrics here.
Her olanzapine was held at recent rehab stay as it was felt it
was not helping. She was receiving prn lorazepam here for
anxiety here and trazodone at night. She frequently appeared
anxious. On night of ___ she received low dose olanzapine 2.5
mg at night for some sleeplessness/anxiety and she responded
very well to this. We will continue her on olanzapine 2.5 mg po
qhs for now, rehab can consider taking her off this. This was
discussed with her daughter who was in agreement. She can
receive trazodone qhs prn, and lorazepam prn for anxiety. If
possible, geriatrics notes that she should be tapered off her
lorazepam.
# Hypernatremia: mild, noted on day of discharge. She was
given hypotonic fluids prior to discharge, rehab should
encourage free water consumption and consider recheck of sodium.
Hypertension
# CKD Stage 3
Renal function stable and at baseline.
- Losartan Potassium 100 mg PO DAILY
# Pulmonary Embolism
Bilateral PE in ___ diagnosed in the setting of syncope.
- Apixaban 5 mg PO BID
# Goals of Care: patient is DNR/DNI, daughter has been
counseled by PCP and geriatrics regarding reduced life
expectancy due to dementia, comorbidities. Rehab, PCp should
continue goals of care conversation with the daughter.
Greater than ___ hour spent on care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
2. Gabapentin 100 mg PO QHS
3. Apixaban 5 mg PO BID
4. Vitamin D 5000 UNIT PO DAILY
5. TraZODone 50 mg PO QHS
6. Losartan Potassium 100 mg PO DAILY
7. Donepezil 5 mg PO QHS
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. LORazepam 0.5 mg PO DAILY:PRN anxiety
10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
11. Loratadine 10 mg PO DAILY:PRN allergies
12. Senna 17.2 mg PO DAILY:PRN constipation
Discharge Medications:
1. OLANZapine 2.5 mg PO QHS
2. Acetaminophen 1000 mg PO Q8H
3. Lidocaine 5% Patch 1 PTCH TD QPM
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Apixaban 5 mg PO BID
6. Donepezil 5 mg PO QHS
7. Gabapentin 100 mg PO QHS
8. Loratadine 10 mg PO DAILY:PRN allergies
9. LORazepam 0.5 mg PO DAILY:PRN anxiety
10. Losartan Potassium 100 mg PO DAILY
11. Senna 17.2 mg PO DAILY:PRN constipation
12. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
13. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Osteoarthritis
Dementia
Anxiety
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 to help get you to a rehab for
strengthening. We worked with our case managers and have now
found you a good rehab facility to go to. Overall, your pain
has been well controlled. You had some abdominal pain earlier
but this has resolved, and your xray of your abdomen looks
normal.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
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