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10757689-DS-21
| 10,757,689 | 24,715,669 |
DS
| 21 |
2115-06-26 00:00:00
|
2115-06-26 15:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilantin / contrast CT dye
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ cardiac catheterization
History of Present Illness:
Ms. ___ is a ___ F hx R posterior ICA aneurysm repair in
___,
who presented to the ___ ER for headache and cough.
In the ER she was noted to have 5 days of occasional fever,
chills, sweats, cough, sinus congestion, as well as wheezing.
The
past 3 days she has noticed constant headache similar to her
migraines prior to her aneurysm coiling. The headache was R>L
and
extended from occiput to forehead, worse with coughing.
Of note, these symptoms are in the setting of recent
intervention. She was seen by neurosurgery here and underwent a
cerebral angiogram on ___, started taking aspirin
and
Plavix 3 days ago per neurosurgery, with plan to recannalize R
ICA aneurysm on ___. Neurosurgery was consulted in the ER,
recommended CTA head and neck, which did not show any acute
findings. Of note, she was pre-medicated for the CT given her
contrast allergy. However, in light of her ongoing cough and
significant wheezing on exam, there was concern for a COPD
exacerbation. She has a distant smoking history.
In the ED, initial vitals were:
T 98.2 HR 84 BP 156/65 RR 16 O2 99% RA
- Exam notable for: lung wheezing
- Labs notable for: CBC, BMP within normal limits; Flu negative
- Imaging was notable for:
CXR: No acute intrathoracic process.
Noncontrast head CT: No acute intracranial process.
CTA neck: No evidence of occlusion, dissection, or flow limiting
stenosis.
CTA head: Status post coiling of a supraclinoid right ICA
aneurysm. Left MCA is either extremely diminutive or completely
occluded. Numerous collateral vessels are seen in the expected
location of the M1 segment of the left MCA. This is similar
compared to report from recent angiogram.
- Patient was given:
Acetaminophen, Metoclopramide, Diphenhydramine, Benzonatate,
Guaifenesin
Albuterol, ipratropium nebs x6
Methylprednisolone 50 mg x1, 125 mg x1
Azithromycin 500 mg x1
Aspirin 324 mg, Clopidogrel 75 mg
Upon arrival to the floor, patient reports again that earlier
last week she began having URI/allergic type symptoms with
congestion, cough. Started taking Claritin but symptoms
progressed. Cough incited a headache, bilateral, frontal. Had
also a 20 min episode of very tight breathing. Never had COPD
exacerbation. Had 15 pack year history but quit many years ago.
Living a very active life in ___ now without limitations
such
as SOB. Currently endorses some SOB.
Past Medical History:
-Right ICA aneurysm s/p coil (___)
-left frontal meningioma
-Schwanomatosis
-Multiple back surgeries, complicated by L foot drop
-MCA dissection
-GERD
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS:
T 98.0 PO BP 163/70 HR 81 RR 18 O2 97 RA
GENERAL: NAD, sitting comfortably in chair
HEENT: OP clear, sclera anicteric
NECK: supple
CARDIAC: RRR, soft systolic murmur best heard over RUSB
LUNGS: Very poor air movement bilaterally, minimal expiratory
wheezing, no crackles
ABDOMEN: non-tender, non-distended
EXTREMITIES: WWP
NEUROLOGIC: L foot drop, baseline.
DISCHARGE PHYSICAL EXAM:
========================
VITAL SIGNS:
___ 0750 Temp: 97.5 PO BP: 105/69 HR: 71 RR: 18 O2 sat: 97%
O2 delivery: Ra
GENERAL: NAD, sitting comfortably in chair
HEENT: OP clear, sclera anicteric, resolving hoarse voice,
tender cervical LAD
NECK: supple
CARDIAC: RRR, no MRG
LUNGS: moderate air movement bilaterally, mild wheezes
intermittently
ABDOMEN: non-tender, non-distended
EXTREMITIES: WWP, neg edema
Pertinent Results:
ADMISSION LABS:
===============
___ 06:40PM BLOOD WBC-9.5 RBC-4.26 Hgb-13.0 Hct-39.0 MCV-92
MCH-30.5 MCHC-33.3 RDW-13.2 RDWSD-43.8 Plt ___
___ 06:40PM BLOOD Neuts-67.3 ___ Monos-5.7 Eos-2.1
Baso-0.5 Im ___ AbsNeut-6.42* AbsLymp-2.30 AbsMono-0.54
AbsEos-0.20 AbsBaso-0.05
___ 06:40PM BLOOD Glucose-124* UreaN-21* Creat-0.9 Na-147
K-4.1 Cl-107 HCO3-25 AnGap-15
PERTINENT/ DISCHARGE LABS:
==========================
___ 05:35AM BLOOD WBC-11.5* RBC-3.63* Hgb-11.2 Hct-33.1*
MCV-91 MCH-30.9 MCHC-33.8 RDW-13.0 RDWSD-43.2 Plt ___
___ 08:10AM BLOOD ___ PTT-24.8* ___
___ 07:05AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-147
K-4.3 Cl-108 HCO3-26 AnGap-13
___ 11:25PM BLOOD CK-MB-6 cTropnT-<0.01
___ 08:10AM BLOOD CK-MB-6 cTropnT-<0.01
___ 05:48PM BLOOD CK-MB-6 cTropnT-<0.01
___ 11:15PM BLOOD CK-MB-7 cTropnT-<0.01
___ 08:10AM BLOOD %HbA1c-6.1* eAG-128*
___ 08:10AM BLOOD Triglyc-92 HDL-49 CHOL/HD-3.9 LDLcalc-123
___ 08:10AM BLOOD ADP-DONE Collage-DONE Arach A-DONE
IMAGING REPORTS:
================
CXR ___:
No acute intrathoracic process.
CTA HEAD AND NECK ___:
IMPRESSION:
No acute intracranial infarct, hemorrhage or mass.
The patient is status post prior coiled right paraclinoid ICA
posterior wall aneurysm. The coil results in beam hardening
artifact which obscures the immediate surroundings and reference
is made to prior angiography report of ___ which
suggested recanalization of the neck of the aneurysm.
There is severe stenosis/occlusion of the proximal left M1
segment with
reconstitution of the distal left MCA branches by collaterals.
Slightly
decreased arborization of the distal left MCA branches compared
to the right.
Small basilar artery with fetal type origins of the PCAs
bilateral.
No proximal ICA stenosis by NASCET criteria.
Dominant left vertebral artery. Diminutive right vertebral
artery which
essentially terminates as the ___.
STRESS TEST ___:
IMPRESSION: Good exercise tolerance. Atypical symptoms with
borderline
ischemic ST segment changes. Appropriate hemodynamic response to
exercise.
CATH REPORT ___:
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is short, without angiographically apparent disease.
* Left Anterior Descending
The LAD is without angiographically apparent disease.
* Circumflex
The Circumflex is without angiographically apparent disease.
* Right Coronary Artery
The RCA is without angiographically apparent disease.
Intra-procedural Complications: None
Impressions:
No angiographically apparent coronary artery disease
Normal left ventricular filling pressure
V/Q SCAN ___:
IMPRESSION: Normal lung scan.
CT SINUS ___:
IMPRESSION:
1. Study is limited by streak artifact from dental amalgam and
right ICA coil mass.
2. No evidence of fracture or soft tissue fluid collection.
3. Within limits of this noncontrast study, no definite evidence
of
maxillofacial mass. If continued concern for maxillofacial or
skullbase mass, consider dedicated contrast facial or skullbase
MRI for further evaluation
4. Paranasal sinus disease with findings concerning for acute,
chronic and/or fungal sinusitis, as described.
Mild systemic arterial hypertension
CT CHEST W/O CONTRAST:
IMPRESSION:
1. No evidence of interstitial lung disease or intrathoracic
malignancy.
2. Findings of reactive small airways disease.
3. Indeterminate 1.3 cm left adrenal nodule, statistically
likely an adenoma.
4. 2.9 x 1.1 cm lobular density within the superior medial left
breast, likely representing patchy parenchymal tissue, although
appearing slightly
asymmetric. Recommend correlation with prior screening
mammograms.
RECOMMENDATION(S): Correlation with prior screening mammograms.
MICRO STUDIES:
==============
___ 1:16 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
NO UTM RECEIVED, UNABLE TO PERFORM VIRAL CULTURE.
NOTIFIED ___ 3.50P ___.
Brief Hospital Course:
Ms. ___ is a ___ female with past medical
history MCA dissection, right posterior ICA aneurysm status post
coiling, who presents with headache, shortness of breath. She
had a negative head CT in the ER. Although she lacked a history
of COPD or reactive airway disease, her exam and clinical
picture fit a post-viral COPD/asthma exacerbation. Her symptoms
were refractory to steroids, and pulmonology was consulted, who
recommended CT imaging of her sinus and chest which were
consistent with a reactive small airway disease and sinusitis.
Her course was also complicated by chest pain, with a borderline
positive exercise tolerance test. She was taken for cardiac
catheterization, which showed clean coronaries, it was presumed
that her chest pain was related to her upper respiratory
infection.
#Shortness of breath
Patient initially presented with approximately 1 week of URI
type symptoms with sinusitis, progressing to worsening cough
with episodic wheezing. Her exam showed very poor air movement,
concerning for reactive airway disease. She has no history of
asthma, a distant 15-pack-year smoking history without formal
diagnosis of COPD or prior exacerbation, and no cardiac history.
She received IV steroids in the ER, then continued on duonebs,
albuterol nebs, transitioned to PO steroids and to complete a 6
day taper after discharge (20 mg x3 days, 10 mg x3 days). VQ
scan negative for PE. Given that her symptoms were refractory to
steroids, with minimal improvement, pulmonology was consulted.
CT chest and sinus were obtained, notable for reactive small
airway disease and sinusitis. Cough was managed by ___
___. She was discharged with albuterol, albuterol-ipratropium
inhalers, prednisone taper, and hypertonic saline nebs (neb
machine delivered to bedside), and return precautions. It was
communicated to her ___ team that pulmonary team recommended
delaying her procedure until resolution of her broncospastic
symptoms, and for formal anesthesia pre-operative evaluation.
She will follow up with ___ Pulmonology for further PFT testing.
# Chest Pressure
Had chest pressure, palpitations, and diaphoresis during
albuterol administration, resolved with SL nitro. Troponin and
CK-MB negative x2 and EKG without any ST elevations/depressions.
ETT with ST depressions inferiorly, anteriorly and chest
pressure symptoms; brought to cath on ___ with clean
coronaries. Chest pressure likely related to ongoing respiratory
pathology.
Chronic Problems:
------------------
#Right ICA aneurysm
Patient followed by neurosurgery here, CTA in the emergency
department was unremarkable for bleed. Planning for pipeline
stent placement on ___. Patient had a platelet aggregation
test which showed borderline Plavix response. After discussion
with neurosurgery, she was switched to aspirin 81 mg and
ticagrelor 90 mg twice daily. Of note ticagrelor is known to
cause worsening dyspnea as a side effect.
#GERD. Patient usually takes omeprazole, but switched recently
given recent initiation of clopidogrel. We continued home
ranitidine 150 mg twice daily
#Constipation
- Senna daily
TRANSITIONAL ISSUES:
====================
[] Please ensure patient follows up with ___ Pulmonology
[] Follow up PFT testing recommended
[] Indeterminate 1.3 cm left adrenal nodule, statistically
likely an adenoma
[] 2.9 x 1.1 cm lobular density within the superior medial left
breast, likely representing patchy parenchymal tissue, although
appearing slightly asymmetric. Recommend correlation with prior
screening mammograms.
[] If sinusitis does not improve, consider repeating sinus
imaging, given CT read which raised possibility of fungal
sinusitis (though this was felt clinically unlikely)
[] Please discuss with patient re: initiating statin given ASCVD
~11%
[] Ensure patient follows up with neurosurgery for planned
procedure on aneurysm
# CODE: full (presumed)
# CONTACT: ___ (Cell) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Senna 17.2 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Ranitidine 150 mg PO BID
6. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
Discharge Medications:
1. Albuterol 0.083% Neb Soln 0.63 mg NEB Q4H:PRN dyspnea
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 mL neb q4h PRN
Disp #*30 Vial Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, shortness of
breath
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff IH q4H PRN
Disp #*1 Inhaler Refills:*0
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30
Capsule Refills:*0
4. Dextromethorphan-Guaifenesin (Sugar Free) ___ mL PO Q6H:PRN
cough
RX *dextromethorphan-guaifenesin [Diabetic Tussin DM] 100 mg-10
mg/5 mL ___ mL by mouth q6h PRN Refills:*0
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff IH twice a day Disp #*1 Disk Refills:*0
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
RX *ipratropium-albuterol [Combivent Respimat] 20 mcg-100
mcg/actuation 1 puff IH every six (6) hours Disp #*1 Inhaler
Refills:*0
7. PredniSONE 20 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 2 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
8. PredniSONE 10 mg PO DAILY Duration: 3 Doses
This is dose # 2 of 2 tapered doses
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H
RX *sodium chloride 3 % 15 mL IH q6h PRN Disp #*30 Vial
Refills:*0
10. Sodium Chloride Nasal ___ SPRY NU BID
RX *sodium chloride [Saline Nasal] 0.65 % ___ spray in each
nostril twice a day Disp #*1 Spray Refills:*0
11. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
12. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth QHS PRN Disp #*14
Tablet Refills:*0
13. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Multivitamins 1 TAB PO DAILY
15. Ranitidine 150 mg PO BID
16. Senna 17.2 mg PO DAILY
17. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
18.Nebulizer Machine
Diagnosis: Asthma, Bronchitis
ICD Code ___
Length of Need: Indefinite
___ ___
Limited ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===============
SHORTNESS OF BREATH
REACTIVE AIRWAY DISEASE
SECONDARY DIAGNOSIS
==================
RIGHT INTERNAL CAROTID ARTERY ANEURYSM
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear ___,
It was a pleasure to care for you during your admission here
Why was I admitted to the hospital?
- You were admitted for concern of your breathing status
What happened while I was admitted?
- You had CT scans of your brain and neck, which showed no
changes.
- You were given IV and oral steroids, and nebulizer treatments.
- You were having chest pain, and had a borderline positive
stress test. He had a cardiac catheterization, which did not
show any significant coronary artery disease.
- You were seen by our pulmonologist, who recommended CT
imaging. Your CT imaging did not show any new concerning
findings.
What should I do when I leave the hospital?
- Please follow up with your neurosurgery team about delaying
your surgery while you recover from this bronchitis.
- Continue taking your medications as listed
- Follow up with your doctor appointments below
We wish you all the best,
___
Followup Instructions:
___
|
10757690-DS-17
| 10,757,690 | 23,721,517 |
DS
| 17 |
2146-05-04 00:00:00
|
2146-05-04 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ left thoracentesis
History of Present Illness:
Mr ___ is a ___ male with hx of HCV cirrhosis
(genotype 2), decompensated with acites, lower extremity edema,
esophageal varices and pleural effusions requiring thoracentesis
(last on ___, with recent admission on ___ for
decompensated cirrhosis, now transferred to ___ from ___
___ for worsening dyspnea on exertion and cough, and
abdominal fullness, over the past several days. His cough has
been non-productive of mucus or blood. He has felt some chest
heaviness with deep breathing, but denies rank chest pain,
palpitations, or lightheadedness. Denies fevers, chills, or
sweats. Has some worsening of his chronic leg swelling. His
abdomen feels more full than usual, but he denies abdominal
pain, nausea, vomiting, diarrhea, constipation, dysuria, or
hematuria. OSH labs notable for TBili/DBili 2.5/0.9, albumin
2.5, Hct 34. CXR showed large L pleural effusion. He was
transferred to ___ as this is where he receives his usual
hepatology care.
.
In the ED, initial vitals were 98.9, 100, 126/68, 16, 95% RA.
Exam notable for soft abdomen. Labs revealed hct 32, INR 1.6,
normal chem panel, Bili 2.6, albumin 2.5. CXR showed large L
pleural effusion. His case was discussed with hepatology, who
recommended admission for diuretic therapy. VS prior to transfer
were: 97, 109/74, 23, 100%2L.
.
ROS: per HPI. Also denies headache, vision changes, congestion,
sore throat, BRBPR, melena, or hematochezia.
Past Medical History:
-- Hepatitis C Genotype 2, cirrhosis, decompensated ascites,
varices, and edema
-- BPH
-- Hypertension
-- Status post cholecystectomy
-- Ataxia of unknown origin currently uses a wheelchair and a
walker
-- Right inguinal hernia s/p repair and now recurrent and
inoperable per pt
Social History:
___
Family History:
uncle with cirrhosis (likely etoh)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9, 118/53, 94, 18, 98% 3L
GENERAL: Cachectic adult male in NAD, speaking in abbreviated
sentences due to dyspnea. Otherwise appears comfortable and
appropriate
HEENT: Sclera anicteric. PERRL, EOMI. MMM
NECK: Thin, supple, no JVD or LAD
CARDIAC: Tachycardic, regular, non-displaced PMI, S1 S2 without
murmurs, rubs or gallops. No S3 or S4 appreciated
LUNGS: Minimal breath sounds halfway up left lung. + expiratory
wheeze throughout. No chest wall deformities but ribs clearly
visualized. Resp mildly labored but no accessory muscle use,
moving
ABDOMEN: Soft, full, non-distended, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly
EXTREMITIES: Symmetric 3+ edema of ___ to thighs bilaterally.
Warm, with palpable DP/radial pulses bilaterally. No asterixis
.
DISCHARGE PHYSICAL EXAM:
VS: 99.6, 92/56, 82, 18, 97% 3L
GENERAL: Cachectic NAD, Appears comfortable and appropriate
HEENT: Sclera anicteric. PERRL, EOMI. MMM
NECK: Thin, supple, no JVD or LAD
CARDIAC: RRR, S1 S2 without murmurs, rubs or gallops.
LUNGS: Comfortable on supplemental O2. Breath sounds decreased
in lower left lung field. Faint wheezing throughout.
ABDOMEN: Soft, mildly distended, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly.
EXTREMITIES: Symmetric 2+ edema of ___ to thighs bilaterally.
NEURO: Strength preserved in all limbs. No gross sensory loss.
CNIII-XII grossly intact. Dysmmetric finger to nose. No
asterixis.
Pertinent Results:
ADMISSION LABS:
___ 10:04PM BLOOD WBC-3.1* RBC-3.03* Hgb-11.3* Hct-32.1*
MCV-106* MCH-37.5* MCHC-35.3* RDW-15.6* Plt Ct-72*
___ 10:04PM BLOOD Neuts-63.8 Lymphs-15.6* Monos-16.1*
Eos-4.0 Baso-0.5
___ 10:04PM BLOOD ___ PTT-32.5 ___
___ 10:04PM BLOOD UreaN-19 Creat-1.0 Na-135 K-4.0 Cl-100
HCO3-31 AnGap-8
___ 10:04PM BLOOD ALT-32 AST-37 LD(LDH)-204 AlkPhos-79
TotBili-2.6* DirBili-1.0* IndBili-1.6
___ 10:04PM BLOOD Albumin-2.5*
.
PLEURAL FLUID:
___ 02:19PM PLEURAL WBC-150* RBC-1638* Polys-5* Lymphs-47*
Monos-5* Atyps-5* Meso-17* Macro-21*
___ 02:19PM PLEURAL TotProt-1.2 Glucose-123 LD(LDH)-63
Albumin-LESS THAN Cholest-PND Triglyc-PND
.
MICRO:
___ PLEURAL FLUID CULTURE NO GROWTH TO DATE
.
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-3.3* RBC-2.94* Hgb-10.7* Hct-31.5*
MCV-107* MCH-36.4* MCHC-34.1 RDW-15.4 Plt Ct-62*
___ 06:30AM BLOOD ___ PTT-34.3 ___
___ 06:30AM BLOOD Glucose-83 UreaN-19 Creat-1.0 Na-136
K-3.8 Cl-98 HCO3-33* AnGap-9
___ 06:30AM BLOOD ALT-30 AST-35 LD(LDH)-194 AlkPhos-69
TotBili-2.1*
___ 06:30AM BLOOD Albumin-2.1* Calcium-8.5 Phos-3.0 Mg-2.0
.
IMAGING:
___ CXR: COMPARISON: Radiograph available from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPHS:
There is a large left pleural effusion, new since ___
examination, obscuring the left hemidiaphragm and left cardiac
border. The
upper mediastinal border is within normal limits. The right lung
volume is
low. There is no right pleural effusion or right consolidation.
There is no
pneumothorax. The hepatic flexure is gas-filled, also seen on
prior chest
radiograph from ___.
IMPRESSION: New large left pleural effusion.
.
___ CT CHEST
INDICATION: ___ man with hepatitis C cirrhosis and
recurrent pleural effusion status post thoracentesis, now with
cough. Please evaluate for source of cough.
COMPARISON: Multiple prior chest radiographs, most recent
performed
approximately two hours prior.
TECHNIQUE: MDCT-acquired images were obtained through the chest
without
contrast. Coronal and sagittal reformatted images were also
displayed.
FINDINGS: A large, nonhemorrhagic, layering, left pleural
effusion has
substantially reaccumulated when compared to the chest
radiograph two hours earlier, responsible for adjacent
compressive atelectasis. Septal thickening and ground-glass
opacities in the left lower lobe and along the fissure in the
left upper lobe are most likely re-expansion pulmonary edema.
The lungs are otherwise clear.
The airways are patent. There is no mediastinal, hilar, or
axillary
lymphadenopathy. The heart size is normal.
This examination is not tailored for subdiaphragmatic
evaluation. The liver is shrunken and nodular in contour,
consistent with patient's known cirrhosis. The patient is status
post cholecystectomy. The spleen is enlarged. Large volume
ascites, nearly isodense with the left pleural effusion elevates
the right hemidiaphragm as seen on prior chest radiographs.
Stranding throughout the subcutaneous fat is consistent with
anasarca.
BONE WINDOWS: Nondisplaced rib fractures are noted of the right
lateral
seventh through ninth ribs and anterior right sixth rib and the
anterolateral aspects of the left eighth through tenth ribs.
There are no osseous lesions concerning for metastatic disease.
Loose bodies are present posterior to the right humeral head.
IMPRESSION:
1. No evidence of pneumonia. Left lung abnormality is best
explained by
re-expansion pulmonary edema.
2. Substantial reaccumulation of large left pleural effusion.
3. Cirrhotic liver, splenomegaly, and a large amount of ascites.
4. Multiple nondisplaced bilateral rib fractures as detailed
above.
Brief Hospital Course:
Mr. ___ is a ___ year old male with hepatitis c (HCV)
cirrhosis, decompensated with ascites, lower extremity edema,
pleural effusions, admitted with worsening dyspnea in setting of
new large left pleural effusion.
ACTIVE ISSUES BY PROBLEM:
# Dyspnea: His chest xray was consistent with a new large left
sided pleural effusion. This was felt to be the likely cause of
his dyspnea, with a possible contribution from ascites. He has
recently required drainage of other pleural effusions. He
underwent thoracentesis and his dyspnea improved following the
procedure. The thoracentisis fluid analysis indicated a
transudative process, most likely from his decompensated
cirrhosis/hepatic hydrothorax. He was maintained on nasal
cannula to maintain O2 sat > 93%. His home torsemide dose was
increased from 20 mg two times a day to 40 mg two times a day.
Home spironolactone was continued. Additionally, since he had
some wheezing on exam originally, he was given nebulizers as
needed.
-Has lab script for ___ to check electrolytes.
.
# Decompensated HCV cirrhosis: Genotype 2. As above, with
pleural effusions, ascites, and possible encephalopathy. Was
not worked up for transplant during this admission. Continued
lactulose 30 mg tid, not on rifaximin currently. No need for
SBP prophylaxis. No need for nadalol as no documented varices.
He did not have a significant elevation of his liver function
tests during this admission, although his total bilirubin did
rise slightly with a direct bilirubin predominance.
.
# Deconditioning: Patient is cachectic and lives alone. Prior
social worker notes indicate he has had ___ in past. He was
started on Ensure supplements with meals and physical therapy
was consulted. However, patient declined working with physical
therapy secondary to fatigue.
.
INACTIVE ISSUES BY PROBLEM:
# Hypertension: Normotensive during admission. Continued home
diuretics.
.
# BPH: Not an active issue during admission. Did not require
medications.
.
.
TRANSITIONAL ISSUES:
PROPHYLAXIS: Received SC heparin in house
CODE: Full (confirmed)
CONTACT: Patient, ___ (sister; ___
*Living situation as above, social work is aware and are
assisting
*Regarding patient's HCV, will need follow up in the liver
clinic for evaluation for treatment.
*CT of the chest final read showed multple right sided rib
fractures not concerning for malignant disease. Calcium and
phoshorus levels were normal. Should receive outpatient workup
including bone mineral density scan and possible PTH level.
Medications on Admission:
-spironolactone 100 mg daily
-camphor-menthol 0.5-0.5 % Lotion QID PRN pruritis
-lactulose 10 gram/15 mL ___ MLs PO TID
-torsemide 40 mg daily
-phytonadione 5 mg daily
-vit D 1000u daily
Discharge Medications:
1. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea, wheeze.
6. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please use if patient is bed
bound/non ambulatory. Otherwise, can hold if
exercising/walking.
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. Outpatient Lab Work
Please get a complete metabolic panel drawn on ___ and fax
results to PCP and hepatologist.
Dr. ___
PCP phone number: ___
Hepatologist
___ MD/ ___ PA
phone number: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Recurrent pleural effusion
Cirrhosis due to hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
.
You were admitted to the hospital because you were having
difficulty breathing. This is because you had an accumulation
of fluid around your lung--called a pleural effusion. This was
drained with a needle but will likely return due to your liver
disease. We have increased the amount of water pills (aka
"Diuretics") to try to keep this fluid away from the lungs. We
have arranged for you to see ___, the physician ___
for Dr. ___, in the liver department to help you with
your liver disease.
.
The following changes were made to your medications:
Increased Torsemide dose to 40 mg two times a day.
Albuterol as needed for wheezing.
.
It is very important that you keep all of the follow-up
appointments listed below. It is also important that you weigh
yourself everyday and call your doctor if your weight goes up
more than 3 lbs.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
___
|
10757690-DS-18
| 10,757,690 | 27,649,555 |
DS
| 18 |
2146-05-31 00:00:00
|
2146-05-31 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
thoracentesis (___)
Dobhoff feeding tube placement (___) and advancement by
endoscopy (___/??)
History of Present Illness:
Patient is a ___ w/HCV cirrhosis c/b esophageal varices and
recurrent hydrothorax as well as ascites but no h/o SBP, not on
transplant list who was sent in from ALF w/increased confusion.
He was oriented to ___. He was feeling ___ last night per
sister. He has had poor po intake. Pt reported slight epigastric
pain earlier today was painfree on arrival. He reports an
episode of vomiting at his ALF yesterday. He denied F/CP/SOB but
has had anorexia and weight loss lately. Of note, patient was
recently admitted in ___ with dyspnea due to a left sided
transudative pleural effusion. This was drained, and torsemide
dose was doubled. Pt's sister reports he is more confused than
normal.
.
In the ED, initial VS: 97.9 100 110/60 16 97%, pt was abdominal
pain-free, labs were significant for UA with 14 WBC and few
bacteria, trace leuk esterace positive, as well as ammonia of
63, ___ with Cr of 1.6 over baseline of 0.9-1.0. Transaminases
to 50's slightly above baseline. CXR demonstrated left pleural
effusion. RUQ US was performed which demonstrated patent portal
vasculature and no tappable pocket. Hepatology saw the patient
in the ED and recommended treatment for UTI. He received
ceftriaxone 1 gm iv x 1 ___s lactulose 10 ml x 1. VS on
transfer were: : 98.8 110/64 88 16 96%RA.
.
Overnight, the patient had no complaints. He states that he
feels back to his baseline and is not confused.
Past Medical History:
-- Hepatitis C Genotype 2, cirrhosis, decompensated ascites,
varices, and edema
-- BPH
-- Hypertension
-- Status post cholecystectomy
-- Ataxia of unknown origin currently uses a wheelchair and a
walker
-- Right inguinal hernia s/p repair and now recurrent and
inoperable per pt
Social History:
___
Family History:
uncle with cirrhosis (likely etoh)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.3 F, BP 101/57, HR 93, R 16, O2-sat 97% RA
GENERAL - wasted, chronically ill appearing man in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, sl dry MM, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, minimally TTP in periumbilical area
with, no rebound/guarding, no masses or HSM
EXTREMITIES - 2+ pedal edema 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout. no asterixis
.
DISCHARGE PHYSICAL EXAM:
VS: 97.6 88/48 95 20 99% RA
GENERAL: chronically ill appearing man in NAD, comfortable,
appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear.
Dobhoff in place.
NECK: supple, no JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: NABS, soft, non-tender, mild distension, no masses or
HSM
EXTREMITIES: trace pedal edema, 2+ peripheral pulses (DPs)
NEURO: awake, A&Ox3, no asterixis
Pertinent Results:
Admission Labs:
___ 05:45PM BLOOD WBC-4.8 RBC-3.32* Hgb-11.9* Hct-34.7*
MCV-104* MCH-35.9* MCHC-34.4 RDW-14.4 Plt Ct-92*
___ 05:45PM BLOOD Neuts-69.6 Lymphs-11.5* Monos-15.8*
Eos-2.7 Baso-0.4
___ 05:45PM BLOOD Glucose-106* UreaN-30* Creat-1.6* Na-134
K-4.7 Cl-99 HCO3-28 AnGap-12
___ 05:45PM BLOOD ALT-59* AST-58* AlkPhos-72 TotBili-2.3*
DirBili-0.9* IndBili-1.4
___ 05:45PM BLOOD Albumin-2.6*
___ 05:45PM BLOOD Ammonia-63*
___ 05:45PM BLOOD Lipase-37
Interim Labs:
___ 06:08AM BLOOD VitB12-909* Folate-9.3
___ 05:45AM BLOOD TSH-4.3*
___ 06:50AM BLOOD Free T4-1.3
___ 11:05AM BLOOD HIV Ab-PND
Urine:
___ 07:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 07:55PM URINE RBC-<1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-0
___ 07:55PM URINE CastHy-37*
___ 07:55PM URINE Mucous-OCC
___ 07:55PM URINE Hours-RANDOM UreaN-451 Creat-86 Na-58
K-64 Cl-42
___ 07:55PM URINE Osmolal-382
___ 06:32PM URINE Eos-PND
___ 06:32PM URINE Hours-RANDOM UreaN-954 Creat-111 Na-10
K-GREATER TH Cl-LESS THAN
Pleural fluid:
___ 04:45PM PLEURAL WBC-600* ___ Polys-6* Lymphs-77*
___ Meso-2* Macro-15*
___ 04:45PM PLEURAL TotProt-1.7 Glucose-137 LD(LDH)-83
Albumin-LESS THAN Cholest-24
Discharge Labs:
___ 06:05AM BLOOD WBC-3.0* RBC-2.69* Hgb-9.9* Hct-28.6*
MCV-106* MCH-36.7* MCHC-34.5 RDW-14.7 Plt Ct-71*
___ 06:05AM BLOOD ___ PTT-36.6* ___
___ 06:05AM BLOOD Glucose-94 UreaN-61* Creat-1.3* Na-133
K-4.8 Cl-100 HCO3-30 AnGap-8
___ 06:05AM BLOOD ALT-70* AST-85* AlkPhos-78 TotBili-1.2
___ 06:05AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.5
Microbiology:
___ 7:55 pm URINE Site: CLEAN CATCH
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ CULTURE - NO GROWTH
___ CULTURE - NO GROWTH
___ 4:45 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 2:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
___ year old man with a history of HCV cirrhosis c/b esophageal
varices and recurrent hydrothorax as well as ascites who
presents with AMS in the setting of decreased po intake and
likely UTI with improved MS after antibiotics and lactulose.
.
# AMS: The patient was altered at the time of admission. This
was thought to be a combination of hepatic encephalopathy and
infection. Urine culture consistent with UTI. Thoracentesis
revealed transudate without sign of infection. Lactulose
returned mental status to baseline within the first day of
admission.
.
# UTI: The patient was initially treated with Cipro. Urine
culture showed enterococcus sensitive to ampicillin. Antibiotic
coverage was changed to Augmentin for a planned 7 day course
(___). The patient denied urinary symptoms.
.
# ___: Baseline 1.0, elevated to 1.6 on admission. This was
thought to be pre-renal due to poor PO intake. Diuretics were
held and the patient was hydrated with good effect. His Cr did
not return to baseline, however, and was at 1.3 the day of
discharge. His diuretics were held on discharge to allow renal
recovery. He was scheduled for an appointment in the Liver
clinic two days following discharge to potentially restart his
diuretics to avoid volume overload.
.
# Weight loss: Patient reported substantial weight loss over
the last month, concerning for systemic cause (endocrine,
malignancy) in addition to poor appetite. Last colonoscopy
normal (per report). TSH was elevated but free T4 normal. A
Dobhoff feeding tube was placed ___ and tube feeding initiated.
HIV test pending on discharge.
.
# Shortness of breath: Pleural effusion drained ___ for over 1
L of fluid. Analysis consistent with transudate, no sign of
infection, likely ___ ascites. Patient experienced shortness of
breath after this procedure, but CXR showed no pneumothorax.
The patient rapidly recovered and had no further oxygen
requirement. His diuretics were held for renal impairment, but
may be restarted by the outpatient clinic.
.
# Hyponatremia: Baseline ___, likely hypovolemic
hyponatremia due to liver disease. Fluid restriction to 1.5L
was effective to maintain sodium level.
.
# Hyperkalemia: K 5.6 ___, received 30g kayexelate with
improvement to 4.8.
.
# Anemia: Hct 28.5, down from 34 on admission. No active
bleeding, near baseline. Macrocytic, normal folate and B12.
Resolved with treatment of UTI, no transfusion necessary.
.
# Cirrhosis: ___ HCV and EtOH. Lactulose was continued with
good effect.
.
# CODE: Full (confirmed with pt)
# CONTACT: Patient and sister
.
___ Issues:
- HIV test pending
- Consider restarting diuretics later this week
- 1 day Augmentin course remaining
Medications on Admission:
-spironolactone 100 mg BID
-lactulose 30 gram TID
-phytonadione 5 mg daily
-docusate sodium 100 mg BID
-albuterol sulfate neb q6h PRN dyspnea
-torsemide 40 mg daily
-Vitamin D 1,000 unit daily
-heparin SC TID if not ambulatory
-Zofran 4 mg po q6h prn nausea
-Hydroxyzine 12.5 mg po TID prn pruritis
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to ___ BMs/day .
2. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for wheezing, sob.
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): if not ambulatory.
7. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea.
8. hydroxyzine HCl 25 mg Tablet Sig: 0.5 Tablet PO three times a
day as needed for itching.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 1 days: through ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary:
acute renal failure
urinary tract infection
pleural effusion
malnutrition
.
secondary:
cirrhosis complicated by ascites, varices, pleural effusion, and
edema
ataxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You came to the hospital with confusion and
shortness of breath. You were found to have a recurrence of
your pleural effusion (fluid in the lung) and to have a urinary
tract infection. You were treated with a thoracentesis, a
procedure in which fluid is removed from the space around the
lung. You received antibiotics for the infection. Your mental
status rapidly improved to normal and your breathing improved.
On admission, you noted that you had lost weight over the last
month. A feeding tube was placed and was advanced with an
endoscope. You were started on tube feeding to improve your
nutrition.
We made the following changes to your medications:
- START augmentin for one more day (through ___ to complete
treatment for a UTI).
- STOP spironolactone, torsemide. Dr. ___ restart these at
a later time.
Please follow-up with your treating physicians as listed below.
You will need labwork done on ___ at your appointment with
Dr. ___.
Followup Instructions:
___
|
10757917-DS-14
| 10,757,917 | 21,853,414 |
DS
| 14 |
2183-09-24 00:00:00
|
2183-11-13 04:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors / codeine
Attending: ___.
Chief Complaint:
Elective Ileostomy Takedown
Major Surgical or Invasive Procedure:
___ Ileostomy Takedown
History of Present Illness:
Ms. ___ is a ___ woman with locally advanced
rectal cancer who underwent a robotic low anterior resection
with
diverting loop ileostomy ___ after neoadjuvant
chemoradiation. Her postop course was uneventful. She came to
the
___ ED today due to approximately ___ weeks of progressively
worsening fatigue and lethargy. She reports sleeping more than
is
typical for her, including during the day. She denies any
nausea,
vomiting, or abdominal pain. She reports "normal" output from
her
ostomy, but is unable to quantify how much she has been emptying
from her bag every day. She says she took a single dose of
lomotil yesterday, but prior to that had taken no lomotil,
psyllium, wafers, metamucil, or any other stool-bulking or
anti-motility agents for at least ___ weeks. She says her urine
color and quantity has been normal, and she denies any dysuria
or
hematuria.
She passed the pouch study. Risks and benefits including, but
not
limited to, infection, bleeding, leak, need for more
procedures, were discussed. Patient understood and agreed to
the procedure.
Past Medical History:
Atrial Fibrillation
Hyperlipidemia
Hypertension
Mild aortic stenosis
Gout
DM2 w/ diabetic neuropathy.
Social History:
___
Family History:
Myocardial infarction in both father and mother.
She had colon cancer in her distant relatives.
Physical Exam:
GEN: Alert and oriented, no acute distress, conversant and
interactive.
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear.
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy, no visible JVD.
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, nondistended, nontender, no rebound or guarding,
nontympanitic, no palpable masses, no hernias, well-healed
incisions, ostomy is pink and patent with both stool and gas in
bag.
Ext: Mild bilateral lower extremity edema, distal extremities
feel warm.
On Discharge,
Incision C/D/I without erythema, edema, or drainage
Brief Hospital Course:
The patient presented to ___ for elective ileostomy takedown.
For full
details of the procedure please see the separately dictated
operative reports. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia, including extubation, was transferred to the floor.
Her postoperative course was complicated by low blood pressure
and low urine output . The patient's home medications were
continued throughout this
hospitalization.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain
3. Losartan Potassium 100 mg PO DAILY
4. LOPERamide 2 mg PO TID:PRN ostomy output is >1200cc/day
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
6. Psyllium Wafer 1 WAF PO TID
7. Lancets,Thin (lancets) 28 gauge miscellaneous BID Use with
glucometer
8. Rivaroxaban 20 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO QPM
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Atenolol 100 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
4. Rivaroxaban 20 mg PO DAILY
5. GlipiZIDE 2.5 mg PO DAILY
RX *glipizide 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
6. Lancets,Thin (lancets) 28 gauge miscellaneous BID Use with
glucometer
7. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
___:
Acute Renal Failure now s/p ileostomy takedown
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 an ileostomy takedown.
You have recovered from this procedure well and you are now
ready to return home. You have tolerated a regular diet, passing
gas and your pain is controlled with pain medications by mouth.
You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are expected however, if you notice that you are passing bright
red blood with bowel your please seek medical attention. If you
are passing loose stool without improvement please call the
office or go to the emergency room if the symptoms are severe.
If you are taking narcotic pain medications there is a risk that
you will have some constipation. Please take an over the counter
stool softener such as Colace, and if the symptoms does not
improve call the office. It is also not uncommon after an
ileostomy takedown to have frequent loose stools until you are
taking more regular food however this should improve.
The muscles of the sphincters have not been used in quite some
time and you may experience urgency or small amounts of
incontinence however this should improve. If you do not show
improvement in these symptoms within ___ days please call the
office for advice. Occasionally, patients will need to take a
medication to slow their bowel movements as their bodies adjust
to the new normal without an ileostomy, you should consult with
our office for advice. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
You have a small wound where the old ileostomy once was. This
should be covered with a dry sterile gauze dressing. The wound
should continue to be packed with a gauze packing strip by the
visiting nurses. ___ monitor the incision for signs and
symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run over
the wound line and pat the area dry with a towel, do not rub.
Please apply a new gauze dressing after showering.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. ___ Dr. ___.
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10758024-DS-12
| 10,758,024 | 24,707,558 |
DS
| 12 |
2166-10-10 00:00:00
|
2166-10-10 16:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ male w/ HTN, DM, CAD (s/p ___ CABG),
carotid stenosis s/p ___ stroke, cognitive impairment, bipolar
d/o, and urinary retention s/p recent indwelling Foley and E
coli UTI, sent from ___ living with
hypotension.
The patient was recently admitted ___ for urinary retention
that resolved with foley placement. He failed a voiding trial so
he was discharged with a foley. He was supposed to have urology
follow up but was hospitalized prior to this appointment. At
that admission, he also had an elevated BNP and pulmonary
vascular congestion thought likely due to renal failure.
Patient was discharged with a Foley, but insisted on being
switched to a straight cath. Patient was getting straight cathed
3 times a day at ___. On ___, he started to become
hypotensive, delirious, and with pyuria. On ___, he had a
fever to ___. Blood pressures were as low as 66/42. He had a
urine culture on ___ that resulted ___ with E coli
sensitive to cefepime so he was started on 2g IV cefepime (2
doses, last given ___ am). He was also given 2L NS. He had one
fall ___ and one again on ___ if these were
witnessed. He was confused with poor oral intake and on ___,
he developed coffee ground emesis and bilious emesis x2. He
complained of fatigue, thirst, and nausea. Due to concern for
delirium and sepsis, he was sent to ___.
In the ED, initial vitals:
98.5 ___ 16 95% RA
Exam notable for:
Alert and oriented Ã2
Negative rush and fast exam
Benign cardiopulmonary exam
Benign abdomen
No spinal tenderness
Trauma survey negative
Labs notable for:
WBC 10.5, hgb 9.4, plt 211
INR 1.3
LFTs unremarkable
BMP notable for Na 136, K 4.5, HCO3 23, BUN 46, Cr 1.9
CK 177, MB 1, trop 0.04
lactate 2.4
___
UA with large leuks, negative nitrites, few bacteria, moderate
blood, WBC 167, protein 100
Imaging:
CT-Spine without contrast
No acute fracture or traumatic malalignment.
CT Head without contrast
No acute intracranial process
CXR
Mild to moderate pulmonary edema, similar to prior study.
Patient received:
IV CefePIME 2 g
IV LORazepam .5 mg
IV Vancomycin 1000 mg
IV Acetaminophen IV 1000 mg
IV OLANZapine 5 mg
IVF NS 3000 mL
Patient had femoral central line placed.
Vitals on transfer:
___ 19 96% RA
Upon arrival to ___, the patient wants to wear clothes and move
his arms. He denies chest pain, shortness of breath, abdominal
pain, or diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
CAD - CABG ___
Stroke - ___ (80-90s% stenosis R MCA CVA , treated TPA)
Cognitive impairment - alzheimers/vascular
___ edema
Urinary incontinence
Visual impairment
Cataracts (s/p lens replacement on R)
Tremor
DM2
cholecystectomy ___
history of cholangitis
HL
bipolar
HTN
constipation
insomnia
Social History:
___
Family History:
None noted.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in Metavision
GENERAL: confused, agitated
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
bilateral ___ edema
SKIN: No rashes
NEURO: intact strength on handgrip, able to move all 4
extremities,
ACCESS: Right femoral line c/d/I
DISCHARGE PHYSICAL EXAM
GEN: elderly man in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G. +presacral edema
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx2 but repeats himself and is a tangential historian.
No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:13PM BLOOD WBC-10.5* (94% polys) RBC-3.10* Hgb-9.4*
Hct-29.6* MCV-96 MCH-30.3 MCHC-31.8* RDW-15.6* RDWSD-53.6* Plt
___
___ 12:13PM BLOOD ___ PTT-30.8 ___
___ 12:13PM BLOOD Glucose-183* UreaN-46* Creat-1.9* Na-136
K-4.5 Cl-100 HCO3-23 AnGap-13
___ 12:13PM BLOOD ALT-15 AST-24 CK(CPK)-177 AlkPhos-92
TotBili-1.3
___ 12:13PM BLOOD CK-MB-1
___ 12:13PM BLOOD cTropnT-0.04*
___ 12:13PM BLOOD Albumin-2.9*
___ 09:02PM BLOOD TIBC-190* VitB12-946* Folate-6
Ferritn-729* Iron 49
___ 09:02PM BLOOD TSH-2.1
___ 12:28PM BLOOD Lactate-2.4*
DISCHARGE LABS:
===============
___ 09:30AM BLOOD WBC-9.0 RBC-2.94* Hgb-8.8* Hct-27.6*
MCV-94 MCH-29.9 MCHC-31.9* RDW-16.3* RDWSD-56.1* Plt ___
___ 09:30AM BLOOD Glucose-124* UreaN-18 Creat-1.1 Na-143
K-3.8 Cl-104 HCO3-28 AnGap-11
MICRO:
===============
Blood culture ___: ESCHERICHIA COLI
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cultures ___: NEGATIVE
IMAGING:
===============
___ CT Head without contrast
1. No acute intracranial process.
2. Chronic right basal ganglia infarct.
___: CT C spine without contrast
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes.
___: CXR
Mild to moderate pulmonary edema, similar to prior study.
Brief Hospital Course:
___ ___ male w/ HTN, DM, CAD (s/p ___ CABG),
carotid stenosis s/p ___ stroke, cognitive impairment, bipolar
d/o, and urinary retention s/p recent indwelling Foley and E
coli UTI,, now admitted with gram-negative bacteremia and
sepsis.
#SEPSIS
#URINARY TRACT INFECTION
#E COLI BACTEREMIA
#METABOLIC ENCEPHALOPATHY
Blood culture from the ED grew E coli, resistant to
fluoroquinolones. This matches the culture results on the urine
from ___, so likely this is of a urinary source.
He was septic on arrival with hypotension and confusion, but
blood pressure responded to fluids and antibiotics. He was
treated with cefepime, then converted to ceftriaxone based on
final susceptibilities. He will complete a fourteen-day course
of antibiotics via his midline.
#URINARY RETENTION
#PRESUMED BPH
His tamsulosis was reduced from 0.8 mg to 0.4 mg due to
orthostatic hypotension. He was started on finasteride. He is
discharged with a Foley in place but is encouraged to go back to
intermittent straight cath as he prefers (and if this can be
accommodated by staff at the rehab). The patient has follow up
with Urology booked and he should have a voiding trial at that
time.
#ACUTE KIDNEY INJURY
Mix of pre-renal from sepsis/hypovolemia and probable
obstructive ___ from ongoing retention. Improving after IVF and
placement of foley in ED. Creatinine 1.1 on day of discharge.
#SCROTAL PAIN
Patient complained of acute pain in his scrotum. Large hydrocele
limited exam, so obtained a scrotal ultrasound, which was fairly
normal. Symptom seemed to be self-limited.
#RECENT FALLS
Patient had falls prior to arrival, presumably in setting of
infection/hypotension, with orthostasis and delirium. Trauma
series imaging negative on arrival.
#COFFEE GROUND EMESIS
Coffee-ground emesis was documented in ___ notes.
Patient has stable HCT and is tolerating po intake. Will
continue PPI and not investigate further. Continue iron
supplementation
#CAD/carotid stenosis:
Right MCA ischemic stroke in ___. Continued on ASA. A
statin should be considered, but this was deferred for now.
#Bipolar
He continues on his home Zyprexa 7.5mg daily.
#Essential tremor and Hypertension
On propranolol 10mg daily at home; this is a small enough dose
that it likely is not really helping. Have stopped this
medication.
___ edema:
Restart home furosemide 20 mg daily at discharge. He has mild
edema from IV fluids for sepsis.
#DM
Continue home metformin.
#insomnia:
Switched trazodone to ramelteon, as trazodone seemed to cause
some delirium.
#vitamin D deficiency:
Continue vitamin D 1000 U daily PO
#Code: full code per MOLST
#HCP: granddaughter ___ ___
TRANSITIONAL ISSUES:
===================
[ ] 11 more days of CTX for UTI and bacteremia (his E coli is
resistant to Cipro and Levaquin).
[ ] voiding trial at his urology follow up (or earlier if
desired, although note that he was started on finasteride on
___, and is being treated for UTI, so he is unlikely to succeed
for a week or two).
[ ] suggest starting statin given CAD and history of stroke.
This was deferred on the assumption that it may have been tried
before. Family were unsure.
[ ] consider elective EGD for reported coffee-ground emesis
prior to arrival, as true UGI bleeding in this age group could
be a sign of upper GI malignancy
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 30 mL PO QID:PRN GI
distress
3. Aspirin 81 mg PO DAILY
4. Bengay Cream 1 Appl TP BID:PRN neck pain
5. Bisacodyl 10 mg PO DAILY
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Propranolol 10 mg PO DAILY
8. Senna 17.2 mg PO BID
9. Tamsulosin 0.8 mg PO QHS
10. TraZODone 25 mg PO BID:PRN anxiety
11. TraZODone 25 mg PO QHS
12. Ciprofloxacin 0.3% Ophth Soln ___ DROP LEFT EYE 5X/D
13. Vitamin D 1000 UNIT PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Furosemide 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO TID:PRN constipation
17. Lactulose 30 mL PO QPM
18. cyanocobalamin (vitamin B-12) 1,000 mcg/mL injection
q2months
19. Ferrous GLUCONATE 324 mg PO Q2DAYS
20. Ascorbic Acid ___ mg PO DAILY
21. OLANZapine 7.5 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H Duration: 11 Days
2. Finasteride 5 mg PO DAILY
3. Ramelteon 8 mg PO QHS
4. Senna 8.6 mg PO BID:PRN Constipation
5. Tamsulosin 0.4 mg PO QHS
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI
distress
8. Aspirin 81 mg PO DAILY
9. Bengay Cream 1 Appl TP BID:PRN neck pain
10. Bisacodyl 10 mg PR QHS:PRN constipation
11. cyanocobalamin (vitamin B-12) 1,000 mcg/mL injection
q2months
12. Ferrous GLUCONATE 324 mg PO Q2DAYS
13. Furosemide 20 mg PO DAILY
14. Lactulose 30 mL PO QPM
15. MetFORMIN (Glucophage) 500 mg PO BID
16. OLANZapine 7.5 mg PO DAILY
17. Polyethylene Glycol 17 g PO TID:PRN constipation
18. TraZODone 25 mg PO BID:PRN anxiety
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis due to E coli
UTI
Bacteremia
Metabolic encephalopathy
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 with a UTI where the bacteria
(E coli) spread to your bloodstream. You will need two weeks of
IV antibiotics for this serious infection.
Your low blood pressure and your confusion were due to sepsis in
the setting of your infection; both have improved with
antibiotic treatment.
Followup Instructions:
___
|
10758024-DS-14
| 10,758,024 | 28,955,647 |
DS
| 14 |
2167-12-29 00:00:00
|
2168-01-01 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Nausea, vomiting, constipation
Major Surgical or Invasive Procedure:
___: Sigmoidoscopy, colonic stent placement
___:
1. Laparoscopic loop sigmoid colostomy.
2. Flexible sigmoidoscopy with aborted stent retrieval.
History of Present Illness:
Mr. ___ is a ___ y/o M w/ HTN, DM, CAD (s/p ___ CABG),
carotid stenosis s/p ___ stroke, cognitive impairment, bipolar
d/o, invasive urologic mass, and urinary retention ___ BPH,
presenting now for N/V and constipation, found to have a large
bowel obstruction.
Unfortunately, most of the history is obtained from report as
patient is a poor historian, and further history could not be
collaborated.
Per report, patient developed multiple episodes of nausea and
vomiting, as well as noted a prolonged course without having a
bowel movement. He also had significant abdominal pain, prompted
the assisted living facility he resides at to call EMS.
In the ED, vital signs were stable. He had a guaiac positive
stool on rectal exam. In the setting of prolonged QTc, Ativan
was
given for Ativan. A CT abd/pelvis w/ contrast was obtained,
which
showed redemonstration of invasive ill-defined mass, however now
with worsening invasion into the rectal/anal area, resulting in
a
large bowel obstruction and diffuse dilation of the colon. ACS
differed management given the mass originates from a urologic
origin. Urology was also consulted, but also differed to ACS for
management of bowel obstruction. Thus, patient was admitted to
medicine for further management of bowel obstruction.
ED course was also complicated by mild hyperkalemia to 5.9 for
which patient received insulin/dextrose and calcium, with
appropriate improvement.
On arrival to the floor, patient is fairly somnolent and soft
spoken, but states that overall he feels much better. His N/V
has
resolved, and his abdominal pain, though still present, is
better. He denies passing any gas. He is unable to provide me
with further history about what led him to being admitted.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
CAD - CABG
Stroke - ___ (80-90s% stenosis R MCA CVA , treated TPA)
Cognitive impairment - alzheimers/vascular
___ edema
Urinary incontinence
Visual impairment
Cataracts (s/p lens replacement on R)
Tremor
DM2
cholecystectomy ___
history of cholangitis
HL
bipolar
HTN
constipation
insomnia
***Urologic mass of unclear etiology: Was first noted in
___,
with evidence of invasion into and around the prostate/bladder.
Per report, at that time patient was referred to a urologist at
an outside institution, where after discussion with the
physician
and his family, he differed further management/evaluation, and
has only been monitored since.
Social History:
___
Family History:
Reviewed and non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in OMR
GENERAL: Somnolent, but in no acute distress
HEENT: Mucus membranes dry. Soft spoken.
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNGS: CTAB
ABDOMEN: Soft, but distended. Mildly tender to palpation in all
quadrants. Ventral hernia present.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Difficult to ascertain as translator was having
difficulty hearing patient, and he was often repeating the same
statements over and over again.
Discharge Physical Exam:
VS: T: 97.7 PO BP: 174/80 R Sitting HR: 78 RR: 16 O2: 97% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation. Lap sites
with no s/s infection. Colostomy with flatus and stool in bag.
EXT: no edema b/l
Pertinent Results:
IMAGING:
___: CT Chest:
Multiple pulmonary nodules bilaterally measuring up to 1.3 cm,
concerning for metastatic disease.
___: CT Head:
1. No acute intracranial process.
2. No intracranial masses, within the limitations of
noncontrast CT.
___: KUB:
1. Mild fecal loading in the ascending colon. Visualized
air-filled loops of large bowel appear improved from CT scan
dated ___.
2. No free air.
___: CXR:
Interval mild worsening of pulmonary edema and dependent
atelectasis within the lung bases, however aspiration pneumonia
cannot be excluded. Recommend following with serial chest
x-rays.
___: KUB:
1. Nonspecific bowel gas pattern. No evidence of obstruction.
2. Rectal stent in unchanged position from prior radiograph
dated ___.
___: Right knee x-ray:
Moderate degenerative changes with evidence of tricompartmental
narrowing and
chondrocalcinosis. Small joint effusion. Extensive vascular
calcifications. No discrete lytic or sclerotic lesions
concerning for metastasis. Multiple surgical clips in the soft
tissues of the lower leg. Bone mineralization is preserved.
LABS:
___ 05:41PM K+-3.8
___ 01:09PM LACTATE-1.6 K+-5.9*
___ 12:50PM GLUCOSE-127* UREA N-39* CREAT-1.7*
SODIUM-133* POTASSIUM-8.0* CHLORIDE-101 TOTAL CO2-19* ANION
GAP-13
___ 12:50PM ALT(SGPT)-17 AST(SGOT)-70* ALK PHOS-101 TOT
BILI-0.6
___ 12:50PM LIPASE-19
___ 12:50PM ALBUMIN-3.5 CALCIUM-9.0 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 12:50PM WBC-8.3 RBC-3.56* HGB-10.4* HCT-33.3* MCV-94
MCH-29.2 MCHC-31.2* RDW-15.3 RDWSD-52.5*
___ 12:50PM NEUTS-77.1* LYMPHS-15.1* MONOS-6.3 EOS-0.7*
BASOS-0.4 IM ___ AbsNeut-6.39* AbsLymp-1.25 AbsMono-0.52
AbsEos-0.06 AbsBaso-0.03
___ 12:50PM PLT COUNT-254
___ 12:50PM ___ PTT-30.7 ___
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ year old man w/ PMHx HTN, DM, CAD (s/p ___
CABG), carotid
stenosis s/p ___ stroke, cognitive impairment, bipolar d/o,
invasive urologic mass (likely prostate cancer), and urinary
retention, who initially presented with large bowel obstruction
___ mass
effect from likely prostate cancer. Conservative management of
obstruction was attempted with rectal tube and then colonic
stenting, both unsuccessfuly. He ultimately underwent diverting
colostomy for definitive management on ___. This procedure
went well (reader, please refer to operative report for further
details). While admitted he was also treated for
infection/sepsis with a 7 day course of broad spectrum
antibiotics. Infectious source somewhat unclear but was likely
either pulmonary or urinary. The antibiotics were discontinued
as they were no longer needed. Post-operatively, discussion was
had with Gastroenterology regarding attempting removal of the
stent. The decision was made to leave the stent in place given
the fact that it had most likely already epithelialized and
removal would likely require an operation which would not be
beneficial to the patient. The patient had return of bowel
function via the ostomy and he was started on a regular diet
which he tolerated. Pain was well-controlled with
acetaminophen. The malecot drain was removed from the ostomy
prior to discharge.
ACUTE/ACTIVE ISSUES:
====================
#. Large Bowel Obstruction
Felt to be related to mass effect from likely prostate cancer,
see below). Failed trial of rectal tube, rectal stent w/ GI.
After family meetings pt underwent plan for diverting colostomy.
Also started on bicalutamide, as below, for palliative
pharmacologic treatment of mass. The stent migrated a few
centimeters proximal to the desirable place, and after weighing
risk and benefits for its removal, the decision to leave it
there was made.
# Invasive Urologic Mass
# Likely Metastatic Prostate Cancer
Per report, patient is followed by urology outpatient, and has
differed work-up for mass previously. Suspect this mass likely
represents prostate cancer, especially w/ highly elevated PSA.
CT revealing likely mets to lung. Heme/Onc was consulted for
palliatve therapy and recommended bicalutamide to shrink mass.
#Sepsis
#Likely Pneumonia vs UTI
Admission CXR w/ concern for pneumonia. Patient started on
levofloxacin which was switched to doxycycline in the setting of
long QTc. Patient was again febrile on ___ after transition to
doxy w/ concurrent hypotension raising concern for sepsis.
However, notably patient was without leukocytosis and BPs
improved prior to fluid resuscitation or broadening of abx.
Meropenem was started and then discontinued as it was no longer
needed.
#Dysphagia:
#Malnutiriton
SLP was consulted for assistance w/ palliative diet that reduces
aspiration risk.
CHRONIC/STABLE ISSUES:
======================
#T2DM
Provided sliding scale insulin with humalog
#H/o Stroke
#CAD s/p CABG
Continued home ASA 81mg
#Urinary Retention
Chronic, likely related to known urologic mass (likely prostate
cancer). Foley catheter continued. Continued home Finasteride.
Bicalutamide was started as above.
#Normocytic Hypochromic Anemia
Chronic and stable with previous lab values. Suspect likely
secondary to mass and inflammation.
#Chronic Kidney Disease
Renal function at baseline for patient.
#Rash:
Erythematous rash noted on patient's chest on admission. Felt to
possibly represent drug allergy from cephalosporin
administration. Received one dose of prednisone and symptoms
were treated with saran lotion.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL injection q2months
4. Finasteride 5 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Polyethylene Glycol 17 g PO TID:PRN constipation
7. Ramelteon 8 mg PO QHS
8. Senna 8.6 mg PO BID:PRN Constipation
9. TraZODone 50 mg PO BID:PRN anxiety
10. Vitamin D 1000 UNIT PO DAILY
11. TraMADol 25 mg PO Q8H:PRN Pain - Moderate
12. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
13. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
14. Lidocaine 5% Patch 1 PTCH TD QPM
15. Ferrous Sulfate 325 mg PO Q2DAYS
Discharge Medications:
1. bicalutamide 50 mg oral DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. cyanocobalamin (vitamin B-12) 1,000 mcg/mL injection
q2months
7. Ferrous Sulfate 325 mg PO Q2DAYS
8. Finasteride 5 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Polyethylene Glycol 17 g PO TID:PRN constipation
12. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
13. Senna 8.6 mg PO BID:PRN Constipation
14. TraMADol 25 mg PO Q8H:PRN Pain - Moderate
15. TraZODone 50 mg PO BID:PRN anxiety
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Partial large bowel obstruction.
Secondary:
Large pelvic mass involving the bladder, prostate and rectum
with extension into right ureter.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation following your bowel obstruction and underwent a
colonic stent placement on ___ followed by a laparoscopic
diverting loop sigmoid colostomy on ___. The colonic
stent migrated upwards, and it will be left in place as the
benefit of leaving the stent outweighs the risk of surgically
removing the stent. 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.
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.
Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
___
|
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| 6 |
2130-09-08 00:00:00
|
2130-09-08 15:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
___: Right burr hole for ___ evacuation
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a mild TBI. Patient states that he fell
yesterday and hit his head on the nightstand, this was witnessed
by his daughter. His other daughter and son in law are at the
bedside, and state that over the past couple of months he has
had a decline in his mental status, including confusion,
dizziness and
new difficulty with balance and gait. He takes care of his dying
wife at home, and over the past two months has had difficulty
with his memory and organizing her daily medications. His
daughter brought him to his PCP today, that ordered a MRI brain.
This showed a right sided subdural hematoma with midline
shift. He was sent to ___ for further neurosurgical
evaluation.
Past Medical History:
Glaucoma
Bilateral hip replacements - ___ years ago
Bilateral cataract removal
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION: ___
============
Physical Exam:
O: T: 97.7 BP: 137/95 HR: 77 RR: 17 O2 Sat: 99% on RA
GCS at the scene: unknown
GCS upon Neurosurgery Evaluation: 15 Time of evaluation: 1515
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: 3-2mm bilaterally - oblong d/t bilateral cataract removal
Wearing glasses
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue with slight left deviation
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Left downward drift without pronation
LUE 4+/5
RUE ___
BLE ___
Sensation: Intact to light touch
------------
ON DISCHARGE
============
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOMs: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch in all four extremities.
Wound:
[x]Clean, dry, intact
Pertinent Results:
See OMR for pertinent imaging & labs
Brief Hospital Course:
#Right Subdural Hematoma
On ___, Mr. ___ presented to the ED per his PCP after mRI
revealed a right sided mixed density SDH. HE was admitted to
___ for pre-op planning where he remained neurologically
stable. Patient was started on Keppra 500mg BID for a total of 7
days post admission for his traumatic SDH. On ___, the patient
went to the OR for right sided burr holes for evacuation of SDH.
Please see dedicated operative note for further detail. OR was
uncomplicated. Postoperatively, the patient recovered from
anesthesia in the PACU. He was transferred back to the NIMU on
POD 0. NCHCT was obtained on POD 1 that showed improvement in
midline shift and reduction of SDH. Subdural JP drain was left
in place intraoperatively which was removed on POD2. Patient was
transferred to the floor on ___ where he continued to be
monitored frequently. Patient remained neurologically intact,
intermittent headaches treated with PRN analgesics. Patient
initially with a decrease in H&H, however this was monitored
closely, remained stable and continued to increase to WNL.
Patient also developed bilateral eye irritation and was ordered
for artificial tears daily which helped improve his eye
irritation. Patient was resumed on his daily, home dose aspirin
on ___. Staples from burr hole incisions were removed on ___.
Patient continued to do well on ___. Was ambulating, tolerating
a diet and remained neurologically intact and was cleared for
discharge to a SNF on ___.
#Afib
The patient was noted to be in afib, rate controlled since he
went to the operating room on ___. On ___, a medicine
consult was obtained who recommended he follow-up with his PCP
to discus the risks and benefits of starting anticoagulation in
the setting of an intracranial hemorrhage. On ___ Medicine
recommended Patient is not a candidate for anticoagulation in
the short-term given SDH and does not appear
to be a good candidate for long-term anticoagulation given
history of severe falls. His HR remained controlled throughout
his hospitalization. He will follow-up with his PCP upon
discharge to further discuss.
#Disposition
Physical and occupational therapy evaluated patient on ___ AM
and recommended discharge to ___ rehab. Patient was
discharged on ___.
Medications on Admission:
Atorvastatin 20mg QHS, Timolol 0.5% gtt - 1 drop both eyes
daily, Calcium, ASA 81mg daily (last taken ___
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
Do not take more than 4 grams per day.
2. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry
eye/irritation
3. Bisacodyl 10 mg PO/PR DAILY
4. Docusate Sodium 100 mg PO BID
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
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 Hemorrhage with Surgery
Surgery
You underwent a surgery called a burr hole evacuation to have
blood removed from your brain.
The staples in your incision were removed while you were
inpatient.
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 (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been restarted on your daily Aspirin.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
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.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10758378-DS-6
| 10,758,378 | 26,107,082 |
DS
| 6 |
2142-08-16 00:00:00
|
2142-08-16 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
epilepsy with increased seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old right handed woman with a seizure disoder who
presents after having 2 seizures this morning. She reports that
since her discharge on ___ she had 1 seizure 2 weeks ago on a
___, and then 2 this morning. The seizure 2 weeks ago was
slightly different in that she had an "aura," which she
describes
as foggy thinking and feeling "not right" prior to the start of
the convulsions, which were witnessed by her roommate. This
morning she awoke around 6:30am, was still in her bed, when she
again had a similar aura, followed by a pulling of her head to
the left with left hemibody tingling. She was still aware of
what
was going on, but unable to speak. She had called out to her
roommate, who came in to look over her during this. After about
20 minutes her roommate tried to give her a glass of water, but
the patient was unable to swallow it correctly and it dribbled
all over her front. As she was beginning to have a typical
headache and tiredness that follows her seizures, she went back
to sleep. Around 9am she had a second seizure, this time
generallized convulsions with no preceeding symptoms that her
roommate witnessed. This lasted only a few seconds to minutes,
after which she had a headache and was sleepy. She tried to call
Dr. ___ was unable to reach him. She then called her PCP
who reached Dr. ___ asked her to come in to the ED.
She
reports that she increased her Lamictal to 50mg BID per Dr.
___ yesterday. She continues on Depakote 750mg BID
and
had a level drawn yesterday, indicating a level near 100. She
takes Xanax occasionally for anxiety, none in the past 3 days.
She reports no recent infectious symptoms or head trauma. She
reports her sleep has been improved recently, currently getting
___ hours per night. No clear new sources of stress in her life,
she did return to work last ___, but does not consider this
stressful. She reports that her mood has been euthymic recently
with no thoughts of hurting herself.
In regard to her seizure history, her first event was ___
when she had a seizure vs choking spell on the couch. She then
had a similar event that night from sleep. After having her
lamotrigine (for mood) was weaned in ___, she had a
third event/seizure in her kitchen ___. After this event
she went to ___, where she had a normal work up
including MRI brain, EEG, LP. She had an event during this stay
that was labeled as "nonepileptic" as well. She was admitted
here
___ for EEG monitoring and Keppra wean as Keppra had
worsened her mood/suicideal ideation. At that time she was
started back on Depakote and Lamictal, currently on a very slow
uptitration of the Lamictal. She was on LTM EEG during this
admission, which showed mostly generalized, frontally
predominant
13 Hz spikes and generalized, frontally predominant rhythmic ___
Hz spike or polyspike and wave discharges occasionally with a
left hemisphere predominance. It was suspected from the EEG
recordings that she has either a primary generalized epilepsy or
less likely, partial complex epilepsy with a frontal focus with
rapid spread.
As of the possible etiology of her seizure disorder, she does
reports that she had staring spells and was a daydreamer in
school. She reports she feels that she still has staring spells.
Despite this she did well in school. She also has a history of
head trauma during a car accident in childhood, as well as
hitting her head this past ___ when she slipped on black ice.
She has not had any CNS infections. Her mother had seizures ___
years ago controlled on Depakene and has some "lesion in the
brain." She did well in school and had no
developmental delay. She denies early morning jerks, sudden
episodes of fear, strange smells, rising sensations,
___.
On neuro ROS, the pt reports headache, typical of her
post-seizure headaches. She denies loss of vision, blurred
vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies vomiting, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-IBS
-Seizure disorder - per HPI
-C section at ___ years of age
-tonsilectomy in ___
-cyst removal in ___
Social History:
___
Family History:
Mother with seizure disorder, seizure free x ___ years.
No other seizure/neurologic history in the family
Physical Exam:
Vitals: T:97 P:88 R:18 BP: 115/83 SaO2:99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions or
tongue
lacs in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
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. Speech
was not dysarthric. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect. Calculation was intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 5mm to 4mm bilaterall. VFF to confrontation.
Fundoscopic exam shows sharp optic discs with venous pulsations.
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. No asterixis.
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, cold, vibration,
proprioception throughout.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
.
-Coordination: No dysmetria on FNF or HKS bilaterally.
.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk on toes, heels, and in tandem with only a
little unsteadiness.
Pertinent Results:
BASIC BLOOD WORK
___ 06:00AM BLOOD WBC-9.1 RBC-4.21 Hgb-14.1 Hct-39.7 MCV-94
MCH-33.4* MCHC-35.5* RDW-12.7 Plt ___
___ 02:15PM BLOOD Neuts-68.4 ___ Monos-6.3 Eos-2.4
Baso-0.6
___ 12:45PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-138 K-4.3
Cl-101 HCO3-26 AnGap-15
___ 12:45PM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9
___ 02:15PM BLOOD ALT-14 AST-22 AlkPhos-57 TotBili-0.2
LAMICTAL LEVEL
LAMOTRIGINE 3.5 L 4.0-18.0
mcg/mL
URINE TOX & URINALYSIS
___ 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:15PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 02:15PM URINE RBC-44* WBC-3 Bacteri-FEW Yeast-NONE
Epi-1
___ 02:15PM URINE UCG-NEGATIVE
___ 02:15PM URINE bnzodzp-POS barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
PRELIMINAR MRI (___): There is slight asymmetry of the
occipital horns, left greater than right, but within normal
physiologic limits. There is no shift of normally midline
structures. The ventricles and sulci are otherwise normal in
size. The gray-white matter differentiation is preserved. There
is no acute infarct or hemorrhage. Major vascular flow voids are
present. There is slight asymmetry of the occipital horns, left
greater than right, but within normal physiologic limits. There
is no shift of normally midline structures. The ventricles and
sulci are otherwise normal in size. The gray-white matter
differentiation is preserved. There is no acute infarct or
hemorrhage. Major vascular flow voids are present. The
hippocampal formation and signal intensity are normal and
symmetric. There is no evidence of mesial temporal sclerosis.
There is an incidental 1.1 x 1.0 x 1.3 cm pineal gland cyst,
without suspicious post-contrast enhancement. There is no
abnormal post-contrast enhancement. The visualized paranasal
sinuses and mastoid air cells are clear. The globes are
symmetric and normal. IMPRESSION: 1. No acute intracranial
process. No acute infarct, hemorrhage, or abnormal post-contrast
enhancement. 2. No evidence of cortical malformation and gray
matter heterotopia. No evidence of mesial temporal sclerosis. 3.
Incidental finding of a 1.2 cm pineal gland cyst. In the absence
of prior studies, consider long-term follow-up to establish
stability if clinically indicated.
ROUTINE EEG (___): read pending; per Dr. ___
is fine.
Brief Hospital Course:
Ms. ___ is a ___ RH woman with seizure d/o previously thought
to be generalized based on prior seizure semiology (GTCs) and
EEG (generalized ___ Spikes on interictal EEG) who presented
with increased seizure frequency (3 since last discharge, two of
which occurred on day of admission). Two of these events were
described as being concerning for partial onset seizures, as
they started with left head turning and left sensory symptoms.
Her exam on admisison was notable for clumsiness of the left
hand on RAM and FNF as well as mild weakness of the L triceps
and IP. Given this, we were concerned both that there was
actually a focal source of her epilepsy that had not been picked
up on prior MRI. We were also concerned that even though she is
currently uptitrating on Lamictal with a VPA bridge (and
reportedly had a VPA level of 100 earlier this week), she was
not well covered so started an Ativan bridge and additionally
initiated Lacosamide 50mg BID (with plans to increase as an
outpatient). We initially planned to monitor for 24 hours and
then plan for MRI as an outpatient.
Unfortunately, the patient was found confused and seeming
post-ictal on hospital day 2 after starting Ativan and
Lacosamide. Therefore, we increased Lacosamide more quickly (to
100mg BID) and got a routine EEG to look for obvious focality.
This EEG was normal per preliminary report. While she was here,
we obtained an MRI with epilepsy protocol which did not show any
concerning findings. She did not have any further events
concerning for seizures, so she was discharged with an Ativan
bridge for ___s a plan to increase Lacosamide to a
goal of 200mg BID over 6 days (by ___. She will
follow-up with her outpatient neurologist, Dr. ___ in the
next few weeks.
In addition, while here, ___ had significant headaches which
improved with Fioricet and IVF. At discharge, she did not have
headache.
Medications on Admission:
-Fiorcet PRN for headache
-Lamictal 50 mg BID (increased yesterday)
-Depakote 750mg BID
-Fluoxetine 60 mg daily
-Magnesium oxide 400 mg BID
-Xanax 0.5 mg tabs 1.5 tablets q 4 hours
Discharge Medications:
1. Divalproex (DELayed Release) 750 mg PO BID
2. Fluoxetine 60 mg PO DAILY
3. LaMOTrigine 50 mg PO BID
4. LACOSamide 200 mg PO BID
___: 100mg BID
___: 150mg BID
___: 200mg BID
RX *lacosamide [Vimpat] 100 mg see instructions tablet(s) by
mouth twice a day Disp #*120 Tablet Refills:*1
5. Lorazepam 0.5 mg PO QID
___: 0.5mg q6hr
___: 0.5mg q8hr
___: 0.5mg BID
___: 0.5mg QD then stop.
RX *lorazepam 0.5 mg see instructionse n by mouth see
instructions Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
98, 101/64, HR 64, RR 18, 100%RA
Gen: NAD
HEENT: MMM, anicteric
CV: RRR, no murmurs
Resp: CTAB
GI: +BS, soft, NTND
Ext: WWP
Neuro
MS: Awake, alert, appropriate attention and memory, speech
fluent
CN: PERRL, EOMI, no nystagmus, face symmetric
Motor: normal bulk and tone; strength ___ bilaterally
___: intact to light touch, vibration, proprioception distally
Coord: dysmetria on FNF, with slower more clumsy movements on
the left
Gait: narrow based and stable
Discharge Instructions:
Dear Ms. ___,
You were admitted to the neurology service for a cluster of
seizures and then had an additional seizure while you were here.
We decided to add a third medication called Vimpat to protect
you against seizures while your Lamictal dose is being
increased.
You will take Vimpat 100 mg (two pills) twice a day for two more
days ___ & ___ and then increase to 150mg (3pills) for three
days (___) and then increase to 200mg (4 pills) twice a day
on ___.
I addition, you will take some scheduled Ativan doses at home
while you are increasing the Vimpat. You will take 0.5mg every 6
hours for two days (___), then decrease to 0.5mg every
8hours for 3 days (___), then decrease to 0.5mg twice a day
for 3 days (___), then take 0.5mg once a day for three days
(___) and then stop. Do not take the Xanax while you are
taking Ativan.
Please continue to take your Depakote and increase your Lamictal
as previously planned.
You may feel quite sleepy while you are taking the Vimpat and
Ativan, but you should become more tolerant of these medications
over time. If you are having significant side effects, please
speak with Dr. ___. Do not stop the medications abruptly.
Please continue to follow seizure precautions as discussed
during this and the prior admission. Do not drive cars until you
have been seizure free for at least 6 months. Do not operate
heavy machinery, go into unguarded bodies of water (including
bathtubs), climb to heights greater than you are tall, or be
around hot surfaces or open flames.
Thank you.
Followup Instructions:
___
|
10758378-DS-7
| 10,758,378 | 25,098,108 |
DS
| 7 |
2142-09-13 00:00:00
|
2142-09-13 17:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
gait difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly Mrs. ___ is a ___ with hx of epilepsy with two
recent
admissions with vEEG monitoring who presented to the ED last
___ with 2 events that were concerning for seizures. She was
observed in the ED and did not have further events and was
continuing to improve and other than mild gait difficulty that
appear somewhat inconsistent she was close to her baseline and
was therefore discharged to outpatient follow up with Dr.
___.
She was told by phone yesterday to increase her vimpat to 100mg
qAM and 125mg QPM (was supposed to be on 200mg BID but did not
reach this titrated amount and reportedly continued taking 100
mg
BID). She saw him in clinic today and continued to be ataxic and
lethargic and was refered back to the ED for further management
and likely admission.
She has not had repeat seizures since ___ but continues to
feel sluggish as is "she is post-ictal".
Otherwise, she denies recent symptoms of infectious illness but
does report that she is in close proximity to sick contacts at
___.
She denies falls or trauma to the head. She continues to be
compliant with her medications.
Past Medical History:
-IBS
-Seizure disorder - per HPI
-C section at ___ years of age
-tonsilectomy in ___
-cyst removal in ___
Social History:
___
Family History:
Mother with seizure disorder, seizure free x ___ years.
No other seizure/neurologic history in the family
Physical Exam:
Physical exam:
AFVSS
GEN: NAD, sitting in bed comfortable
HEENT: neck supple, normocephalic and atraumatic,
CV: RRR
Lungs: CTA
Abd: soft, nt nd
Ext wwp, no edema
Neuro
-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. Mild intention tremor noted L>R. 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 3 2 (no clonus)
R 2 2 2 3 2 (no clonus)
Plantar response was flexor bilaterally.
-Coordination: Slight intention tremor worse on the left, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally. Mild orbiting of left hand.
-Gait: Good initiation. Romberg with sway that attenuates when
she is distracted (for instance writting on her forehead), gait
is varied with large amplitude swaying without falls, able to
stand on each foot with falling, able to balance on her toes and
heels,.
Upon discharge: Exam was unchanged with the exception that her
gait had normalized, she was able to walk steadily and had a
negative Romberg without sway.
Pertinent Results:
___ 06:15AM BLOOD WBC-7.4 RBC-4.25 Hgb-13.9 Hct-41.1 MCV-97
MCH-32.8* MCHC-33.9 RDW-12.9 Plt ___
___ 04:00PM BLOOD Neuts-64.8 ___ Monos-5.1 Eos-3.5
Baso-0.9
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-139 K-4.3
Cl-101 HCO3-29 AnGap-13
___ 06:15AM BLOOD ALT-8 AST-13 LD(LDH)-144 AlkPhos-38
TotBili-0.2
___ 06:15AM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.5# Mg-2.1
U/A negative/normal
Brief Hospital Course:
Patient was admitted from outpatient Neurology Clinic for EEG
monitoring in the setting of ataxia/unsteady gait. She was
unsure of exact medication dosing upon admisison and so got less
medication than usual (what we had in our system- only 100mg
Vimpat, and only 50mg of Lamictal). Despite this, there was no
seizure activity and her preliminary EEG read was at her
baseline: "IMPRESSION: This is an abnormal continuous EMU
monitoring study because of sleep related paroxysmal interictal
epileptic activity that appears to be generalized. There were
however no sustained events during this recording session." The
EEG read from the last 12 hours of admission is pending at the
time of discharge. The morning following admission, ___,
she felt completely better and her walking was back to baseline.
She remained neurologically at her baseline and received the
extra dose of medications when her correct dosage was figured
out (Vimpat 200mg BID and Lamictal 100mg qAM and 125mg qPM).
She was discharged on all of her home medications and will touch
base with her outpatient neurologist Dr. ___ thing on
___ morning ___.
Medications on Admission:
Divalproex (DELayed Release) 750 mg PO BID
Fluoxetine 60 mg PO DAILY
LaMOTrigine 50 mg PO BID **DOSE INCORRECT
LACOSamide 200 mg PO BID **DOSE INCORRECT
Discharge Medications:
1. Divalproex (DELayed Release) 750 mg PO BID
2. Fluoxetine 60 mg PO DAILY
3. LACOSamide 200 mg PO BID
4. LaMOTrigine 100 mg PO QAM **DOSE TO BE INCREASED BY
OUTPATIENT NEUROLOGIST
5. LaMOTrigine 125 mg PO QPM **DOSE TO BE INCREASED BY
OUTPATIENT NEUROLOGIST
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of difficulty walking
and concern for seizure activity. You EEG did not show seizure
activity and your walking was back to normal by the following
day. You are back to baseline so you are safe to go home.
Please take it easy this weekend, drink plenty of fluids and get
plenty of rest. You may return to your normal activities on
___. Please call Dr. ___ first thing ___
morning to touch base and see when he would like to follow up
with you next. Please return to the nearest emergency room for
any persistent worsening of your symptoms or new concerns for
seizure.
There was some confusion regarding the dose of your home
medications upon your admission to the hospital. We recommend
that you make an up to date list of your current home
medications, including doses and how many times a day you take
each medication, and keep a copy of this in your purse or wallet
to help prevent this confusion from happening in the future.
Followup Instructions:
___
|
10758594-DS-9
| 10,758,594 | 28,635,205 |
DS
| 9 |
2112-05-24 00:00:00
|
2112-05-28 00:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of pancreas divisum and chronic pancreatitis since last
___ p/w worsening epigastric pain x5 days, no inciting event.
States was admitted here 6 weeks ago and found to have a large
pseudocyst. No fever. + nausea and some vomiting, unable to keep
food down. No diarrhea. No dysuria. Feels like his pancreatitis.
Does not drink alcohol since last ___. Drinks ___ as well
as marijuana. Denies other illicits.
Of note he was admitted in ___ for pancreatitis. At
that time lipase was 143. He denied ETOH use at that time. ERCP
was unsuccessful at draining pseudocyst due to abnormal
pancreatic anatomy (divisum confirmed by MRCP). It was thought
this was the cause of his recurrent pancreatitis. He was treated
with aggressive IVF, bowel rest, IV to PO dilaudid. GI
recommended conservative treatment at that time.
In the ED, initial vitals were: 97.8 F, BP 140/80s, HR ___, RR
17, 98% RA
- Exam notable for: a&o, RRR, CTAB, abd soft, nd, tender in
epigastrum
no ___ edema
- Labs notable for: lactate 1.6, bland UA, Na 139, K 4, Cr 0.7,
lipase 140, WBC 9
- Imaging was notable for: RUS u/s that showed
1. No evidence of cholelithiasis or cholecystitis.
2. There is partial visualization of a heterogeneous well
circumscribed complex cystic collection measuring approximately
5.7 x 3.8 cm, likely related to the known wallled off necrotic
collection, better seen on a prior MRCP from ___.
- Patient was given: IV morphine x1, IV dilaudid 1 mg x3,
multiple liters of NS
Upon arrival to the floor, patient reports that his pain never
really stopped since his last admission. He felt like he needed
to come in yesterday because "it was flaring up bad." He denies
fever, diarrhea, bloody stool, endorses 60 lb weight loss over
the past 6 months, nausea, vomiting.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Asthma
pancreatitis
hypertension
Anxiety
Social History:
___
Family History:
Father died age ___ alcohol related causes. Mother
alive and no issues he knows of. Family history of Breast and
Rectal cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS: afebrile, 124/82, HR 62, 18, 97 RA
GENERAL: visibly uncomfortable, pleasant, NAD
HEENT: pupils 4-5 mm, reactive, EOMI, MMM
NECK: supple
CARDIAC: RRR
LUNGS: CTAB
ABDOMEN: +BS, very tender to palpation and auscultation in the
epigastric and RUQ area.
EXTREMITIES: WWP without edema
NEUROLOGIC: grossly intact
SKIN: no rashes
DISCHARGE PHYSICAL EXAM
Vitals- Tm 98.4 ___ 18 95-97RA
General- Alert, oriented, slightly distressed but conversational
HEENT- Sclera anicteric, MMM
Lungs- CTAB, no R/R/W
CARDIO - RRR, nl S1 S2, no M/R/G
Abdomen- soft, minimal epigastric tenderness (improvement from
prior days), non-distended, bowel sounds present, no ecchymoses.
Ext- warm, well perfused. no clubbing, cyanosis or edema
Neuro- motor function grossly normal
Pertinent Results:
ADMISSION LABS
------------------
___ 06:50PM BLOOD WBC-9.0# RBC-5.04 Hgb-15.3 Hct-45.9
MCV-91 MCH-30.4 MCHC-33.3 RDW-13.6 RDWSD-46.1 Plt ___
___ 06:50PM BLOOD Neuts-63.7 ___ Monos-8.8 Eos-1.4
Baso-0.6 Im ___ AbsNeut-5.72# AbsLymp-2.27 AbsMono-0.79
AbsEos-0.13 AbsBaso-0.05
___ 06:50PM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-139
K-4.0 Cl-100 HCO3-25 AnGap-18
___ 06:50PM BLOOD Albumin-4.5
___ 08:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:50PM BLOOD Lactate-1.6
___ 07:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:50PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY
----------------
___ 2:34 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
----------
RUQ ULTRASOUND ___: 1. No evidence of cholelithiasis or
cholecystitis.
2. Partial visualization of a complex cystic collection
compatible with the
previously seen walled-off necrotic collection, better evaluated
on prior MRCP
from ___.
MRCP ___: 1. Known pseudocyst is slightly smaller in this
patient with known chronic pancreatitis.
2. Pancreas divisum.
G-TUBE POSITIONING ___: Successful post-pyloric advancement
of a Dobhoff feeding tube. The tube is ready to use.
DISCHARGE/INTERVAL LABS
___ 07:40AM BLOOD WBC-4.9 RBC-4.69 Hgb-14.7 Hct-43.1 MCV-92
MCH-31.3 MCHC-34.1 RDW-13.8 RDWSD-46.9* Plt ___
___ 06:10AM BLOOD Glucose-110* UreaN-9 Creat-0.7 Na-139
K-4.1 Cl-98 HCO3-27 AnGap-18
___ 08:00AM BLOOD ALT-19 AST-14 AlkPhos-56 TotBili-0.6
___ 06:10AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
Brief Hospital Course:
Key Information for Outpatient Providers:Mr. ___ is a ___
y/o M with history of alcoholic pancreatitis and symptomatic
pseudocyst s/p ERCP drainage attempt in the past, complicated by
pancreas divisum, who presents with persistent epigastric pain.
# Abdominal pain
# Pancreatic pseudocyst. He has a history of alcoholic
pancreatitis. Although he no longer drinks alcohol, his current
presentation for abdominal pain is an acute exacerbation of his
chronic pain likely related to his pseudocyst, which has
extended into the mediastinum. Given past workup and imaging,
the ERCP team does not feel that his pseudocyst is amenable to
drainage. MRI on this admission reveals that his pseudocyst has
been decreasing in size. Patient was evaluated by ERCP while
hospitalized who recommended bowel rest with post-pyloric
feeding through an NJ tube to improve pseudocyst decompression.
He was maintained on his home Creon and Pantoprazole. For pain
relief, patient was treated with home Gabapentin, Tylenol and
Dilaudid as needed. He was evaluated by the Chronic Pain service
who recommended up-titration of his Gabapentin regimen. He will
be discharged with follow-up with Dr. ___.
# Fever. Developed a temperature to 101.4F on ___. Patient
did not endorse focal infectious symptoms, specifically denying
cough, diarrhea, or dysuria at that time. Blood and urine
cultures were sent off and are without growth to date.
CHRONIC ISSUES:
===============
# Anxiety: Continue home Xanax, Clonazepam, and Trazodone.
TRANSITIONAL ISSUES
===================
[ ] Will require NJ-tube post-pyloric tube feeds after discharge
and require additional management with Dr. ___
(appointment on ___ at 9:20 am)
[ ] Pain is likely to be a chronic issue for the patient. Advise
close follow-up with the Chronic Pain clinic after discharge and
weaning off opioids
[ ] 1. Acetaminophen 1 gram every 8 hours as needed (DO NOT take
more than 3 grams in one day). 2. Dilaudid 2 mg every four hours
as needed. 3. Gabapentin 300 mg three times per day as needed.
If this medication is making you more sleepy, please reduce how
much you are taking.
# Code: FULL CODE
# Communication: ___ ___ (wife)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H sob, wheezing
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. ClonazePAM 2 mg PO QHS
4. Creon 12 3 CAP PO TID W/MEALS
5. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN shortness of
breath, wheezing
6. Propranolol 20 mg PO BID
7. TraZODone 200 mg PO QHS:PRN insomnia
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Pantoprazole 40 mg PO QAM
10. Acetaminophen 1000 mg PO TID
11. Senna 8.6 mg PO BID
12. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q8H PRN
BREAKTHROUGH PAIN
13. terbinafine HCl 250 mg oral DAILY
14. Gabapentin 100 mg PO BID
15. Gabapentin 200 mg PO QHS
Discharge Medications:
1. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg 1 lozenge(s) by mouth q2H Disp #*16 Lozenge Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Mild
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*21 Tablet Refills:*0
3. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 3 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*2
4. Acetaminophen 1000 mg PO TID
5. Albuterol Inhaler 2 PUFF IH Q4H sob, wheezing
6. ALPRAZolam 0.5 mg PO TID:PRN anxiety
7. ClonazePAM 2 mg PO QHS
8. Creon 12 3 CAP PO TID W/MEALS
9. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN shortness of
breath, wheezing
10. Pantoprazole 40 mg PO QAM
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Propranolol 20 mg PO BID
13. Senna 8.6 mg PO BID
14. terbinafine HCl 250 mg oral DAILY
15. TraZODone 200 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic abdominal pain
Pancreatic pseudocyst
Pancreatic divisum
Secondary Diagnoses:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
You were hospitalized at ___ due to an acute flare of your
abdominal pain. We believe that your pain is related to this
pancreatic pseudocyst. As you have been informed of in the past,
this cyst cannot be drained and this is partly complicated by
the anatomy of your pancreas. Repeat imaging of the cyst does
show that it has decreased in size. We have started you on tube
feeds which have been redirected to a separate part of your GI
tract. Our hope is that this will avoid activation of your
pancreas, allowing it to rest and therefore promoting
decompression of the pseudocyst.
Given your abdominal findings, pain is likely to be a chronic
rather than acute issue. You have been treated with a variety of
pain medications and have been seen by our chronic pain service.
You will be seen by the Pain Clinic after discharge for ongoing
management of your pain.
Your pain regimen on discharge:
- Acetaminophen 1 gram every 8 hours as needed (DO NOT take more
than 3 grams in one day)
- Dilaudid 2 mg every four hours as needed
- Gabapentin 300 mg three times per day as needed. If this
medication is making you more sleepy, please reduce how much you
are taking.
It is very important that you attend your appointments listed
below.
It was a pleasure taking care of you! We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10758777-DS-23
| 10,758,777 | 25,035,558 |
DS
| 23 |
2186-09-06 00:00:00
|
2186-09-07 08:47:00
|
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 shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with JAK2 positive essential thrombocythemia,
anemia ___ beta thalassemia trait, transfusion dependent MDS,
DM2, htn, HL who presents to the ED with acute onset left
shoulder pain. Patient reports doing vigorous yoga today at the
___ followed by lunch and then bingo. While at ___,
she raised her hand and then developed intense pain in her left
shoulder. The pain began at ~ 1:30PM. She denies any trauma.
The pain was worse with any movement and got better keeping the
arm still. She denied any associated chest pressure,
palpitations, SOB, or radiation. It persisted for more than 4
hours despite tylenol. She has never had pain like this before
in the left shoulder although she does have arthritis and has
had pain in the right shoulder in the past. She also noted LUQ
pain after her shoulder pain began. She does not feel the two
are related. Her abdominal pain is pleuritic. She initially
thought it was due to constipation but the pain did not get
better after a BM. She was worried it was related to her known
splenomegaly. She could not say clearly when this pain started.
She was scheduled to have a transfusion tomorrow as an
outpatient and feels that she is due for a transfusion. She
called the Heme/Onc fellow to report her symptoms when they did
not resolve and she was referred to the ED. Of note, she was
recently seen in the ED for syncope which was thought to be
vasovagal in origin. She was treated with 7 days of Bactrim for
a UTI at that time. She had no symptoms of UTI prior to
diagnosis and she denies any current dysuria, fevers, or chills.
.
In ED, 97.7, 150/48, 71, 16, 96% RA. Exam notable for LUQ
tenderness. Labs revealed severe anemia with Hct of 18.3 from 25
on ___ and platelets of 71 down from 106. Differential with
18% bands with multiple atypical cells but this is not
inconsistent with prior draws. Cr was 1.8 close to her usual
baseline. ALT/AST elevated compared to prior but last checked
___. CXR was without free air under diaphragm nor acute
cardiopulmonary process. CT abdomen/pelvis was performed given
her abdominal pain which revealed splenomegaly without splenic
rupture. She was given tylenol ___ mg x 1 and morphine 4 mg IV x
2 with improved pain control. PRBC transfusion was initiated
and she was given 10 mg IV lasix in the ED given patient reports
of prior pulmonary edema with transfusions.
.
Currently, her shoulder pain has improved. She has more range of
motion now with less pain. Her left sided abdominal pain
persistsbut is improving as well. Of note, she has not passed
any urine since 4 pm today despite IV lasix in the ED. She does
think she has been drinking less than usual today. She denies
any fevers, chills, cough, melena, hematochezia. All other ROS
negative except as noted above.
Past Medical History:
-diabetes type II
-peripheral neuropathy
-laparoscopic cholecystectomy ___
-Anemia ___ beta thalassemia trait
-MDS
-___ thrombocytosis
-___ s/p treatment
-Type 2 diabetes diagnosed ___.
-Asthma.
-Hypertension.
-osteoporosis.
-lumbar spinal stenosis.
-hypercholesterolemia.
-s/p appendectomy at age ___.
Social History:
___
Family History:
Mother had thalassemia as well, unable to obtain additional
history
Physical Exam:
T: 97.9 BP: 142/50 HR: 58 RR: 18 O2 100% 2LNC
Gen: Pleasant, pale appearing, NAD
HEENT: (+) conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, JVP low.
CV: RRR. nl S1, S2. ___ holosys murmur
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft. TTP in L abdomen with fullness. Cannot due
complete assessment of spleen as patient requests only light
palpation. No rebound or guarding. No CVA tenderness. No
suprapubic tenderness. (+) periumbilical hernia easily
reducible.
EXT: WWP, NO CCE. Full distal pulses bilaterally. L shoulder
tender to palpation around joint with minimal pain on active and
passive range of motion.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Moving all
extremities.
Physical Exam unchanged upon discharge. Patient with less
conjunctival pallor
Pertinent Results:
___ 07:55PM BLOOD WBC-6.6 RBC-2.23* Hgb-6.3* Hct-18.3*#
MCV-82 MCH-28.1 MCHC-34.1 RDW-16.9* Plt Ct-71*
___ 08:36AM BLOOD WBC-7.2 RBC-2.82*# Hgb-8.0*# Hct-23.1*#
MCV-82 MCH-28.5 MCHC-34.9 RDW-16.4* Plt Ct-73*
___ 05:20PM BLOOD WBC-11.3*# RBC-3.04* Hgb-8.7* Hct-25.0*
MCV-82 MCH-28.8 MCHC-35.0 RDW-16.8* Plt Ct-79*
___ 06:15AM BLOOD WBC-7.2 RBC-2.84* Hgb-8.0* Hct-23.4*
MCV-82 MCH-28.0 MCHC-34.1 RDW-16.7* Plt Ct-81*
___ 06:15AM BLOOD Glucose-104* UreaN-40* Creat-1.6* Na-138
K-3.7 Cl-103 HCO3-28 AnGap-11
___:36AM BLOOD Glucose-111* UreaN-45* Creat-1.7* Na-140
K-3.9 Cl-104 HCO3-28 AnGap-12
___ 07:55PM BLOOD Glucose-236* UreaN-49* Creat-1.8* Na-136
K-4.0 Cl-100 HCO3-23 AnGap-17
___ 06:15AM BLOOD ALT-45* AST-54* LD(___)-846* AlkPhos-33*
TotBili-1.4
___ 05:20PM BLOOD LD(___)-869* TotBili-1.4 DirBili-0.6*
IndBili-0.8
___ 08:36AM BLOOD ALT-49* AST-57* AlkPhos-32* TotBili-1.3
___ 07:55PM BLOOD ALT-50* AST-58* LD(___)-800* AlkPhos-29*
TotBili-1.2
___ 06:15AM BLOOD Albumin-3.6 Calcium-8.2* Phos-5.0*#
Mg-1.4*
___ 05:20PM BLOOD calTIBC-267 Hapto-<5* Ferritn-5948*
TRF-205
___. ___ F ___ ___BDOMEN W/O CONTRAST Study Date of ___
10:02 ___
___ ___ 10:___BDOMEN W/O CONTRAST Clip # ___
Reason: eval for splenic lac/rupture, other acute pathology
Field of view: 36
UNDERLYING MEDICAL CONDITION:
___ year old woman with myelodysplastic syndrome now with LUQ
and left shoulder
pain
REASON FOR THIS EXAMINATION:
eval for splenic lac/rupture, other acute pathology
CONTRAINDICATIONS FOR IV CONTRAST:
renal failure
Wet Read: ___ ___ 11:00 ___
Splenomegaly but no splenic rupture.
Left lower renal pole cyst.
Wet Read Audit # 1
Final Report
INDICATION: ___ woman with myelodysplastic syndrome, now
with left
upper quadrant and left shoulder pain. Evaluate for splenic
laceration or
rupture.
COMPARISON: CT torso with contrast, ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen
without the
administration of IV contrast. Multiplanar reformats were
generated and
reviewed.
CT OF THE ABDOMEN: The visualized lung bases show mild
atelectasis,
prominently at the right lung base (2, 3). The visualized heart
and
pericardium are unremarkable. Trace physiologic pericardial
effusion is
noted.
Evaluation of solid organs and intra-abdominal vasculature is
limited by
non-contrast technique. Within this limitation, the liver and
bilateral
adrenal glands appear unremarkable. The patient is status post
cholecystectomy. The pancreas appears mildly atrophic.
Calcification is
noted within the splenic vessels. The right kidney appears
unremarkable. The
left kidney demonstrates a 15 mm x 12 mm hypodensity in the
lower pole of the
left kidney, likely cyst.
Trace left subdiaphragmatic fluid appears simple in appearance,
overall
decreased from prior. Retroperitoneal and mesenteric lymph nodes
do not meet
size criteria for pathologic enlargement. Intra-abdominal loops
of large and
small bowel are within normal limits. The spleen is again noted
to be
massively enlarged measuring approximately 20.1 cm in length.
There is no
evidence of splenic laceration.
Visualized osseous structures show no focal lytic or sclerotic
lesion
suspicious for malignancy. Multilevel degenerative changes are
noted within
the visualized thoracolumbar spine.
IMPRESSION: Massive splenomegaly with no evidence of splenic
rupture. Trace
left subdiaphragmatic fluid appears simple in appearance.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: WED ___ 12:02 ___
Imaging Lab
Brief Hospital Course:
Ms. ___ is a ___ year old woman with JAK2 positive essential
thrombocythemia, anemia secondary to beta thalassemia trait,
transfusion dependent MDS, DM2, HTN, HL who presented with left
shoulder pain and splenomegaly.
# LUQ pain: Likely secondary to massive splenomegaly.
Differential on admission also included UTI/Pyelonephritis and
nephrolitiasis. Urinalysis was negative for UTI or PRBC making
nephrolithaisis or pyelonephritis unlikely. Pain control was
achieved with PRN oxycodone. After consultation with Dr. ___,
___ was initiated to diminish extramedullary
hematopoiesis in the spleen. No immediate effect on massive
splenectomy on exam was appreciated, but a rapid response was
not expected.
# anemia: Secondary to underlying beta thalassemia trait and
transfusion dependent MDS. ___ dependent. Generally
requires 2 units PRBCs for Hct<23. No evidence of active
bleeding during this admission. Hct remained stable at 23 after
2 PRBC transfusions.
# shoulder pain: Likely musculoskeletal given physical exam
findings and 3 view shoulder films which demonstrate arthritic
changes. MI was ruled out with normal EKG and negative
troponins. Also likely a component of referred pain from splenic
irritation of the diaphragm. Outpatient physical therapy
evaluation may be indicated if the pain does not resolve with
treatment of hypersplenism.
Medications on Admission:
acyclovir 400 mg BID
albuterol 90 ug 2 p prior to pentamidine
norvasc 5 mg daily
atenolol 50 mg daily
budesonide 3 mg tid
flexeril 5 mg tid PRN pain
cyclosporine 75 mg QAM, 50 mg Q ___ (Gengraf)
Vitamin D2 50000u Q1wk
Fluconazole 400 mg Q24 hours
Folic acid - 4 mg daily
loperamide 2 mg 4x/day PRN diarreha
ativan ___ mg QHS PRN insomnia
mycophenolate 500 mg BID
oxycodone ___ mg q6hour
pentamidine 300 mg inhaled Q6 months
Prednisone 5 mg QD
Zantac 150 mg BID PRN
MgOxide 266 mg BID
MVI 1 tab Daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for severe pain.
Disp:*90 Tablet(s)* Refills:*0*
13. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Myelodysplastic syndrome
Essential Thrombocythemia
Chronic Kidney Disease
Diastolic congestive Heart Failure
Type II Diabetes
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 taking care of you at ___. You were
admitted with abdominal pain which is likely due to an enlarged
spleen. While you were here, we treated you with oral pain
medications, gave you 3 units of blood, and obtained an X ray of
your shoulder which ruled out a fracture. We were able to rule
out dangerous causes of pain such as a heart attack or ruptured
spleen. We also gave you a chemotherapeutic agent known as
hydroxyurea.
The following medication changes have been made:
START Oxycodone ___ every 3 hours as needed for pain
START Hydroxyurea 500mg daily
START Colace twice daily
START Senna twice daily (as needed for constipation)
Please take all other medications as directed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10758777-DS-24
| 10,758,777 | 22,988,680 |
DS
| 24 |
2187-04-16 00:00:00
|
2187-04-20 16:48:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with JAK2 positive essential thrombocythemia,
anemia ___ beta thalassemia trait, transfusion dependent MDS,
DM2, hypertensive heart disease with heart failure, diabetes,
recurrent UTI, atrial fibrillation not on anticoagulation
presenting with weakness x 2 days. She had a scheduled
transfusion in ___ clinic ___ and felt weak with difficulty
standing up the following day as well as nauseated, vomiting and
inability to tolerate PO. She also noticed shortness of breath
that began last night when she woke up to use the toilet.
Patient denies ever having dyspnea in the past. Temp 100.4 at
home. Denied any CP, cough, abdominal pain, diarrhea,
orthopnea, dysuria, skin changes, or lower ext edema.
In ED initial vitals were 98.3 88 130/70 16 98%
Labs were significant for UA with mod leuk, lg blood, >182 WBC,
few bact, 44 RBC, <1 epi; LDH 844, Tbili 1.7, Dbili 1.0, ALT 47,
AST 51
Patient was given ceftriaxone for possible UTI
Final vitals prior to transfer were 98.3, 116/35, 16, 69, 100%
ra
Access 18g R fa
IVF 1 L of NS
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
-diabetes type II
-peripheral neuropathy
-laparoscopic cholecystectomy ___
-Anemia ___ beta thalassemia trait
-MDS
-___ thrombocytosis
-___ s/p treatment
-Type 2 diabetes diagnosed ___.
-Asthma.
-Hypertension.
-osteoporosis.
-lumbar spinal stenosis.
-hypercholesterolemia.
-s/p appendectomy at age ___.
Social History:
___
Family History:
Mother had thalassemia as well, unable to obtain additional
history
Physical Exam:
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: few diffuse crackles and expiratory wheezes
ABDOMEN: LUQ tenderness to palpation, nondistended, +BS, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Discharge:
GENERAL: NAD, sitting up in chair
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: diffuse crackles in all lung fields b/l.
ABDOMEN: mild tenderness in LLQ, splenomegaly, nondistended,
+BS, no rebound/guarding
EXTREMITIES: trace b/l pedal edema, moving all extremities well,
no cyanosis, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
___ 05:00PM CK-MB-1 cTropnT-0.03*
___ 08:43AM LACTATE-1.0
___ 08:37AM GLUCOSE-288* UREA N-57* CREAT-2.5* SODIUM-135
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
___ 08:37AM ALT(SGPT)-47* AST(SGOT)-51* LD(LDH)-844*
CK(CPK)-34 ALK PHOS-31* TOT BILI-1.7* DIR BILI-1.0* INDIR
BIL-0.7
___ 08:37AM LIPASE-28
___ 08:37AM cTropnT-0.02*
___ 08:37AM WBC-7.3# RBC-2.91*# HGB-7.9*# HCT-24.2*#
MCV-83 MCH-27.1 MCHC-32.5 RDW-19.3*
___ 08:37AM NEUTS-68 BANDS-9* LYMPHS-16* MONOS-4 EOS-0
BASOS-0 ___ METAS-2* MYELOS-1* NUC RBCS-11*
___ 08:37AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD
___ 08:37AM URINE RBC-44* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-<1 TRANS EPI-<1
___ 08:10AM BLOOD WBC-7.5 RBC-2.94* Hgb-8.1* Hct-24.7*
MCV-84 MCH-27.4 MCHC-32.7 RDW-19.4* Plt ___
___ 08:10AM BLOOD Neuts-67 Bands-10* Lymphs-10* Monos-4
Eos-1 Baso-2 ___ Metas-4* Myelos-2* NRBC-10*
___ 08:10AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Tear Dr-1+
Ellipto-OCCASIONAL
___ 08:10AM BLOOD Glucose-123* UreaN-30* Creat-1.5* Na-137
K-5.6* Cl-105 HCO3-19* AnGap-19
___ 01:10PM BLOOD LD(LDH)-766*
___ 06:35AM BLOOD CK-MB-1 cTropnT-0.02* proBNP-2271*
___ 01:10PM BLOOD B-GLUCAN-PND
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 2152 ON
___ - ___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
CXR ___: IMPRESSION:
1. New multifocal pneumonia.
2. Increase in small left greater than right pleural effusions,
and mild pulmonary edema from ___ 06:10AM BLOOD WBC-7.4 RBC-3.15* Hgb-8.8* Hct-26.6*
MCV-84 MCH-27.9 MCHC-33.1 RDW-19.1* Plt ___
___ 06:10AM BLOOD Glucose-191* UreaN-24* Creat-1.2* Na-134
K-4.3 Cl-104 HCO3-23 AnGap-11
Brief Hospital Course:
Ms. ___ is a ___ year old woman with JAK2 positive essential
thrombocythemia,
anemia ___ beta thalassemia trait, transfusion dependent MDS,
DM2, hypertensive heart disease with heart failure, diabetes,
recurrent UTI, atrial fibrillation not on anticoagulation who
presented with weakness and vomiting secondary to anaerobic GNR
urosepsis. She was found to have multifocal pneumonia on ___
which was believed to be community acquired based on her dyspnea
on admission and became apparent on CXR after rehydration.
ACUTE CONDITIONS MANAGED:
#Pyelonephritis: Diagnosed on positive e.coli blood cultures and
clinical CVA tenderness. Pt had been started on broad spectrum
coverage with Zosyn and switched to levaquin when sensitivity
panel came back. Bilateral renal ultrasound ruled out
hydronephrosis. Cr trended down to baseline of 1.3 at discharge
from 2.8.
#Pneumonia: Diagnosed on CXR on ___ which showed multifocal
pneumonia. The PNA only showed up on cxr following hydration.
Since she was SOB on admission, she was treated for CAP with
Levaquin on ___. She was continued on scheduled Duoneb, with
PRN albuterol.Pt did not require steroids. After falling improve
for several days and an elevated LDH, a chest CT and b-glucgan
were ordered. CT showed some ground glass opacities but
b-glucgan was negative. Pt's O2 sats eventually rebounded and
here WBC trended down to baseline.
#LUQ abdominal pain: we believe this pain is due to her known
splenomegaly. It may be possible that the bacteremia allowed for
seeding of the spleen and an infarct. The pain responded well to
tylenol with codeine.
Loose stools: starting ___ and were most likely secondary to
ABX. C.diff ws negative. Pt's loose stools resolved several days
prior to discharge.
CHRONIC CONDITIONS MANAGED:
CKD Stage III: Creatinine improved to below her baseline of 2.1
CHF: was stable throughout admission. She continued her home
meds Metoprolol Succinate XL 25 mg and Amiodarone 200 mg. Lasix
was held on admission due to dehydrated status. Several doses
were given throughout admission for slightly elevated K+ and
increased fluid in lungs. Diabetes Mellitus: stable
DM: Pt was put on ISS due to highly variable renal function.
Hypertension: stable on home meds Metoprolol Succinate XL 25 mg
and Amlodipine 10 mg.
MDS/Anemia: Pt was continued on Folic Acid 1 mg PO BID
throughout admission. She received roughly 4 units of pRBC
throughout admission to keep her her Hct >21
Hyperlipidemia: stable on statin throughout admission.
TRANSITIONS OF CARE:
1. CODE: FULL CODE
2. Pt will follow-up with Dr. ___ on ___ and her primary
doctors
4. Medications: Pt will finish treatment with levaquin and is
also given albuterol and spiriva prn.
Medications on Admission:
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth one daily
AMLODIPINE - 10 mg Tablet - one Tablet(s) by mouth once daily
FENOFIBRATE - 160 mg Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - 1 mg Tablet - one Tablet(s) by mouth twice a day
FUROSEMIDE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 20 mg Tablet - 1 (One) Tablet(s) by mouth twice a day
GLIMEPIRIDE - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - (converting) - 20 mg Capsule, Delayed
Release(E.C.)
- 1 Capsule(s) by mouth once a day
PRAVASTATIN [PRAVACHOL] - 40 mg Tablet - 1 Tablet(s) by mouth
once a day
TRIMETHOPRIM - 100 mg Tablet - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider;
___; Dose adjustment - no new Rx) - 600 mg-400 unit Tablet - 1
Tablet(s) by mouth 1.5 tablet by mouth in the morning, 1 tablet
by mouth in the evening
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet
- 1 Tablet(s) by mouth daily No IRON
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
4. glimepiride 1 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
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. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet
Sig: 1.5 Tablets PO twice a day: 1.5 qam, 1 tablet in the
evening.
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing: Please f/u with PCP if wheezing and SOB
persists longer than 1 week.
Disp:*1 inhaler* Refills:*2*
11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) pump Inhalation once a day for 1 weeks: Please
contact pcp if SOB and wheezing persist over a week.
Disp:*1 device* Refills:*2*
12. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
13. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 3 days: last day = ___.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Pyelonephritis, community-acquired pneumonia
Secondary:
myelodysplastic syndrome
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 this admission. You
were admitted for feeling weak, and found to have a urinary
infection and pneumonia. You were placed on antibiotics and
improved. You had some diarrhea, but there was no evidence of
infection, and this may have been from the antibiotics.
The following medications were STARTED:
- Albuterol ___ puffs every ___ hours as needed for wheezing
- Spiriva inhaled once daily
- Levofloxacin for 3 more days
The following medications were changed during this admission:
- Decrease Furosemide to 20mg daily (from twice daily)
- STOP Trimethoprim
PLEASE continue all other medications you were taking prior to
this admission.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10759281-DS-16
| 10,759,281 | 21,880,481 |
DS
| 16 |
2177-08-07 00:00:00
|
2177-08-07 15:12:00
|
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 cholecystectomy
History of Present Illness:
___ year old female with PMH cholelithiasis is admitted with
abdominal pain and pancreatitis.
The day after ___ (5 days ago) she developed bloating
and dyspepsia and epigastric discomfort which she attributed to
gas. The symptoms worsened and she presented to her PCP on the
day prior to admission and was given omeprazole for possible
gastritis. She denies nausea, vomiting or intolareance to PO
intake. reported lack of appetite over the last 4 days. Labs
checked in clinc were remarkable for ___, AST/ALT
___, Amylase 2870, tBili: 2.2, WBC 10. She was referred to
the ___ ED.
In the ED, initial VS were: T98.2 P60 BP109/64 RR18 SaO296% Exam
was remarkable for epigastric and RUQ tenderness. RUQ U/S showed
gall bladder filled with stones, CBD 4mm and normal, pancreatic
head could not be evaluated due to bowel gas. Labs had
downtrended to Lipase:537, AST/ALT 267/769. Tbili had normalized
at 0.8, WBC unchanged at 10. EKG showed sinus rhythm with TWI in
III avF and V1 apparently new from EKG ___.
On arrival to the floor, she reports no abdominal pain or
discomfort, no nausea or vomiting, asking for po intake.
REVIEW OF SYSTEMS:
(+) as in HPI
(-) fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Cholelithiasis
- Hyperlipidemia
- Obesity
- Depression
- GERD
- Familial tremor (on Nadolol)
Social History:
___
Family History:
Father: deceased age ___ of liver cancer.
Mother: living in her ___, asthma, tremor.
Physical Exam:
VS - Temp 98.1F, BP 137/58 , HR 61 , R 13, O2-sat 100% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Physical examination upon discharge: ___
vital signs: t=97.9, hr=55, bp=114/54, rr=18, oxygen sat= 95%
General: NAD
CV: ns1, s2, -s3, -s4, no murmurs
LUNGS: clear
ABDOMEN: soft, tender at port sites, port dressings clean and
dry
EXT: + dp bil., no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 03:52PM PLT COUNT-382
___ 03:52PM WBC-10.2 RBC-4.24 HGB-13.2 HCT-39.9 MCV-94
MCH-31.2 MCHC-33.2 RDW-13.5
___ 03:52PM ___
___ 03:52PM ALT(SGPT)-1017* AST(SGOT)-425* ALK PHOS-231*
AMYLASE-2870* TOT BILI-2.2*
___ 03:10PM PLT COUNT-394
___ 03:10PM NEUTS-72.3* LYMPHS-16.9* MONOS-7.0 EOS-3.3
BASOS-0.6
___ 03:10PM WBC-10.5 RBC-4.24 HGB-13.2 HCT-39.8 MCV-94
MCH-31.1 MCHC-33.1 RDW-13.1
___ 03:10PM ALBUMIN-4.5 CALCIUM-9.7 PHOSPHATE-3.6
MAGNESIUM-2.2
___ 03:10PM cTropnT-<0.01
___ 03:10PM ALT(SGPT)-769* AST(SGOT)-267* ALK PHOS-247*
TOT BILI-0.8
___ 03:10PM GLUCOSE-94 UREA N-12 CREAT-1.0 SODIUM-136
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:02PM ___ PTT-31.9 ___
___ 11:02PM CK-MB-2 cTropnT-<0.01
___ 11:02PM CK(CPK)-63
RUQ US:
1. Cholelithiasis without evidence of acute cholecystitis.
2. No biliary ductal dilatation. CBD measures 4 mm.
3. Mild intrahepatic pneumobilia
4. Normal appearance of the pancreatic head and neck. Limited
evaluation of the body and tail.
___: EKG:
Sinus rhythm. Non-specific anterior and inferior ST-T wave
changes. Compared to the previous tracing of ___ the axis
is less rightward and the rate has slowed. There are ST-T wave
changes. Otherwise, no diagnostic interim change.
TRACING #1
___: EKG:
Sinus rhythm. Compared to the previous tracing of ___
there are new
T wave inversions in leads V1-V4 raising the question of active
anterior
ischemia. Followup and clinical correlation are suggested.
TRACING #2
Brief Hospital Course:
The patient was admitted to the acute care service with
abdominal pain. Blood work drawn prior to admission showed
elevated LFT's, lipase and amylase suggestive of gallstone
pancreatitis. The patient was instructed to report to the
emergency room. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. She was reported on
ultrasound to have a gallbladder filled with stones, but with no
wall thickening.
Her EKG on admission was remarkable for T wave inversion in III,
avF and V1 apparently new from an EKG in ___. Cardiac enzymes
were negative x 3 which raised a low suspicion for myocardidal
infarction. She was monitered on telemetry for one night without
events.
Her vital signs and liver enzymes were closely monitored. On HD
#4,she was taken to the operating room where she underwent a
laparoscopic cholecystectomy. She also underwent a
intraoperative cholangiogram which showed filling of the
duodenum and the right and left hepatic ducts, with no filling
defects.
The operative course was stable with minimal blood loss. She
was extubated after the procedure and monitored in the recovery
room.
Her post-operative course has been stable. The patient was
started on clear liquids and transitioned to a regular diet.
She has been voiding without difficulty. Her incisional pain is
controlled with oral analgesia.
On POD #1, the patient was discharged home with stable vital
signs. An appointment for follow-up was made with the acute
care service.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. econazole *NF* 1 % Topical BID
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Nadolol 20 mg PO DAILY
For tremor
5. Omeprazole 20 mg PO DAILY
6. Loratadine *NF* 10 mg Oral Daily
Discharge Medications:
1. nadolol 20 mg tablet Sig: One (1) tablet PO DAILY (Daily).
2. fluoxetine 40 mg capsule Sig: One (1) capsule PO DAILY
(Daily).
3. omeprazole 20 mg capsule,delayed ___ Sig: One (1)
capsule,delayed ___ PO DAILY (Daily).
4. Colace 100 mg capsule Sig: One (1) capsule PO twice a day:
hold for loose stool.
5. Percocet ___ mg tablet Sig: ___ tablets PO every ___ hours
as needed for pain: may cause increased drowsiness, avoid
driving while on this medicaiton.
Disp:*25 tablet(s)* Refills:*0*
6. senna 8.6 mg tablet Sig: One (1) tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hosptial with abdominal pain. You
underwent an ultrasound of your abdomen which showed gallstones.
You were taken to the operating room where you had your
gallbladder removed. You are slowly recovering from your
surgery and you are preparing for discharge home:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10759357-DS-10
| 10,759,357 | 20,248,614 |
DS
| 10 |
2139-08-27 00:00:00
|
2139-08-27 11:15:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
simvastatin / Bactrim / Linzess / Sulfa (Sulfonamide
Antibiotics) / Macrodantin / Rosophin in Dextrose
Attending: ___.
Chief Complaint:
Right Femur fx
Major Surgical or Invasive Procedure:
R femur retrograde IMN (___)
History of Present Illness:
___ w/hx of MS and HTN presenting from rehab with a fall from
her wheelchair between ___, presents to ED with distal right
femur fx. Patient reports that she was bending down and slipped
out of her wheelchair, landing on her right leg. No head strike,
no LOC. Patient has pain in right leg, no pain elsewhere. No CP,
no SOB. Reports DVT in RLE right on coumadin. Head CT and Cspine
were negative per report. Trauma consulted given fall hx, noted
abd bruising, planning to obtian abd CT scan.
Past Medical History:
MS, obesity, and HTN
Social History:
___
Family History:
NC
Physical Exam:
RLE - foot drop, no motor in foot, SILT SSSPDPPT, WWP. inc cdi
with staples
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R distal femur frx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R femur retrograde IMN, 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 patient was transfused 1u pRBCs on ___ for low Hct 21.8
that responded appropriately. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the RL extremity, and will be discharged on coumadin
(bridged from lovenox) for DVT prophylaxis. The patient will
follow up with Dr. ___ trauma team per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Modafinil 200 mg PO DAILY
2. Sertraline 50 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Baclofen 20 mg PO QID
5. methenamine hippurate 1 gram oral BID
6. Tamsulosin 0.4 mg PO QHS
7. Tizanidine 4 mg PO QHS
8. Topiramate (Topamax) 50 mg PO QHS:PRN weight loss
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Baclofen 20 mg PO QID
3. methenamine hippurate 1 gram oral BID
4. Modafinil 200 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Tizanidine 4 mg PO QHS
8. Topiramate (Topamax) 50 mg PO QHS:PRN weight loss
9. Acetaminophen 500 mg PO Q4H
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Docusate Sodium 100 mg PO BID
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
13. Senna 8.6 mg PO BID
14. Warfarin 5 mg PO DAILY
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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 bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take your Coumadin as prescribed and monitored
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: touch down weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: To be changed DAILY by ___ starting POD ___. RN - please
overwrap any dressing bleedthrough with ABDs and ACE
Followup Instructions:
___
|
10760019-DS-6
| 10,760,019 | 20,606,838 |
DS
| 6 |
2138-06-05 00:00:00
|
2138-07-23 15:46:00
|
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:
Ms. ___ is an ___ otherwise healthy who presents with RLQ
adbominal for ~20 hours duration. Briefly, she states that she
began developing vague midline abdominal pain late yesterday
evening that has progressively worsened with
migration/localization to the RLQ at this time. She also reports
subjective chills, nausea and three episodes of emesis. She has
anorexia and has not taken any PO since yesterday evening. She
otherwise denies CP/SOB, diarrhea/constipation, bleeding.
Past Medical History:
None
Social History:
___
Family History:
No h/o colon cancer/GI malignancy
Physical Exam:
Physical Exam on admission:
Vitals: 98.1 50 130/82 18 99% RA
Gen: A&Ox3, fatiguedl-appearing female, in NAD
HEENT: No scleral icterus, no palpable LAD
Pulm: comfortable on room air
CV: NRRR, no m/r/g
Abd: soft, nondistended, TTP in RLQ without rebound/guarding, no
palpable masses
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Physical Exam on discharge:
VS: 98.3 PO 112 / 74 L Lying 70 20 98 Ra
GEN: Awake, alert, pleasant and interactive.
CV: RRR
PULM: Clear to auscultation bilaterally
ABD: Soft, non-distended, tender to palp incisionally. active
bowel sounds.
EXT: Warm and dry. 2+ ___ pulse.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 02:07PM BLOOD WBC-11.0* RBC-4.77 Hgb-12.9 Hct-41.3
MCV-87 MCH-27.0 MCHC-31.2* RDW-14.0 RDWSD-44.0 Plt ___
___ 02:07PM BLOOD Neuts-78.3* Lymphs-15.3* Monos-5.2
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.58* AbsLymp-1.68
AbsMono-0.57 AbsEos-0.06 AbsBaso-0.03
___ 02:07PM BLOOD ___ PTT-31.8 ___
___ 02:07PM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-23 AnGap-14
___ 02:12PM BLOOD Lactate-1.1
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Acute uncomplicated appendicitis. High-density intraluminal
material
throughout a large portion of the appendix likely
appendicoliths.
2. Heterogeneous enhancement of the liver is likely secondary to
contrast
timing. Correlation with LFTs is recommended.
Brief Hospital Course:
P.___. is a ___ year old female, who was admitted to ___ on
___ for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed acute uncomplicated appendicitis.
The patient underwent laparoscopic appendectomy on ___, which
went well without complication (reader referred to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient arrived on the floor hemodynamically stable.
The patient was advanced to a regular diet, which she was
tolerating. She was converted to oral pain medication with
continued good effect. The patient voided without problem.
During this hospitalization, the patient ambulated early and was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not exceed 4gm in a 24 hour period.
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Please take with food.
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
Please take lowest effective dose. Wean as tolerated.
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*4 Tablet Refills:*0
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:
Dear Ms. ___,
You were admitted to the hospital because of abdominal pain. CT
imaging showed an infection in your appendix. You had your
appendix removed laparoscopically. You are doing well,
tolerating a regular diet, and your pain is well-controlled, so
you are ready to go home. Please follow the 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.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
Followup Instructions:
___
|
10760122-DS-12
| 10,760,122 | 25,305,407 |
DS
| 12 |
2118-05-04 00:00:00
|
2118-05-04 15:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest and back pain
Major Surgical or Invasive Procedure:
___: Thoracic endograft repair for penetrating thoracic
aortic ulcer of the descending thoracic aorta
History of Present Illness:
___ gentleman with an intramural hematoma and
penetrating aotic ulceration of the descending thoracic aorta
presents with symptoms
of persistant lower chest and epigastric pain radiating to the
back depite normal BP.
Past Medical History:
Past Medical History: Hypertension, PTSD, mood disorder
Past Surgical History: lipoma removal, facial reconstruction s/p
MVA
Social History:
___
Family History:
Mother had MI, no marfans or connective tissue disorder
Physical Exam:
Vitals:
GEN: A&O, NAD, interactive and cooperative
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, tender with deep palpation in lower-mid
abdomen, no pulsatile mass
Ext: No ___ edema, ___ warm and well perfused, palpable bilateral
pedal pulses, no wounds or ulcers
Pulses: R: p/p/p/p L: p/p/p/p
Pertinent Results:
___ 03:20AM BLOOD WBC-7.4 RBC-3.82* Hgb-13.0* Hct-36.0*
MCV-94 MCH-33.9* MCHC-36.0* RDW-13.7 Plt ___
___ 03:20AM BLOOD ___ PTT-44.9* ___
___ 03:20AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-134
K-4.4 Cl-104 HCO3-28 AnGap-___ 03:20AM BLOOD ALT-79* AST-94* CK(CPK)-131 AlkPhos-130
TotBili-0.8
___ 03:20AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.2
CTA (___):
Intramural hematoma extending from the level of the left
subclavian artery and terminating at the level of the renal
arteries, not significantly changed from ___. Intramural
ulcers ulcer of the level of the descending thoracic aorta, also
unchanged (series 2, image 74, series 2, image 78). There may be
intramural hematoma extending into the proximal left subclavian
artery (series 2, image 6). Descending thoracic aorta measuring
up to approximately 4.4 cm, not significantly changed. All
vessels off of the abdominal aorta appear patent.
Brief Hospital Course:
Mr ___ presented to ___ on ___ for evaluation of
persistent symptoms of chest and abdominal pain radiating to the
back presumed to be secondary to a known intramural aortic
hematoma.
He was admitted to the vascular surgery service. He was
initially admitted to the CVICU for close monitoring fo his
blood pressure with esmolol drip. On ___ he was weaned off
the esmolol drip and his blood pressure was adequately
controlled with PO medication. On ___ a CTA was done which
revealed an unchanged intramural hematoma but continued to have
pain. As such, was taken to the OR on ___ for TEVAR. He
tolerated the procedure well without complications. After a
brief and uneventful stay in the PACU, the patient was
transferred to the floor for further post-operative management.
Neuro: Intact with no focal deficiet.
CV: The patient remained stable from a cardiovascular standpoint
on lisinopril and metoprolol.
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: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
GU: The patient had a foley catheter placed in the OR, which was
removed on midnight of POD#. After the foley was removed, the
patient voided without difficulty.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection, of which there were
none.
Hematology: The patient's complete blood count was examined
routinely.
EXtremities: Groin puncture sites are well healed without
hematoma or ecchymosis. Distal pulses are intact.
Prophylaxis: The patient received subcutaneous heparin. Patient
wore venodyne boots and was encouraged to get up and ambulate as
early as possible following surgery.
On POD 2, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in
clinic in 4 weeks. This information was communicated to the
patient directly prior to discharge with verbalized
understanding and agreement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Aspirin Childrens] 81 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Ibuprofen 800 mg PO Q8H:PRN pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times daily as
needed. Disp #*90 Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Penetrating descending thoracic aortic ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
MEDICATIONS:
Take Aspirin 81mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, gradually increase your activities and distance
walked as you can tolerate
Followup Instructions:
___
|
10760122-DS-19
| 10,760,122 | 23,490,086 |
DS
| 19 |
2120-08-24 00:00:00
|
2120-08-24 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / epidural
injection / tramadol / Tylenol
Attending: ___.
Chief Complaint:
abdominal pain, volume overload
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Mr. ___ is a ___ yo M w/medical history notable for HCV/EtOH
cirrhosis (Child B) c/b ___ s/p RFA ___, ascites,
varices/PHG,
HIV (most recent CD4 ___ with multiple recent
admissions
for abdominal pain and volume overload, presenting today with
abd
pain and volume overload.
In the ED complained of worsening abd pain over last 5 days, not
relieved by his standing oxycodone. He endorses lethargy,
inability to sleep. He also reports a 7 pound weight gain x2
days, denies missing medication doses, change in diet. Reports
has abdominal pain straight down the middle of his abdomen from
epigastrium down to umbilicus; denies radiation, association
with
eating, vomiting, changes in bowel movements. Given worsening of
his pain and volume overload, he was referred to the ED for
further evaluation.
In the ED initial vitals: T97.6, HR91, BP156/82, RR18, PO2 96
- Exam notable for: Tender to palpation throughout
the most notably in the epigastrium and around the umbilicus, no
rebound, no guarding, no fluid wave
- Imaging notable for: RUQ with no ascites; patent portal vein
- Labs notable for WBC 10.7 left shift, INR 1.5, K 5.1, ALT
100,
AST 176, Alkphos 205, Tbili 3.3, lipase 63, albumin 3.2
- Patient was given: oxycodone 5mg x2
- Vitals prior to transfer: 97.8 71 131/90 15 94% RA
On the floor, patient reports ongoing pain.
Patient was admitted ___ at ___ and received work-up
for transaminitis and diffuse abdominal pain revealing
acalculous
cholecystitis and LLL PNA. He was treated with IV amp/sulbactam,
that was then transitioned to vanc/zosyn, and then to
augmentin+azithromycin to complete as an outpatient.
He was then admitted 24 hours later to ___ for volume overload.
Paracentesis with 0.9L fluid out, no SBP. Was diuresed with IV
lasix. On discharge, Lasix 10mg was stopped, and he was started
on Torsemide 20mg, and Spironolactone increased from 25mg to
50mg.
Presented to BI again ___ for dizziness and fatigue, likely ___
overdiuresis. addition of Torsemide at OSH. Received IV Albumin
for 3 days, and although orthostatics normalized, his dizziness
did not completely resolve. Meclizine started ___ with moderate
effect. Started back on prior home doses of Lasix 10mg and
Spironolactone 25mg daily. Given rising potassium (5.3) on day
of discharge, Spironolactone was stopped on discharge (___).
Past Medical History:
PAST MEDICAL HISTORY:
- HCV/EtOH cirrhosis (Child B), c/b HCC s/p RFA
- HIV well controlled
- HTN
- PTSD
- Mood disorder
- Penetrating thoracic aortic ulcer of the descending thoracic
aorta s/p TEVAR ___
- Cervical disk herniation
- GIB
- ?COPD
PAST SURGICAL HX:
- Lipoma removal L upper arm
- Facial reconstruction s/p MVA (wire mesh) after accident ___
y/o (bicycle accident)
- ___: Thoracic endograft repair for penetrating thoracic
aortic ulcer of the descending thoracic aorta
- b/l ___ metacarpal injuries s/p repair
Social History:
___
Family History:
CAD in mother
Physical ___:
ADMISSION EXAM
==============
VS: 98.0 PO 158 / 98 70 18 96 Ra
GENERAL: well appearing, no NAD
HEENT: AT/NC, PERRL, EOMI. OP clear, adentulous
NECK: supple, no LAD, no elevated JVP
CARDIAC: RRR, (+)S1, S2, no m/r/g
PULMONARY: prolonged expiratory phase, no wheeze/rales/rhonchi
ABDOMEN: soft, mild distended, diffuse TTP, negative ___
sign, (+)BS
EXTREMITIES: WWP, no edema
SKIN: few red patches, excoriations
NEUROLOGIC: AAOx3, moves all extremities spontaneously, no
asterixis
PSYCHIATRIC: appropriate, interactive
DISCHARGE EXAM
==============
VS: T 97.9, BP 138 / 87, P79, RR18, PO2 97 Ra
GENERAL: well appearing, no NAD
HEENT: AT/NC, PERRL, EOMI. OP clear; scleral icterus
CARDIAC: RRR, (+)S1, S2, no murmurs
PULMONARY: distant lung sound, no crackles or rhonchi
ABDOMEN: soft, mild distension, negative Murphys; epigastric TTP
EXTREMITIES: WWP, trace edema bilaterally
NEUROLOGIC: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS
===============
___ 09:05AM BLOOD WBC-10.7* RBC-3.95* Hgb-14.2 Hct-41.8
MCV-106* MCH-35.9* MCHC-34.0 RDW-17.3* RDWSD-68.1* Plt ___
___ 09:05AM BLOOD Neuts-80* Bands-1 Lymphs-9* Monos-6 Eos-4
Baso-0 ___ Myelos-0 AbsNeut-8.67* AbsLymp-0.96*
AbsMono-0.64 AbsEos-0.43 AbsBaso-0.00*
___ 09:05AM BLOOD Plt Smr-LOW* Plt ___
___:16AM BLOOD ___ PTT-29.5 ___
___ 09:05AM BLOOD Glucose-133* UreaN-16 Creat-0.7 Na-139
K-5.1 Cl-106 HCO3-21* AnGap-12
___ 09:05AM BLOOD ALT-100* AST-176* AlkPhos-205*
TotBili-3.3*
___ 09:05AM BLOOD Lipase-63*
___ 09:05AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.5 Mg-2.1
MICRO/OTHER PERTINENT LABS
===========================
___ 9:17 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-8.8 RBC-3.56* Hgb-12.9* Hct-38.5*
MCV-108* MCH-36.2* MCHC-33.5 RDW-17.2* RDWSD-69.2* Plt Ct-86*
___ 06:50AM BLOOD ___ PTT-66.4* ___
___ 06:50AM BLOOD Glucose-88 UreaN-14 Creat-0.7 Na-142
K-4.7 Cl-105 HCO3-24 AnGap-13
___ 06:50AM BLOOD ALT-100* AST-158* AlkPhos-160*
TotBili-3.0*
___ 06:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
Brief Hospital Course:
Outpatient Providers: ___ yo M w/medical history notable for
HCV/EtOH cirrhosis (Child B) c/b ___ s/p RFA ___, ascites,
varices/PHG, HIV (most recent CD4 ___ with multiple
recent admissions (last discharge ___, presenting with abd
pain/volume overload.
# Abdominal pain: in the setting of cirrhosis, there was initial
concern for decompensation with volume overload and acutely
worsened abd pain. No PVT on RUQ US, no ascites (on CT and
bedside US). HCC lesion in right lobe appeared stable in size
but with enhancement on recent MRI and CT, with concern for
recurrence in the setting of rapidly rising AFP levels. However,
multiphase CT did not show evidence of infiltrative HCC. CT
thorax was done showing no metastatic lesions. LFTs and Tbili
were elevated but near baseline. Lipase was normal with low
concern for pancreatitis. Had new penetrating atheroma seen on
CT, but vascular surgery said it was stable and no intervention
was appropriate at this time. Abdominal pain thought to be
secondary to GERD and PPI was increased to BID dosing. Patient
to follow with vascular surgery outpatient.
# Volume overload: discharged ___ on Lasix 10mg, and was taken
off spironolactone due to hyperK. Weight 185 on ___, admission
192 (up 7 lbs). Likely ___ to suboptimal diuretic regimen.
Received IV Lasix with improvement of weight and euvolemic on
exam. Transitioned to lasix 40mg po. Will need close monitoring
of electrolytes on increased dose. Discharge Cr 1.3. Discharge
weight 185.6 lb.
#New Penetrating atheroma on CT: patient with hx of penetrating
descending thoracic aortic ulcers s/p TEVAR ___ here w/
abdominal pain. As per vascular surgery, there are several scans
within the past year that look very similar to the most recent
and there has not been any recent change in the aneurysm size
over the past 6 months. There is perhaps 1-2mm growth compared
to the scan from 16 months ago but this is consistent with
normal progression. He is a poor candidate for open surgery.
Given apparent stability on imaging, treatment deferred unless
there is significant growth or convincing symptoms attributable
to the aorta. Patient has had stable vital signs, and with
inconsistent description of pain. Vascular will follow and
monitor outpatient.
#Coagulopathy: INR up from baseline 1.5-->1.8 on admission.
Likely ___ liver disease, but could also be secondary to
inadequate po. s/p po vitK 5mg, back down to 1.5.
# EtOH/HCV Cirrhosis MELD 16(Child B)
- HE: hx in the past. Continued on rifaxmin 550 BID and
lactulose 30ml QID. Patent portal vein on US ___
- GIB/VARICES: last EGD in ___ showed 2 small cords of
varices and PHG, no banding, not on nadolol. Repeat EGD ___ with
no varices
- ASCITES: h/o ascites in the past requiring paracentesis. No
ascites on US ___. Now on Lasix 40mg (home dose 10mg daily and
off spirono last admission).
- SBP: No hx, no need for ppx at this time
- HCV status: untreated; genotype 3A, VL 256,000 (diagnosed
?___ ago, thinks it was a from car accident when he was
___ old with blood transfusion)
- ___: history of ___ s/p RFA ___, and of note, review of his
recent labs shows a persistently rising AFP level of AFP 491.8
from 278.3. US ___ with stable lesion in right lobe 2.1 x 1.9 x
1.7 cm at the site of prior ablation. MR abd ___ with mild
enhancement at inferior aspect of ablation cavity unchanged from
___. Multiphase CT with same intensity around ablated region,
no infiltrative cancer. CT chest without metastases. Will follow
with liver clinic and liver tumor clinic outpatient.
- Transplant list: was to be listed again. Original concern for
___ met to left acromion but diagnosed as subchondral cyst by
ortho
- MELD at discharge: 15.
# HIV:
His HIV is well controlled. His most recent CD4 was ___,
and his VL was less than assay. Continued on home descovy and
dolutegravir.
# HLD - continued home atorvastatin
# Supplementation - continued home calcium.
# Insomnia - continued ramelteon
# COPD- continued home albuterol and ipratropium PRN
TRANSITIONAL ISSUES
==================
#Discharge weight: 185.6 lb
[ ] f/u PCP in ___ week to monitor electrolyes and Cr
[ ] can decrease PPI back to once daily from BID if no
improvement in abdominal pain
[ ] f/u liver clinic for transplant workup
[ [ f/u liver tumor clinic for ___ s/p RFA now with rising AFP
(no infiltrative HCC on multiphase CT and no mets in the chest)
[ ] f/u vascular surgery outpatient for monitoring of atheroma.
#Code status: full
#Contact: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Calcium Carbonate 500 mg PO BID
3. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral DAILY
4. Dolutegravir 50 mg PO DAILY
5. Lactulose 30 mL PO TID
6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild
7. Rifaximin 550 mg PO BID
8. TraZODone 100 mg PO QHS:PRN insomnia
9. Multivitamins 1 TAB PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
11. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Furosemide 10 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
4. Atorvastatin 10 mg PO QPM
5. Calcium Carbonate 500 mg PO BID
6. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral
DAILY
7. Dolutegravir 50 mg PO DAILY
8. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN
9. Lactulose 30 mL PO TID
10. Multivitamins 1 TAB PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild
13. Rifaximin 550 mg PO BID
14. TraZODone 100 mg PO QHS:PRN insomnia
15.Outpatient Lab Work
571.5
CMP with LFTs, ___, CBC on ___ and fax results to liver
center ATTN Dr. ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Abdominal pain
HCV Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
-You had worsening of your abdominal pain and your weight went
up.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received IV Lasix to remove the extra fluid.
-You had imaging of your abdomen which did not show any
concerning findings. We think reflux might be causing your
abdominal pain.
- You had imaging of your liver that did not show any
progression of the cancer.
- You had imaging of your chest that showed no spread of cancer.
- You had imaging of your aorta that showed a plaque/ballooning
of the vessel that is common after surgery, but will need to be
monitored closely by vascular surgery.
WHAT SHOULD I DO WHEN I GO HOME?
-Please weigh yourself every morning, before you eat or take
your medications. Please call your doctor if your weight changes
by more than 3 pounds in one day or more than 5 pounds in three
days.
-Please continue to make your medications as prescribed. You
will now take your pantoprazole twice a day to help with the
abdominal pain. You are now on lasix 40mg daily for your
swelling.
-Please keep your appointments with your team of doctors.
-___ will need to call ___ to confirm appointment with
Dr. ___ (vascular surgery. This is VERY important.
WHEN SHOULD I COME BACK TO THE HOSPITAL?
- If you have fevers, chills, confusion, worsening abdominal
pain, diarrhea, vomiting, or blood or black in your stool.
- If you have any symptoms that concern you.
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
|
10760122-DS-20
| 10,760,122 | 29,707,276 |
DS
| 20 |
2120-09-15 00:00:00
|
2120-09-15 15:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / epidural
injection / tramadol / Tylenol
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ with history of Hep C cirrhosis (Childs B), HIV (CD4 1106
___ who presents from home with abdominal pain.
Patient has many recent admissions for abdominal pain with some
equivocal imaging for cholecystitis, however surgical teams have
not considered him to have acute cholecystitis and so no
intervention pursued.
Patient states he was recently hospitalized at ___
___
for severe lower R-sided abd pain. He says they mostly just
monitored him, no procedures were pursued, and he was discharged
on ___ mostly because he wanted to leave. This morning he
was
at home and had recurrent severe R-sided lower abd pain. This
radiates up to his RUQ. No associated n/v/d. No diaphoresis.
He then presented to the ED.
Past Medical History:
PAST MEDICAL HISTORY:
- HCV/EtOH cirrhosis (Child B), c/b HCC s/p RFA
- HIV well controlled
- HTN
- PTSD
- Mood disorder
- Penetrating thoracic aortic ulcer of the descending thoracic
aorta s/p TEVAR ___
- Cervical disk herniation
- GIB
- ?COPD
PAST SURGICAL HX:
- Lipoma removal L upper arm
- Facial reconstruction s/p MVA (wire mesh) after accident ___
y/o (bicycle accident)
- ___: Thoracic endograft repair for penetrating thoracic
aortic ulcer of the descending thoracic aorta
- b/l ___ metacarpal injuries s/p repair
Social History:
___
Family History:
CAD in mother
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.8 BP 128/70 HR 82 RR 14 O2 94% RA
General: Alert, oriented, no acute distress
HEENT: slight scleral icterus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: severe TTP diffusely, most notable in RUQ and RLQ
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: no asterixis
DISCHARGE PHYSICAL EXAM:
========================
VS: T 97.7 BP 107 / 68 HR 62 RR 16 O2 95% RA
Weight: (188 lb admission) 192.31 lb
GENERAL: Tired appearing, NAD, AAOx3
HEENT: NCAT, MMM, anicteric sclera
NECK: Neck supple, no JVD
HEART: RRR, no MRG, 2+ radial pulses
LUNGS: CTAB, no increased work of breathing
ABDOMEN: Soft, nondistended, tenderness to palpation throughout
abdomen, particularly RUQ/RLQ.
EXTREMITIES: Warm and well-perfused, no edema or cyanosis.
Clubbing of the fingernails.
NEURO: AAOx3, CN II-XII grossly intact. Asterixis not present
SKIN: no jaundice
Pertinent Results:
ADMISSION LABS:
================
___ 03:15PM BLOOD WBC-9.6 RBC-3.66* Hgb-13.7 Hct-40.0
MCV-109* MCH-37.4* MCHC-34.3 RDW-17.2* RDWSD-69.7* Plt Ct-79*
___ 03:15PM BLOOD Neuts-71.8* Lymphs-16.4* Monos-7.7
Eos-3.1 Baso-0.2 Im ___ AbsNeut-6.84* AbsLymp-1.57
AbsMono-0.74 AbsEos-0.30 AbsBaso-0.02
___ 03:15PM BLOOD ___ PTT-41.4* ___
___ 03:15PM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-138
K-4.7 Cl-104 HCO3-26 AnGap-8*
___ 03:15PM BLOOD ALT-176* AST-304* AlkPhos-193*
TotBili-4.1*
___ 05:25AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.9
Mg-1.5*
___ 03:22PM BLOOD Lactate-1.5
IMAGING:
========
___ LIVER/GALLBLADDER ULTRASOUND
IMPRESSION:
1. Cirrhotic liver with moderate perihepatic ascites.
2. Gallbladder is distended with wall thickening, similar to
multiple prior studies.
3. Patent portal vein.
___ MRCP
IMPRESSION:
1. Cirrhotic liver morphology. Unable to evaluate for
hepatocellular
carcinoma given extensive artifact from thoracic vascular stent
graft.
Screening examinations should be done with multiphasic CT.
2. Decreased gallbladder distension with persistent mild wall
edema, findings are most likely related to background liver
disease especially in the setting of a normal HIDA scan.
3. Normal biliary tree.
___ CTA ABDOMEN
Cirrhotic liver morphology with evidence of portal hypertension
and new trace ascites. Findings are again concerning for
recurrence inferior to the treatment segment VII cavity, stable
from prior exam.
DISCHARGE LABS:
===============
___ 05:48AM BLOOD WBC-7.1 RBC-3.37* Hgb-12.3* Hct-36.3*
MCV-108* MCH-36.5* MCHC-33.9 RDW-17.5* RDWSD-70.4* Plt Ct-81*
___ 05:48AM BLOOD ___ PTT-72.6* ___
___ 05:48AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-141
K-4.5 Cl-109* HCO3-26 AnGap-6*
___ 05:48AM BLOOD ALT-123* AST-217* AlkPhos-155*
TotBili-3.4*
___ 05:48AM BLOOD Albumin-2.0* Mg-1.7
Brief Hospital Course:
PATIENT SUMMARY
___ with history of Hep C cirrhosis who presents from home with
severe acute on chronic abdominal pain, with a hepatocellular
and cholestatic liver injury pattern, but with negative workup
including HIDA scan and MRCP. CTA Liver showed recurrence of his
known HCC, s/p RFA in the past. The patient had persistent pain,
and his course was complicated by one day of axillary fevers. He
was discharged with plan for follow up of his recurrent HCC for
radiofrequency ablation, which may help his pain.
ACTIVE ISSUES
================
#Acute on chronic Abdominal pain:
Patient has been in and out of hospitals for months due to
abdominal pain, which has been steadily worsening. There was no
ascites pocket seen on ultrasound for ___ to tap, thus making SBP
less likely as a potential cause. On prior admission, his CT A/P
was not consistent with any acute abdominal process, per
surgery. His RUQUS showed gallbladder wall distension and a
patent portal vein. Subsequent imaging was also unremarkable,
including an MRCP and a HIDA scan. However, there is still no
identified etiology for his persistent transaminitis and
bilirubin elevation over past several months. His case was
discussed at the ___ Surgery Conference. They suggested a
CTA liver, which showed interval recurrence of his known HCC
inferior to the treatment segment VII cavity, which could be
contributing to his pain. and it was suggested that outpatient
Radiofrequency Ablation be performed, in the setting of
recurrent tumor seen on CT with rising AFP.
His pain was controlled with Oxycodone (7.5 mg q6h PRN
initially, weaned back to 5mg q6h PRN). Amytriptiline was
started to help with a possible component of somatic symptom
disorder, which seemed to help. He was discharged with close
outpatient follow up.
#Fever:
Patient was febrile by axillary temperature on ___, but never
by PO measurement. He was pancultured (Blood and urine cultures
were all negative). CXR was also negative. He was given IV
Fluids, and his fever curve was trended with no further fevers.
#Hep C cirrhosis:
#Coagulopathy
#HCC s/p radiofrequency ablation
Childs C on admission, MELD-Na 19 with history HE and ___ s/p
RFA, but no history ascites or varices. Last EGD on ___ showed
no varices. INR was 1.8 on ___, for which he was given Vitamin
K. HIDA scan was normal. MRCP was unremarkable except for mild
gallbladder wall edema. CTA liver with interval recurrence
inferior to the treatment segment VII cavity, stable from prior
imaging. His last EGD was on ___, with no evidence varices.
His home Spironolactone and Lasix were continued, as were
Lactulose and Rifaximin. Plan for outpatient RFA in the setting
of recurrence with rising AFP, although patient is very worried
that this will jeopardize his position on the transplant list.
STABLE ISSUES:
================
#HIV:
Stable on Dolutegravir + Emtricitabine + Tenofovir, well
controlled with CD4 count of 1,106 and Viral Load of 1.4 on
___.
#Penetrating thoracic aortic ulcer of the descending thoracic
Aorta s/p TEVAR ___. No intervention per recent vascular
note. Continue outpatient follow up with vascular.
#HTN:
Continued diuresis with Lasix, ___ as above.
#HLD:
Continued Atorvastatin 10.
#COPD:
Continued Duonebs q6h prn.
=======================
TRANSITIONAL ISSUES
=======================
[ ] Continue ___ RFA, scheduled for ___.
[ ] Follow up with transplant clinic on ___.
[ ] Can consider up titrating amitriptyline for pain control.
[ ] Continue to follow with vascular for penetrating thoracic
aorta.
[ ] Consider metoclopramide for functional pain if Amitriptyline
does not help.
#Discharge Stats
-INR at discharge: 1.7
-Cr at discharge: 0.7
-Weight at discharge: 87.14 kg (192.11 lb)
#New meds:
- Acetaminophen 1000mg BID
- Amitriptyline 25mg QHS
- Maalox/Diphenhydramine/Lidocaine 15 mL PO TID
- Miralax and Senna
#Changed meds:
- Oxycodone 5 mg q6h prn pain (prescribed 15 tabs)
#Code status: Full (confirmed)
#Health care proxy/emergency contact: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
2. Atorvastatin 10 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral DAILY
5. Dolutegravir 50 mg PO DAILY
6. Lactulose 30 mL PO QID
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild
9. Rifaximin 550 mg PO BID
10. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Pantoprazole 40 mg PO Q12H
14. Furosemide 40 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO BID
RX *acetaminophen 500 mg 2 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. Amitriptyline 25 mg PO QHS
RX *amitriptyline 25 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
3. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL 15 mL by mouth three times a day Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
7. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
8. Atorvastatin 10 mg PO QPM
9. Calcium Carbonate 500 mg PO BID
10. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral
DAILY
11. Dolutegravir 50 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. ipratropium-albuterol ___ inh inhalation Q6H:PRN dyspnea
14. Lactulose 30 mL PO QID
15. Multivitamins 1 TAB PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Pantoprazole 40 mg PO Q12H
18. Rifaximin 550 mg PO BID
19. Spironolactone 25 mg PO DAILY
20. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute on chronic Abdominal Pain
SECONDARY DIAGNOSES
Hepatocellular Carcinoma
Hep C Cirrhosis
HIV
HTN
Known Thoracic Aorta Ulcer
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 part in your care at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
====================================
- You were having belly pain.
WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL?
==================================================
- Your HIDA scan and MRCP (abdominal MRI) were all negative and
did not reveal a cause for the belly pain.
- Your CT scan was the same as before, and we felt it best for
you to continue the microwave RFA treatments.
- Your pain was controlled with medications and you were able to
eat.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
============================================
- Your medications have changed. See the list below.
- Your follow up appointments are below.
- Continue the microwave RFA treatments.
WHEN SHOULD I RETURN TO THE HOSPITAL?
======================================
- If you are having more severe pain that is not controlled by
the medications.
- If you are unable to eat, or having severe nausea and
vomiting.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10760122-DS-25
| 10,760,122 | 21,187,951 |
DS
| 25 |
2120-12-28 00:00:00
|
2120-12-28 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / epidural
injection / tramadol / Tylenol
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Large volume paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HCV
cirrhosis (Child C/___, MELD 24) in the setting of HIV
coinfection, complicated by portal hypertension (rectal varices,
ascites, hepatic encephalopathy), and metastatic HCC with mets
to shoulder s/p resection and palliative XRT, with plan to start
sorafenib who presents with abdominal pain and worsening volume
overload.
Patient was recently seen in ___ clinic, with increased
abdominal ascites and weight increase from 180s to 204 pounds.
At that time he denied any other fevers or chills, but did
complain of new RUQ abdominal pain. He received a diagnostic and
therapeutic paracentesis on ___, with no evidence of SBP, but
only 210 mL of ascites fluid was able to be removed per
radiology note and per patient. Patient notes he isn't quite
sure why they were unable to remove more fluid, but that the
person doing the procedure was communicating with an attending 2
doors away. For his new RUQ abdominal pain, he received
ultrasound, which did not demonstrate any new lesions, only old
radiofrequency ablation site in right hepatic lobe, and
increased ascites. Portal venous system was unable to be well
assessed. His home furosemide and spironolactone dosing were
increased, per notes to spironolactone 150 mg daily and
furosemide 60 mg daily, but patient reports taking
spironolactone 100 mg and furosemide 100 mg daily. Patient
also notes new onset of epigastric abdominal pain for the past
week, described as like someone stabbing him with needle, with
oxycodone as the only thing that helps. He notes minimal urine
output to increased dose of diuretics, with persistent weight
gain, now to 210 lbs. He notes increased shortness of breath
with exertion, such that he is unable to cook/clean for himself
now and his sister is helping him. Although his legs are
swollen, he does not think they are more edematous than usual.
No fevers, chills, confusion, black or bloody stools.
On ___, due to concern for worsening abdominal
pain/distension and jaundice, he was advised to present to ED
for labs and attempt at another large volume paracentesis.
In the ED, initial VS were: 95.9 98 ___ 97% RA
Exam notable for: severe abdominal ttp, trace pedal edema
Labs showed:
WBC 7.0 Hgb 12.6 Plt 109
133 | 98 | 9
-------------
3.8 | 25 | 0.8
ALT 37 AST 82 AlkPhos 243 Tbili 5.0 Alb 2.5
Lactate 1.5
Ascites: WBC 294, 6% poly, RBC 64, protein 0.5, glucose 101
U/A 7 WBC, mod leuk, neg nitr
Imaging showed:
___ CT A/P with contrast
1. No free intraperitoneal air. No evidence of liver bowel
injury.
2. Cirrhotic liver with moderate ascites, minimally increased
from prior. Overall slight decrease in size of prior ablation
site in segment 7 of the liver.
3. Distal descending thoracic aortic aneurysm measuring up to
4.0 Cm superior to the stent and suprarenal aortic aneurysm
measuring up to 4.0 cm in greatest diameter just inferior to the
endovascular stent are unchanged compared to prior.
___ CXR
Subsegmental atelectasis in the lung bases. No pneumothorax.
Small left pleural effusion.
Consults: Hepatology "Given worsening pain not controlled after
recent outpatient clinic visit and attempt at large volume para,
I suspect he will require admission for re-attempt at LVP +/-
pain control. Labs ordered, not yet pending. Vitals with HR 98
and BP 110/73. Diagnostic para if labs worse, if febrile, or
abdominal pain is worse than 2 days ago. Admit to ___
if stable for the floor.
Patient received:
___ 20:44 IV Morphine Sulfate 4 mg ___
___ 22:46 PO/NG Amitriptyline 25 mg ___
___ 22:46 PO/NG Lactulose 30 mL ___
___ 22:46 PO/NG Magnesium Oxide 800 mg ___
___ 22:46 PO/NG OxyCODONE (Immediate Release) 10 mg
___
___ 22:46 PO OxyCODONE SR (OxyconTIN) 10 mg
___
Past Medical History:
1. Penetrating thoracic aortic aneurysm of the descending aorta
status post TAVR on ___
2. Cirrhosis ___ chronic genotype hepatitis C, ETOH
3. Hypertension
4. PTSD
5. Cervical disc herniations
6. Gastritis with bleeding
7. Lipoma
8. HIV on ART
Social History:
___
Family History:
Mom with CAD. Multiple prior family malignancies. The patient
is unsure of the
type.
Physical Exam:
ADMISSION EXAM:
===============
VS: ___ 0020 Temp: 97.9 PO BP: 119/83 L Lying HR: 104 RR:
20 O2 sat: 94% O2 delivery: Ra
GENERAL: NAD, lying in bed with 2 pillows
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: Distended and tense, + fluid wave, TTP most markedly in
RUQ and epigastrium without rebound or guarding, paracentesis
site in L flank c/d/i
EXTREMITIES: +clubbing (per patient chronic), 2+ edema to level
of knee
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, + asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
VS: 97.4 123/85 97 18 99%RA
GENERAL: NAD, ambulating independently
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP at 8 cm H2O
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, + fluid wave, TTP in RUQ without rebound or
guarding, paracentesis site in L flank c/d/I.
EXTREMITIES: +clubbing (per patient chronic), 2+ edema to level
of knee. Difficulty lifting left arm/shoulder due to "cancer" in
the bone.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, no asterixis noted.
SKIN: Pale lower extremities, warm and well perfused, no
excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00PM ASCITES TOT PROT-0.5 GLUCOSE-101
___ 10:00PM ASCITES TNC-294* RBC-64* POLYS-6* LYMPHS-26*
___ MESOTHELI-4* MACROPHAG-62* OTHER-2*
___ 05:52PM LACTATE-1.5
___ 05:40PM GLUCOSE-84 UREA N-9 CREAT-0.8 SODIUM-133*
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-10
___ 05:40PM ALT(SGPT)-37 AST(SGOT)-82* ALK PHOS-243* TOT
BILI-5.9* DIR BILI-2.9* INDIR BIL-3.0
___ 05:40PM LIPASE-29
___ 05:40PM ALBUMIN-2.5*
___ 05:40PM WBC-7.0 RBC-3.54* HGB-12.6* HCT-36.4*
MCV-103* MCH-35.6* MCHC-34.6 RDW-19.7* RDWSD-74.6*
___ 05:40PM NEUTS-66.6 LYMPHS-17.8* MONOS-11.1 EOS-2.7
BASOS-0.7 IM ___ AbsNeut-4.63 AbsLymp-1.24 AbsMono-0.77
AbsEos-0.19 AbsBaso-0.05
___ 05:40PM PLT COUNT-109*
___ 05:40PM ___ PTT-42.7* ___
___ 04:06PM URINE HOURS-RANDOM
___ 04:06PM URINE HOURS-RANDOM
___ 04:06PM URINE UHOLD-HOLD
___ 04:06PM URINE GR HOLD-HOLD
___ 04:06PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 04:06PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 04:06PM URINE RBC-2 WBC-7* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 04:06PM URINE HYALINE-4*
___ 04:06PM URINE MUCOUS-OCC*
DISCHARGE LABS:
===============
MICRO:
======
___ 10:00 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
IMAGING:
========
Chest PA/Lateral ___:
FINDINGS:
Heart size is normal. The aorta remains tortuous. Mediastinal
and hilar
contours are unremarkable. Pulmonary vasculature is not
engorged.
Subsegmental atelectasis is seen in the lung bases. Small left
pleural
effusion is noted. No right-sided pleural effusion or
pneumothorax is
detected. No subdiaphragmatic free air is present. Stent graft
is seen
within the distal descending thoracic/proximal abdominal aorta.
IMPRESSION:
Subsegmental atelectasis in the lung bases. No pneumothorax.
Small left
pleural effusion.
CT ABDOMEN/PELVIS ___:
IMPRESSION:
1. No free intraperitoneal air. No evidence of liver bowel
injury.
2. Cirrhotic liver with moderate ascites, minimally increased
from prior.
Overall slight decrease in size of prior ablation site in
segment 7 of the
liver.
3. Distal descending thoracic aortic aneurysm measuring up to
4.0 Cm superior to the stent and suprarenal aortic aneurysm
measuring up to 4.0 cm in greatest diameter just inferior to the
endovascular stent are unchanged compared to prior.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old gentleman with history of HCV
cirrhosis (Child ___, MELD ___) in the setting of HIV
coinfection, complicated by portal hypertension (rectal varices,
ascites, hepatic encephalopathy), and metastatic HCC with
metastatic disease to left shoulder s/p resection and palliative
XRT, who presented with RUQ/epigastric abdominal pain and volume
overload.
# HCV Cirrhosis (Child ___, MELD 24)
Patient presented with worsening volume overload despite
increasing outpatient diuretics. Outpatient hepatologist
believed patient would benefit from repeat attempt at large
volume paracentesis, unclear why only 210 mL was
able to be removed during last attempt. SAAG > 1.1, consistent
with portal hypertension, no evidence of SBP on diagnostic
paracentesis. He does have asterixis on exam at this time.
Continued home spironolactone 150 mg and furosemide 60 mg daily.
Patient underwent therapeutic paracentesis with 1.5 L of ascitic
fluid removed. Patient's abdominal pain improved after the
paracentesis. Continued Lactulose 30 mL QID, titrated to ___ BM
daily and home rifaxamin 550 mg daily.
# Hyperbilirubinemia
# RUQ/epigastric abdominal pain
Etiology of abdominal pain is unclear with no evidence of
complication from recent paracentesis on CT A/P, as well as no
evidence of intrahepatic or extrahepatic biliary dilation. No
new liver lesions identified, and gallbladder appeared WNL.
Lipase WNL, making pancreatitis unlikely. Certainly worsening
ascites can contribute to pain, although focal nature is
unusual. Pain improved following large volume paracentesis. Pain
controlled with oxycodone 5 mg q4H and oxycontin 10 mg BID.
# HCC with known bony metastases to L shoulder
Per most recent oncology notes, patient planned to start on
sorafenib at reduced dose of 200 mg BID after risk/benefit
discussion, though this is a regimen that may be contraindicated
with child ___ class C cirrhosis or poor liver function. He has
yet to start this medication pending delivery. He is otherwise
s/p RFA x 2 and palliative XRT to the shoulder. Pain controlled
with above oxycodone regimen.
CHRONIC ISSUES:
===============
# HIV on ART: Last CD4 count ___
Continued home dolutegravir 50 mg daily and descovy 1 tab daily.
# Hyperlipidemia
Continued home atorvastatin 10 mg daily.
# PTSD/insomnia
Continued amitriptyline 25 mg PO QHS.
# Supplements
Continued home magnesium oxide 800 mg BID and Vitamin D 800
UNITP O DAILY.
# Macrocytic anemia
Chronic, improved from prior. Hgb 12.1 on admission.
TRANSITIONAL ISSUES:
====================
[ ] Please schedule follow up with Dr. ___ in next week or two
as you may need repeat large volume paracentesis.
[ ] Would consult with your liver doctor prior to travel.
[ ] Would consider further up-titrating outpatient diuretic
regimen
#CODE: DNR/DNI (on MOLST from ___ and confirmed with pt)
#CONTACT: ___ (son/HCP) ___ ___
(friend) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lactulose 30 mL PO QID
2. Magnesium Oxide 800 mg PO BID
3. Sorafenib 200 mg PO Q12H
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Dolutegravir 50 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Furosemide 60 mg PO DAILY
8. Spironolactone 150 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
10. Rifaximin 550 mg PO DAILY
11. Amitriptyline 25 mg PO QHS
12. Vitamin D 800 UNIT PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
14. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
3. Amitriptyline 25 mg PO QHS
4. Atorvastatin 10 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Dolutegravir 50 mg PO DAILY
7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
8. Furosemide 60 mg PO DAILY
9. Lactulose 30 mL PO QID
10. Magnesium Oxide 800 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Rifaximin 550 mg PO DAILY
13. Sorafenib 200 mg PO Q12H
14. Spironolactone 150 mg PO DAILY
15. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
HCV cirrhosis
HCC
HIV
Refractory ascites
SECONDARY:
==========
Hypertension
PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were referred to the hospital by Dr. ___ in order
to help remove extra fluid that had accumulated in your abdomen.
We think this caused your belly pain.
WHAT HAPPENED IN THE HOSPITAL?
- You had a CT scan of the abdomen which was overall unchanged
when compared to prior.
- You had a large volume paracentesis performed.
- This showed that you did not have an infection.
- 1.5 liters of fluid was removed from your abdomen.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should continue to take all of your medications as
prescribed.
- You should follow up with your doctors as ___ below.
- IF you notice the size of your belly increasing, call your
liver doctor to discuss increasing the frequency of your Lasix
or scheduling an appointment to have fluid taken off.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10760122-DS-26
| 10,760,122 | 22,048,195 |
DS
| 26 |
2121-01-04 00:00:00
|
2121-01-05 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / epidural
injection / tramadol / Tylenol
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound-guided diagnostic paracentesis ___
___ diagnostic paracentesis ___
History of Present Illness:
This is a ___ year old gentleman with PMH of HCV cirrhosis (Child
C/___, MELD 24), HIV co-infection, portal hypertension (c/b
rectal varices, ascites, hepatic encephalopathy), and HCC with
metastatic disease to the left shoulder s/p resection and
palliative XRT recently admitted for refractory ascites and
abdominal pain s/p therapeutic paracentesis now re-presenting
with worsening RLQ abdominal pain.
Patient was admitted to the liver service at ___ (___) for
large volume paracentesis and pain control. The patient
underwent diagnostic/therapeutic paracentesis on ___ with 1.5 L
ascites removed and subjective improvement in abdominal pain.
Ascites fluid without evidence of SBP at that time. The
patient's pain was controlled with PO oxycodone and he was
discharge home ___ with the plan for outpatient follow up.
The patient returned home without any abdominal pain. That
night, at approximately 3 AM, he awoke suddenly with a
"stabbing" pain in the RLQ of his abdomen. He states that it
felt as if his abdomen had popped. The patient was ultimately
able to fall back asleep after taking his oxycodone. He then
represented to ___ ___ with persistent RLQ
abdominal pain. The patient was then transferred back to ___
for further management.
In the ED, initial vitals were: Temp 97.6, HR 97, BP 128/75, RR
19, Sa 92% 4L NC.
Exam notable for: RLQ tenderness, 2+ pitting edema bilaterally
Labs notable for: Na 130, AST 72, ALT 32, AP 180, Tbili 5.8,
Dbili 3.0, Alb 2.3, WBC 10.1, H/H 11.4/33.2, Plt 97.
Imaging was notable for:
- CXR: Mild bilateral pulmonary vascular congestion.
- Liver U/S: 1. Cirrhotic liver with moderate ascites. No
splenomegaly. Radiofrequency ablation site again demonstrated in
the right hepatic lobe. No ___ lesions. 2. Poor visualization of
the main portal vein.
Patient was given:
PO/NG OxyCODONE (Immediate Release) 5 mg
PO OxyCODONE SR (OxyconTIN) 10 mg
PO/NG Furosemide 60 mg
PO/NG Lactulose 30 mL
PO/NG Spironolactone 200 mg
PO/NG Rifaximin 550 mg
PO/NG OxyCODONE (Immediate Release) 5 mg
PO/NG Lactulose 30 mL
IV Morphine Sulfate 4 mg
Hepatology evaluated the patient in ED and recommended:
- If stable for floor can admit to ___ under Dr. ___
- Would consider non-contrast imaging for LQG pain since
although his Cr is normal now, he just got a CT with contrast a
few days ago, a LVP, likely to get another LVP this week, and
diuretic-dependent.
- Repeat diagnostic para to look for secondary bacterial
peritonitis after his recent para.
Upon arrival to the floor, patient reports "rebound" tenderness
in his lower abdomen. Also states that he feels like he has
"gained back all the weight they took off" while he was admitted
despite being compliant with his medications. The patient
endorses decreased UOP since returning home. He also had some
palpitations during the worst of the pain. He also notes that
the "inside" of his abdomen feels "hot." He otherwise denies
fevers, chills, SOB.
Past Medical History:
1. Penetrating thoracic aortic aneurysm of the descending aorta
status post TAVR on ___
2. Cirrhosis ___ chronic genotype hepatitis C, ETOH
3. Hypertension
4. PTSD
5. Cervical disc herniations
6. Gastritis with bleeding
7. Lipoma
8. HIV on ART
Social History:
___
Family History:
Mom with CAD. Multiple prior family malignancies. The patient
is unsure of the
type.
Physical Exam:
ADMISSION EXAM:
===============
Temp: 98.3 (Tm 98.3), BP: 116/76, HR: 94, RR: 18, O2 sat: 95%,
O2 delivery: Ra, Wt: 197 lb/89.36 kg
GENERAL: NAD, lying in bed with shirt lifted up so as not to
make contact with abdomen.
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: Distended and tense, + fluid wave, TTP most markedly in
RLQ and suprapubic region with minimal rebound and voluntary
guarding, paracentesis site in R lower flank c/d/i with minimal
ecchymosis surrounding puncture site. Sporadic ecchymoses
___.
EXTREMITIES: + clubbing (per patient chronic), 2+ pitting edema
to level of knee
PULSES: 2+ ___ pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, NO
asterixis, pleasant and interactive.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
VITAL SIGNS: 98.1 111/70 96 18 96%RA
GENERAL: NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, slightly icteric 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: Slightly distended and tense, TTP most markedly in RLQ
and suprapubic region without rebound.
EXTREMITIES: + clubbing (per patient chronic), 2+ pitting edema
to level of mid-shin
PULSES: 2+ ___ pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis, pleasant and interactive.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 07:20PM GLUCOSE-88 UREA N-8 CREAT-0.8 SODIUM-129*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-29 ANION GAP-6*
___ 07:20PM ALT(SGPT)-34 AST(SGOT)-76* LD(LDH)-310* ALK
PHOS-184* TOT BILI-6.6*
___ 07:20PM ALBUMIN-2.2* CALCIUM-8.0* PHOSPHATE-2.4*
MAGNESIUM-1.7
___ 07:20PM ___
___ 07:20PM HAPTOGLOB-<10*
___ 07:20PM WBC-7.8 RBC-3.27* HGB-11.6* HCT-34.0*
MCV-104* MCH-35.5* MCHC-34.1 RDW-19.2* RDWSD-74.0*
___ 07:20PM NEUTS-61.1 ___ MONOS-11.9 EOS-3.3
BASOS-0.5 IM ___ AbsNeut-4.78 AbsLymp-1.71 AbsMono-0.93*
AbsEos-0.26 AbsBaso-0.04
___ 07:20PM PLT COUNT-116*
___ 07:20PM ___ PTT-47.5* ___
___ 07:20PM ___
___ 06:33PM ASCITES TNC-1187* RBC-350* POLYS-47* LYMPHS-8*
___ MESOTHELI-2* MACROPHAG-43*
___ 09:10AM ___ PTT-35.2 ___
___ 03:50AM GLUCOSE-81 UREA N-8 CREAT-0.7 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-24 ANION GAP-9*
___ 03:50AM ALT(SGPT)-33 AST(SGOT)-73* ALK PHOS-191* TOT
BILI-6.3* DIR BILI-3.0* INDIR BIL-3.3
___ 03:50AM ALBUMIN-2.4*
___ 03:50AM URINE HOURS-RANDOM
___ 03:50AM URINE UHOLD-HOLD
___ 03:50AM WBC-9.4 RBC-3.40* HGB-12.0* HCT-35.0*
MCV-103* MCH-35.3* MCHC-34.3 RDW-19.5* RDWSD-73.8*
___ 03:50AM NEUTS-61.5 ___ MONOS-10.9 EOS-2.5
BASOS-0.3 IM ___ AbsNeut-5.77 AbsLymp-2.20 AbsMono-1.02*
AbsEos-0.23 AbsBaso-0.03
___ 03:50AM PLT COUNT-114*
___ 03:50AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 03:50AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 03:50AM URINE RBC-9* WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:50AM URINE MUCOUS-RARE*
___ 02:00AM GLUCOSE-85 UREA N-8 CREAT-0.7 SODIUM-130*
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-23 ANION GAP-9*
___ 02:00AM ALT(SGPT)-32 AST(SGOT)-72* ALK PHOS-180* TOT
BILI-5.8*
___ 02:00AM ALBUMIN-2.3*
___ 02:00AM WBC-10.1*# RBC-3.22* HGB-11.4* HCT-33.2*
MCV-103* MCH-35.4* MCHC-34.3 RDW-19.2* RDWSD-72.8*
___ 02:00AM NEUTS-62.1 ___ MONOS-11.6 EOS-2.3
BASOS-0.6 IM ___ AbsNeut-6.24* AbsLymp-2.23 AbsMono-1.17*
AbsEos-0.23 AbsBaso-0.06
___ 02:00AM PLT COUNT-97*
PARACENTESIS LABS:
==================
___ 06:33PM ASCITES TNC-1187* RBC-350* Polys-47* Lymphs-8*
___ Mesothe-2* Macroph-43*
___ 06:33PM ASCITES TNC-918* RBC-263* Polys-12* Lymphs-53*
___ Mesothe-2* Macroph-33*
DISCHARGE LABS:
===============
___ 07:59AM BLOOD WBC-6.0 RBC-2.79* Hgb-10.3* Hct-30.1*
MCV-108* MCH-36.9* MCHC-34.2 RDW-19.6* RDWSD-78.5* Plt Ct-92*
___ 07:59AM BLOOD ___
___ 07:59AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-138 K-4.2
Cl-99 HCO3-28 AnGap-11
___ 05:23AM BLOOD FacVIII-139
___ 07:59AM BLOOD ALT-20 AST-45* LD(LDH)-230 AlkPhos-137*
TotBili-5.4*
___ 07:59AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
___ 07:20PM BLOOD ___
___ 05:04AM BLOOD AFP-182.2*
IMAGING:
========
CXR ___:
FINDINGS:
Vascular stent noted in the descending aorta is similar in
position compared to prior.There is mild bilateral pulmonary
vascular congestion. No focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unchanged.
IMPRESSION:
Mild bilateral pulmonary vascular congestion.
Liver ultrasound ___:
IMPRESSION:
1. Cirrhotic liver with moderate ascites. No splenomegaly.
Radiofrequency ablation site again demonstrated in the right
hepatic lobe. No ___ lesions.
2. Poor visualization of the main portal vein.
KUB ___:
FINDINGS:
There are multiple air-filled loops of small bowel with
air-fluid levels,
several which may be minimally dilated. Air is seen within the
colon and
within the rectum. There is no free air. There is no free
intraperitoneal air. An aortic stent is re-demonstrated. There
are no unexplained soft tissue calcifications or radiopaque
foreign bodies.
IMPRESSION:
Air in multiple loops of small bowel, several of which may be
minimally
dilated. Air seen within the colon and rectum. Findings are
most compatible with ileus.
Left shoulder X-ray ___:
FINDINGS:
Again seen is aggressive osteolysis of the acromion. Compared
to ___, the degree of osteolysis posteriorly may
have increased and the associated lucent area traverses the
entire craniocaudad diameter of the bone, compatible with a
nondisplaced pathologic fracture of the acromion.
Bulbous enlargement of the distal clavicle is similar to prior,
compatible
with degenerative changes. There is also suggestion of
osteolysis along the distal edge of the clavicle, similar to
prior, though this area is not well depicted on these views.
There are moderate degenerative changes of
glenohumeral joint, with superior subluxation of the humerus
with respect to the glenoid, that is more pronounced on today's
examination, question due to differences in positioning versus
differential differences in function of the rotator cuff.
There is diffuse osteopenia. However, no other focal lytic or
sclerotic
lesions and no other areas of fracture are identified.
Abutting portion of the left lung is grossly clear.
IMPRESSION:
Apparent interval progression of lytic lesion in the acromion.
Extent of the osteolysis is compatible with a nondisplaced
pathologic fracture. Suspected osteolysis of the distal edge of
the clavicle, not well depicted on these views.
Elsewhere, no focal lytic or sclerotic lesion is detected. No
other evidence of fracture. No dislocation.
Osteopenia and glenohumeral joint degenerative changes again
noted.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old gentleman with history of HCV
cirrhosis (Child C/___, MELD 24) in the setting of HIV
coinfection, complicated by portal hypertension (rectal varices,
ascites, hepatic encephalopathy), and metastatic HCC with mets
to shoulder s/p resection and palliative XRT, who presented with
recurrent abdominal pain following recent admission for
RUQ/epigastric abdominal pain and refractory ascites s/p LVP.
ACUTE ISSUES:
=============
# HCV Cirrhosis (Child C/___, MELD ___)
# Refractory Ascites
# Abdominal Pain
# SBP
Patient presented with RLQ abdominal pain following a very
similar presentation over the prior weekend. Initial
differential included SBP (though no evidence of this on
multiple recent diagnostic paracenteses), secondary bacterial
peritonitis following recent paracentesis, and portal vein
thrombosis given poor visualization of the main portal vein.
Repeat paracentesis performed on admission was consistent with
SBP (TNC 1187, RBC 350, Polys 47, Lymphs 8, Monos 0, Mesothe 2,
Macroph 43). Cultures with no growth. Patient was thus started
on IV ceftriaxone and MetroNIDAZOLE 500 mg PO. Repeat
paracentesis performed on ___ showed resolution of SBP
(TNC 918, RBC 263, Polys 12, Lymphs 53, Monos 0, Mesothe 2,
Macroph 33). His abdominal pain improved and the patient was
transitioned to an oral regimen of ciprofloxacin at a dose of
500 mg Q12h prior to discharge. His oral diuretics were
initially held in the setting of SBP. They were resumed at
reduced doses of 100 mg spironolactone and 40 mg PO Lasix. Upon
discharge, Lasix and spironolactone ***were/were not*** resumed
at home doses.
# HCC with Metastases to Left Shoulder
# Non-displaced pathologic fracture of acromion
Per most recent oncology notes, patient planned to start on
sorafenib at reduced dose of 200 mg BID after risk/benefit
discussion, though this is a regimen that may be contraindicated
with Child ___ Class C cirrhosis or poor liver function. He has
yet to start this medication. He is otherwise s/p RFA x 2 and
palliative XRT to the shoulder. He had repeat shoulder imaging
with X-ray this admission which showed "apparent interval
progression of lytic lesion in the acromion. Extent of the
osteolysis is compatible with a nondisplaced pathologic
fracture. Suspected osteolysis of the distal edge of the
clavicle, not well depicted on these views. Elsewhere, no focal
lytic or sclerotic lesion is detected. No other evidence of
fracture. No dislocation." The acute pain service was consulted
for help with pain management. They recommended increasing the
oxycodone and oxycontin to ___ mg q4H and oxycontin 10 mg TID.
Orthopedics was also consulted given the non-displaced
pathologic fracture. The patient's orthopedic oncologic surgeons
were contacted; updates will be provided in the event there are
further recommendations regarding this patient's care. The
patient will follow-up with Dr. ___ in clinic following
discharge. Per discussion with Dr. ___
oncologist, the patient was advised to start sorafenib upon
discharge given resolution of SBP.
CHRONIC ISSUES:
===============
# HIV on ART
Last CD4 count ___. Continued home dolutegravir 50 mg
daily and descovy 1 tab daily.
# Hyperlipidemia
Continued home atorvastatin 10 mg daily.
# PTSD/insomnia
Continued amitriptyline 25 mg PO QHS.
# Supplements
Continued home magnesium oxide 800 mg BID and Vitamin D 800 UNIT
PO DAILY
# Macrocytic anemia
Monitored in house. Hgb 10.1 on discharge.
TRANSITIONAL ISSUES:
====================
# Advised to start sorafenib on discharge given progression of
HCC.
# Palliative care consulted in house. They recommended minor
upward adjustments in his oxycodone as recommended by the
chronic pain service.
# The patient's orthopedic oncologic surgeons were contacted
during this admission due to progression of left shoulder
lesion; updates will be provided in the event there are further
recommendations regarding this patient's care. The patient will
follow-up with Dr. ___ in clinic following discharge.
# Patient will need long-term antibiotic therapy with
Ciprofloxacin given SBP this admission.
[ ] Outpatient lab work to be obtained ___ and faxed to Dr.
___ Dr. ___
___ MEDICATIONS:
- Ciprofloxacin at a dose of 500 mg PO Q12h for 2 days followed
by 500 mg daily
- Sorafenib 200 mg PO Q12H
CHANGED MEDICATIONS:
- OxyCODONE (Immediate Release) increased to ___ mg PO/NG
Q4H:PRN
- OxyCODONE SR (OxyconTIN) increased to 10 mg PO Q8H
HELD MEDICATIONS: NONE
#CODE: DNR/DNI (on MOLST from ___ and confirmed with
patient)
#CONTACT: ___ (son/HCP) ___ ___
(friend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Amitriptyline 25 mg PO QHS
3. Atorvastatin 10 mg PO QPM
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
6. Furosemide 60 mg PO DAILY
7. Lactulose 30 mL PO QID
8. Magnesium Oxide 800 mg PO BID
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
10. Rifaximin 550 mg PO DAILY
11. Spironolactone 150 mg PO DAILY
12. Vitamin D 800 UNIT PO DAILY
13. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
14. Bisacodyl 10 mg PO DAILY:PRN constipation
15. Sorafenib 200 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
2. Sorafenib 200 mg PO Q12H
3. Furosemide 40 mg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
6. Spironolactone 100 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
8. Amitriptyline 25 mg PO QHS
9. Atorvastatin 10 mg PO QPM
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Dolutegravir 50 mg PO DAILY
12. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
13. Lactulose 30 mL PO QID
14. Magnesium Oxide 800 mg PO BID
15. Rifaximin 550 mg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
17.Outpatient Lab Work
Obtain CBC, chemistry and transaminases with total bilirubin.
ICD ___
Please fax to ___ at ___ and Dr.
___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
Spontaneous bacterial peritonitis
HCV cirrhosis
Metastatic HCC c/b left acromion fracture
HIV
Refractory ascites
SECONDARY:
==========
Hypertension
PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were transferred to ___ because of worsening abdominal
pain. The pain was severe enough to wake you from sleep.
WHAT HAPPENED IN THE HOSPITAL?
- You had another diagnostic paracentesis performed which showed
an infection in your abdomen.
- You were given antibiotics to treat the infection and your
pain improved.
- You had a shoulder X-ray which showed that there was some
progression of the lytic lesion in the acromion of your left
shoulder.
- Your pain medications were increased to better control your
pain.
- You had another paracentesis performed to make sure that the
infection in your abdomen got better. This showed that the
infection is gone.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should continue to take all of your medications as
prescribed.
- You can now start the chemotherapy medicine that was
prescribed previously.
- You should follow up with your doctors as ___ below.
- IF you notice the size of your belly increasing, call your
liver doctor to discuss increasing the frequency of your Lasix
or scheduling an appointment to have fluid taken off.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10760122-DS-27
| 10,760,122 | 21,234,042 |
DS
| 27 |
2121-01-31 00:00:00
|
2121-01-31 14:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / epidural
injection / tramadol / Tylenol
Attending: ___.
Chief Complaint:
Body Aches
Major Surgical or Invasive Procedure:
ERCP common bile duct stent placement
History of Present Illness:
Mr ___ is a pleasant ___ w/ HCV cirrhosis (Child C/___, MELD
___), HIV co-infection, portal HTN (c/b rectal varices, ascites,
hepatic encephalopathy), and HCC with metastatic disease to the
left shoulder s/p resection and palliative XRT then w.
pathologic
fx, who presents with body aches.
Body aches began ___, relatively sudden onset. No associated
respiratory symptoms or fevers. No associated specific abdominal
pain or chest pain. He states that his "whole body aches" and
that he has intermittent sharp pains of lightening. He has not
noted any swelling in any of his extremities. He has never had
pain like this before. He is on oral oxycodone and OxyContin at
home which has not been able to control his pain
In the ED, VS unremarkable. Found to have icterus and diffusely
tender abd w/o fluid wave or pocket on POCUS. Received morphine
and IV NS and transferred to 11R.
On arrival to 11R, pt noted no changes in his symptoms, feeling
"horrible," admitting to poor PO intake since ___, sleeping
around the clock. HE admits to RLQ pain that has been stable x 2
months.
Past Medical History:
1. Penetrating thoracic aortic aneurysm of the descending
aorta status post TAVR on ___
2. Cirrhosis ___ chronic genotype hepatitis C, ETOH
3. Hypertension
4. PTSD
5. Cervical disc herniations
6. Gastritis with bleeding
7. Lipoma
8. HIV on ART
Social History:
___
Family History:
Multiple prior family malignancies. The patient is unsure of
the
type.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 99 Axillary 124 / 87 R Lying 90 16 95 RA
HEENT: MMM, notable icterus
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, TTP in RLQ
LIMBS: + b/l pedal edema, +clubbing, +asterixis
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves III-XII intact, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 11:30PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 11:30PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 11:30PM URINE RBC-10* WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 11:30PM URINE MUCOUS-RARE*
___ 03:01PM LACTATE-2.4*
___ 02:45PM GLUCOSE-124* UREA N-9 CREAT-0.8 SODIUM-130*
POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-20* ANION GAP-14
___ 02:45PM estGFR-Using this
___ 02:45PM ALT(SGPT)-40 AST(SGOT)-99* CK(CPK)-126 ALK
PHOS-173* TOT BILI-8.6* DIR BILI-3.0* INDIR BIL-5.6
___ 02:45PM LIPASE-29
___ 02:45PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-2.0*
MAGNESIUM-1.6
___ 02:45PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 02:45PM WBC-9.6 RBC-3.68* HGB-13.2* HCT-37.7*
MCV-102* MCH-35.9* MCHC-35.0 RDW-17.7* RDWSD-67.1*
___ 02:45PM NEUTS-74.2* LYMPHS-16.6* MONOS-7.0 EOS-1.0
BASOS-0.4 IM ___ AbsNeut-7.09* AbsLymp-1.59 AbsMono-0.67
AbsEos-0.10 AbsBaso-0.04
___ 02:45PM PLT COUNT-97*
___ 02:45PM ___ PTT-50.8* ___
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-8.7 RBC-3.01* Hgb-11.3* Hct-31.7*
MCV-105* MCH-37.5* MCHC-35.6 RDW-18.6* RDWSD-71.9* Plt Ct-93*
___ 07:50AM BLOOD Plt Ct-93*
___ 05:00AM BLOOD Neuts-61.9 ___ Monos-8.4 Eos-4.1
Baso-0.4 Im ___ AbsNeut-4.67 AbsLymp-1.84 AbsMono-0.63
AbsEos-0.31 AbsBaso-0.03
___ 07:50AM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-127*
K-4.5 Cl-93* HCO3-26 AnGap-8*
___ 07:50AM BLOOD ALT-44* AST-100* LD(LDH)-283*
AlkPhos-188* TotBili-7.9*
___ 07:50AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.8
___:50AM BLOOD Osmolal-265*
IMAGING:
___ Abdominal Duplex:
1. Cirrhotic liver with grossly unchanged ablation cavity in
segment VII. No
new focal hepatic lesion. No ascites.
2. Distended gallbladder without wall thickening or gallstone
to suggest
acute cholecystitis.
3. The portal veins are not well visualized as on prior study
from ___.
___ RUQ U/S:
1. Cirrhotic liver with grossly unchanged ablation cavity in
segment VII. No
new focal hepatic lesion. No ascites.
2. Distended gallbladder without wall thickening or gallstone
to suggest
acute cholecystitis.
3. The portal veins are not well visualized as on prior study
from ___.
___ Renal U/S:
Unremarkable renal ultrasound. No hydronephrosis.
___ CT a/p w/ con:
1. No evidence of bowel ischemia or diverticulitis.
2. Moderate extrahepatic biliary and distal main pancreatic
ductal dilatation.
Although stable compared to recent CT from ___, this is
significantly
increased from the prior CT from ___. Correlation with
lab findings
and further assessment with ERCP/MRCP (biliary) is recommended
for further
assessment of the distal CBD/ampullary region.
MICRO:
___ Blood Cx x2: No growth
___ Urine Cx: No growth
___ Urine Cx: No growth
___ 7:00 am Blood (CMV AB) CMVP,EBVP ADDED ___.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
332 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
___ 7:00 am Blood (EBV) CMVP,EBVP ADDED ___.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___:
Test canceled and patient credited due to a prior EBV
panel sent on
___ indicating evidence of past infection (EBV VCA-IgG
positive,
EBNA IgG positive and EBV VCA-IgM negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3 months.
For any questions, contact the Microbiology Medical
Director.
___ VIRUS EBNA IgG AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ VIRUS VCA-IgM AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Brief Hospital Course:
SUMMARY
========
___ w/ HCV cirrhosis (Child ___, MELD 24), HIV co-infection,
portal HTN (c/b rectal varices, ascites, hepatic
encephalopathy), and HCC with metastatic disease to the left
shoulder s/p resection and palliative XRT then w. pathologic fx,
who presents with diffuse myalgias and malaise likely ___ his
sorafenib medication which was held. He also received a common
bile duct stent w/ ERCP during his in house stay and had control
of his abdominal pains via liquid Dilaudid. He underwent a GOC
discussion with alteration of his code status to DNR/DNI and
plan for transition to home hospice.
ACUTE ISSUES:
# Severe Abdominal pain: Pt had episodes of severe, gripping
abdominal pain - focused in RuQ. These usually responded to IV
hydromorphone. Pain was carefully assessed and monitored.
Opioids adjusted. By time of discharge, the pain was better
controlled and he was able to manage it with PO prn medications.
# Hyperbilirubinemia:
Diffuse abdominal pain likely multifactorial in the setting of
known HCC, concern for possible biliary obstruction based on
obstructive pattern on labs and biliary dilatation on CT scan.
No associated nausea/vomiting, no correlation with exertion or
eating, no ischemia or obstruction seen on CT scan reassuring.
Now s/p ERCP on ___ with temporary stent placement. Repeat LFTs
displaying down-trend following stenting. Attempts to identify a
fluid pocket for potential abdominal drainage unsuccessful on
___ given bowel contiguous with abdominal wall. Following ___
discussion on ___ was understanding of disease state and opted
to transition to DNR/DNI status with transition to home hospice.
Pain well controlled with dilaudid liquid given more rapid onset
phase covering his acute episodes while Oxycontin coverage of
baseline pain. Will need repeat ERCP in 2 weeks from ___ for
possible stent removal, and outpatient apt w/ Dr ___.
# Myalgias: Most likely deriving from viral illness or his
sorafenib medication in the context of potential decreased liver
clearance with dysfunction. Myalgias improved prior to
discharge.
# UTI: Positive UA on admission, treated with 5 days CTX, urine
culture negative. Renal US without abnormality. Asymptomatic.
# HCC w/ metastatic osseous lesions: Admitted on outpatient
sorafenib. This was held during admission and decision was made
to hold on discharge given preference to pursue palliative
hospice care. Outpatient oncologist Dr. ___ was aware and
involved during admission.
# HCV cirrhosis
# Coagulopathy
# Peripheral Edema
# Acute Hepatic Encephalopathy
He presented with decompensated w/ hepatic encephalopathy on
admission (overt lethargy, asterixis). Treated for possible UTI,
and s/p ERCP to relieve possible biliary obstruction. He was
maintained on home Lasix, spironolactone, lactulose and
rifaximin. He improved and was clinically stable with improved
mental status. He was placed on ciprofloxacin daily for SBP
prophylaxis following UTI tx completion. Unfortunately, liver
function never returned to ___ prior baseline. TB
remained above 7 and MELD score was ___. Decision was made to
pursue hospice care given underlying medical conditions.
Sorafenib was held on discharge as above and in the setting of
worsened liver failure.
CHRONIC ISSUES:
# HIV: VL < 1.3. Continued Descovy
# COPD: Quiescent, albuterol prn
# Hypomagnesemia: Continued home mag ox
# HTN: Home spironolactone and Lasix diuretics
TRANSITIONAL ISSUES:
[]Repeat ERCP in 2 weeks for stent pull and re-evaluation.
[]Follow-up with Dr. ___ as previously scheduled.
[]Discharged to home with hospice services. Elected to
discontinue sorafenib.
CODE STATUS: DNR/DNI on MOLST
HCP: Health Care Proxy: ___ (son/HCP) ___
___ (friend) ___
PCP: ___, MD, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Amitriptyline 25 mg PO QHS
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
6. Lactulose 30 mL PO QID
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
9. Rifaximin 550 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Atorvastatin 10 mg PO QPM
12. Magnesium Oxide 800 mg PO BID
13. Furosemide 40 mg PO DAILY
14. Spironolactone 100 mg PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*2
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 1 mg/mL ___ mL by mouth every 4 hours
Refills:*0
3. Metoclopramide 5 mg PO QIDACHS
RX *metoclopramide HCl 5 mg 1 tablet by mouth 3 times a day
before meals Disp #*15 Tablet Refills:*0
4. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone 20 mg 1 tablet(s) by mouth every 8 hours Disp #*15
Tablet Refills:*0
5. Rifaximin 550 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Ciprofloxacin HCl 500 mg PO Q12H
9. Dolutegravir 50 mg PO DAILY
10. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
11. Furosemide 40 mg PO DAILY
12. Lactulose 30 mL PO QID
13. Magnesium Oxide 800 mg PO BID
14. Spironolactone 100 mg PO DAILY
15. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Metastatic hepatocellular carcinoma
Urinary tract infection
Cirrhosis
Diffuse myalgia
SECONDARY:
Human immunodeficiency virus
Hepatitis C
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because you presented with generalized
body aches and pains which you have not experienced before in
addition to decreased food and drink intake, and there was
concern for possible worsening of your liver disease.
What was done while I was in the hospital?
- Picutres were taken that showed you did not have acute
disease of your kidney, and intestines which caused either your
generalized pains or your sudden sharp pains in the hospital.
- Liver pictures did show you had some increases in the size
of the ducts that run in the liver which could be from disease
in those ducts.
- You were taken with our liver specialists to receive a stent
to open the obstruction which may have been causing your ducts
to increase in size and had successful implantation of this
stent.
- Your chemotherapy medication sorafenib was held and your
generalized pains subsequently resovled.
- Your sudden pains were treated with liquid Dilaudid as well
as your long acting Oxycontin which you were stabilized on.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have vomiting of blood, increased swelling in your
belly or legs, please tell your primary doctor or go to the
emergency room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10760830-DS-3
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| 3 |
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2156-03-01 17:32:00
|
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:
___ s/p laparoscopic appendectomy ___ who reports all
was well post-operatively until 1 week ago, when she noted
abdominal pain similar to her appendicitis pain. It slowly
worsened, and she noted decreased oral intake as well. She has
been having bowel movements, including one on the day of
presentation to the ED. She had a fever to 102 at home. Denies
nausea, emesis, rigors, chest pain or shortness of breath. CT
scan in the ED revealed 6 x 2cm collection at the staple line in
RLQ. Incidental finding of LLL PE on CT abd/pelvis,
asymptomatic.
Past Medical History:
Past medical history: HLD, asthma, anxiety
PSH: laparoscopic appendectomy ___
Social History:
___
Family History:
Mother with colon cancer at age ___ but lived until age ___.
Physical Exam:
Admission Physical Exam:
Vitals: 100.9 103 140/70 16 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation in the RLQ without
rebound or guarding, no palpable masses
DRE: deferred
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: T:99 HR: 78 BP: 103/63 RR: 16 O2sat: 96% RA
GEN: A&O, NAD
HEENT: normocephalic, atraumatic, no scleral icterus, MMM
CV: warm and well perfused
Pulm: breathing comfortably on room air
Abd: soft, nondistended, no palpable masses, mildly tender to
palpation in RLQ without rebound or guarding
Ext: warm and well perfused, no edema or tenderness
Pertinent Results:
___ 09:50PM BLOOD WBC-14.3* RBC-3.61* Hgb-11.0* Hct-33.7*
MCV-93 MCH-30.5 MCHC-32.6 RDW-12.8 RDWSD-44.2 Plt ___
___ 09:50PM BLOOD Neuts-77.4* Lymphs-13.1* Monos-7.9
Eos-0.6* Baso-0.4 Im ___ AbsNeut-11.05* AbsLymp-1.86
AbsMono-1.12* AbsEos-0.08 AbsBaso-0.06
___ 11:52PM BLOOD ___ PTT-25.4 ___
___ 09:50PM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-142
K-4.7 Cl-103 HCO3-26 AnGap-13
___ 09:50PM BLOOD ALT-27 AST-27 CK(CPK)-34 AlkPhos-84
TotBili-0.6
___ 09:50PM BLOOD Lipase-42
___ 09:50PM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-151
___ 09:50PM BLOOD Albumin-3.9
___ 09:53PM BLOOD Lactate-0.8
___ 05:26AM BLOOD WBC-10.7* RBC-3.31* Hgb-10.2* Hct-31.0*
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.8 RDWSD-44.3 Plt ___
___ 05:26AM BLOOD ___ PTT-65.7* ___
___ 07:13AM BLOOD Glucose-132* UreaN-6 Creat-0.7 Na-141
K-4.6 Cl-103 HCO3-26 AnGap-12
IMAGING:
=========
___ CHEST (PA & LAT)
No evidence of pneumonia.
___ CT ABD & PELVIS WITH CONTRAST
1. Status post appendectomy with a tubular collection tracking
along the
suture line measuring approximately 5 cc. This could represent
small amount of hemorrhage, though superinfection cannot be
excluded.
2. Questioned filling defect in the left lower lobe segmental
pulmonary artery concerning for pulmonary embolism. CTA chest
for evaluation of pulmonary embolism is recommended.
___ CTA CHEST
1. Segmental pulmonary embolism involving the bifurcation of
the anteromedial and lateral basal segmental arteries of the
left lower lobe. No evidence of right heart strain or pulmonary
infarction.
2. Tubular opacity in the right upper lobe anterior segment,
decreased in
size compared to ___, with surrounding hyperlucency
likely
representing an impacted bronchus with air trapping.
3. Please see separate report performed on the same day for
detailed
evaluation of the abdomen pelvis.
___ BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Brief Hospital Course:
The patient presented to the emergency room on ___ with 1
week of abdominal pain after recent laparoscopic appendectomy
___. Upon arrival to ED, she was found to be febrile to
100.9 with WBC elevated to 14.3. CT abdomen/pelvis scan was
performed in the ED and revealed 6 x 2cm collection at the
staple line in RLQ. There was also an incidental finding of LLL
PE on CT abd/pelvis, which was completely asymptomatic. She was
breathing well on room air. Further CTA chest confirmed this,
although bilateral LENIs showed no DVTs.
Given findings, the patient was admitted to the Acute Care
Service. For her RLQ collection, she was started on IV
antibiotics (cipro/flagyl). ___ drainage of collection was felt
to not indicated. Her white count downtrended throughout her
stay and she was transitioned to oral antibiotics.
For her incidental and asymptomatic PE, she was started on a
heparin drip per PE protocol with goal PTT of 60-80, which was
achieved. Her pulmonary/cardiovascular function was stable
throughout this admission.
Neuro: The patient was alert and oriented throughout
hospitalization.
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 patient was initially kept NPO for possible
procedure, but was advanced to a Regular diet when no
interventions were felt to be indicated, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for
infection improvment. She was afebrile at the time of discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. Her ultimately WBC
trended down during her stay.
Prophylaxis: The patient received a heparin drip for her PE, and
___ dyne boots were used during this stay and she was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. She was breathing comfortably on
room air and abdominal exam was reassuring. 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. She was
discharged on Pradaxa for anticoagulation as well as 10 day
course of antibiotics.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs(s) inhaled four times a day as needed
for shortness of breath or wheeze
CITALOPRAM - citalopram 40 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY MORNING
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. Instill 1 to 2 sprays into each nostril once
to twice daily
FLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation
aerosol inhaler. 1 inhalation by mouth twice a day Rinse mouth
after use, (call if not covered)
HYDROCORTISONE ACETATE [ANUSOL-HC] - Anusol-HC 25 mg rectal
suppository. apply rectally twice a day as needed for
hemorroidal flare
PRAVASTATIN - pravastatin 20 mg tablet. TAKE 1 TABLET NIGHTLY AT
BEDTIME
Medications - OTC
ASPIRIN - aspirin 81 mg chewable tablet. 1 Tablet(s) by mouth
once a day - (OTC)
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] -
Calcarb 600 With Vitamin D 600 mg (1,500 mg)-400 unit tablet. 1
tablet(s) by mouth prn dietary calcium intake <1200mg
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain -
(Prescribed by Other Provider; 1 qod)
MELATONIN - Dosage uncertain - (OTC; 1 qhs)
MULTIVITAMIN - Dosage uncertain - (Prescribed by Other
Provider;
OTC)
--------------- --------------- --------------- ---------------
Discharge Medications:
NEW MEDICATIONS
1. Acetaminophen 650 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. Dabigatran Etexilate 75 mg PO BID Pulmonary Emoblism
RX *dabigatran etexilate [Pradaxa] 75 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*31 Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Right Lower Quadrant Abscess
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
abdominal pain. You were found to have a small abscess in your
abdomen and clot in your lungs. 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.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10760967-DS-11
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DS
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2122-11-20 00:00:00
|
2122-12-12 13:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no known past medical history who presents after motor
vehicle
crash. The patient speaks ___ only. He was reportedly being
chased by
the cops and flipped his car. Was reportedly wearing a seatbelt
with no airbag
deployment. Denies any LOC. Reportedly self extricated. Has an
abrasion on his
nose but was brought to the hospital for evaluation. No pain in
his extremities.
No chest pain, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea.
Physical exam shows a minor abrasion over his nasal bridge in
between his
eyebrows but no other deficits. He is intoxicated.
Past Medical History:
Unknown
Social History:
___
Family History:
Non-contributory
Physical Exam:
Temp: 97.7 HR: 120 BP: 146/84 Resp: 19 O2 Sat: 98
Constitutional: Intoxicated
Head / Eyes: Mild abrasions over the bridge of his nose, Pupils
equal, round and reactive to light, no hemotympanum
ENT / Neck: Oropharynx within normal limits
Chest/Resp: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
GI / Abdominal: Soft, Nontender, Nondistended
Musc/Extr/Back: No spinal tenderness or back tenderness. No
tenderness in any of his extremities with full mobility.
Skin: No rash, Warm and dry
Neuro: No focal neurological deficits.
Psych: Normal mood, Normal mentation but intoxicated
Discharge Physical Exam:
VS: T: 97.8 PO BP: 124/72 HR: 79 RR: 18 O2: 99% RA
GEN: A+Ox3, NAD
HEENT: MMM
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CXR:
No acute cardiopulmonary process.
___: CT Head:
1. No acute intracranial process.
2. Soft tissue swelling overlying the bridge of the nose without
underlying fracture.
___: CT Chest:
1. Mildly displaced acute left posterolateral seventh rib
fracture. Subtle cortical irregularities of the anterior
superior T5, T6, and T7 vertebral bodies are consistent with
compression fractures. No additional acute fractures are
identified.
2. No traumatic organ injury in the chest, abdomen, or pelvis.
___: CT C-spine:
No acute fracture or traumatic malalignment.
___: T Spine x-ray:
Unchanged mild compression deformities of the superior endplates
of 3 mid
thoracic vertebral bodies corresponding to T5, T6 and T7 as
previously
characterized on the CT scan of the torso.
LABS:
___ 09:30AM GLUCOSE-107* UREA N-5* CREAT-0.6 SODIUM-145
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
___ 09:30AM CALCIUM-9.9 PHOSPHATE-2.6* MAGNESIUM-2.2
___ 09:30AM WBC-11.3* RBC-4.90 HGB-15.1 HCT-43.8 MCV-89
MCH-30.8 MCHC-34.5 RDW-12.4 RDWSD-40.5
___ 09:30AM PLT COUNT-306
___ 10:39PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:06PM ___ PO2-104 PCO2-37 PH-7.35 TOTAL CO2-21
BASE XS--4
___ 10:06PM GLUCOSE-115* LACTATE-3.2* NA+-140 K+-3.4
CL--104
___ 10:06PM HGB-16.5 calcHCT-50 O2 SAT-91 CARBOXYHB-7*
MET HGB-0
___ 10:06PM freeCa-1.09*
___ 09:51PM UREA N-6 CREAT-0.7
___ 09:51PM LIPASE-31
___ 09:51PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:51PM WBC-12.5* RBC-5.16 HGB-16.0 HCT-45.7 MCV-89
MCH-31.0 MCHC-35.0 RDW-11.9 RDWSD-38.8
___ 09:51PM PLT COUNT-330
___ 09:51PM ___ PTT-25.5 ___
___ 09:51PM ___
Brief Hospital Course:
Mr. ___ is a ___ with no known past medical history who
presented to ___ on ___ after motor vehicle crash, +EtOH.
He was found on imaging to have compression fractures of T5, T6
and T7 and a left 2nd rib fracture. He also had soft tissue
swelling of the nose with no underlying fracture, and tertiary
exam was otherwise negative. The patient was admitted to the
Acute Care Surgery service. Orthopedic Spine Surgery was
consulted for the thoracic fractures and no surgical
intervention was warranted. They recommended consulting
physical therapy and the patient may ambulate as tolerated. The
patient ambulated independently and pain was well controlled on
acetaminophen prn. Occupational Therapy was consulted and he was
cleared for discharge home without services. Social Work
provided alcohol counseling to the patient. The patient was
started on thiamine, folate and a multivitamin in the hospital,
but these medications were later discontinued as the patient
states he normally has 1 beer every 3 days and denies excessive
alcohol consumption.
The patient remained stable from a cardiovascular and pulmonary
standpoint; vital signs were routinely monitored. Incentive
spirometry was encouraged. The patient tolerated a regular
diet, intake and output were monitored. The patient received
subcutaneous heparin for DVT prophylaxis. At the time of
discharge, the patient was hemodynamically stable, alert and
oriented x 3 and ambulating independently and he was cleared for
discharge home without services.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
-Left posterolateral 7th rib fractures
-Compression fractures T5, T6, T7
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 ___ after
a motor vehicle crash. You sustained a left-sided rib fracture
as well as thoracic spine compression fractures. For your spine
fractures, you were followed by the Orthopaedic Spine service
and your injuries will heal on their own. You worked with
Physical and Occupational Therapy and were cleared for discharge
home. You have now recovered and are ready to be discharged.
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.
* Your injury caused a left 7th rib fracture 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:
___
|
10761087-DS-19
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DS
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2182-06-11 00:00:00
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2182-06-13 14:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Decadron
Attending: ___.
Chief Complaint:
weakness, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary ___. MD
Primary Care Physician: ___. MD
Primary Oncologic Diagnosis: lung adenoca, lll mass, small brain
metastasis
___ y/o female with a history of adenocarcinoma of the lung with
brain metastasis, last dose of maintenance Altima chemotherapy
___ presents to the ER with weakness, nausea, and malaise. She
was admitted to ___ from ___ for dyspnea and Hct of 18
and was given 3 units PRBCs. Hemolysis ahd GI bleeding were
ruled-out and the anemia was attributed to chemotherapy. She
also had ___ (Cr 1.7 from 0.9) with FeNa 1.03%. Her Cr did not
improve on IVF and Renal Ultrasound was normal.
Since her last chemotherapy, she states she has felt weak,
nauseous, tired, and has had poor appetite. She has been able
to drink fluids but has not noticed any bloody stools. These
symptoms have been chronic for the past 3 weeks, but last night
she experienced mild chest pain at rest that resolved
spontaneously. She went to her outpatient oncology office for a
regular appointment where Cr was elevated to 3.3 and HCt was
16.2. Vitals in the ER: 97.9 91 130/77 16 94% ra. Repeat Hct
was 36. The patient received 1 unit PRBCs.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, headache. Denies change in cough or
cough, shortness of breath. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes. All other ROS negative
Past Medical History:
ONCOLOGIC HISTORY:
Mrs. ___ is a ___ retired ___, lifelong
smoker who underwent preoperative chest x-ray on ___ prior
to cataract surgery. Her chest x-ray demonstrated a mass in the
left lung.
___: CT scan of the chest on revealed a 6 cm left lower
lobe mass extending from the hilum to the posterior medial
pleural surface.
___: The patient was seen on an urgent basis in oncology.
___: She was referred to the ___
___ a PET which revealed the known left lower lobe mass
measuring 4.7 cm, SUV of 12. There is a small rounded nodule
that may be contiguous with the dominant lesion or may be a
small satellite. The mass was not invading through the chest
wall or into her rib. There were no FDG-avid axillary,
mediastinal, or hilar lymph odes. There was no evidence of
distant metastatic disease, however, the patient went on to have
an MRI of the brain.
___: Brain MRI which demonstrated a possible metastasis, a
rounded right cerebellar lesion about 5 mm. The initial MRI was
done without gadolinium so a repeat MRI with gadolinium was
advised and performed on ___, which demonstrated that the 5 mm
right cerebellar lesion was ring enhancing consistent with
metastasis. There were no other enhancing lesions or abnormal
leptomeningeal enhancement.
___: The patient underwent CT-guided biopsy of the lung
lesion, which demonstrated adenocarcinoma of the lung positive
for CK7 and TTF-1 and negative for CK20.
___: EGFR and ALK negative
___: The patient was referred for consultation with Dr.
___ radiation oncology and also Dr. ___
thoracic surgery. ___: Mediastinoscopy was performed and
remarkably cytology from 2L, 4L, 2R, 4R, and level 7 were all
negative for tumor.
___: The patient endorsed being quite sore after the
mediastinoscopy, and on ___ en route to her CyberKnife
treatment of the small cerebellar met, the patient became quite
dyspneic. Oxygen saturation was 77%, she was sent to the ___
Emergency Department and the brain lesion was not treated. She
was sent to the emergency department where a chest x-ray
revealed a new right pleural effusion, thoracentesis was
performed, and approximately 600 mL of bloody fluid was drained.
Cytology is pending. Her post-procedure chest x-ray showed
improved aeration of the lung without pneumothorax.
___: Cytology of pleural fluid negative for malignant
cells. See below for full report.
___: Cyberknife(2200cGy) to right cerebellar lesion at
___
___: C1 ___, consent signed. Will be given
Prednisone instead of Dexamethasone
___: post radiation Brain MRI planned: no growth
___: C#2 carboplatin & pemetrexed.
___: C#3 carboplatin and pemetrexed
___: re-staging PET/CT: LLL tumor decreased (4.7x4.2cm
___ but still FDG avid SUV 13.3. Necrosis
present.
___ C#4 carboplatin and pemetrexed
___ ___ neuro onc follow up MRI brain improved
___ C#5 carboplatin and pemetrexed
___ HCT 23.8% repeat 24%, txfuse ___, C#6 ___ AUC 5
pemetrexed, order restaging PET prior to next appt
___ PET stable disease LLL no new lesions
___ C#1 maintenance ___
MEDICAL HISTORY:
Hypercholesterolemia
DIVERTICULOSIS
TOBACCO DEPENDENCE
OBESITY UNSPEC
Hyperlipidemia LDL goal <160
Impaired glucose tolerance
Non-small cell lung cancer
Brain metastasis
Anemia
Seizures, last grand mal seizure was about ___ years ago.
Impaired hearing.
Social History:
___
Family History:
Father committed suicide. Mother died of abdominal aortic
aneurysm. She has one sister and two half sisters. Her one
sister had early stage colon cancer.
Physical Exam:
Vitals: T T 98.1 bp 110/70 HR 75 RR 18 SaO2 98 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 04:48PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:48PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 03:13PM LACTATE-3.1* K+-4.3
___ 03:13PM HGB-12.1 calcHCT-36
___ 02:55PM GLUCOSE-215* UREA N-53* CREAT-3.0*#
SODIUM-138 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
___ 02:55PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-82 TOT
BILI-0.2
___ 02:55PM LIPASE-40
___ 02:55PM ALBUMIN-3.6 CALCIUM-8.1* PHOSPHATE-3.5
MAGNESIUM-2.2
___ 02:55PM WBC-4.1 RBC-1.49*# HGB-5.2*# HCT-15.1*#
MCV-101* MCH-35.2* MCHC-34.9 RDW-19.2*
___ 02:55PM NEUTS-59 BANDS-0 ___ MONOS-11 EOS-1
BASOS-0 ___ MYELOS-0
___ 02:55PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
___ 02:55PM PLT COUNT-53*
___ 02:55PM ___ PTT-28.4 ___
___ 03:44PM BLOOD Lactate-1.7
___ 02:55PM BLOOD calTIBC-247 Hapto-259* Ferritn-2262*
TRF-190*
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-5.1 RBC-2.93* Hgb-9.5* Hct-27.0*
MCV-92 MCH-32.3* MCHC-35.1* RDW-19.9* Plt Ct-64*
___ 06:05AM BLOOD Ret Aut-0.6*
___ 06:15AM BLOOD Glucose-92 UreaN-46* Creat-2.8* Na-143
K-4.6 Cl-107 HCO3-28 AnGap-13
___ 06:15AM BLOOD Calcium-7.4* Phos-3.5 Mg-2.1
IMAGING:
CT Abd & Pelvis W/O Contrast ___ IMPRESSION:
1. No evidence of retroperitoneal or intra-abdominal
hemorrhage.
2. Diverticulosis without evidence of diverticulitis.
3. Partially imaged left lower lobe opacity which is most
likely focal atelectasis.
Renal U/S ___ IMPRESSION:
Symmetric, normal size kidneys with no hydronephrosis or
nephrolithiasis. Preserved cortical thickness.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of adenocarcinoma
of the lung with brain metastasis, last dose of maintenance
Altima chemotherapy ___ presents to the ER with weakness,
nausea, dyspnea on exertion and malaise due to anemia and
progressive ___.
# Anemia, Normocytic - Likely due to chemo. Labs do not suggest
any hemolysis. Iron & Ferritin rule out Fe deficiency.
Transfused 3 units overnight on ___ with appropriate Hct
bump from 15.1 to 23.9. patient has a history of significant
anemia of unclear etiology. Last admission in mid ___,
she was not hemolyzing or having GI bleeding, and is not on this
admission either. CT abd/pelv on ___ ruled out RP bleed.
Reticulocyte count <1%. Transfused 1 unit RBC on ___ with
appropriate bump to Hgb 9.5. Held Pemetrexed. Guaiac stools:
negative.
# ___ - Patient has had progressive ___ over the past 2 months
which is likely related to Dehydration +/- ATN. FENA 1.9%
suggesting not prerenal. Creatinine 3.0 on admission and was
1.87 on ___, 1.25 on ___, and 1.06 on ___. Renal
Ultrasound in ___ was normal. Good UOP. IVF. Nephrology
consult: UPEP neg, SPEP neg, renal ultrasound neg, hold
Pemetrexed. Instructed to try to have about 2L of fluid daily.
Please f/u creatinine at outpatient appt
# Dizziness, chronic: Mild with standing since starting
chemotherapy. Orthostatics: negative. ___ concerned for
cerebellar dysfunction, especially given mets; Patient refused
to go to rehab. Plans to use walker and shower seat at home.
Home ___.
# Lung Adenocarcinoma, NSCLC: Metastatic disease to bone and
brain. Followed by Dr. ___. Holding Pemetrexed
maintenance chemotherapy, last dose on ___.
# Cerebellar Metastases: Patient is s/p treatment ___
stable MRI ___. She presented on last admission with
worsening balance and cerebellar exam concerning for increasing
size of met. MRI head done on ___ showed stable cerebellar
met. Likely source of her dizziness as above.
# Bony metastatic disease. Will continue Zometa as outpatient.
# Seizures, last grand mal seizure was ___ ___ontinued
on phenytoin.
# Hypercholesterolemia: Diet controlled.
CONTACT: ___ HCP
CODE: DNR/DNI
### TRANSITIONAL ISSUES ###
-Instructed to try to have about 2L of fluid daily
-Please f/u creatinine at outpatient appt
-Will f/u w/ Hem/Onc Dr. ___ home walker use and home ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 400 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety
4. Multivitamins 1 TAB PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Phenytoin Sodium Extended 100 mg PO QAM
7. Phenytoin Sodium Extended 300 mg PO QPM
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Medications:
1. Calcium Carbonate 400 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety
4. Multivitamins 1 TAB PO DAILY
5. Phenytoin Sodium Extended 100 mg PO QAM
6. Phenytoin Sodium Extended 300 mg PO QPM
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
9. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Anemia
Renal Failure
Lung cancer, metatstatic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to our hospital with weakness and nausea. We
found you to have a low blood count (anemia) as well as kidney
failure. We gave you blood and fluids through your IV. It is
important that you follow up with Dr. ___.
Followup Instructions:
___
|
10761742-DS-15
| 10,761,742 | 21,706,431 |
DS
| 15 |
2136-12-04 00:00:00
|
2136-12-04 18:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / quetiapine / Motrin
Attending: ___.
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with past medical history notable for severe
dementia who presents from her nursing home after an unwitnessed
fall.
Per the facility, patient was found on the ground, in no acute
distress, without obvious signs of trauma. At baseline, she is
minimally communicative; staff reports no recent change in her
mental status or behavior. They deny recent fevers, chills, or
medication changes.
Patient's daughter was called and also reported concern over
recent 15lb. weight loss secondary to inability to take in PO's.
On arrival to the ED, initial vitals T 97.3 HR 105 BP 149/72 RR
16 O2 100% RA
Exam notable for:
- In no acute distress, not answering questions, follows most
commands appropriately
Labs notable for:
- WBC 9.9, Hgb 12.1, plts 138
- LFTs unremarkable
- K 3.3, BUN 26, Cr 0.9
- UA 23 WBCs, few bacteria, sml leuks, pos nitrites, tr protein
Imaging notable for:
- CT C-spine: No acute fracture or traumatic subluxation.
- CT head w/o contrast: No acute intracranial abnormality.
- CXR: No acute cardiopulmonary abnormality. Possible right
ninth
posterior rib fracture.
Patient received: IV ceftriaxone 1g, 1L NS with 40meQ KCl at
250cc/hr
Transfer vitals: T 98.6 HR 94 BP 139/82 RR 16 O2 99% RA
Past Medical History:
Dementia (mixed vascular/Alzheimer)
Hypertension
Hypothyroidism
Anxiety
Social History:
___
Family History:
Per prior notes, heart disease in both parents. Otherwise
negative.
Physical Exam:
Admission Physical Exam
=======================
VS: T 97.6 BP 161/75 HR 97 RR 20 O2 100 Ra
GENERAL: Well-appearing elderly woman, laying in bed
comforatably, in NAD
HEENT: NC/AT, EOMI, anicteric sclera, MMM
NECK: Supple, no LAD
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, breathing comfortably on RA without use of
accessory muscles
ABDOMEN: Soft, mild TTP above bladder with voluntary guarding,
no
rebound, non-distended, hyperactive bowel sounds
EXTREMITIES: No c/c/e
SKIN: Warm, well-perfused, no rashes
NEURO: Alert, unable to assess orientation due to being
non-verbal, not following commands, moving all extremities with
purpose, no facial asymmetry
Discharge Physical Exam
=======================
GENERAL: Well-appearing elderly woman, laying in bed
comforatably, in NAD
HEENT: NC/AT, EOMI, anicteric sclera, MMM
NECK: Supple, no LAD
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, breathing comfortably on RA without use of
accessory muscles
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: No c/c/e
SKIN: Warm, well-perfused, no rashes
NEURO: Alert, unable to assess orientation due to being
non-verbal, not following commands, moving all extremities with
purpose, no facial asymmetry
Pertinent Results:
Admission Labs
==============
___ 09:07PM BLOOD WBC-9.9 RBC-4.13 Hgb-12.1 Hct-36.7 MCV-89
MCH-29.3 MCHC-33.0 RDW-15.6* RDWSD-51.0* Plt ___
___ 09:07PM BLOOD Glucose-147* UreaN-26* Creat-0.9 Na-143
K-3.3* Cl-105 HCO3-24 AnGap-14
___ 09:07PM BLOOD ALT-21 AST-17 CK(CPK)-116 AlkPhos-100
TotBili-0.7
___ 09:07PM BLOOD Albumin-4.2 Calcium-10.7* Phos-2.1*
Mg-2.1
Pertinent Labs
==============
___ 06:29AM BLOOD VitB12-___
___ 06:29AM BLOOD TSH-4.9*
Discharge Labs
==============
___ 06:42AM BLOOD WBC-9.8 RBC-3.88* Hgb-11.5 Hct-34.4
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.9* RDWSD-51.2* Plt ___
___ 06:42AM BLOOD Glucose-130* UreaN-8 Creat-0.5 Na-141
K-3.4* Cl-102 HCO3-22 AnGap-17
___ 06:42AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.8
Imaging
=======
CXR (___):
No definite displaced rib fractures. The previously seen
cortical
discontinuity in the right posterior ninth rib is not well seen
and may have been artifactual on the prior study or healed since
previous.
Non-con head CT (___):
1. No evidence for an acute intracranial abnormality.
2. Stable 10 mm ossified extradural lesion along the left
frontal lobe,
consistent with a meningioma
Non-con CT spine (___):
1. No evidence for an acute fracture or acute subluxation.
2. Multilevel degenerative disease.
Brief Hospital Course:
Ms. ___ is a ___ with history of mixed vascular/Alzheimers
dementia, hypothyroidism, HTN, generalized anxiety disorder who
presents from her nursing home after an unwitnessed fall, found
to have orthostatic hypotension and asymptomatic bacteruria.
# Fall
Patient with unwitnessed fall at assisted living. C-spine/NCHCT
negative, CXR with possible right ninth posterior rib fx but on
repeat rib series this is not seen. Deferred further
neuroimaging as unlikely to change management. Fall is likely
multifactorial in setting of gait imbalance, decreased PO
intake, orthostasis, underlying dementia. Unclear if patient has
vision or hearing impairment. No report of new environmental
hazards. No history of valvular dysfunction and no murmur heard
on exam, no history of arrhythmia, low suspicion for syncope at
this time, deferred TTE. Note that she saw PCP ___ ___ with
concern for TIA, deferred MRI/MRA at that time. No clear risk
factors for neuropathy, vit B12 WNL.
She was noted to be orthostatic, for which she was given IV NS
500 mL x 2 and amlodipine was discontinued.
# Weight loss
# Failure to thrive
# Advanced stage Dementia
Patient with mixed vascular/Alzhiemer dementia, minimally verbal
at this time. Patient has lost ___ pounds over the past few
months with decreased PO intake and refusing meds. This is
likely secondary to progression of her underlying dementia.
There is no indication for feeding tube placement in patients in
advanced stage dementia. Note that previously levothyroxine
d/c'd by PCP ___ ___ in setting of weight loss, at that time
TSH 6.29; repeat TSH 4.9 here, hence we continued to hold
levothyroxine. Mammogram in ___ without concerning findings,
unsure about colonoscopy history, although this is likely not
within goals of care and unlikely to change management given
advanced dementia. Nutrition was consulted and we repleted her K
and phos.
We deferred trials of megace (risks: death, VTE, edema) or
dronabinol given low likelihood of efficacy and potential harms.
Per discussion with family, they will be hiring ___ care
following this admission, which is appropriate. In future ___
consider whether family would like to bring a hospice benefit
into her home in the dementia unit.
# Asymptomatic bacteriuria
Prelim urine culture growing >100,000 CFU GNR, UA with 23 WBCs,
few bacteria, pos nitrites. Per health aid, no change in urinary
patterns, does not note pain on urination; pt is non-tender on
abdominal exam. Got CTX x 1 in ED, but in setting of no symptoms
suggesting UTI, this was discontinued.
CHRONIC ISSUES
==============
# Hypertension
Amlodipine was discontinued for orthostasis (Lying BP 155/78 HR
84 -> standing 132/70 HR 90) and recent fall. We will plan to
tolerate SBP<180.
# Hypothyroidism
TSH 4.9; PCP discontinued levothyroxine in ___ (TSH 6.8 then)
due to weight loss and age. We continued to hold this
medication.
# Anxiety
Continued mirtazapine 7.5mg qHS, also for appetite stimulation.
TRANSITIONAL ISSUES
===================
# Fall
[] Please recheck orhostatics at next PCP ___
[] Discontinued amlodipine; please reassess need for this
medication should SBP>180
[] Given risk/benefit of aspirin 325 mg (which patient was
taking per daughter but not on medication list from assisted
living facility), opted to discontinue this medication in
context of progressive dementia and desire to decrease pill
burden
# Weight loss/Failure to thrive/Progressive dementia
[] Monitor weekly weights at assisted living
[] Continue goals of care discussion as an outpatient with Dr.
___ consider whether family is interested in
palliative care
# Asymptomatic bacteriuria
[] F/u urine cx
# Hypothyroidism
- TSH 4.9 in ___, did not restart levothyroxine
# Code status: DNR/DNI (MOLST in OMR)
# Name of health care proxy: ___ Phone number:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Vitamin B Complex w/C 1 TAB PO DAILY
4. Calcium Carbonate 750 mg PO BID
5. Acetaminophen 1300 mg PO BID
6. Mirtazapine 7.5 mg PO QHS
7. Vitamin D 1000 UNIT PO QHS
8. Ibuprofen Suspension 200 mg PO Q12H:PRN Pain - Moderate
9. melatonin 1 mg oral QHS
Discharge Medications:
1. Acetaminophen 1300 mg PO BID
2. Calcium Carbonate 750 mg PO BID
3. Ibuprofen Suspension 200 mg PO Q12H:PRN Pain - Moderate
4. melatonin 1 mg oral QHS
5. Mirtazapine 7.5 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Vitamin B Complex w/C 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO QHS
9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your doctor tells ___ to
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Mixed Alzheimer/vascular Dementia
Failure to thrive
Asymptomatic bacteriuria
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital after having an unwitnessed
fall at your assisted living facility. Your head and spine
imaging did not show anything concerning. Your blood pressure
was noted to be lower on standing ("orthostatic hypotension"),
so we gave ___ IV fluids and discontinued your amlodipine, as
dehydration and medications can both contribute. The low blood
pressure may contribute to your risk of fall.
Your family and assisted living facility told us that ___ have
been eating less in the past few months and that ___ have had
weight loss. Your potassium and phosphate levels were low, so we
gave ___ IV supplementation to replete this.
When ___ arrived, ___ were found to have a few bacteria in your
urine and got a single dose of antibiotics. However, since ___
were not symptomatic and have not had changes in urinary
patterns, we stopped your antibiotics on ___.
Your thyroid levels still showed ___ had hypothyroidism, but we
did not re-start levothyroxine as your PCP had stopped this in
___ due to concerns with weight loss and age.
After ___ leave the hospital,
- Please follow up with your PCP.
- Please discontinue aspirin, statin, amlodipine, and
levothyroxine.
It was a pleasure taking care of ___!
Your ___ team
Followup Instructions:
___
|
10761750-DS-10
| 10,761,750 | 28,486,191 |
DS
| 10 |
2177-10-17 00:00:00
|
2177-10-28 11:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of chronic back pain recently had spinal stimulator
placed here last ___ who awoke after the surgery with
pressure like lower abdominal pain that has steadily been
worsening. Has been inpatient at ___ with 2 negative
CTs, negative TVUS whose mother drove her to ___ for further
evaluation since no cause has been found. No fevers. No n/v. No
cp, sob, cough. Has pressure w/ urination. No diarrhea. No groin
anesthesia. No difficulty controlling urine/stool. Back pain
controlled. Denies ___ weakness.
In the ED, initial vitals were: 97.9 86 164/90 16 100% RA
Exam notable for: alert, uncomfortable, lying on left side; RRR;
CTAB
abd soft, nd, diffusely tender; back: 2 incision c/d/I, mild
tenderness at baseline per patient; sensation/motor intact in
lower extremities
Labs notable for: negative U/A
Imaging notable for: Abd supine/upright which showed
nonobstructive bowel gas pattern with very little colonic stool
burden.
Patient was given: Morphine sulfate 4mg IV x 4
Patient was seen by neurosurgery who recommended no further
neurosurgical intervention or spinal imaging.
Decision was made to admit for pain control
Vitals notable for 98.1 74 129/77 16 99% RA
On the floor, the patient complains of ___ abdominal pain which
does not resolve with change in position. She states she has the
same lower extremity pain as before her stimulator was placed,
and that she has not passed bowel movements or flatus since
before her procedure on ___. She reports her abdominal pain
worsens when her bladder is full, and that she gets some relief
from emptying her bladder.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, or
diarrhea. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- chronic low back pain
- DJD of lumbar spine
- autoimmune thyroiditis
- hypertension
- s/p spinal cord stimulator (placed at ___ ___
Social History:
___
Family History:
- non-contributory
Physical Exam:
ADMISSION EXAM:
GEN: NAD, lying in bed with blankets on
HEENT: AT/NC; EOMI, PERRL, sclera anicteric
CV: RRR, no M/R/G, +S1/S2
PULM: CTAB anteriorly and laterally, no W/R/R
ABD: no scars visualized, mildly distended appearing, tender to
palpation in left periumbilical area; +BS, tympanitic to
percussion
GU: no Foley in place
EXT: nontender to palpation, nonedematous
SKIN: no rashes or ecchymoses
NEURO: A/Ox3, CNII-XII grossly intact, intact sensation in ___
without saddle anesthesia; motor exam deferred due to patient
discomfort, but able to ambulate
PSYCH: depressed mood, flat affect
DISCHARGE EXAM:
VS: 98.7 144/86 69 18 98RA
GEN: NAD, lying in bed with blankets on
HEENT: AT/NC; EOMI, PERRL, sclera anicteric
CV: RRR, no M/R/G, +S1/S2
PULM: CTAB anteriorly and laterally, no W/R/R
ABD: no scars visualized, less distended appearing, tender to
palpation in right periumbilical area; +BS, tympanitic to
percussion
GU: no Foley in place
EXT: nontender to palpation, nonedematous
SKIN: no rashes or ecchymoses
NEURO: A/Ox3, CNII-XII grossly intact, intact sensation in ___
without saddle anesthesia; patient ambulating daily
PSYCH: depressed mood, flat affect
Pertinent Results:
ADMISISON LABS:
___ 10:44AM BLOOD WBC-6.0 RBC-4.26 Hgb-12.9 Hct-37.9 MCV-89
MCH-30.3 MCHC-34.0 RDW-11.3 RDWSD-36.1 Plt ___
___ 10:44AM BLOOD Glucose-82 UreaN-8 Creat-0.8 Na-139 K-3.9
Cl-100 HCO3-29 AnGap-14
___ 07:42AM BLOOD ALT-118* AST-103* LD(LDH)-338*
AlkPhos-123* TotBili-1.1
___ 10:44AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9
___ 11:09PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:09PM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 07:49AM BLOOD WBC-4.3 RBC-4.31 Hgb-12.9 Hct-37.6 MCV-87
MCH-29.9 MCHC-34.3 RDW-11.3 RDWSD-35.8 Plt ___
___ 07:49AM BLOOD ___ PTT-34.7 ___
___ 07:49AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-137
K-3.9 Cl-99 HCO3-25 AnGap-17
___ 07:49AM BLOOD ALT-68* AST-36 LD(LDH)-190 AlkPhos-100
TotBili-0.8
___ 07:49AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.5 Mg-1.9
MICRO:
___ UCx: NG Final
STUDIES:
None
IMAGING:
___ Abdomen (supine/erect) film:
IMPRESSION:
N
o
n
o
b
s
t
ructive bowel gas pattern with very little colonic stool burden.
P
a
t
c
h
y
opacities at both lung bases, best assessed by chest radiograph.
___ TVUS:
IMPRESSION:
1
. Unremarkable sonographic appearance of the uterus and ovaries.
2
.
1
.
8
c
m
s
i
m
ple appearing right paraovarian cyst. Recommend ___ year followup
pelvic ultrasound.
___ CT T-spine w/o contrast:
IMPRESSION:
1
.
S
p
i
n
e
s
t
i
m
u
lator in place terminating at T8 level. No paraspinal hematoma.
No CT evidence of central canal abnormality.
2
.
I
n
d
eterminate 1.4 cm sclerotic lesion involving T11 vertebral body,
possibly hemangioma
___ Abdominal U/S: Normal abdominal ultrasound.
Brief Hospital Course:
This is a ___ year old woman with medical history notable for
chronic low back pain and radicular leg pain with recent spinal
stimulator implantation (___) who presented with low
abdominal pain after having OSH negative workup concerning for
ileus or other postoperative complication. At the outside
hospital she was ruled out for bowel obstruction or any
complications from the device placement. She came to ___ to be
seen by her neurosurgeon and for pain control. She was evaluated
and thought to have postoperative ileus in the setting of
receiving copious IV morphine at OSH as well as in the ___ ED.
# Abdominal pain: The patient presented after AMA from OSH after
having spinal stimulator surgically implanted on ___ at
___. At the time of admission, she was ambulating, and had
intact neurological examination in lower extremities. She was
seen by the neurosurgery team in the ED, who initially deemed
her symptoms not related to her recent procedure The patient had
multiple studies in OSH which ruled out intra-abdominal process
with CT A/P and TVUS. She had an abdominal film and repeat TVUS
which showed no acute intra-abdominal process, but an incidental
finding of ovarian cyst was noted. As the patient had received
significant amounts of opioid pain medication (morphine)
post-operatively, at OSH, and in ___ ED, ileus was the favored
diagnosis, however there question as to whether her pain was a
result of her recent procedure. Her pain was much improved after
initiation of a bowel regimen (senna/docusate/PEG) and
simethicone and all opioids stopped; she had multiple bowel
movements with reduction in pain. Neurosurgery formally
re-evaluated the patient and determined her pain might be a rare
adverse event related to stimulator placement, which typically
resolves without intervention. They recommend typical post
device placement follow-up. The patient was discharged home with
close follow-up with neurosurgery and her PCP.
# low back pain: Present at baseline, reason for spinal
stimulator placement. The patient had an unchanged lower
extremity neurological examination. Initially, her home
tizanidine and cyclobenzaprine were held, but they were
restarted once she had less abdominal pain. During her stay, she
activated her spinal stimulator with moderate relief in her back
pain. She will follow up with the neurosurgery device clinic for
further adjustment in her treatment.
# hypothyroidism: The patient's levothyroxine was continued on
home schedule, which is ___ 125mcg and ___ 112mcg.
# hypertension: Stable on home amlodipine, which was continued
during her stay.
# encephalomalacia: Reportedly secondary to thyroid disease. Her
home dextroamphetamine (Adderall) was continued during the stay.
TRANSITIONAL ISSUES:
- new medications: docusate sodium, senna, simethicone,
polyethylene glycol
- Patient should follow up with neurosurgical NP ___ days
post-operatively for suture/staple removal and Dr. ___ ___
weeks post-operatively for evaluation.
- Avoid opioid pain medications given potential ileus
postoperatively.
- Assist with activation and utilization of spinal stimulator.
- 1.8 cm simple appearing right paraovarian cyst on TVUS will
require ___ year f/u ultrasound
- Contact: ___mother) ___ ___ (___) ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
3. Levothyroxine Sodium 112 mcg PO 4X/WEEK (___)
4. Levothyroxine Sodium 125 mcg PO 3X/WEEK (___)
5. Vitamin D ___ UNIT PO DAILY
6. Tizanidine 2 mg PO QAM
7. Cyclobenzaprine 10 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID:PRN constipation
4. Simethicone 40-80 mg PO QID:PRN abdominal pain
5. amLODIPine 2.5 mg PO DAILY
6. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
7. Cyclobenzaprine 10 mg PO QHS
8. Levothyroxine Sodium 112 mcg PO 4X/WEEK (___)
9. Levothyroxine Sodium 125 mcg PO 3X/WEEK (___)
10. Tizanidine 2 mg PO QAM
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Abdominal pain due to surgery and ileus
Secondary Diagnosis:
- Low back pain
- Hypothyroidism
- Hypertension
- Encephalomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care while at
___.
Why did I come to the hospital?
- You were having severe abdominal pain after having surgery to
implant a spinal stimulator in your back on ___.
What was done for me while I was in the hospital?
- You were given medication to help make your bowels more
active, which was thought to be part of the reason for your
pain.
- You were seen by your surgeon who believes the pain might have
been a side effect from the surgery, but that it should go away
on its own within a week or so.
- You turned on your spinal stimulator to see if you would get
some pain relief.
What should I do when I leave the hospital?
- Continue to take your medications as instructed.
- Keep your follow up appointments with your doctor and surgeon.
- Contact your surgeon if you feel the pain is not improving or
getting worse.
It was a pleasure caring for you while you were here.
Best regards,
Your ___ Care Team
Followup Instructions:
___
|
10761861-DS-8
| 10,761,861 | 21,687,459 |
DS
| 8 |
2116-02-20 00:00:00
|
2116-02-21 09:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, lower extremity swelling
Major Surgical or Invasive Procedure:
Cardiac Cath Study Date of ___:
Hemodynamic Measurements (mmHg)
Baseline
Site ___ ___ End Mean A Wave V Wave HR
___
Coronary angiography: right dominant
LMCA: normal
LAD: 50% distal. 70% very distal in small caliber trans-apical
segments.
LCX: 60% in large OM1
RCA: 40% ___, 40% distal. 40% in PDA, 60% in small PL-1, 60%
in
large PL-2
History of Present Illness:
The patient is a ___ y/o M with PMHx significant for HTN and IDDM
who presents with dyspnea on exertion, wheezing for the past
several weeks as well as ___ edema for 5 weeks. He's been
sleeping in a recliner, and feeling short of breath when walking
short distances. No chest pain, but has felt his heart racing
intermittently over the last several months. He did have a cold
~ 5 weeks ago, but no other viral illnessess. No cough, no
fevers, no tick exposure, no ETOH abuse.
He went to his PCP's office today for these symptoms, and was
sent to the ED. O2 sat at the PCP's office was noted to be 88%
on RA.He has no known history of CHF and has never seen a
cardiologist.
In the ED intial vitals were: 97.3 112 143/99 22 96% on RA but
felt tachypneic so was placed on 4L nasal cannula for comfort.
Labs were significant for Cr of 1.3 (baseline 1.1) as well as
proBNP of 4367. Troponin x1 was negative. EKG was significant
for sinus tachycardia to 114. CXR was notable for pulmonary
edema. Given that CXR could not r/o PNA, patient was given
Azithromycin 500mg PO. He was also given ASA 325mg PO x1 as well
as lasix 40mg IV x1.
Past Medical History:
IDDM
HTN
HLD
Gout
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 BP 127/98 P ___ R 20 O2 Sat 94 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: atraumatic, anicteric sclera. PERRL. MMM.
NECK: Supple, JVP difficult to assess. Non-tender non-enlarged
thyroid.
CARDIAC: tachycardic, regular with frequent skipped beats, no
murmurs heard
LUNGS: mildly dyspnic when speaking multiple sentences and with
movement. Crackles bilaterally at bases. Dullness to percussion
on RLL. No wheezes.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: WWP, pitting edema almost to knees.
SKIN: no rashes
DISCHARGE PHYSICAL EXAMINATION:
VS: T 98.3 97.9 119/81 (94-119/60-81) 95 (76-101) 20 100% ra
I/O: 8hr -- / 400 24 hr 1600/1695; glucose 100-195
Wt: 106.9 on discharge <-- 107.4 <-- 109.7 <-- 110.2 <-- 111.7
<-- 111.5 <-- 112.0
GENERAL: Energetic, cheerful, NAD. Oriented x3.
HEENT: atraumatic, anicteric sclera. PERRL. MMM.
NECK: Supple, JVP difficult to assess. Non-tender non-enlarged
thyroid.
CARDIAC: regular rate with frequent skipped beats, no murmurs
heard
LUNGS: Breathing comfortably. CTAB. No wheezes.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: WWP, 1+ pitting edema to mid shin
SKIN: no rashes
Pertinent Results:
ON ADMISSION
==============
___ 04:30PM BLOOD WBC-8.8 RBC-5.99 Hgb-15.1 Hct-51.1 MCV-85
MCH-25.2* MCHC-29.5* RDW-17.4* Plt ___
___ 04:30PM BLOOD Neuts-62.0 ___ Monos-7.6 Eos-1.2
Baso-0.3
___ 04:30PM BLOOD Plt ___
___ 06:08PM BLOOD ___ PTT-31.3 ___
___ 04:30PM BLOOD Glucose-110* UreaN-14 Creat-1.3* Na-138
K-4.6 Cl-104 HCO3-26 AnGap-13
___ 04:30PM BLOOD proBNP-4647*
___ 04:30PM BLOOD cTropnT-0.01
___ 06:50AM BLOOD TotProt-6.0* Calcium-8.9 Phos-2.8 Mg-1.7
___ 06:50AM BLOOD Ferritn-35
___ 06:50AM BLOOD TSH-1.4
___ 06:50AM BLOOD CRP-17.8*
___ 06:50AM BLOOD PEP-NO SPECIFI
___ 03:00PM BLOOD HIV Ab-NEGATIVE
___ 06:50AM BLOOD HCV Ab-NEGATIVE
___ 07:03PM BLOOD Lactate-1.3
ANGIOTENSIN 1 - CONVERTING ___
Test Result Reference
Range/Units
ACE, SERUM 17 ___ U/L
ON DISCHARGE
================
___ 06:25AM BLOOD WBC-6.2 RBC-5.78 Hgb-14.8 Hct-49.6 MCV-86
MCH-25.5* MCHC-29.8* RDW-17.0* Plt ___
___ 06:40AM BLOOD Neuts-55.8 ___ Monos-8.3 Eos-3.3
Baso-0.8
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-110* UreaN-19 Creat-1.2 Na-140
K-4.1 Cl-98 HCO3-35* AnGap-11
___ 06:25AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
MICRO
___ 6:53 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
PERTINENT RESULTS:
======================
___ Creat-1.3*
___ Creat-1.2
___ proBNP-4647*
___ cTropnT-0.01
___ Ferritn-35
___ TSH-1.4
___ CRP-17.8*
___ PEP-NO SPECIFI
___ HIV Ab-NEGATIVE
IMAGING
===============
C.cath ___: prelim read at time of discharge
ECHO ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is at least 15
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis (LVEF = ___ %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate left ventricular cavity dilation with
severe global hypokinesis. Elevated PCWP. Moderate right
ventricular cavity dilatation with mild global Moderate
pulmonary hypertension. Mild mitral regurgitation. Aortic root
dilatation. Biatrial dilatation.
Chest pa/lat ___:
Cardiomegaly with mild pulmonary edema. Possible pneumonia at
the right medial lung base.
ECG ___:
Sinus tachycardia. Premture ventricular complexes. Left atrial
abnormality. Non-diagnostic Q waves inferiorly. Delayed R wave
transition. Non-specific ST segment flattening. Low voltage in
the limb leads. No previous tracing available for comparison.
Brief Hospital Course:
Hospital course: ___ y/o M with PMHx significant for HTN and IDDM
who presented with dyspnea on exertion and ___ edema for 5 weeks.
Active issues:
# New onset acute CHF exacerbation: Admission chest x-ray with
pulmonary edema, BNP 4367. Troponin x 1 negative, no ischemic
changes on EKG. On ECHO he was found to have severe global left
ventricular hypokinesis on ECHO with LVEF ___. C cath on
___ with moderate diffuse CAD as well as markedly elevated
left and right heart filling pressures. Cardiac MRI showed
severe biventricular dysfunction with early and late gadolinium
enhancement of the septal mid-myocardium, consistent with
idiopathic, post-viral, or perhaps cardiac sarcoid. Unclear
etiology at this time for his CHF: Hep C, HIV negative. ACE,
ferritin, and SPEP/UPEP not elevated. CRP elevated at 17.8. Less
likely HTN-induced cardiomyopathy given non-thickened LV. Less
likely ischemic given global hypokinesis and cath results
without significant stenoses. For his CHF, he was started on
Spironolactone 12.5 mg PO/NG DAILY; Metoprolol Succinate was
increased to 37.5 daily; he was continued on Amlodipine 10 mg
PO/NG DAILY and Lisinopril 40 mg PO/NG DAILY. Moderate CAD also
seen on C Cath: for this he was started on ASA 81 daily and
Atorvastatin 40 daily. He did have some short runs of
asymptomatic ventricular tachycardia: EP was consulted, who
recommended discharge with a LifeVest pending follow-up ECHO.
Unclear ideal dry weight given that patient is actively
dieting/loosing weight. Last documented weights at PCP: 108.8 kg
___ 117 kg ___. Admission weight: 112 kg, discharge
weight: 106.9 kg.
# ___: Creatinine of 1.3 on admission and 1.2 on discharge: 1.1
on ___, 0.9 on ___. Mild elevation likely cardio-renal in the
setting of CHF. Improved with diuresis.
Chronic issues:
# Hypertension: on metoprolol succintate, amlodipine, lisinopril
at home, which were continued during admission.
# Type 2 Diabetes: HbA1c 7.3 ___. Albumin/Cre ration 62.4.
On Insulin, glipizide, and metformin at home. On home dose
lantus and insulin SSI during admission.
# Hyperlipidemia: has been on rosuvastatin 20 in the past; PCP
___ several months ago. Restarted on
- have restarted high potency statin given moderate CAD on cath
# Gout: continued on home dose allopurinol.
TRANSITIONAL ISSUES:
============================
- Followup final read of cardiac MRI
- consider outpatient FDG-PET to evaluate for cardiac sarcoid
- EP consulted ___ for 38 beats of aysmptomatic VT; this
was likely provoked in the setting of decompensated heart
failure. He was discharged with a Life Vest and may require an
ICD
- torsemide was started at a dose of 40 mg daily, which may be
managed as an outpatient
- potassium 10 mg and magnesium 400 mg daily supplementation was
initiated
- check electrolytes in one week
- Needs to be scheduled in ___ EP and general cardiology
clinics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO DAILY
2. Allopurinol ___ mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Viagra (sildenafil) 100 mg oral PRN ED
8. Glargine 12 Units Bedtime
9. Rosuvastatin Calcium 20 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. Amlodipine 10 mg PO DAILY
3. Glargine 12 Units Bedtime
4. Lisinopril 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
8. GlipiZIDE 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*0
11. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
12. Potassium Chloride 10 mEq PO DAILY
RX *potassium chloride 10 mEq 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
13. Magnesium Oxide 400 mg PO DAILY Duration: 1 Dose
RX *magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
New onset systolic congestive heart failure
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 recent
hospitalization. You were admitted because you were having
trouble breathing and because your legs had become swollen.
These symptoms are from fluid backing up into your lungs/legs
because your heart is not working as well as it used to. We
studied your heart with an ultrasound and an MRI to get a better
sense of why this is happening. We were able to rule out some
causes, but we still do not know exactly what's causing your
heart failure and will continue to monitor this in the
outpatient setting. You may require additional tests after being
discharged, which will be coordinated by your outpatient
cardiologists.
We have started you on several medications as detailed in your
discharge packet.
It's important for you to wear the LifeVest over the next
several weeks. Please also take your medications as prescribed,
and follow-up with your doctors as ___ below. Weight
yourself every morning, and call your doctor if your weight
increases by more than 3 pounds.
Please take your potassium and magnesium supplements. Avoid
foods that are high in potassium, such as potatoes and bananas.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10762097-DS-7
| 10,762,097 | 22,527,538 |
DS
| 7 |
2125-11-22 00:00:00
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2125-11-22 11:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, lysis of adhesions, small
bowel resection, hernia repair
History of Present Illness:
___ h/o open hiatal hernia repair (___), multiple ventral hernia
repairs, s/p LBR for incarcerated hernia w perforation (___),
now p/w abd pain of approximately 1 week duration. With this
pain, he has transitioned his diet from solids to mainly
liquids.
He noted a baseball sized mass ___ his L periumbilical area. He
presented to ___ where a CT scan showed incarcerated
hernia and free air concerning for perforation. He continues to
pass stool, althought it is less than his usual amount. Today,
he
passed a small liquid bowel movement. He has not passed gas ___
the past week. He denies nausea/ vomiting, fevers.
Past Medical History:
ventral hernias,
incarcerated ventral hernia
HTN
GERD
Social History:
___
Family History:
noncontributory
Physical Exam:
PE: upon admission: ___
Vitals: AVSS
Gen: morbidly obese, NAD
CV: RRR, S1S2, no m/r/g
Pulm: CTAB
Abd: morbidle obese, multiple well healed surgical scars,
softball sized firm bulge ___ L mid-abdomen, TTP throughout,
mostly ___ area of bulge, no rebound or guarding, +peritoneal
signs
___: no edema
Pertinent Results:
___ 07:46AM HCT-43.0
___ 01:06AM LACTATE-1.2
___ 12:38AM COMMENTS-GREEN TOP
___ 12:25AM GLUCOSE-88 UREA N-19 CREAT-1.0 SODIUM-134
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-19* ANION GAP-18
___ 12:25AM estGFR-Using this
___ 12:25AM WBC-15.7* RBC-4.90 HGB-14.6 HCT-43.0 MCV-88
MCH-29.8 MCHC-33.9 RDW-15.6*
___ 12:25AM PLT COUNT-241
___ 12:25AM ___ PTT-29.1 ___
___ 06:00AM BLOOD WBC-11.0 RBC-4.35* Hgb-13.6* Hct-39.9*
MCV-92 MCH-31.2 MCHC-34.0 RDW-15.1 Plt ___
___ 05:12AM BLOOD WBC-10.4 RBC-4.24* Hgb-12.9* Hct-37.9*
MCV-89 MCH-30.5 MCHC-34.2 RDW-15.4 Plt ___
___ 04:44AM BLOOD WBC-9.0 RBC-4.23* Hgb-12.8* Hct-38.6*
MCV-91 MCH-30.2 MCHC-33.1 RDW-15.7* Plt ___
___ 04:54AM BLOOD WBC-8.3 RBC-4.03* Hgb-12.0* Hct-36.8*
MCV-91 MCH-29.8 MCHC-32.6 RDW-15.5 Plt ___
___ 05:24AM BLOOD WBC-8.1 RBC-4.08* Hgb-12.2* Hct-37.0*
MCV-91 MCH-30.0 MCHC-33.0 RDW-15.7* Plt ___
___ 04:42AM BLOOD WBC-8.2 RBC-4.09* Hgb-12.2* Hct-37.0*
MCV-90 MCH-29.9 MCHC-33.1 RDW-15.5 Plt ___
___ 07:46AM BLOOD Na-135 K-3.9 Cl-102
___ 06:00AM BLOOD Glucose-103* UreaN-22* Creat-0.9 Na-136
K-4.5 Cl-102 HCO3-26 AnGap-13
___ 06:00AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-26 AnGap-13
___ 05:12AM BLOOD Glucose-80 UreaN-21* Creat-0.6 Na-137
K-4.1 Cl-105 HCO3-22 AnGap-14
___ 04:44AM BLOOD Glucose-98 UreaN-21* Creat-0.7 Na-136
K-3.9 Cl-102 HCO3-29 AnGap-9
___ 04:54AM BLOOD Glucose-112* UreaN-17 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-26 AnGap-13
___ 05:24AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 04:42AM BLOOD Glucose-105* UreaN-11 Creat-0.6 Na-135
K-3.6 Cl-102 HCO3-27 AnGap-10
___ 06:00AM BLOOD ALT-23 AST-31 AlkPhos-89 TotBili-7.4*
___ 05:12AM BLOOD ALT-25 AST-37 AlkPhos-85 Amylase-46
TotBili-6.0* DirBili-4.6* IndBili-1.4
___ 04:44AM BLOOD ALT-37 AST-65* AlkPhos-94 Amylase-37
TotBili-5.3* DirBili-4.4* IndBili-0.9
___ 04:54AM BLOOD ALT-42* AST-70* AlkPhos-140* Amylase-46
TotBili-4.9* DirBili-4.0* IndBili-0.9
___ 05:24AM BLOOD ALT-46* AST-62* AlkPhos-218* Amylase-64
TotBili-4.2* DirBili-3.0* IndBili-1.2
___ 04:42AM BLOOD ALT-41* AST-52* AlkPhos-260* TotBili-2.7*
___ 07:46AM BLOOD Mg-1.8
___ 06:00AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.4
___ 06:00AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.3
___ 05:12AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.9#
___ 04:44AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
___ 04:54AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
___ 05:24AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
___ 04:42AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.1
___: EKG:
Atrial fibrillation with rapid ventricular response. No previous
tracing
available for comparison
___: chest x-ray:
Subject to technical limitations ___ imaging a patient this size,
NG tube can be traced only as far as the gastroesophageal
junction. Moderate
cardiomegaly and mediastinal vascular engorgement have
increased. Soft
tissue obscures the lower lungs. There could be a small right
pleural effusion.
___: liver/gallbladder US:
Cholelithiasis as seen on prior CT. No biliary dilatation
visualized.
2. Limited exam of the liver due to the patient body habitus.
___: x-ray of the abdomen:
An enteric tube is seen terminating ___ the stomach. Can be
advanced
approximately 3-4 cm.
Dilated loops of small bowel likely represent post operative
___ 3:00 am SWAB
HERNIA FLUID CULTURES Fluid should not be sent ___ swab
transport
media. Submit fluids ___ a capped syringe (no needle), red
top tube,
or sterile cup.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
FLUID CULTURE (Final ___:
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 ___ this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
FUSOBACTERIUM NUCLEATUM. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
Brief Hospital Course:
___ year old male admitted to the acute care service with
abdominal pain. A cat scan done at an outside hospital showed
an incarcerated hernia, small bowel obstruction with
pneumo-peritoneium. He was started on zosyn and flagyl.
Attempts at reducing the hernia were unsuccessful. The patient
was transferred here for further management. He underwent
abdominal assessment and his vital signs remained stable. On HD
#2, he was taken to the operating room where he underwent an
exploratory laparotomy, extensive lysis of adhesions, small
bowel resection of 60 cm, primary
anastomosis and repair of ventral hernia with bioprosthetic
mesh. There were multiple
adhesions throughout to the abdominal wall and to the bowel. The
operative course was stable with a 250cc blood loss. Two JP
drains were placed on either side of his abdomen at the close of
the procedure. The patient was extubated after the procedure
and monitored ___ the recovery room. Wound culture from the
hernia repair fluid grew E.Coli and the patient was treated with
a week course of ciprofloxacin.
The post-operative course was notable for nausea and an
isoalated episode of vomiting. A ___ tube was placed
for decompression. It was removed and later replaced. Abdominal
x-ray was notable for an ileus. The patient also had an episode
of atrial fibrillation which was treated with metoprolol. His
heart rate converted to normal sinus rhythm and there were no
further episodes of rapid heart rate. The patient was placed on
telemetry and closely monitored. The patient's surgical pain was
controlled with intravenous analgesia. As his bowel function
slowly recovered, the ___ tube and foley catheter were
removed on POD #4. The patient was started on clear liquids and
advanced to a regular diet. His intravenous analgesia was
converted to oral agents. His right drain, which had limited
output, was removed on POD # 6. The left JP continued to drain
serosanguinous fluid and remained ___ place. During his
post-operative recovery, the patient was noted to be jaundiced.
Liver functions tests were notable for an elevation of the total
bilirubin to 7.4. His liver enzymes were trended and slowly
decreased. ___ search of an etiology, the patient underwent an
ultrasound of the liver and gallbladder which showed numerous
gallstones without ___ fluid or gallbladder wall
edema. Hepatitis serology was drawn and it returned normal. On
POD #9 his total bilirubin had decreased to 2.1, but his lipase
and alkaline phosphatase remained mildly elevated.
The patient was seen by physical therapy and recommendations
were made to discharge to rehabilitation facility where he could
further regain his strength and mobility. On POD 8, the patient
was discharged ___ stable condition.
Medications on Admission:
HCTZ 25', omeprazole 20'', unisome for sleep
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Heparin 5000 UNIT SC TID
3. Metoprolol Tartrate 12.5 mg PO TID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
incarcerated hernia
Secondary:
elevated liver enzymes
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood ___ your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change ___ your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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:
___
|
10762495-DS-5
| 10,762,495 | 24,289,430 |
DS
| 5 |
2129-01-12 00:00:00
|
2129-01-12 16:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of malignant
paraganglioma s/p debulking and palliative chemo/XRT followed at
___, who was transferred from ___ for further
management of symptomatic orthostasis with markedly labile blood
pressures in setting of known neuroendocrine tumor.
The patient was recently hospitalized at ___ from ___ to ___
for
further control of her extremely labile blood pressure with SBPs
> 180s as well as symptomatic orthostatic hypotension. Given her
known pheo, adjustment of antihypertensive regimen made
alongside
input for Endocrine team. She was continued on her home
phenoxybenzamine 40/40/60, TID pronpanolol, and lisinopril for
renal protection. Her home nifedipine was discontinued due to
recurrent symptomatic hypotension. Additional interventions for
her severe orthostasis included abdominal binder and 0.05mg
Florinef. Patient was discharged to rehab.
While at rehab earlier today, she developed acute onset of
lightheadedness with the feeling that she was going to faint.
She
was subsequently taken to ___ where she had an ECG
that demonstrated mild sinus tachycardia but was otherwise
benign. At ___, the patient was again symptomatic with
abrupt position change. She was given 1L IVF. Given her
complicated oncologic history, the ___ did not
feel comfortable admitting the patient for observation. Plan was
to admit the patient to ___ where she receives all of her
medical
care, but the hospital was full. ___ also declined, thus she was
transferred to ___.
In the ED, initial VS were T97.8, BP 188/94, HR 101, RR16, 96%
RA.
ECG sinus rhythm without evidence of right heart strain. BMP
demonstrated Cr 2.0 and Ca of 10.8 (no albumin) otherwise normal
electrolytes, Hg 8.9, WBC 8.4, glucose 194. Patient received
propranolol 20mg and lisinopril 5mg. Transfer VS were: HR 100,
BP
180/87.
On arrival to the floor, the patient reports feeling well as she
is laying in bed. She denies any symptoms with orthostatic
vitals
obtained on arrival. Later that evening, she was observed by
nursing experiencing an episode of expressive aphasia that
lasted
for one minute that resolved completely on repeat assessment.
Of note, patient was last seen by oncologist, Dr. ___, on ___
to discuss the fact that recent CT scan from ___ that
demonstrated progression of disease to her lungs and spine. Plan
at that time was to start temozolomide, but this has not yet
occurred, likely pending discharge from rehab.
Past Medical History:
Type 2 diabetes mellitus
Diabetic peripheral neuropathy
CKD (baseline Cr 1.9-2.1)
Osteoporosis
Cardiomyopathy
Malignant paraganglioma
Hyperlipidemia
Hypertensive urgency
Orthostatic hypotension
Social History:
___
Family History:
Father ? colon cancer; Mother alive, recent ___ diagnosis. No
known family history of MEN or other endocrine tumors.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: T98.5 BP 182/100, HR 101, RR16 96% RA
GENERAL: laying in bed in 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: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CNII-XII intact; ___ strength in all extremities.
Sensation grossly intact. No ataxia.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
VITALS: Temp: 98.6 PO BP: 131/76 R Sitting HR: 77 RR: 18 O2 sat:
95% O2 delivery: RA
GENERAL: Older appearing woman in no acute distress. AAOx3.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Rapid rate, regular rhythm. Normal S1/S2. No murmurs,
rubs, or gallops.
PULMONARY: Frequent expiratory wheezes over bilateral lung
fields, improved. No increased work of breathing.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, non-edematous.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
==============
___ 06:26PM BLOOD WBC-8.4 RBC-3.36* Hgb-8.9* Hct-29.1*
MCV-87 MCH-26.5 MCHC-30.6* RDW-20.2* RDWSD-62.2* Plt ___
___ 06:26PM BLOOD Neuts-63.6 Lymphs-18.1* Monos-10.6
Eos-3.3 Baso-0.5 NRBC-0.2* Im ___ AbsNeut-5.36
AbsLymp-1.53 AbsMono-0.89* AbsEos-0.28 AbsBaso-0.04
___ 04:54AM BLOOD ___ PTT-29.7 ___
___ 06:26PM BLOOD Glucose-194* UreaN-32* Creat-2.0* Na-140
K-4.4 Cl-96 HCO3-27 AnGap-17
___ 04:54AM BLOOD ALT-16 AST-36 LD(LDH)-340* AlkPhos-163*
TotBili-0.2
___ 06:26PM BLOOD Calcium-10.8* Phos-4.6* Mg-1.6
___ 04:54AM BLOOD calTIBC-178* Hapto-469* Ferritn-599*
TRF-137*
___ 05:55AM BLOOD %HbA1c-8.4* eAG-194*
___ 05:55AM BLOOD Triglyc-176* HDL-43 CHOL/HD-3.1
LDLcalc-55
___ 05:55AM BLOOD TSH-3.2
___ 08:37AM BLOOD Type-ART pO2-106* pCO2-50* pH-7.41
calTCO2-33* Base XS-5
___ 08:37AM BLOOD Lactate-1.6
DISCHARGE/PERTINENT LABS:
=======================
___ 07:45AM BLOOD WBC-7.6 RBC-3.00* Hgb-7.9* Hct-25.9*
MCV-86 MCH-26.3 MCHC-30.5* RDW-20.1* RDWSD-63.0* Plt ___
___ 07:45AM BLOOD Glucose-207* UreaN-22* Creat-2.1* Na-144
K-3.9 Cl-100 HCO3-26 AnGap-18
___ 07:45AM BLOOD Calcium-10.2 Phos-3.8 Mg-1.7
___ 04:54AM BLOOD calTIBC-178* Hapto-469* Ferritn-599*
TRF-137*
___ 05:55AM BLOOD %HbA1c-8.4* eAG-194*
___ 05:55AM BLOOD Triglyc-176* HDL-43 CHOL/HD-3.1
LDLcalc-55
___ 05:55AM BLOOD TSH-3.2
___ 06:50AM BLOOD PTH-8___ 06:50AM BLOOD Cortsol-14.4
___ 08:02AM BLOOD freeCa-1.31
IMAGING:
========
___ CT HEAD W/O CONTRAST:
1. No acute hemorrhage.
2
.
N
o
C
T
evidence for an acute major vascular territorial infarction; MRI
would be more sensitive if clinically warranted.
3
.
M
u
l
t
i
p
l
e hypodensities in the subcortical and deep supratentorial white
m
a
t
t
e
r
a
r
e
nonspecific but likely sequela of chronic small vessel ischemic
d
i
s
e
a
s
e
i
n
this age group. However, MRI would be more sensitive for small
intracranial metastases, if clinically warranted.
___ MRI/MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST
1. No acute intracranial infarct mass effect or hydrocephalus.
2
.
N
o
s
i
g
nificant abnormalities on MRA of the head and neck with somewhat
limited neck MRA without contrast.
3
.
L
e
f
t
s
i
d
e
d
neck mass is incompletely evaluated if clinically indicated neck
CT or MRI can be obtained for further evaluation.
R
E
C
O
M
M
E
N
D
A
T
I
O
N Neck CT or MRI for further evaluationn of partially visualize
neck mass.
___ CTA HEAD/NECK:
1. No acute intracranial abnormality.
2. No dissection, aneurysm or occlusion of the head neck.
3. No significant ICA stenosis by NASCET criteria.
4. Evidence of a 2.7 cm heterogeneously enhancing partially
calcified mass
resulting in erosion of the left C2 superior tick inner facet
and possibly
extending through the left C2-C3 and to a lesser extent C1-C2
neural foramen where causes mild encroachment on the spinal
canal. Findings likely correlate with the patient's history of
malignant paraganglioma.
5. The left cervical vertebral artery is at least partially
encased by the
mass.
6. A couple sclerotic lesions of the occipital calvarium
measuring up to 1.0 cm are suspicious for metastatic deposits.
7. Multiple enlarged mediastinal lymph nodes measuring up to 1.5
cm in short axis possibly relates to the patient's history of a
malignant paraganglioma. Addition, there are a few prominent
left supraclavicular and posterior cervical space lymph nodes.
8. A 4 mm right upper lobe pulmonary nodule. Consider obtaining
a complete CT chest for complete evaluation given patient's
history of malignancy.
9. Right thyroid lobe 0.5 cm hypodense nodule for which no
follow-up imaging is recommended.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
___ CXR PORTABLE AP: No acute intrathoracic process.
MICROBIOLOGY:
=============
NONE
Brief Hospital Course:
___ woman with history of malignant paraganglioma s/p
debulking and palliative chemo/XRT admitted for symptomatic
orthostasis with markedly labile blood pressures, with hospital
course complicated by episode of transient expressive aphasia
___ severe hypoglycemia.
# LABILE BLOOD PRESSURE
# SUPINE HYPERTENSION
# ORTHOSTATIC HYPOTENSION
Initially admitted for orhostatic episode at rehab facility.
Overall no significant change from her prior ongoing symptoms.
Continued on
phenoxybenzamine/propranolol/lisinopril/fludrocortisone as part
of complex regimen started by her primary oncologist for control
of her hypertension that is secondary to her pheo and her
orthostatic hypotension. The patient was euvolemic on exam so
only received minimal fluid resuscitation, which did not make a
difference in her orthostatics. AM cortisol was within normal
limits. Thigh-high compression stockings and an abdominal binder
were placed with some improvement in the patient's symptoms.
After discussion with her primary oncologist, decision was made
to keep her current regimen unchanged. We continued to provide
teaching on positional changes and techniques to avoid loss of
consciousness or falls.
# ACUTE ENCEPHALOPATHY
# TRANSIENT EXPRESSIVE APHASIA
# SEVERE HYPOGLYCEMIA / TYPE 2 DIABETES
Overnight ___ - ___ was found unresponsive with blood glucose
<20. Resuscitated with D50 bolus / D10 water with modest
improvement in mental status, however due to persistent
somnolence was transferred to MICU for closer monitoring.
Underwent repeat head imaging with CTA head/neck demonstrating
no vascular territory infarct to account for symptoms. EEG
without evidence of seizure activity. Mental status gradually
improved overall consistent with severe hypoglycemia as etiology
for her symptoms. Of note, the patient was previously on 45U of
Lantus BID per her last ___ discharge summary and prior to
discharge, was dropped to 18U daily given hypoglycemia. She was
uptitrated back to 30U daily at rehab prior to readmission to
the hospital. The etiology behind the declining insulin
requirement was likely the severely decreased PO intake and
malnutrition with 13kg weight loss in the last 5 months, likely
with decreased insulin resistance. C-peptide was noted to be
low. ___ was consulted and insulin continued to be
downtitrated. Patient did not have any further episodes of
unresponsiveness and blood glucose remained normal. At the time
of discharge, was on 8U of Lantus QHS and was requiring 2U of
Humalog TID per a standard sliding scale.
# HYPERCALCEMIA
Recent labs notable for elevated calcium to 12.8 (corrected for
hypoalbuminemia) but with normal ionized calcium. On review of
___ records this appears to be relatively acute since her prior
discharge. Unclear etiology, though suspicious for for
malignancy-related hypercalcemia secondary to bony metastases.
PTH was appropriately low. No EKG changes. Started on IV fluids
with improvement in her serum calcium. Did not require further
interventions, but needs further monitoring and may require
bisphosphonate therapy if continues to worsen, given suspected
etiology.
# CONSTIPATION
Patient presented with severe constipation without BM for up to
1 week prior to admission. Started on aggressive bowel regimen
with 2 small BMs noted on ___ and ___. Abdominal XR still
showing significantly large stool burden.
# SEVERE MALNUTRITION
Patient noted to have poor PO intake while in the hospital.
Evaluated by nutrition and meets criteria for severe
malnutrition. This is thought to be related to increasing
nutrient needs due to her prolonged catabolic illness as well as
poor PO intake for > 5 months due to poor appetite. The patient
was lost 12.3 kg in the past few months with mild-moderate
muscle/fat depletion noted. She was started on nutritional
supplements (Glucerna 3x/day and Scandishake 2x/day), MVI with
minerals, and thiamine. She was also started on Dronabinol on
___.
# C1-C3 MASS
# METASTATIC PHEOCHROMOCYTOMA PARAGANGLIOMA
CTA neck with partially calcified mass eroding into C2 with
extension from C1-C3. Overall most consistent with known
paraganglioma. Unclear acuity. Continued management of Discussed
with regular oncologist who agreed with transfer to ___ where
normally receives care.
# CHRONIC KIDNEY DISEASE
Creatinine baseline approximately 1.8-2. Currently stable.
TRANSITIONAL ISSUES:
==================
[ ] Discuss blood pressure medication regimen with primary
oncologist Dr. ___
[ ] Continue with aggressive bowel regimen given large stool
burden and constipation
[ ] F/U serum calcium
[ ] Continue nutritional supplementation and monitor PO intake
[ ] Monitor blood sugars and adjust insulin as needed
[ ] Noted to have thyroid nodule on neck imaging
# CODE STATUS: Full
# CONTACT: ___ - ___ - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Gabapentin 100 mg PO TID
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. Vitamin D ___ UNIT PO 1X/WEEK (FR)
6. Fludrocortisone Acetate 0.05 mg PO DAILY
7. Propranolol 20 mg PO TID
8. Senna 17.2 mg PO BID
9. Atorvastatin 80 mg PO QPM
10. Lisinopril 5 mg PO DAILY
11. Phenoxybenzamine HCl 40 mg PO BID
12. Lactulose 30 mL PO Q8H:PRN constipation
13. Phenoxybenzamine HCl 60 mg PO QHS
14. Melatin (melatonin) 3 mg oral qHS
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
17. Ondansetron 8 mg PO Q8H:PRN nausea
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
2. Dronabinol 2.5 mg PO BID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY Duration: 5 Days
5. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
7. Atorvastatin 80 mg PO QPM
8. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
9. Fludrocortisone Acetate 0.05 mg PO DAILY
10. Gabapentin 100 mg PO TID
11. Lactulose 30 mL PO Q8H:PRN constipation
12. Lisinopril 5 mg PO DAILY
13. Melatin (melatonin) 3 mg oral qHS
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. Phenoxybenzamine HCl 40 mg PO BID
16. Phenoxybenzamine HCl 60 mg PO QHS
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
18. Propranolol 20 mg PO TID
19. Senna 17.2 mg PO BID
20. TraZODone 25 mg PO QHS:PRN insomnia
21. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- ORTHOSTATIC HYPOTENSION
- HYPOGLYCEMIA
- HYPERCALCEMIA
- CONSTIPATION
- SEVERE MALNUTRITION
SECONDARY DIAGNOSES:
- METASTATIC PARAGANGLIOMA
- CHRONIC KIDNEY DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were feeling lightheaded and almost passed out while
you were at rehab. This was thought to be related to your
underlying paraganglioma and your current medications to control
your blood pressure. You were given a small amount of fluids,
and we used a combination of thigh-high compression stockings
and an abdominal binder to maintain your blood pressure from
fluctuating too much while you had positional changes.
While you were in the hospital, you had an episode of where you
lost consciousness and you were noted to have a blood sugar of
20. You quickly recovered after we corrected your blood sugar.
This was thought to be related to an insulin dose that was too
high for you. We adjusted your home insulin dosing and lowered
it further. You were also treated for constipation and were
given supplements because you were not eating very well.
After a discussion with your primary oncologist, Dr. ___
are transferring you to ___ for further
management.
Wishing you a speedy recovery,
Your ___ Care Team
Followup Instructions:
___
|
10762742-DS-17
| 10,762,742 | 22,694,250 |
DS
| 17 |
2164-08-04 00:00:00
|
2164-08-07 09:51:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, cough, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ with past medical
history of atrial fibrillation, HLD who presents with ___ days
of
productive cough, fever to 101 and body aches. He arrived to
urgent care rigoring with oxygen saturation to 82% on room air
improving with nasal cannula. He was given nebulizer treatment
given diffuse wheezing. Chest x-ray revealing likely pneumonia.
Patient ordered for ceftriaxone and azithromycin. Flu test was
negative. Patient transferred to ___ emergency department for
further care.
He denies chest pain, extremity weakness or paresthesia,
headache, neck pain.
Past Medical History:
HYPERLIPIDEMIA
PALPITATIONS
SLEEP APNEA
ASTHMA
COLONIC ADENOMA
ATRIAL FIBRILLATION
Social History:
___
Family History:
Father
- ATRIAL FIBRILLATION
- PROSTATE CANCER
Physical Exam:
Admission Physical Exam
=====================================
VITALS: ___ 2356 Temp: 98.5 PO BP: 115/71 R HR: 76 RR: 18
O2 sat: 91% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Scattered rhonchi and end-expiratory wheezes.
Abdomen: Normoaactive bowel sounds. Soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace
peripheral edema ___ b/l ___.
Skin: Skin type III. Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact. A&Ox3. No gross focal deficits.
Discharge Physical Exam
=====================================
Vitals: Temp 98.5 BP 117/69 HR 70 RR 16 O2sat 93 RA
General: NAD
Neck: No lymphadenopathy
Lungs: Diffuse expiratory wheezing w/ rhonchi; no crackles;
decreased air movement
CV: RRR, no MRG
GI: Soft, nondistended, no TTP diffusely
Ext: No edema, erythema, TTP of ___: PERRL, EOMI
Pertinent Results:
ADMISSION LABS
=================
___ 05:20PM WBC-12.5* RBC-5.07 HGB-16.1 HCT-46.7 MCV-92
MCH-31.8 MCHC-34.5 RDW-12.5 RDWSD-42.0
___ 05:20PM NEUTS-66.8 ___ MONOS-11.1 EOS-2.3
BASOS-0.2 IM ___ AbsNeut-8.31* AbsLymp-2.40 AbsMono-1.38*
AbsEos-0.29 AbsBaso-0.03
___ 05:20PM PLT COUNT-256
___ 05:05PM OTHER BODY FLUID FLU A PCR-NEG FLU B PCR-NEG
___ 05:20PM GLUCOSE-141* UREA N-14 CREAT-1.0 SODIUM-144
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18
DISCHARGE LABS
====================
___ 07:05AM BLOOD WBC-8.7 RBC-4.20* Hgb-13.1* Hct-38.6*
MCV-92 MCH-31.2 MCHC-33.9 RDW-12.6 RDWSD-41.7 Plt ___
___ 07:05AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-142
K-3.6 Cl-102 HCO3-25 AnGap-15
___ 07:05AM BLOOD ALT-30 AST-19 LD(LDH)-234 AlkPhos-51
TotBili-0.4
MICROBIOLOGY
=================
___ 6:29 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 12:53 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
Test Result Reference
Range/Units
S. PNEUMONIAE ANTIGENS, Not Detected Not Detected
URINE
IMAGING
==============
CXR IMPRESSION:
Patchy right upper lobe consolidation compatible with pneumonia
___ the proper clinical setting. Follow-up after treatment is
suggested to document resolution.
Brief Hospital Course:
Brief Hospital Course
=========================================
___ w/ hx of HLD, OSA, afib, and mediastinal lymphadenopathy
presenting with 3 days of increasing cough, fevers, and SOB,
discovered to have PNA on CXR, hypoxia and treated with CTX +
Azithro.
#Community Acquired Pneumonia:
#Hypoxemic respiratory failure:
Patient presented with several days of cough, fevers, malaise at
home. Patient was diagnosed with CAP due to clinical signs and
symptoms as well as a CXR demonstrating a RUL consolidation. At
urgent care, he was noted to be hypoxic to 82% on room air,
prompting referral to ___ and admission. Patient was started
on IV CTX + Azithromycin which was then switched to PO Levaquin
x5 days given the sputum Gram stain demonstrating GPCs and GNRs.
Patient remained afebrile and his WBC decreased after initiation
of antibiotics, and he was weaned to room air. Ambulatory O2 sat
___ the afternoon was 94% on room air. Patient discharged on oral
levofloxacin 750mg PO Q24H to complete 5 day course (D1 =
___.
#Headache: Patient noted a headache that had begun after
admission. Given the dull, gradual onset, holosystolic nature of
the headache without associated symptoms, headache is most
likely related to his current infection as above. Improved with
PRN acetaminophen and ibuprofen.
#ETOH Use: Patient noted that he drank ___ drinks per day. No
signs of ETOH withdrawal.
Transitional Issues
=========================================
[ ] Complete 5-day course of antibiotics for CAP treatment (D1 =
___ - D5 = ___. Discharged on levofloxacin 750mg PO
Q24H.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO QHS
2. Metoprolol Succinate XL 25 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Cetirizine 10 mg PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN SOB or
wheezing
7. Benzonatate 200 mg PO TID:PRN cough
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN SOB or
wheezing
3. Benzonatate 200 mg PO TID:PRN cough
4. Cetirizine 10 mg PO DAILY
5. Diazepam 10 mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Succinate XL 25 mg PO QPM
8. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Community-acquired pneumonia
Hypoxemic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ___ THE HOSPITAL?
- You were ___ the hospital for trouble breathing and your oxygen
levels were low. Your chest x-ray showed a pneumonia (lung
infection).
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- We treated you with antibiotics and you felt better.
- Your oxygen levels improved after IV antibiotics, and you were
ready to go home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please take your first dose of your antibiotic, levofloxacin,
tonight (___), and take until gone.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10762830-DS-20
| 10,762,830 | 23,483,846 |
DS
| 20 |
2113-10-20 00:00:00
|
2113-10-24 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Trauma: struck in face with pipe
Major Surgical or Invasive Procedure:
___ intra oral ORIF mandible
History of Present Illness:
This patient is a ___ year old male who complains of
ASSAULT. ___ was assaulted tonight with a lead pipe the left
side of his face. + LOC. Was seen at ___ where he had a cat scan of the head and neck which were
reportedly
negative. He was found to have a comminuted mandibular fracture
with dental injuries. Received 1 g of Ancef and morphine.
Patient denies neck pain, back pain, chest pain, nausea,
vomiting, shortness of breath or abdominal pain, extremity
trauma. Takes Zoloft. Drinks alcohol, denies smoking or
recreational drug use. He is allergic to penicillin. Labs at
the outside hospital were unremarkable.
Past Medical History:
IVDA, Depression
Social History:
___
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 100.2 HR: 90 BP: 130/65 Resp: 16 O(2)Sat: 100 Normal
HEENT: Pupils equal, round and reactive to light
+ deformity of the jaw
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Physical examination upon discharge: ___:
vital signs:
97.8, bp=102/42, hr=73, 16, oxygen saturation 97% room air
___: resting, ice packs to face, face swollen
CV: ns1, s2, -s3 -s4
LUNGS: clear
ABDOMEN: soft, non-tender, hypoactive BS
EXT: no pedal edema bil., + dp bil., mild tenderness right
great toe, full flexion/extension
NEURO: alert and oriented x 3, speech garbled related to jaw
swelling
Pertinent Results:
___ 12:31AM BLOOD WBC-17.7* RBC-4.91 Hgb-15.1 Hct-44.6
MCV-91 MCH-30.8 MCHC-33.9 RDW-12.9 Plt ___
___ 12:31AM BLOOD Neuts-80.1* Lymphs-15.2* Monos-3.3
Eos-1.0 Baso-0.4
___ 12:31AM BLOOD Plt ___
___ 12:31AM BLOOD Glucose-100 UreaN-15 Creat-0.9 Na-148*
K-3.9 Cl-107 HCO3-23 AnGap-22*
___ 12:31AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Panorex of mandible: ___:
Fracture through the left mandibular body which appears to
traverse the root of the bottom ___ left molar tooth.
___: panorex mandible:
FINDINGS: In comparison with the study of ___, there is a
fixation device about the fracture near the angle of the
mandible on the left with_ no appreciable displacement. There
are also metallic fixation devices about the medial aspect of
the right mandible.
Brief Hospital Course:
The patient was admitted to the hospital after being struck in
the face with a lead pipe. He reportedly sustained a loss of
consciousness. Imaging studies of the head and neck were normal
but the patient was reported to have a comminuted mandibular
fracture with dental injuries. He was given a dose of ancef in
the emergency room and was seen by OMFS. After examination by
the ___ service, the patient was started on an intravenous
course of clindamycin. The patient was taken to the operating
room on HD #1 where he underwent an intraoral ORIF of bilateral
mandible fracture. The operative course was stable with a 50 cc
blood loss.
The post-operative course was stable. The patient's was
transitioned from intravenous analgesia to oral agents for
management of his surgical pain. He was started on clears and
advanced to full liquids. He was voiding without difficulty.
Panorex imaging was obtained prior to discharge. Because of his
loss of consciousness, the patient was evaulated by Occupational
therapy to assess the need for outpatient cognitive therapy. No
cognitive follow-up was indicated. The social worker provided
social support and addressed the patient's concerns. The
patient was discharged on POD #1 in stable condition. An
appointment for follow-up was made with the ___ service. The
patient was instructed to complete a 7 day course of clindamycin
as per recommendations of the ___ service.
Medications on Admission:
zoloft 50 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % rinse mouth with 15cc twice a
day Disp #*1 Bottle Refills:*0
3. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*26 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
avoid driving while on this medication, may cause drowsiness
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp
#*40 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
fractured mandible
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital after ___ were hit in the face
with a pipe. ___ sustained a loss of consciousness related to
the injury. Imaging of your face showed a fractured jaw. ___
were taken to the operating room where ___ had your jaw
repaired. Your vital signs have been stable and ___ are now
preparing for discharge home with the following instructions:
Postoperative instructions following jaw surgery
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If ___ have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If ___ had
nasal surgery, ___ may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, ___ should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If ___ do not see continued improvement, please call our office.
Physical activity: It is recommended that ___ not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless ___
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If ___ have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
___ may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as ___
like, but ___ should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: ___ may shower ___ days after surgery, but please ask
your surgeon about this. If ___ have any incisions on the skin
of your face or body, ___ should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As ___ may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist ___ in case if ___ may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing ___ to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. ___ will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if ___ precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If ___ do not achieve adequate pain relief at first
___ may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If ___ find that ___ are taking large amounts
of pain medications at frequent intervals, please call our
office.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, ___ can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
It is important not to skip any meals. If ___ take nourishment
regularly ___ will feel better, gain strength, have less
discomfort and heal faster. Over the counter meal supplements
are helpful to support nutritional needs in the first few days
after surgery. A nutrition guidebook will be given to ___ before
___ are discharged from the hospital. Remember to rinse your
mouth after any food intake, failure to do this may cause
infections and gum disease and possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if ___ do not
feel better. If your jaws are wired shut with elastics and ___
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If ___ feel that ___ cannot safely expel the vomitus in
this manner, ___ can cut elastics/wires and open your mouth.
Inform our office immediately if ___ elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
___ will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal sprays
and pain medications. Use them as directed. A daily multivitamin
pill for ___ weeks after surgery is recommended but not
essential.
Followup Instructions:
___
|
10762853-DS-18
| 10,762,853 | 26,021,014 |
DS
| 18 |
2184-11-24 00:00:00
|
2184-12-10 00:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Possible syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ with history of dementia, HTN, cataracts who
is presenting s/p possible syncopal event. Per the patient's
son, the patient was eating dinner at 1:30 this morning when she
slumped over to the right; the son repots that she was
unresponsive for 5 minutes; however, he also states that he
asked if she was alright during this time, and she said "no".
The patient does not recall this event. Pt.'s son is not sure if
she just fell asleep at the table; nothing like this has ever
happened before prompting him to bring her to the ER. The
patient's son reports that prior to this event she was in her
usual state of good health.
The son reports that after event, patient is currently back to
her baseline now, AAOx1. She lives with her son and by report
receives assistance with her ADLs. She can feed herself and
often dress herself, but her son has helped her with these
things as well. Her daughter will reportedly bathe her.
On the floor, patient denies any palpitations, lightheadedness,
chest pain, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, constipation, fevers/chills.
Past Medical History:
Hypertension
Cataracts
Osteoarthritis
Fracture of surgical neck humerus (___), with non-operative
management
Dementia
Social History:
___
Family History:
Brother died of throat cancer.
Physical Exam:
ADMISSION:
VS: ___ 94RA
GENERAL: pleasantly demented, well appearing elderly woman, NAD,
laying comfortably in bed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
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: no edema, 2+ pulses radial pulses
NEURO: awake, A&Ox0-1 (she remembered her maiden name only),CNs
II-XII grossly intact, able to do finger to nose though slowly,
normal muscle strength throughout, able to ambulate with
assistance
DISCHARGE:
VS: 98.5 ___ 94%RA
GENERAL: well appearing elderly woman, NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
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: no edema, 2+ pulses radial pulses
NEURO: awake, A&Ox1, CNs II-XII grossly intact, able to do
finger to nose though slowly, normal muscle strength throughout
Pertinent Results:
LABS:
___ 02:40AM BLOOD WBC-7.8# RBC-4.62 Hgb-14.7 Hct-45.7
MCV-99*# MCH-31.8 MCHC-32.2 RDW-12.4 Plt ___
___ 06:55AM BLOOD WBC-10.4 RBC-4.29 Hgb-13.2 Hct-41.6
MCV-97 MCH-30.8 MCHC-31.8 RDW-12.4 Plt ___
___ 08:00AM BLOOD WBC-6.1 RBC-4.08* Hgb-13.0 Hct-39.5
MCV-97 MCH-31.9 MCHC-32.9 RDW-12.6 Plt ___
___ 02:40AM BLOOD Glucose-134* UreaN-16 Creat-1.0 Na-143
K-3.5 Cl-100 HCO3-32 AnGap-15
___ 06:55AM BLOOD Glucose-115* UreaN-16 Creat-0.9 Na-144
K-3.8 Cl-101 HCO3-31 AnGap-16
___ 08:00AM BLOOD Glucose-83 UreaN-17 Creat-0.9 Na-143
K-3.3 Cl-102 HCO3-34* AnGap-10
___ 02:40AM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2
___ 01:40AM URINE Color-Straw Appear-Hazy Sp ___
___ 01:40AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 01:40AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
=
=
=
=
================================================================
IMAGING/OTHER STUDIES:
EKG ___
Sinus rhythm. Prolonged P-R interval. Possible old inferior
myocardial
infarction. Borderline left ventricular hypertrophy. Compared to
the previous tracing of ___ ventricular ectopy is resolved.
CXR ___
FINDINGS: PA and lateral views of the chest demonstrate
cardiomegaly with
some increased interstitial markings again noted. Costophrenic
angles are
clear. A tortuous aorta and scoliosis centered in the upper
lumbar/lower
thoracic spine is again present. No focal consolidations
concerning for
pneumonia.
Brief Hospital Course:
Ms. ___ is ___ with history of dementia, HTN who is was
brought in by her son in the setting of possible syncope. While
she did appear to have a brief episode of decreased
consciousness, it does not appear classic for either a syncope
or a seizure. The reported symptoms do resemble fatigue or
decreased alertness, although they did not recurr during the
admission, while the patient was continued on her home
medication regimen.
#Possible syncope: The patient slumped to the R while eating her
dinner. Unclear precipitant and unclear if true syncope versus
falling asleep, but differential includes cardiogenic versus
neurocardiogenic. Orthostasis unlikely as the patient was not
going from sitting to standing. She denied having any chest pain
or shortness of breath (though unclear how reliable of a
historian the patient is), and EKG without any evidence of ST-T
changes that could be consistent with ischemia. There was report
that the patient was unresponsive, but unclear if there was LOC
or loss of pulse. Seizure unlikely as there was no reported
post-ictal period. If indeed was true syncopal episode, most
likely explanation would be bradyarrhythmia caused by high
degree AV blook in setting of worsening 1st degree block (PR
206) and beta blockade. Upon admission, patient was back at her
baseline, as per son. She was monitored overnight on telemetry
without any evidence of significant bradycardia or high degree
AV block. Most likely explanation is that patient fell asleep in
setting of eating dinner at 1AM. We wondered if her multiple
dementia/anti-parkinsonian medications could be contributing to
generalized lethargy or possible hypotensive episodes, although
she did not have similar episodes while admitted to our service.
# Chronic Systolic CHF: Last ECHO in ___ with e/o dilated and
globally hypokinetic LV, with mild pulmonary HTN, and MR.
___ home Lasix, ASA, lisinopril and metoprolol
# Dementia: Unclear type, but possible that there is element of
___ disease, given her tremor. Continued home donepezil,
Namenda, and Sinemet.
=
================================================================
TRANSITIONAL ISSUES:
Consider adjusting Dementia/Anti-Parkinsonian medications as
they may be having significant sedative effects on patient, if
the presenting symptoms recurr as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Donepezil 10 mg PO HS
3. Memantine 10 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Lisinopril 10 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
10. Carbidopa-Levodopa (___) 1 TAB PO TID
Discharge Medications:
1. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
2. Multivitamins 1 TAB PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Memantine 10 mg PO BID
5. Lisinopril 10 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Donepezil 10 mg PO HS
8. Docusate Sodium 100 mg PO BID
9. Carbidopa-Levodopa (___) 1 TAB PO TID
10. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
presyncope
possible sedation effect of medications
Secondary:
Dementia
Chronic systolic congestive heart failure
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 ___,
___ were admitted to ___ for evaluation of an episode of
unresponsiveness. Your lab work, chest x-ray, and urinalysis
were all normal, with no evidence of infection. There was also
no evidence of a stroke or seizure. There was no evidence of a
heart attack or abnormal rhythm. This is all very reassuring. It
is possible that some of your medications, including Sinemet,
Namenda, and Aricept could be contributing to your sleepiness or
affecting your blood pressure, so ___ should talk with your
doctors about possibly ___ these medications.
It was a pleasure taking part in your care and we wish ___ a
speedy recovery!
Followup Instructions:
___
|
10762853-DS-19
| 10,762,853 | 22,720,205 |
DS
| 19 |
2186-04-28 00:00:00
|
2186-04-28 20:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee pain
Right knee swelling
Major Surgical or Invasive Procedure:
Arthrocentesis of right knee (___)
Video oropharyngeal swallow (___)
History of Present Illness:
Ms. ___ is a ___ with advanced dementia (AOx0), HTN, and
cataracts who presented with right medial knee swelling and
pain. The patient is mostly non-verbal at baseline and was
unable to provide an account of his her history. Per her son,
who cares for her and is her legal guardian, the patient had
demonstrated increased difficulty ambulating during the week
prior to admisison. Typically, the patient had been able to
ambulate with the assistance of one nursing aid. However,
beginning a week prior to admission, the patient required the
assistance of multiple family members to ambulate. During this
time the patient would say "ouch" when her right knee was
manipulated. Her difficulty ambulating progressed to the point
of requiring a wheelchair a few days prior to admission.
Patient's son notes the patient has always had asymmetry between
her knee (right larger than left), but the pain is new. Patient
has been breathing more rapidly and shallowly over the past
week. Patient's family denies patient having fever, cough,
complaints of other pain, and emesis.
Per patient's son and daughter: At baseline, the patient is
mostly ___, speaking only single words when she is
audible. Patient is urinary incontinent in the nighttime at
baseline. Over the past week, the patient has been having
increased daytime urinary incontinence. Over the past several
months, the patient has demonstrated difficulty swallowing
liquids, solids and medications. The patient's family notes they
have been mixing the patient's medications in apple sauce
instead of with the water they usually give her. As a
consequence, they note the patient has been getting lees water
than ususal. Patient has been noted to always be
thirsty--drinking large beverages in seconds. Patient has a
nurisng aid at home who helped care for her. Patient's son and
daughter are patient's legal gaurdians.
In the ED initial vitals were: 97.6 91 125/73 26 90%RA. Labs
were significant for Na 157, K 3.1, Cl 114, Bicarb 37, BUN 47,
Cr, 1.7. WBC 14.8 with 86%N. Patient had a joint aspiration
performed that showed 10,167 WBC and ___ RBC's. Lactate 1.7.
Patient was given Vancomycin 1g IV x1. Also, was given 40meq KCl
in D5W 175cc/hr.
On the floor, the patient says "hi." She says "no" when asked if
she has pain. She does not follow commands. Interview is limited
due to advanced dementia. Nurse notes patient has been
incontinent. No complaints of shortness of breath, no cough. She
hasn't been having diarrhea, vomiting.
Past Medical History:
Hypertension
Cataracts
Osteoarthritis
Fracture of surgical neck humerus (___), with non-operative
management
Dementia
Social History:
___
Family History:
Brother died of throat cancer.
Father died of lung cancer-was a smoker and worked in ___.
Physical Exam:
=======================================
PHYSICAL EXAM ON ADMISSION: ___
=======================================
VITALS: T: 98.0 140/63 89 24 95%1LNC, 90%RA
GENERAL: NAD, nonverbal, tracks, does not follow commands
HEENT: AT/NC anicteric sclera, dry MM
NECK: no JVD
CARDIAC: RRR, S1/S2, no murmurs
LUNG: rapid shallow breaths, no accessroy muscle use, CTAB, no
wheezes, rales, rhonchi, comfortable
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: R knee swollen, nontender, warm, no erythema,
dressing in place
=======================================
PHYSICAL EXAM AT DISCHARGE: ___
=======================================
Vitals: 98.7 | 98.2 | 140s-170s/60s-80s | 70s | 16 | 93% 2L
General: NAD, lying comfortably, non-toxic appearing
HEENT: AT/NC, PERRL, tracks, sclera anicteric, MMM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bilateral lung bases, no w/r/r, no appearance
of resp distress, no accessory muscle use
CV: RRR, normal S1/S2, no m/r/g
Abdomen: soft, NT/ND, no rebounding or guarding, no organomegaly
GU: no foley, in diaper
Ext: R knee w/o swelling and erythema, no wincing when R knee is
palpated, full passive motion of R knee w/o wincing, pt unable
to cooperate for active motion testing, R foot WWP w/ palpable
pulses, pneumoboots intact, dressing around R foot c/d/i
Neuro: limited testing ___ advanced dementia, single words,
tracks, smiles, resting tremor, spontaneously moves upper
extremities, will move lower in response to painful stimulus,
sensation unable to test
Pertinent Results:
===============================
LABS ON ADMISSION: ___
===============================
WBC-14.8*# RBC-4.19* Hgb-13.4 Hct-43.3 MCV-103* MCH-31.9
MCHC-30.9* RDW-13.2 Plt ___
BLOOD Neuts-86.2* Lymphs-6.7* Monos-6.4 Eos-0.7 Baso-0.1
BLOOD Plt ___
BLOOD Glucose-128* UreaN-47* Creat-1.7* Na-157* K-3.1* Cl-114*
HCO3-37* AnGap-9
BLOOD Type-ART pO2-49* pCO2-54* pH-7.41 calTCO2-35* Base XS-7
BLOOD Calcium-8.3* Phos-2.9 Mg-2.5
BLOOD Lactate-1.7
===============================
PERTINENT LABS:
===============================
___ 07:33AM BLOOD WBC-10.0 RBC-3.41* Hgb-11.1* Hct-35.6*
MCV-104* MCH-32.4* MCHC-31.1 RDW-13.1 Plt ___
___ 07:07AM BLOOD WBC-7.8 RBC-3.46* Hgb-11.0* Hct-34.7*
MCV-100* MCH-31.9 MCHC-31.8 RDW-13.0 Plt ___
___ 08:10AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.2* Hct-35.0*
MCV-100* MCH-31.9 MCHC-31.9 RDW-13.7 Plt ___
___ 08:32PM BLOOD Glucose-173* UreaN-35* Creat-1.2* Na-147*
K-4.1 Cl-109* HCO3-33* AnGap-9
___ 03:00PM BLOOD Glucose-138* UreaN-28* Creat-0.9 Na-144
K-4.1 Cl-109* HCO3-30 AnGap-9
___ 05:00PM BLOOD Glucose-103* UreaN-16 Creat-0.8 Na-144
K-4.0 Cl-106 HCO3-34* AnGap-8
___ 08:00AM BLOOD Glucose-101* UreaN-10 Creat-0.7 Na-145
K-3.9 Cl-106 HCO3-33* AnGap-10
===============================
LABS AT DISCHARGE: ___
===============================
BLOOD WBC-8.6 RBC-3.47* Hgb-11.1* Hct-35.4* MCV-102* MCH-31.9
MCHC-31.3 RDW-14.1 Plt ___
BLOOD Plt ___
BLOOD Glucose-84 UreaN-13 Creat-0.7 Na-140 K-4.9 Cl-103 HCO3-32
AnGap-10
==========
MICRO:
==========
BLOOD CULTURE, ___: Negative
BLOOD CULTURE, ___:
- Culture (Final ___: Moraxella species. Beta lactamase
negative.
- Aerobic Bottle Gram Stain (Final ___: Gram negative
rods.
JOINT FLUID, ___:
- Gram Stain (Final ___: PMN leukocytes. No
microorganisms seen.
- Fluid culture (Final ___: No growth.
==========
IMAGING:
==========
CXR, ___: Moderate cardiomegaly and pulmonary vascular
congestion persist, but there is no pulmonary edema, pneumonia,
or appreciable pleural effusion.
Video Swallow, ___: Penetration with nectar and thin liquid.
CXR, ___: The right lung base opacity is likely a pulmonary
nodule, but may still represent overlapping structures. New
platelike atelectasis at the left lung base.
RIGHT LOWER EXT U/S, ___: No evidence of deep venous thrombosis
in the right lower extremity veins.
CXR, ___: The right lung base opacity is likely a pulmonary
nodule, but may still represent overlapping structures. New
platelike atelectasis at the left lung base.
CXR, ___: 4 mm nodular opacity projecting over the right lung
base, new since the prior study, for which shallow oblique
radiographs or chest CT recommended for further evaluation.
Vascular congestion. Streaky left basilar opacity may relate to
atelectasis. If/when patient able, PA and lateral views may be
helpful for further evaluation.
XR R KNEE, ___: Osteoarthritic changes are seen including
severe medial greater than lateral joint compartment narrowing
and some marginal osteophytes. Tiny posterior patellar spurs are
seen. There is a small to moderate suprapatellar joint effusion
without fat fluid level seen. No acute fracture or dislocation
is seen.
XR PELVIS, ___: No evidence of acute fracture or dislocation is
seen. There is relative osteopenia diffusely. The pubic
symphysis and sacroiliac joints do not appear widened although
the sacrum and sacroiliac joints are partially obscured by bowel
gas. A large stool ball is noted in the rectum. There is lumbar
scoliosis partially imaged and likely degenerative changes along
the lower lumbar spine.
Brief Hospital Course:
Patient is a ___ woman with a history of advanced
dementia (AOx0 baseline), HTN, cataracts who presented with
right knee pain, warmth and swelling in the setting of a right
knee effusion and SIRS, found to be hypernatremic and
hypokalemic with ___, subsequently found to have Moraxella
postive blood culture (likely of pulmonary etiology). ___
hospital course is listed by problem below:
===============
ACTIVE ISSUES:
===============
# Right Knee Effusion: Presented with right knee warmth,
swelling, no erythema s/p resolution. Likely from an inflammtory
process given aspirate WBC of 10k and underlying osteoarthritic
changes seen on XR. Clinical picture was not consistent with
septic arthritis since the patient was afebrile, with no pain on
joint motion, aspirate WBC <50k with no prosthetic joint,
negative aspirate cultures. In the setting of patient meeting
___ SIRS criteria with tachynpea, HR>90 and leukocytosis, along
with elevated lactate, an infectious process could not be ruled
out. Patient was initially treated with antibiotics as stated
below. Less likely gout given no crystals in aspirated fluid.
Tylenol and Tramadol were given as needed for pain control.
# SIRS w/ Moraxella Bacteremia: Presented with tachynpea, HR>90
and leukocytosis--meeting ___ SIRS criteria. Blood cultures from
___ were positive for Moraxella species (beta lactamase
negative) suggesting pulmonary etiology, especially in the
setting of the productive cough she developed when initially
taken off antibiotics. CXR did not show consolidated pneumonia,
however other sources of infections were less likely given
positive culture data for Morexlla (which commonly presents from
the lungs), no urinary symptoms, joint w/o evidence of septic
arthritis and benign abdomen. Patient was afebrile. Patient
initially treated with 3d course Vancomycin 1g qdaily and
Ceftriaxone 2gm qdaily (___). Subsequently, restarted on
Ceftriaxone 1gm qdaily on ___ after culture data grew gram
negative rods. Her Ceftriaxone was discontinued and she was
transitioned to Levofloxacin 500 mg po qdaily on ___ after her
cultures became positive for Moraxella. Scheduled to stop
Levofloxacin on ___.
# Functional Status (Ambulation/Cognition/Aspiration): Per
family, patient demonstrated increased diffculty ambulating,
poorer cognition, and increased trouble swallowing. Patient with
strong social support from son and daughter who serve as the
patient's legal ___. Patient receives home nursing aid x3
weekly. Recent decrease in functional status likely percipitated
by subacute infection and underlying advanced dementia. Status
post antibiotic therapy and correction of electrolye
abnormalities, patient's cognition improved to better than
baseline. Physical therapy recommended dispo to rehab. Per video
swallow results, patient was recommended regular diet with thin
liquids and crushed medications with puree by the speech and
swallow team.
# Right heel bulla: Solitary bulla on right heel likely from
prolonged pressure in the setting of decreased right lower
extremity movement prior to admission. The area was kept clean,
kept dry and dressed appropriately during hospitalization.
=================
RESOLVED ISSUES:
=================
# Hypernatremia: Resolved. Patient hypernatremic to 158 on
presentation likely from decreased free water intake and
overdiuresis in the in the setting of poor mental status at
baseline. Her Na downtrended from 158 to 143 over first 48 hours
w/ D5W. Her Na remained stable and within normal limits
subsequently. Her home Furosemide was held.
# Acute Kidney Injury: Resolved. Presented with Cr up to 1.7
from baseline <1.0. Likely due to dehydration and overdiuresis
in the setting of poor mental status at baseline. Cr downtrended
to 0.7. Her home Furosemide was held. Her home Lisinopril was
restarted upon her return of baseline Cr.
================
CHRONIC ISSUES:
================
# Dementia: Continued home Carbidopa/Levodopa, Donepezil,
Memantine.
# HTN: Continued home Metoprolol. Held home Furosemide.
Restarted home Lisinopril after improvement resolution ___
and Furosemide at a reduced dose.
# CV: Continued home Aspirin.
=====================
TRANSITIONAL ISSUES:
=====================
- Continue Levofloxacin 500mg for an additional 3 days (to
finish ___
- New 4 mm pulmonary nodule was seen on CXR ___. Will
require follow-up imaging.
- Follow-up needed for patient's right heel blister.
- Patient should only be fed only feed when awake, alert,
attentive (regular solids, thin liquids, whole meds are safe per
video swallow).
- Patient would benefit from continued physical rehabilitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
2. Multivitamins 1 TAB PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Memantine 10 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Donepezil 10 mg PO HS
8. Docusate Sodium 100 mg PO BID
9. Carbidopa-Levodopa (___) 1 TAB PO TID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO HS
5. Lisinopril 40 mg PO DAILY
6. Memantine 10 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Levofloxacin 500 mg PO DAILY Duration: 3 Days
To finish on ___.
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
12. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
13. Furosemide 20 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Osteoarthritis
Acute blood stream infection
Hyperatremia
Acute kidney injury
Pulmonary nodule
SECONDARY DIAGNOSES:
Dementia
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 ___,
___ was a pleasure taking care of you during your
hospitalization. You presented to the ___ for evaluation of
right knee pain and difficulty walking. In the Emergency
Department, samples of the fluid in your right knee were
collected. You were started on antibiotics for concern of an
underlying infection. Blood samples were also collected and
showed that your sodium was high and your potassium was low. You
were given IV fluids with potassium to correct your abnormal
sodium and potassium abnormailites. You had a chest x-ray which
did not show a pneumonia. However, incidentally, a lung nodule
was seen which you should arrange follow-up for with your
primary care provider.
You were transferred to the medicine floor where you were seen
by many doctors. ___ antibiotics were continued.. Significant
improvement in your physical exam was observed. You were
intermittently given IV fluids and your electrolyte
abnormalities got better.
While on the medicine floor, you were seen by wound care who
took care of the ulcer on your right heel. Physical therapy and
speech and swallow also saw you. It was felt by your family and
physical therapy that you would benefit from rehab after leaving
the hospital. Speech and swallow felt it was safe for you to
continue eating your normal diet.
Again, please follow up on the incidental lung nodule that was
found. Please also remember to get drink an adequate amount of
fluids to prevent your sodium from becoming high again.
It was a pleasure taking part in your care and we wish you the
best!
Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10762853-DS-20
| 10,762,853 | 23,294,985 |
DS
| 20 |
2186-06-17 00:00:00
|
2186-06-17 22:06:00
|
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:
PICC line placement
Lumbar Puncture (unsuccessful)
History of Present Illness:
Ms. ___ is a ___ year old female with advanced dementia, HTN,
cataracts, recent hospitalization from ___ for right
knee pain, lethargy and hypernatremia who is presenting from
home with fatigue, fever, lethargy and tachypnea.
She was discharged to rehab after her most recent
hospitalization where she was ultimately treated for Moraxella
bacteremia with Levofloxacin. She was at ___ Living for 2
weeks initially for rehab and then her stay was prolonged by an
additional two weeks as the family was unsure whether they
wanted to keep her there or bring her home. Her son notes that
since last ___, she has become increasingly lethargic,
sleeping more, not getting out of bed. ___ she did not get
out of bed at all and did not take any of her medications, food
or water. Her son decided that she wasn't getting adequate care
and brought her home on ___ where he had ___ services set up
(this is where she was initially living prior to her previous
hospitalization). The ___ went in to see her yesterday (___)
and noted her to be febrile and tachypneic and advised him to
call ___.
In the ED, initial vitals: T 102 P ___ BP 110/61 RR 30 O2 92%
3L NC. She was noted to be obtunded and not opening her eyes to
stimuli. She was initially satting 92% on 3L NC and was
tachypneic to the ___. She had a fever to 102 and blood
cultures were drawn. She was then given Tylenol, Vancomycin and
Zosyn. It was initially quite difficult to get a urine sample
given baseline incontinence and multiple attempts at placing a
Foley failed. Subsequently Urology was paged who was able to
place a ___ coude with digital guidance in the setting of
severe atrophic vaginitis. A urine sample was sent which was
not concerning for infection. Because of her change in mental
status and lack of focal infectious source, an LP was attempted
by both ED resident and attending without success given her
significant kyphosis.
On transfer, vitals were: 98.8 90 114/48 28 100% RA.
On arrival to the MICU, patient was obtunded with minimal
response to pain.
Review of systems:
Unable to obtain
Past Medical History:
Hypertension
Cataracts
Osteoarthritis
Fracture of surgical neck humerus (___), with non-operative
management
Dementia
Social History:
___
Family History:
Brother died of throat cancer.
Father died of lung cancer-was a smoker and worked in ___.
Physical Exam:
>>EXAM ON ADMISSION:
Vitals- T:98.9 BP:98/50 P:87 R:29 O2: 100% on shovel mask
GENERAL: obtunded, no acute distress, tachypneic
HEENT: Pupils pinpoint bilaterally, equal, sclera anicteric,
mucus membranes very dry
NECK: supple, JVP not elevated, no LAD
LUNGS: coarse breath sounds on anterior exam but no wheezing or
crackles
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, 1+ pulses, no clubbing, cyanosis or
edema
SKIN: right heel ulcer, bandaged
NEURO: unresponsive, unable to arouse, does not open eyes
.
>>EXAM ON DISCHARGE:
Vitals: T 98.6, BP 150s/78-82, RR 20, O2 94 RA.
General: Appears comfortable, no grimacing to pain. Warm to
touch, no signs of distress.
HEENT: Eyes edematous, sclera anicteric. Pupils reactive to
light bilaterally, EOMI unable to examine.
Neck: Supple, no cervical lymphad.
Cardiac: Tachycardic. S1, S2. No extra sounds heard.
Abd: Soft, does not grimace to pain. Non-distended. BS+
Extremities: 1+ bilaterally in hands and lower extremities.
GYN: Foley in place.
Neuro: GCS (3+1+4): 8 ; opens eyes to voice, no tracking.
Non-purposeful movements.
.
Pertinent Results:
LAB ON ADMISSION:
___ 03:00PM WBC-17.7*# RBC-4.54# HGB-14.3# HCT-48.0#
MCV-106* MCH-31.6 MCHC-29.9* RDW-14.6
___ 03:00PM NEUTS-87.0* LYMPHS-8.5* MONOS-4.2 EOS-0.2
BASOS-0.1
___ 03:00PM PLT COUNT-115*#
___ 03:00PM ___ PTT-24.5* ___
___ 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:00PM ALBUMIN-3.6
___ 03:00PM proBNP-1236*
___ 03:00PM cTropnT-0.09*
___ 03:00PM LIPASE-63*
___ 03:00PM ALT(SGPT)-36 AST(SGOT)-64* ALK PHOS-26* TOT
BILI-0.5
___ 03:00PM GLUCOSE-129* UREA N-90* CREAT-2.2*#
SODIUM-170* POTASSIUM-5.7* CHLORIDE-128* TOTAL CO2-31 ANION
GAP-17
___ 03:50PM O2 SAT-87
___ 03:50PM LACTATE-2.0 K+-4.4
___ 03:50PM ___ PO2-59* PCO2-52* PH-7.41 TOTAL
CO2-34* BASE XS-6
___ 10:25PM URINE AMORPH-RARE
___ 10:25PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 10:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:25PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:45PM OSMOLAL-374*
___ 10:45PM cTropnT-0.07*
___ 10:45PM GLUCOSE-149* UREA N-89* CREAT-2.3*
SODIUM-171* POTASSIUM-4.5 CHLORIDE-132* TOTAL CO2-33* ANION
GAP-11
___ 10:50PM LACTATE-1.5
PERTINENT LABS:
___ 10:45PM BLOOD Glucose-149* UreaN-89* Creat-2.3* Na-171*
K-4.5 Cl-132* HCO3-33* AnGap-11
___ 04:17AM BLOOD Glucose-137* UreaN-89* Creat-2.1* Na-170*
K-4.5 Cl-132* HCO3-30 AnGap-13
___ 06:30PM BLOOD Glucose-119* UreaN-80* Creat-1.7* Na-171*
K-4.2 Cl-132* HCO3-30 AnGap-13
___ 11:40PM BLOOD UreaN-84* Creat-1.8* Na-170* K-4.1
Cl-129* HCO3-30 AnGap-15
___ 05:27AM BLOOD Glucose-394* UreaN-79* Creat-1.7* Na-165*
K-3.7 Cl-129* HCO3-30 AnGap-10
___ 11:32AM BLOOD Glucose-327* UreaN-67* Creat-1.5* Na-167*
K-3.2* Cl-131* HCO3-31 AnGap-8
___ 05:01PM BLOOD Glucose-174* UreaN-64* Creat-1.4* Na-168*
K-3.5 Cl-133* HCO3-31 AnGap-8
DISCHARGE LABS:
___ 05:43AM BLOOD WBC-5.1 RBC-2.43* Hgb-7.7* Hct-24.3*
MCV-100* MCH-31.5 MCHC-31.5 RDW-14.7 Plt ___
___ 05:43AM BLOOD Glucose-94 UreaN-4* Creat-0.5 Na-144
K-3.9 Cl-108 HCO3-30 AnGap-10
MICROBIOLOGY:
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
___ CXR
IMPRESSION: No evidence of acute disease. However, there is a
new nodular focus in the right lower lung, likely a form of
atelectasis; short-term follow-up radiographs are recommended to
show resolution.
___ CT HEAD NONCONTRAST:
IMPRESSION: Increase in prominence of ventricles with increased
periventricular hypodensities from prior exam may represent
normal pressure hydrocephalus and transependymal CSF migration.
CXR ___
IMPRESSION: Left basal consolidation appears to be progressing
and although might represent a combination of atelectasis with
some degree of hiatal hernia still is very concerning for
infectious process. Cardiomediastinal silhouette is unchanged.
Right lung and left upper lungs are essentially clear
LENIS ___
IMPRESSION: Left calf DVT in one of the two posterior tibial
veins.
Brief Hospital Course:
Ms. ___ is a ___ with advanced dementia and recent
hospitalization from ___ for right knee pain,
lethargy, and hypernatremia who presented from home with fever,
somnolence, and tachypnea and was found to have hypernatremia.
Despite correction of laboratory abnormalities, she had very
minimal neurologic recovery, and therefore palliative care and
geriatric service were consulted to help address goals of care.
.
>> ACTIVE ISSUES:
# Encephalopathy: Patient's baseline is at least AxOx1; however,
presented obtunded, non-responsive and non-verbal, with
worsening over several days prior to admission. Her altered
mental status was likely ___ to hypernatremia (described below),
and hypercarbia in the setting of obtundation with respiratory
depression and possible healthcare associated pneumonia. Upon
admission, non-contrast CT was negative for acute intracranial
abnormality, but did demonstrate ventriculomegaly, raising
concern for normal pressure hydrocephalus, which might have been
contributory. Lumbar puncture was attempted unsuccessfully in
the ED, with lesser clinical suspicion for meningoencephalitis.
Mental status improved slightly with correction of hypernatremia
and hypercarbia as below, however continued to be obtunded and
only opened eye to voice spontaneously. Discussions with family
regarding prognosis and neurologic recovery was discussed.
During stay on hospital floor after being transferred from ICU,
palliative care involved regarding neurologic recovery
prognosis. Patient intermittently had minimal improvements, with
intermittent episodes of tolerating PO thick liquids very
slowly. However, daily discussions with palliative care, and
geriatric service regarding grave prognosis in this case and
unlikelihood of recovery. Family continued to want to wait to
weigh options and wait for neurologic recovery. Although risks
regarding aspirations were discussed, family would like to
attempt feeding as much as possible, and therefore diet was
liberalized. Patient was able to take soft PO intake, however
very minimal with at times coughing. Patient continued to have
no improvement in her neurologic status, opening eyes only to
voice and tactile stimuli, with non-purposeful movements. After
discussions with the family repeatedly for several days, focus
of care regarding comfort and home based services with hospice
were finalized. With this decision, patient's PICC line was
discontinued and patient was transitioned home.
.
# Goals of care: As described above, goals of care were
revisited frequently during hospital stay with family members.
Patient was DNR/DNI, however after resolution of her
hypernatremia and ___, neurologic recovery was poor. Palliative
care was consulted regarding grave prognosis, and discussion
revolved around goals of care and family did not want to
transition to comfort measures and wanted to wait for more
neurologic recovery. Patient was continued on IVF as below, and
per goals of care discussions, PO feeding was attempted with
aspiration precautions per family's interests. It was decided
not to transfer to ICU if needed, however despite continuous
conversations, family continued to have difficulty coping.
Discussions with palliative care and the geriatrics service,
with family helped delineate goals of care and focus on comfort
at home with hospice.
.
# Hypernatremia: Sodium of 171 on presentation was felt to
reflect poor access to free water in discussion with the
nephrology service. Her free water deficit was corrected by
approximately 8mEq per day with intravenous D5W, and upon
transfer from the ICU her Sodium level was 150. While on the
hospital floor, her sodium was kept in her baseline range of
145's with continuous intravenous hydration. Given a recurrence
of her hypernatremia, it was discussed that it would highly
likely for this hypernatremia to recur as she may have a
diminished thirst drive and PO intake. Patient was placed on
continuous D5w and electrolytes were checked. After discussions
of goals of care, decided ultimately that continuous intravenous
fluids did not align, and her PICC line was discontinued, and
patient was transitioned home.
.
# Hypercarbic Respiratory Failure: She was hypercarbia to
___ on admission, likely due to obtundation with respiratory
depression, obesity hypoventilation, severe kyphosis, and
possible healthcare-associated pneumonia. In light of her
DNR/DNI status, which was confirmed on admission, she was
trialed on noninvasive ventilation, with eventual improvement in
hypercarbia, and treated empirically with vancomycin,
piperacillin/tazobactam, and levofloxacin, particularly in light
of recent Moraxella bacteremia, though CXR never demonstrated a
clear focal infiltrate. Broad-spectrum antibiotic regimen
ultimately was narrowed to levofloxacin monotherapy, for a
planned 7-day total course. She completed this, and was
breathing well on room air without evidence of pulmonary
infection.
.
# Sepsis: She meets SIRS criteria on admission on the basis of
fever and leukocytosis, with possible pulmonary source of
infection as above, prompting initiation of broad-spectrum
antibiotics, with improvement in SIRS physiology. However, after
receiving hydration and correction of her hypercarbia and
hypernatremia, and patient remained normotensive and no
increased tachycardia. Patient completed a 7 day complete course
of Levofloxacin, and no other signs of infection.
.
# Acute kidney injury: Creatinine was 2.3 on admission, up from
baseline of 0.7-0.8, felt to be prerenal in etiology in the
setting of poor access to free water, with return to baseline
following volume resuscitation and correction of free water
deficit. Home lisinopril and furosemide were held in this
setting. However, with continuous IVF her creatinine function
improved significantly.
.
# Left lower extremity deep venous thrombosis: She was found to
have left lower extremity deep venous thrombosis on admission,
prompting initiation of systemic anticoagulation with heparin
gtt. Patient was continued on heparing gtt, however after her
kidney function had improved, she was transitioned to
therapeutic dosing of Lovenox. Goals of care discussions
regarding risks and benefits of anticoagulation in the acute
setting were discussed, and ultimately decided that
anticoagulation would be discontinued.
.
# Acute normocytic anemia: Hemoglobin down trended from 14 to 8
over the course of admission, likely in the setting of
hydration, phlebotomy and oozing from multiple sites in the
setting of systemic anticoagulation.
.
# Thrombocytopenia: Platelets were found to be ___ over the
course of admission, down from 270s at baseline, likely
reflecting marrow suppression in the setting of multiple
physiologic insults and marrow suppression. Chronicity of
decline was felt to be less consistent with HITT, and started to
have resolution with increasing counts while on hospital floor.
.
# Troponinemia: Troponinemia peaked at 0.09 without associated
acute ischemic EKG changes, likely reflecting demand in the
setting of multiple physiologic insults, with contribution from
poor renal clearance.
.
>> CHRONIC ISSUES
# Right heel pressure ulcer: There was no evidence of
superinfection throughout admission. Patient was continued on
waffle boots and basic wound care with dressings on this ulcer
during hospital stay.
.
# Dementia: Home dementia regimen was held in the setting of
obtundation.
.
>> TRANSITIONAL ISSUES:
# DNR/DNI, NO TRANSFER TO ICU ; ___, is Health Care Proxy.
Patient has been transitioned to home hospice, with goals of
care focused on comfort. HCP would like to have patient at home,
and will attempt to feed PO slowly as tolerated. Throughout
multiple family meetings held during hospitliazation, grave
prognosis was discussed and patient's family ultimately decided
on comfort measures as focus of care. Patient was also
discharged with morphine 20 mg/ml, 30 cc for comfort measures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO HS
5. Lisinopril 40 mg PO DAILY
6. Memantine 10 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
11. Furosemide 20 mg PO EVERY OTHER DAY
Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) ___ mg SL Q1H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg SL Q1
hour Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Severe Hypernatremia
2. Hypercarbic Respiratory Failure
3. Left lower extremity deep vein thrombosis
SECONDARY DIAGNOSES:
1. Advanced Dementia
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic and not arousable.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted here for
concerns of a change in your mental status, and found to have a
very high sodium level and difficulty breathing. You were
admitted to the intensive care unit to lower this sodium in a
controlled and safe environment, and it was lowered back to a
normal level. You were then transferred to the medical floor,
and we kept these IV fluids to make sure your salt level
continued to stay at a normal level. While here, you were also
found to have a blood clot in your left leg, and to prevent the
clot from increasing in size or mobilizing to other areas of the
body, you were placed on a blood thinner called Enoxaparin.
Towards the end of your hospital stay, we had discussions with
the palliative care team and your family, and we focused your
health care towards comfort.
We have discontinued your medications in an effort to focus on
your comfort. Services regarding hospice at home have been set
up.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10762976-DS-5
| 10,762,976 | 24,206,390 |
DS
| 5 |
2170-05-11 00:00:00
|
2170-05-11 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin / Heparin Agents / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
Endotracheal Intubation and Mechanical Ventilation
History of Present Illness:
___ with a history of mitral valve prolapse, atrial
fibrillation s/p MAZE and mitral valvuloplasty in ___ at ___
that was complicated by a right MCA CVA, RLE DVT treated with
coumadin presenting status post fall during transfer and
fracture of his left hip.
Patient underwent arthroplasty of the left hip on ___.
After the operation, he developed a new oxygen requirement and
was on 4L NC for the past 2 days until he was found to have a HR
of 140s on tele on ___ at 1830 and an O2 sat of 71% on 4L NC.
He was given 40mg IV lasix and 5mg IV lopressor, which was
repeated when heart rates did not decrease with another 5mg IV
lopressor. He diuresed 1 L of urine and his oxygen saturations
increased to 100% on the non-rebreather.
On arrival to the MICU, O2 sats are 100% on non-rebreather and
patient has a new fever of 101.2. Patient denies chest pain,
dyspnea, headache, or pleuritic pain. He is only AAO x name,
and is unclear where he is or why he is here. His family is
very involved in his care and were involved with this history
taking.
Past Medical History:
- ___: AFib and went to ___ were mitral
valvuloplasty/L atrial maze and L atrial appendage resection
were done. After this surgery on post-po day 1 he suffered a
long-standing post-op seizure tonic clonic and found on imaging
a R+ MCA CVA.
--- Pt reports that his Vimpat is being de-escalated and that he
hasn't had a seizure since his initial seizure.
- ___: pseudoaneurysm from R common femoral artery
(discovered after going to the hospital bc swelling of L+ ankle)
and DVT in R+ lower extremity.
- Mitral valve prolapse
- h/o DVT on Coumadin
- Bilateral inguinal hernia repair
- L+ knee arthroscopic surgery
- h/o heparin-induced thrombocytopenia
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: T: 101.2 BP:100/52 P:118 R:21 O2: 100% on
non-rebreather
General: Alert, oriented only to person, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi, although upper airway sounds throughout.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, teds and SCDs in place
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities on
right, 3+ on left, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred
Discharge exam:
Pertinent Results:
___ 07:05PM GLUCOSE-115* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
___ 07:05PM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6
___ 07:05PM WBC-21.8*# RBC-3.79* HGB-11.4* HCT-34.0*
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.7
___ 07:05PM PLT COUNT-223
___ 07:05PM ___ PTT-27.5 ___
___ 12:48PM HCT-36.6*
___ 12:48PM HCT-36.6*
___ 11:50AM GLUCOSE-87 UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
___ 11:50AM estGFR-Using this
___ 11:50AM WBC-10.8# RBC-4.34*# HGB-13.0*# HCT-38.1*#
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.5
___ 11:50AM NEUTS-82.4* LYMPHS-13.6* MONOS-3.0 EOS-0.9
BASOS-0.1
___ 11:50AM PLT COUNT-247
___ 11:50AM ___ PTT-30.0 ___
___ 11:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ Path Gross: The specimen is received fresh in a container
labeled with the patient's name, ___, the medical
record number, and additionally labeled "left femoral head".
It consists of a normally shaped femoral head without a portion
of femoral neck that measures 5.5 x 4.5 x 4.5 cm. The articular
surface is unremarkable. Osteophytes are not present. The
femoral neck margin is irregular. The specimen is cut along
its length perpendicular to the articular cartilage. The cut
surfaces reveal yellow-tan hemorrhagic cut surfaces. A fragment
of femoral neck is also received in the container and measures
4.5 x 4.0 x 2.5 cm. It is cut perpendicular to the articular
surface to reveal hemorrhagic bone marrow. Tissue is not
present. Representative sections of the specimen are submitted
for decalcification as follows: A= representative sections of
femoral head, B = representative sections of femoral neck.
___ ECG: Sinus bradycardia. Intraventricular conduction defect.
Left axis deviation, possibly due to left anterior fascicular
block. Diffuse non-specific ST-T wave abnormalities. Compared to
tracing #1 the heart rate is decreased but there are no other
significant changes.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 0 ___ 0 -57 ___ Hip Xray:
FINDINGS: Single frontal view of the pelvis and three views of
the left hip were obtained. a complete fracture of the left
femoral neck is present with mild varus angulation. No
dislocation is identified. Vague lucencies of the left femoral
shaft is suggestive of osteopenia. No radiopaque foreign
bodies.
IMPRESSION:
1. Left femoral neck fracture with mild varus angulation.
2. Left femoral shaft lucencies suggestive of osteopenia in the
setting of decreased weght bearing from prior stroke.
___ CXR: FINDINGS: Single portable view of the chest compared
to previous exam from ___. The lungs are clear of
focal consolidation or effusion. Cardiomediastinal silhouette is
within normal limits. Median sternotomy wires are again noted.
The osseous and soft tissue structures otherwise unremarkable.
IMPRESSION: No acute cardiopulmonary process.
___ Knee xray
No prior studies for comparison.
FINDINGS: Three views of the left knee demonstrate no evidence
of acute
fracture, dislocation, joint effusion, or soft tissue foreign
body.
___ Cpine xrays
CERVICAL SPINE, ___
No prior studies for comparison.
On the lateral view, all seven cervical vertebral bodies are
visualized, but the superior aspect of T1 is obscured and cannot
be assessed. Prevertebral soft tissue structures are within
normal limits. Bone mineral density is apparently slightly
decreased throughout. Multilevel degenerative changes are
present with small anterior osteophytes particularly at the C3
through C6 levels, as well as very minimal disc space narrowing.
Reversal of the normal cervical lordosis is evident at C4-C5.
Flexion and extension views demonstrate no evidence of
instability. Incidental note is made of an oval-shaped
calcification posterior to the spinous processes of C4 and C5,
which may represent ossification or calcification of the
posterior longitudinal ligament.
IMPRESSION:
1. Multilevel degenerative changes in the cervical spine as
described. No acute fracture or dislocation identified, but CT
of the cervical spine is much more sensitive than conventional
radiographs for detecting traumatic abnormalities and would be
suggested if there is persistent clinical suspicion for a
cervical spine injury.
2. Exam is limited by absence of an odontoid view and lack of
visualization of C7-T1 disc space and top of T-1.
AP CXR on ___
IMPRESSION: AP chest compared to ___:
Lungs are appreciably smaller and there is greater but symmetric
opacification in the lower lungs. Contributing to elevation of
the diaphragm is a stomach severely distended with air and
fluid. Since there is also increased upper lobe vascular
congestion, and new small left pleural effusion, appearance
could be explained by either bibasilar pneumonia or a
combination of atelectasis and edema. Subsequent chest CT
reported separately has findings of left lower lobe atelectasis,
right lower lobe pneumonia and multifocal small regions of
peribronchial opacification, probably bronchopneumonia. It
shows vascular congestion but no pulmonary edema, and a stomach
severely distended with air and fluid.
CT Chest: FINDINGS: The thyroid gland, aorta and major
branches, heart and pericardium are unremarkable with the
exception of changes of mitral valve annuloplasty. No
pericardial effusion is seen. The esophagus is patulous and
fluid filled. There is no axillary, hilar, or mediastinal
adenopathy. Gynecomastia is noted bilaterally. Though this
study is not tailored for subdiaphragmatic evaluation, imaged
upper abdomen reveals distended stomach.
The trachea and central airways are patent to the segmental
level. The
pulmonary arterial tree is well opacified without filling defect
to suggest
pulmonary embolism, though evaluation of the subsegmental
vessels is limited due to respiratory motion. Small bilateral
pleural effusions are dependent and nonhemorrhagic. Right
greater than left basal opacities with milder opacification of
the dependent segment of the right upper lobe and right middle
lobe are concerning for multifocal pneumonia which likely
includes the anterior subpleural opacities.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
to suggest
osseous malignancy.
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Multifocla pneumonia with opacities in the lower lobes and
left upper
lobe.
3. Patulous esophagus, correlate with symptoms of dysphagia and
outpatient
esophagram can be obtained if indicated.
Echo ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are myxomatous. A mitral valve annuloplasty ring
is present. The mitral annular ring appears well seated with
normal gradient. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well seated mitral annuloplasty ring with normal
gradient and mild mitral regurgitation. Pulmonary artery
hypertension. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
AP CXR ___
FINDINGS: As compared to the previous radiograph, there is a
substantial
increase in extent and severity of the pre-existing multifocal
pneumonia.
These changes are evident at both lung bases. The lung apices
are bilaterally spared from the pathologic process. Unchanged
borderline size of the cardiac silhouette. Minimal fluid
overload cannot be excluded. No larger pleural effusions. No
pneumothorax. Mild over distention of the stomach, unchanged
normal alignment of the sternal wires.
ECG ___
Sinus tachycardia. Left anterior fascicular block. Non-specific
ST-T wave
abnormalities. Compared to the previous tracing of ___ the
heart rate has increased, ST-T wave abnormalities have improved.
TRACING #1
IntervalsAxes
___
___
AP CXR ___ Last of 3 for the day
There is again seen diffuse air space opacities bilaterally,
more confluent in the right lung and have increased slightly
since the prior study. Atelectasis at the left lung base is
again seen. There are low lung volumes with poor inspiratory
effort. There are no pneumothoraces. Median sternotomy wires
are present.
AP CXR ___
FINDINGS: A new left PICC terminates approximately 1 cm beyond
the cavoatrial junction. Dense consolidation of the entire
right lung as well as right-sided pleural effusion are
unchanged. There is a persistent retrocardiac opacity as well
as worsening consolidation of the left upper lobe when compared
to the prior study from yesterday. There is improved aeration
at the left costophrenic angle. There is no pneumothorax.
Heart size is top normal and unchanged. Sternotomy cerclage
wires are intact.
IMPRESSION:
1. New left PICC should be withdrawn by 1.5 cm to ensure proper
positioning
in the lower SVC.
2. Multifocal pneumonia, slightly worse in the left upper lobe.
BAL ___
Bronchioalveolar lavage:
NEGATIVE FOR MALIGNANT CELLS.
Numerous neutrophils, bronchial cells, and pulmonary
macrophages.
No viral cytopathic changes or fungi seen.
AP CXR ___
CHEST, SINGLE AP PORTABLE VIEW
The patient is status post sternotomy. An ET tube is present,
tip in
satisfactory position approximately 4.3 cm above the carina. A
left-sided
PICC line is present, tip over distal SVC. An NG tube is
present, tip and
side port beneath diaphragm, extending off film.
There is diffuse alveolar opacity and air bronchograms
throughout the right
lung, with relative sparing of the right lung apex and minimal
residual
lucency at the right base. This has progressed compared with
___.
Possibility of an associated effusion cannot be excluded.
There is also prominent focal interstitial and alveolar opacity
in the left upper zone, which appears more confluent than on the
earlier film. There is increased retrocardiac density, with
obscuration of the left hemidiaphragm, unchanged. The small
left effusion is slightly more prominent on this exam. There is
relative lucency at the left lung apex. However, I doubt this
represents a pneumothorax.
IMPRESSION:
Interstitial and alveolar opacities in both lungs, progressed
compared with
___ at 12:09 p.m. Differential diagnosis includes multifocal
pneumonic
infiltrates, ARDS and CHF.
CHEST: Imaged portions of the thyroid gland appear within
normal limits.
There is a left upper extremity PICC line with its tip
terminating in the SVC. The patient is status post endotracheal
intubation with the tip of the ET tube lying approximately 4.9
cm above the carina. An NG tube is seen with its tip
terminating in the stomach.
There is no axillary, mediastinal, or hilar lymphadenopathy.
The cardiac
chambers appear grossly within normal limits. There are no
filling defects
within the central pulmonary arterial tree. The patient is
status post median sternotomy and mitral valve replacement.
There are large bilateral pleural effusions with adjacent
compressive
atelectasis, right greater than left. Patchy pulmonary
opacities are noted in the remainder of the inflated upper lobes
with hint of appearance of crazy pavement (series 2, image 13)
in the left upper lobe and also within the right upper lobe
(series 2, image 17) suggestive of pulmonary edema. There is no
pneumothorax.
Additional scattered regions of ground-glass opacification are
also seen
scattered within the lungs, for example, on series 2, image 35,
suggestive of edema.
FINDINGS IN THE ABDOMEN AND PELVIS: In the liver, there are two
focal
hypodensities seen centrally (series 2, image 56), which are
less than a
centimeter in size and are not well characterized on the current
examination.
There is no intra- or extra-hepatic biliary ductal dilatation.
The portal
vein is patent.
The spleen is within normal limits in size. The adrenal glands,
pancreas, and kidneys appear unremarkable. There is no
mesenteric or retroperitoneal
lymphadenopathy.
There is minimal quantity of perihepatic fluid as well as a
small quantity of fluid tracking into the right paracolic
gutter. The gallbladder is distended and there is a small
quantity of pericholecystic fluid (2, 82). Minimal periportal
edema is seen in the liver.
There is a small quantity of fluid in the dependent pelvis (2,
108).
The urinary bladder demonstrates no obvious abnormalities. A
Foley catheter
is seen in place.
No obvious abnormalities are seen in the colon. The stomach is
slightly
decompressed with NG tube in place, limiting evaluation. Small
bowel appears within normal limits.
There is subcutaneous soft tissue edema, most predominantly
noted in the
gluteal region as well as in the upper thighs.
There are flame-shaped opacities involving the retroareolar
regions suggestive of gynecomastia.
Left hip replacement arthroplasty is seen. There are no
suspicious osteolytic or osteoblastic lesions seen to suggest
tumor.
Surgical staples are seen in the left gluteal region.
IMPRESSION:
Large bilateral pleural effusions with adjacent compressive
atelectasis.
Crazy pavement changes in the lungs suggestive of mild pulmonary
edema.
Additional multifocal regions of atelectasis and consolidation,
underlying
pneumonia is not excluded.
No intra-abdominal abscess.
Distended gallbladder with small amount of pericholecystic
fluid. Findings
are nonspecific. If there is clinical concern for acute
cholecystitis, this can be further evaluated with right upper
quadrant sonogram.
Minimal quantity of perihepatic and pelvic fluid, which could be
related to
third spacing.
Additional diffuse regions of subcutaneous soft tissue edema in
the pelvic
girdle.
CXR ___
INDICATION: Pneumonia, questionable ET tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are constant. The tip of the
endotracheal tube projects 4.9 cm above the carina. The
parenchymal opacity at the left lung apex is minimally
decreasing in extent. The extensive right-sided opacity is
unchanged. Moderate cardiomegaly with borderline size of the
cardiac silhouette and unchanged minimal blunting of the left
costophrenic sinus, potentially reflecting a small pleural
effusion. No evidence of pneumothorax.
Brief Hospital Course:
___ y/o M with a history of mitral valve prolapse, atrial
fibrillation s/p MAZE and mitral valvuloplasty in ___ that
was complicated by a right MCA CVA and a RLE DVT presented
status post fall and fracture of his left hip on ___. His
hip was repaired with a L hemiarthroplasty on ___, and in
the post-operative setting, he had persistent high oxygen
requirements. He progressed to respiratory failure secondary to
multifocal pneumonia and pulmonary edema, requiring
re-intubation and transfer to the MICU. He was treated with a 10
day course of antibiotics and aggressive diuresis, as well as
vasopressors until he improved. He was extubated and gradually
weaned off oxygen. Once medically stable, ___ advised further
inpatient physical therapy in ___ rehab.
Active Problems:
# Respiratory Failure: Multifocal PNA (aspiration?) and
pulmonary edema. Following extubation from his orthopedic
procedure, patient was maintained on 5L nasal canula on the
floor. The evening of ___, he developed respiratory
distress, not responsive to lasix. Patient was then transferred
to the MICU, meeting SIRS criteria by RR, temperature, and heart
rate. Pt was evaluated for a PE; CTA showed no evidence of PE,
but did show a multifocal PNA. He was placed on broad-spectrum
antibiotics (including vancomycin, and, at different points,
cefepime, levofloxacin, and Meropenem). Blood, urine, and
sputum cultures did not grow out any organism. The patient also
developed hypotension and was volume-recusitated aggressively.
His tachypnea increased, and he became hypoxic on BiPAP and
required intubation on ___. Cultures from bronchoscopy
following intubation were unremarkable, and visual inspection of
the airways did not demonstate purulence. Further imaging with
chest CT showed large bilateral pulmonary effusions, multifocal
PNA, and pulmonary edema. He received a 10-day course of
antibiotics for VAP coverage. As his pneumonia improved,
concern lingered for pulmonary edema. He was started on Lasix
drip for diuresis, and was extubated on ___. By ___, he
was was able to oxygenate well on 2L by NC. By ___ he was
stable on room air.
.
# Hip Fracture: His hip was repaired with a L hemiarthroplasty
on ___. Orthopedic surgery followed the patient throughout
his stay in the MICU. His surgical wound healed well, and
staples were removed on ___, there was no concern for
infection. Physical therapy began working with the patient when
he was weaned off sedation prior to being extubated. They
continued working with him during the remainder of his
hospitalization and recommended ___ rehab after discharge.
.
# Pain Control: Patient had post-operative pain in his left
thigh and hip. Before and during intubation and after
extubation, the patient had pleuritic chest pain as well. At
different points during his hospitalization, his pain was
controlled with morphine, fentanyl, ibuprofen, IV Tylenol,
and/or lidocaine patch. He will be discharged on tylenol and
morphine prn.
.
# Fever/Thrombocytosis: Likely reactive to pneumonia versus drug
reaction. The patient continued to spike fevers during his MICU
stay. Initially the fever was c/w PNA and sepsis. However,
even as his PNA resolved, he continued to spike fevers. He also
developed a thrombocytosis to the 900s. The fever and
thrombocytosis are thought to be due to systemic inflammation in
the setting of resolving PNA. His platelets were down-trending
by day of discharge. He has been afebrile for several days.
.
# Persistent sinus tachycardia in the MICU: This tachycardia was
likely due to hypovolemia versus sepsis versus hypoxia. The
patient's home metoprolol was held in the setting of
hypotension. Troponins were sent and were negative. When the
patient was extubated and his tachycardia resolved, he was
restarted on metoprolol, and switched to metoprolol 75mg XL
daily the day of discharge. However his dose was held on
discharge due to his SBP in the ~90s.
.
# Hypotension: In the setting of SIRS and multifocal PNA. He
required norepinephrine drip, but this was discontinued in the
MICU when his BP improved with MAPs in the ___. He was
normotensive on transfer to the floor and his Metoprolol was
held with his SBP in the ~90s.
.
# Nausea/GERD: Likely mutifactorial, with components of GERD,
clinical illness, and not taking POs for several days. Patient
with history of GERD. Pt was initially on IV Protonix, then was
switched to PO PPI. He was treated with Zofran, calcium
carbonate, Aluminum-Magnesium Hydrox, and simethicone. On CTA
of the chest, patulous esophagus was also seen (see transitional
issues below), which may have also contributed to his difficulty
taking POs. His symptoms had resolved by day of discharge.
.
# Rash: Over back, consistent with heat-induced follicullitis.
First noted and resolved in the MICU.
.
# Altered mental status: On arrival to MICU, question hypoxia
precipitating versus history of previous stroke. Per family,
patient was initially off baseline, but improved with oxygen
saturations, although patient still having episodes of confusion
prior to intubation. He was treated with quetiapine, and his
mental status improved while he weaned off sedation when he was
intubated and then improved further after extubation. On
transfer to the medical floor he was stable and remained
oriented.
.
# Dropping HCT: HCT dropped from 28 on ___ to 22 on ___ without
a source of bleeding. This may have been dilutional, but the
patient was transfused with 1 unit PRBCs on ___. From that
point, his HCT has been increasing.
.
Chronic Problems:
# History of DVT: Pt has a hx of DVT and was treated previously
with Coumadin. This was held during his hospitalization. Due
to his history of being HIT antibody +, he was not treated with
unfractionated heparin. He was treated with aspirin 81 mg PO/NG
DAILY and Fondaparinux Sodium 2.5 mg SC DAILY.
.
# BPH: On Flomax at home. This was initially held, but was
restarted on ___ The patient's Foley was removed on ___ and he
maintained urine output on discontinuation of the Foley.
.
# History of stroke and seizures: The patient remained
clinically stable on his home Lacosamide 50 mg PO/NG DAILY,
Pravastatin 20 mg PO HS, and Aspirin 81 mg PO/NG DAILY.
.
# History of seasonal allergies: Inactive during this
hospitalization. Home medications were initially held, but were
restarted on discharge.
.
# History of depression: The patient remained clinically stable.
His home Duloxetine 60 mg PO DAILY was held initially but
restarted on ___ .
.
# Skin conditions: Pt on several home medications that were
continued, including Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN
intching, Ketoconazole 2% 1 Appl TP DAILY, and Triamcinolone
Acetonide 0.1% Cream 1 Appl TP BID to scalp as needed.
.
Transitional issues:
# The patient responds well to diuresis with IV furosemide 20mg
if there are signs of fluid overload.
# The patient's metoprolol 25mg tid was consolidated to
metoprolol succinate 75 once a day, but his SBP has been in the
high ___ towards the end of his hospital stay, so
antihypertensives had been held.
# Patulous esophagus seen on CTA Chest ___: outpatient
esophagram can be obtained if indicated
# The patient will need rehab for his left hip surgery.
Medications on Admission:
-Lacosamide (VIMPAT) 100 mg Oral Tablet ___ tab daily
-Fluticasone 50 mcg/actuation Nasal Spray, Suspension Use 2
sprays in each nostril once daily
-Tamsulosin (FLOMAX) 0.4 mg Oral Capsule, Ext Release 24 hr 1
tablet daily 30 minutes after breakfast
-Nystatin (MYCOSTATIN) 100,000 unit/g Topical Powder use bid
-Duloxetine (CYMBALTA) 60 mg Oral Capsule, Delayed Release(E.C.)
1 tab qd
-Fluocinonide 0.05 % Topical Solution Apply twice daily as
directed
-Fexofenadine (ALLEGRA) 180 mg Oral Tablet Take 1 tablet daily
as needed. Available over the counter.
-Pravastatin (PRAVACHOL) 20 mg Oral Tablet 1 tablet in the
evening
-Metoprolol Tartrate 25 mg Oral Tablet 3 tablets daily total
75mg
-Ketoconazole (NIZORAL) 2 % Topical Cream Apply twice daily
-Ketoconazole (NIZORAL) 2 % Topical Shampoo Shampoo 5 minutes 2
to 5 times per week or as directed
-Dantrolene (DANTRIUM) 25 mg Oral Capsule as directed
-Triamcinolone Acetonide 0.1 % Topical Lotion apply bid to the
scalp as needed
-Lorazepam (ATIVAN) 0.5 mg Oral Tablet ___ tablet q 6hrs as need
for anxiety
-Acetaminophen (TYLENOL EXTRA STRENGTH) 500 mg Oral Tablet 2
tablets bid
-Docusate Sodium (COLACE) 100 mg Oral Capsule once daily
-SENNOSIDES (SENNA LAXATIVE ORAL) one tablet daily as needed for
constipation
-MULTIVITAMIN ORAL once a day
-ASPIRIN 81 MG TAB
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain or fever
patient may refuse
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Calcium Carbonate 500 mg PO BID calcium supplement
please do not administer within 2 hours of Cipro doses
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 60 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fondaparinux Sodium 2.5 mg SC DAILY
10. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN intching
11. Ketoconazole 2% 1 Appl TP DAILY
12. Lacosamide 50 mg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. Miconazole Powder 2% 1 Appl TP BID
15. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN pain
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Ondansetron 4 mg IV Q6H:PRN nausea
19. Pravastatin 20 mg PO HS
20. Prochlorperazine 10 mg PO Q6H:PRN nausea
Caution oversedation
21. Quetiapine Fumarate 25 mg PO TID:PRN agitation
22. Senna 1 TAB PO BID
23. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
25. Tamsulosin 0.4 mg PO DAILY
26. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID to scalp as
needed
27. Vitamin D 800 UNIT PO DAILY
28. Metoprolol Succinate XL 75 mg PO DAILY
Hold if SBP<100, HR<60
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary: Left Hip Fracture, Respiratory Failure, Pneumonia,
Pulmonary Edema
Secondary: Depression, Congestive Heart Failure, Hypertension
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 at ___
___. You were admitted because you had a broken hip
which required surgery. Your recovery was complicated by
pneumonia, pulmonary edema (fluid in your lungs), and
respiratory failure, which required that we insert a breathing
tube and provide mechanical ventilations in the medical ICU. We
also treated you with oxygen, antibiotics for the pneumonia and
diuretic medications, which remove fluid from your body. We also
gave you medications to maintain your blood pressure.
.
You responded to treatment well, except for some confusion known
at ICU delirium. Once you improved, we transferred you to the
general medicine floor and monitored you for several more days
until your oxygen was stopped completely.
Please note the following changes in your medications:
You should START Fondaparinux to prevent blood clots, as managed
by your orthopedic surgeon.
You should CHANGE Metoprolol to Metoprolol 75mg XL once a day
for high blood pressure.
You should START the skin ointments and powders for your rashes,
as needed, for ___ weeks until they resolve.
You may START acetaminophen and morphine for pain control, as
needed.
You may continue the rest of your medications as previously
prescribed.
Followup Instructions:
___
|
10762976-DS-8
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DS
| 8 |
2172-08-17 00:00:00
|
2172-08-17 19:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin / Heparin Agents / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o history CVA (___) c/b subsequent
DVT and seizure, mitral valve repair, HTN, and chronic anemia
who presents with almost ~5 days of worsening right-sided chest
pain/pressure. He was seen at ___ urgent care 2 days prior to
admission where he was diagnosed with pnemonia/pleural effusion
and prescibed 10 day course of levofloxacin. On day prior to
admission he saw his neurologist who recommended changing
antibiotics given that levofloxacin may lower seizure threshold.
On night prior to admission his chest pain became very severe
(___) while lying in bed, which prompted his presentation to
the ED. He describes the pain as a pressure that feels like
indigestion, most painful in center and right side of chest,
with radiation to his right shoulder and down his right arm. He
endorses pain with inspiration and worse with movement of the
arm. Otherwise denies any palpitations, dyspean, shortness of
breath, fever, chills, cough, leg swelling, hemoptysis. Patient
reports some heart burn, indigestion, and constipation, last BM
was four days ago.
In the ED, initial vitals were: 97.2 86 146/84 18 99% RA. Labs
were notable for a white count of 12.3K, Hgb 11.6 (c/w
baseline), and normal electrolytes except for sodium of 131
(baseline low 130s). CTPA was negative for PE, showed
small-moderate right pleural effusion with significant adjacent
atelectasis, mild cardiomegaly, and not definitive lobar
consolidation. EKG showed sinus rhythm, old LBBB, and no acute
ST segment changes. Blood cultures were sent and patient was
started on ceftriaxone and doxycycline and admitted to medicine.
Vitals prior to transfer were: 98 146/79 18 99% RA.
Past Medical History:
- ___: AFib and went to ___ were mitral
valvuloplasty/L atrial maze and L atrial appendage resection
were done. After this surgery on post-po day 1 he suffered a
long-standing post-op seizure tonic clonic and found on imaging
a R+ MCA CVA.
- Seizures
- ___: pseudoaneurysm from R common femoral artery
(discovered after going to the hospital bc swelling of L+ ankle)
and DVT in R+ lower extremity.
- Mitral valve prolapse
- h/o DVT on Coumadin
- Bilateral inguinal hernia repair
- L+ knee arthroscopic surgery
- h/o heparin-induced thrombocytopenia
Social History:
___
Family History:
No known fhx of cva
Physical Exam:
Admission physical:
Discharge physical:
Vitals- T 98.2 BP 136/75 HR 82 RR 18 SaO2 96%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- decreased breath sounds b/l (R>L), faint crackles in RLL,
no focal rales or rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, speech fluent
Discharge physical:
Vitals- T 98.2 BP 102/57 HR 76 RR 20
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB but faint breath sounds b/l, faint crackles in RLL,
no focal rales or rhonchi
Chest- No TTP over anterior chest wall
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, speech fluent, ___ strength in RUE
otherwise not tested
Pertinent Results:
Admission labs:
___ 02:20AM BLOOD WBC-12.3*# RBC-3.97* Hgb-11.6* Hct-35.3*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.0 Plt ___
___ 02:20AM BLOOD Neuts-79.4* Lymphs-11.3* Monos-7.8
Eos-1.2 Baso-0.1
___ 02:20AM BLOOD ___ PTT-30.4 ___
___ 02:20AM BLOOD Plt ___
___ 02:20AM BLOOD Glucose-109* UreaN-12 Creat-0.7 Na-131*
K-4.3 Cl-94* HCO3-26 AnGap-15
___ 02:20AM BLOOD ALT-13 AST-16 AlkPhos-78 TotBili-0.6
___ 02:20AM BLOOD Lipase-20
___ 07:35PM BLOOD cTropnT-<0.01
___ 02:20AM BLOOD cTropnT-<0.01
___ 07:35PM BLOOD CRP-183.6*
Discharge labs:
___ 07:30AM BLOOD WBC-9.4 RBC-3.55* Hgb-10.6* Hct-31.0*
MCV-87 MCH-29.8 MCHC-34.0 RDW-13.1 Plt ___
___ 07:30AM BLOOD Neuts-68.5 ___ Monos-7.6 Eos-4.1*
Baso-0.2
___ 07:30AM BLOOD Plt ___
Pertinent labs:
___ 02:20AM BLOOD WBC-12.3*
___ 07:35PM BLOOD CRP-183.6*
IMAGING:
RUQ ___: Impression
1. Two stable hepatic hemangiomas.
2. No cholelithiasis.
3. Recurrent small bilateral pleural effusions, decreased in
size compared to the prior CT of ___.
CTPA ___: Impression
1. No evidence of pulmonary embolism.
2. Small-moderate right pleural effusion with significant
adjacent
atelectasis. No definitive lobar consolidation is identified.
3. 3 mm solid left perifissural nodule, stable since ___.
4. Moderate cardiomegaly.
CXR ___: Lung volumes are low leading to crowding of the
bronchovascular structures. Portions of the right hemidiaphragm
and right heart border are obscured by a and adjacent airspace
opacity. Streaky bibasilar atelectasis is present. The upper
lung zones are clear. There is no pneumothorax or definite
pleural effusion. The patient is status post median sternotomy.
Mild cardiomegaly is noted, exaggerated by technique and poor
inspiration.
IMPRESSION: New airspace opacity overlying the right heart
border is compatible with pneumonia in the appropriate clinical
setting. Bibasilar atelectasis. Mild cardiomegaly.
Brief Hospital Course:
___ with h/o history CVA (___) c/b subsequent DVT and
seizure, mitral valve repair, HTN, and chronic anemia who
presents with worsening right-sided pleuritic chest pain w/
radiation to the right shoulder and arm.
# Chest pain: Pt presenting w/ pleuritic chest pain in setting
of negative CTPA and normal vital signs. ___ be ___
diaphragmatic irritation due to pleural effusion/atelectasis
resulting in referred right shoulder/arm pain. Pain w/
inspiration likely causing poor inspiratory effort and leading
to further atelectasis of right lower lobe. Patient w/ some
tenderness to palpation over anterior chest wall - questionable
component of MSK strain to chest pain, improving with flexeril
use. Patient reporting significant indigestion, acid reflux, and
constipation - some improvement of pain w/ aggressive bowel
regimen and GI cocktail. Radiographic findings with potential
RLL pneumonia. Cardiac etiology unlikely given normal EKG and
atypical presentation. Trops were negative x 3 LFTs and RUQ US
were unremarkable. The pt was seen by IP who recommended follow
up in ___ clinic with thoracentesis if effusion persistent.
-Patient to continue antibiotics Augmentin 875mg BID (end date
___
-Patient to continue incentive spirometry and pulmonary
conditioning w/ acapella/flutter valve at home
-Patient to follow-up @ ___ at ___, will receive
CXR prior to appt
# Hyponatremia: Patient w/ baseline Na in 130s, presenting w/ Na
131. Stable during hospitalization.
Inactive issues:
# Anemia: stable
# Hypertension: stable, continued home meds
# S/p CVA with residual hemiparesis: received ___ eval who
recommended home ___ services
Transitional: ___ clinic for tapping of effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO QAM
2. Multivitamins 1 TAB PO QAM
3. Metoprolol Tartrate 37.5 mg PO BID
4. Pravastatin 20 mg PO HS
5. Duloxetine 60 mg PO BID
6. Tamsulosin 0.4 mg PO QAM
7. Dantrolene Sodium 50 mg PO BID
8. Omeprazole 40 mg PO BID
9. LACOSamide 200 mg PO QAM
10. LACOSamide 100-200 mg PO QPM
11. Loratadine 10 mg PO QAM
12. Aspirin 81 mg PO QAM
13. Senna 8.6 mg PO BID constipation
14. Ibuprofen 400 mg PO Q6H:PRN pain
15. Acetaminophen 1000 mg PO Q8H:PRN pain
16. Fluticasone Propionate NASAL 1 SPRY NU DAILY to each nostril
17. Lorazepam 0.25 mg PO Q6H:PRN anxiety
18. Calcium Carbonate 500 mg PO QID:PRN heart burn
19. Levofloxacin 500 mg PO Q24H
20. Olux (clobetasol) 0.05 % topical daily to scalp
21. Clindamycin 1% Solution 1 Appl TP BID:PRN to chest
22. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to scalp,
forehead, nose, sparingly to eyelids
23. Docusate Sodium 100 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO QAM
3. Calcium Carbonate 500 mg PO QID:PRN heart burn
4. Clindamycin 1% Solution 1 Appl TP BID:PRN to chest
5. Dantrolene Sodium 50 mg PO BID
6. Docusate Sodium 100 mg PO TID
7. Duloxetine 60 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY to each nostril
9. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to scalp,
forehead, nose, sparingly to eyelids
10. Ibuprofen 400 mg PO Q6H:PRN pain
11. LACOSamide 200 mg PO QAM
12. LACOSamide 100-200 mg PO QPM
13. Loratadine 10 mg PO QAM
14. Lorazepam 0.25 mg PO Q6H:PRN anxiety
15. Metoprolol Tartrate 37.5 mg PO BID
16. Multivitamins 1 TAB PO QAM
17. Omeprazole 40 mg PO BID
18. Pravastatin 20 mg PO HS
19. Vitamin D 1000 UNIT PO QAM
20. Olux (clobetasol) 0.05 % topical daily to scalp
21. Tamsulosin 0.4 mg PO QAM
22. Senna 8.6 mg PO BID constipation
23. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last day of antibiotic is ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg one tablet(s) by
mouth twice a day Disp #*17 Tablet Refills:*0
24. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg one suppository(s) rectally daily Disp #*10
Suppository Refills:*0
25. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram one powder(s) by mouth
daily Disp #*30 Packet Refills:*0
26. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN
epigastric pain
You can take this as needed.
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 ml by
mouth three times a day Refills:*0
27. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
For limited time only. No alcohol or driving while on this
medication.
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every 8
hours Disp #*15 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right lower-lobe pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) *consistent w/ baseline
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. As you may know, you were admitted to the
hospital for right-sided chest pain, worse with breathing, with
radiation to your right shoulder and arm. When you arrived to
the hospital, you received a CT scan of your lungs which did not
show any evidence of blood clot to your lungs. Your EKG and labs
were normal, which suggested this was not a heart attack.
Your CT scan and chest x-ray did reveal a right lung pneumonia
and a small collection of fluid in your right lung. It is likely
that your pain with breathing is due to your pneumonia and this
fluid collection. We consulted the pulmonary (lung) doctors who
would ___ to see you in several weeks, please see the details
below. Please call the number below and find out where and what
time to report for your chest xray BEFORE the appointment.
When you leave the hospital please continue taking your
Augmentin antibiotics (two pills daily) until you finish the 10
day course on ___. Please continue strengthening your
lungs and using the incentive spirometer and flutter/acapella
valve at home.
It is likely that your chest pain was also due to a combination
of muscular strain as well as acid reflux. Please continue
taking the muscle relaxant at home if needed as well as the acid
suppressing medicines as needed. These should also help alleve
your symptoms.
Again, it was a pleasure taking care of you, we wish you all the
best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10762976-DS-9
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DS
| 9 |
2173-05-24 00:00:00
|
2173-05-27 09:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin / Heparin Agents / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization without intervention
History of Present Illness:
___ hx of mitral valve repair ___ c/b stroke, seizures, left
hemiparesis, heparin induced thrombocytopenia, DVT on coumadin,
HTN and hyperlipidemia who presents with 2 months of anginal
symptoms, ruled out in ED, neg stress, admitted for
catheterization.
Pt describes 2 months of left sided chest tightness with
exertion after 5 minutes. The pain always occurs with exertion,
never at rest. He has also noted more general faitigue over this
time. Over the last 2 days he noticed the pain starting to
radiate down his left arm. Once it starts, it takes about ___
minutes of stopping and resting to relieve. Not positional,
respiratory or reproducible with palpation. Pt notes is seperate
and distinct from reflux. Was at the gym yesterday morning and
noticed the same pain starting when he completed his work out.
It lasted about 10 minutes. He took his daily baby aspirin and
came to the ED. There troponins were negative x2 and EKG showed
LBBB (chronic, w/ neg sgarbossa). Vital signs were stable.
Concern for ACS remained high and patient underwent stress
testing which was "Probably normal myocardial perfusion" but
persantine portion induced symptoms in the presence of
non-specific
EKG changes. Accordingly, case was discussed w/ ___ attending
who rec'd admission for cath.
Of note, patient has remained chest pain free since ED.
Past Medical History:
- ___: AFib and went to ___ were mitral
valvuloplasty/L atrial maze and L atrial appendage resection
were done. After this surgery on post-po day 1 he suffered a
long-standing post-op seizure tonic clonic and found on imaging
a R+ MCA CVA.
- Seizures
- ___: pseudoaneurysm from R common femoral artery
(discovered after going to the hospital bc swelling of L+ ankle)
and DVT in R+ lower extremity.
- Mitral valve prolapse
- h/o DVT on Coumadin
- Bilateral inguinal hernia repair
- L+ knee arthroscopic surgery
- h/o heparin-induced thrombocytopenia
Social History:
___
Family History:
No known fhx of cva
Physical Exam:
Admission Exam:
VS: 97.6 84 130/87 16 100%RA
GENERAL: Adult male in NAD. Oriented x3. Sitting comfortably in
bed.
NEURO: CNII-XII intact besides left shoulder shrug, strength ___
in upper extremities aside from ___ left deltoid, strength ___
in lower extremities aside from left ankle which was unable to
plantar flex and minimally dorsiflex, sensation grossly intact
to light touch
HEENT: NCAT. PERRL, EOMI. Moist mucous membranes.
NECK: Supple without JVD.
CARDIAC: Regular with ___ systolic murmur
LUNGS: Clear to ausculatation without wheezes or crackles, no
accessory muscle use.
ABDOMEN: Soft, NTND. BS+
EXTREMITIES: WWP, no edema, 2+ peripheral pulses
Discharge Exam:
Vitals: 98.4 75 125/75 18 97%RA
General: Adult male in NAD, lying in bed comfortably
HEENT: NCAT, MMM, no JVD
Lungs: CTAB without increased WOB
CV: RRR with ___ systolic murmur
Abdomen: soft, NTND, BS+
Ext: WWP without edema
Pertinent Results:
Admission Labs
===================
___ 02:59PM BLOOD WBC-7.1 RBC-3.98* Hgb-11.8* Hct-35.3*
MCV-89 MCH-29.6 MCHC-33.4 RDW-12.4 RDWSD-40.5 Plt ___
___ 02:59PM BLOOD Neuts-64.0 ___ Monos-7.8 Eos-2.7
Baso-0.3 Im ___ AbsNeut-4.57 AbsLymp-1.77 AbsMono-0.56
AbsEos-0.19 AbsBaso-0.02
___ 02:59PM BLOOD ___ PTT-30.9 ___
___ 02:59PM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-133
K-4.2 Cl-97 HCO3-26 AnGap-14
___ 02:59PM BLOOD cTropnT-<0.01
___ 02:59PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
Imaging
========================
CXR ___:
Trace blunting of the bilateral posterior costophrenic angles
suggests trace pleural effusions/pleural thickening.
STRESS ___
INTERPRETATION: This ___ yo man with h/o PAF, MVR, HTN, and HLD
was
referred to the lab from the ED following negative serial
cardiac
enzymes for evaluation of chest discomfort. The patient was
administered
0.142 mg/kg/min of Persantine over 4 minutes. There were no
reports of
chest, back, neck, or arm discomforts during the infusion. At 1
minute
of recovery, the patient reported a ___ left-sided chest
tightness.
Post-MIBI, the Persantine was reversed with 125 mg Aminophylline
IV and
the chest discomfort resolved completely by 5 minutes of
recovery. At
peak infusion and early recovery, biphasic T waves were noted in
leads
V5-V6 before resolving back to baseline by 7 minutes of
recovery. Rhythm
was sinus with rare isolated VPBs and one APB. There was an
appropriate
heart rate and blood pressure response to the infusion.
IMPRESSION: Persantine-induced symptoms in the presence of
non-specific
EKG changes. Nuclear report sent separately.
SIGNED: ___
Cardiac Catheterization ___
LMCA normal, LAD 30% ostial stenosis, LCx normal, Ramus is a
large vessel w/ 30% stenosis, RCA normal
Discharge Labs
========================
___ 08:00AM BLOOD WBC-8.2 RBC-4.40* Hgb-12.7* Hct-39.6*
MCV-90 MCH-28.9 MCHC-32.1 RDW-12.6 RDWSD-41.3 Plt ___
___ 08:00AM BLOOD Neuts-68.4 ___ Monos-7.6 Eos-2.9
Baso-0.2 Im ___ AbsNeut-5.60 AbsLymp-1.68 AbsMono-0.62
AbsEos-0.24 AbsBaso-0.02
___ 08:00AM BLOOD ___ PTT-31.6 ___
___ 08:00AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-29 AnGap-10
___ 08:55PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8
Brief Hospital Course:
Summary
=====================================
___ PMH of mitral valve repair ___ (c/b stroke resulting in
seizures, occurring to this day), left hemiparesis, heparin
induced thrombocytopenia, DVT on coumadin, HTN and
hyperlipidemia who presented to ED w/ 2 months of exertional
chest pain. Underwent cardiac catheterization with non-occlusive
disease and no intervention. Was chest pain free and discharged
home in good condition.
Chest pain
=====================================
Presented to ED w/ 2 months of exertional chest pain, ruled out
for ACS in ED, but stress test elicited symptoms and
non-specific EKG changes so he was admitted to cardiology for
catheterization. On ___ cardiac catheterization completed
which revealed 30% pLAD, 30% ramus, 0% in the RCA which had
previously been described as 30%. In light of arterial
narrowing, his low dose statin was increased to 80mg of
Atorvastatin. Fortunately, patient did not have any symptoms
while hospitalized. He was discharged on an appropriate
medication regimen with instructions to follow up with his
primary care doctor regarding his shortness of breath and chest
pain while exerting himself.
Transitional Issues:
========================================
1. Given exertional SOB, patient may benefit from outpatient
PFTs and evaluation of asthma.
2. Patient should continue his current medications, and follow
up with his primary care doctor regarding his chest pain with
exertion.
3. Continue Atorvastatin 80mg given catheterization findings.
4. Due to catheterization with right wrist approach, patient was
intstructed to avoid bearing to much pressure on this wrist for
a few days. As this is his cane and transfer arm, he may need
some additional assistance.
# CODE: FULL confirmed
# CONTACT: ___, wife: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Dantrolene Sodium 50 mg PO DAILY
3. Duloxetine 60 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Ibuprofen 400 mg PO Q6H:PRN pain
6. LACOSamide 200 mg PO QAM
7. Lorazepam 0.25 mg PO Q4H:PRN anxiety
8. Omeprazole 20 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO QID:PRN nausea
13. Vitamin D 1000 UNIT PO DAILY
14. Docusate Sodium 100 mg PO TID
15. Loratadine 10 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
18. Metoprolol Tartrate 37.5 mg PO BID
19. LACOSamide 200 mg PO EVERY OTHER NIGHT
20. LACOSamide 100 mg PO EVERY OTHER NIGHT
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN nausea
4. Dantrolene Sodium 50 mg PO DAILY
5. Docusate Sodium 100 mg PO TID
6. Duloxetine 60 mg PO BID
7. LACOSamide 200 mg PO QAM
8. LACOSamide 200 mg PO EVERY OTHER NIGHT
9. LACOSamide 100 mg PO EVERY OTHER NIGHT
10. Lorazepam 0.25 mg PO Q4H:PRN anxiety
11. Metoprolol Tartrate 37.5 mg PO BID
12. Omeprazole 20 mg PO BID
13. Senna 8.6 mg PO BID:PRN constipation
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Ibuprofen 400 mg PO Q6H:PRN pain
18. Loratadine 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical Chest Pain
Shortness of breath
Discharge Condition:
Discharge Condition: Stable
Mental Status: AOx3
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted for chest pain, but fortunately, your EKG and lab
studies showed that you were NOT suffering a heart attack. As
you know, we performed a stress test which was slightly
concerning so we proceeded with a catheterization of the heart
which fortunately did not show any significant areas of
narrowing or blockage. That said, it did show that you have some
buildup in your arteries. While this is great news, it does not
explain why you were newly short of breath while working with
your personal trainer. Accordingly, you will need to follow up
with your primary care doctor regarding these symptoms.
We wish you the best!
Your ___ team
Followup Instructions:
___
|
10762986-DS-12
| 10,762,986 | 21,596,248 |
DS
| 12 |
2138-04-25 00:00:00
|
2138-04-25 21:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HTN, HLD, h/o PE on warfarin, recent diagnosis of left
temporoparietal mass with high grade glioma on biopsy,
presenting
today from rehab with seizures.
She was recently on the Neurology service for workup of new
brain
mass and seizure management, discovered because she presented
with seizures. She underwent brain biopsy on ___. She is on
warfarin for PE, which was resumed after the biopsy and she was
discharged to rehab. During that recent hospitalization she was
started on AEDs by ___ for convulsive events - because of the
location of her tumor, these were continued (Lacosamide and
Keppra). She also had an EEG for several days negative for
seizure, and had auditory hallucinations for which she started
zyprexa. As above DCd from neurology service to rehab on ___.
She presents today via ambulance from her rehabilitation
facility
after experiencing several seizures. She had another seizure en
route to ___ in the ambulance. She is accompanied by her
daughter who states that over the past 24-hour hours she has has
been eating less and communicating less.
Spoke with her daughter on the phone who states the seizures are
that she is unresponsive and cant follow fingers and just
stares.
She comes out of it but when she came out of it a few minutes
ago
she was uncontrollably blinking. She has lost her ability to
communicate in this past week and is not eating and drinking
much. The seizures are lasting 45 seconds 1 minute max. in the
last day including in ED pt has had 5 seizures per dtr. She is
not able to interact in the past 36 hours even between seizures.
When she left BI ___ she was able to communicate (was
"frustrated in terms of word finding") but at this point per dtr
you can't have a conversation with her at all. She has been
reporting that her neck and head have been sore since before the
biopsy and all along at rehab. She is continuing to say her neck
and head hurt. Her voice has also become very weak per dtr.
In the ED, initial VS were: 98.3 -> 101.6 111 138/68 16 95% RA.
Labs were notable for: WBC 9.1 with 80% PMNs, CBC all up from
prior. BUN 38, Cr 1.0. INR 4.8. UA neg.
Imaging included: CT head neg. CXR neg.
Consults called: Neurosurgery - recs: no surgical intervention
Treatments received: lorazepam 1mg IV, APAP PR 650mg, 1L NS
On arrival to the floor, initially she was answering questions
without making much sense and only following some commands.
However 20 minutes after arrival she suddently woke up
completely, was fully oriented and conversant and able to give a
complete review of systems and have coherent conversations which
is much improved from what her daughter reported had been the
status quo at this point. States that she is aware she was
confused and seizing at rehab and states "but I am completely
clear now".
REVIEW OF SYSTEMS:
Denies nausea/vomiting. Denies headache at this time. Has some
right sided only neck pain but claims only mild and this has
been
going on since prior to last admission, not worse or new. States
she has no nausea/vomiting. Denies dysuria denies
hematuria/BRBPR, fever/chills, or rash. Endorses dehydration.
All
other 10 point ROS neg.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ Seizure
___ Brain biopsy by Dr. ___. Pathology is high grade
glioma
PAST MEDICAL HISTORY:
1. Left temporoparietal mass with path showing high grade glioma
2. Hypertension
3. Dyslipidemia
4. GERD
5. PE, on warfarin
6. Migraine headaches
7. Partial colectomy ___
8. Hysterectomy
Social History:
___
Family History:
She has three daughters, one has MS, and she is taking care of
her. Of her three siblings, one brother died of emphysema at ___
and the two
sisters are healthy.
Physical Exam:
ADMISSION:
VS: 98.7 122/78 86 18 98% RA
GENERAL: NAD, when clear is fully oriented and conversant
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, lower extremities very weak but ___ strength,
symmetric. Upper extr ___ strength, symmetric. PERRLA EOMI no
asterixis or tremor
SKIN: Warm and dry, without rashes
DISCHARGE:
VS: 98.1 125/59 59 16 96%RA
Gen: sitting up in bed, comfortable-appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 03:00PM BLOOD WBC-9.1# RBC-3.99 Hgb-12.4 Hct-37.0
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.6 RDWSD-49.4* Plt ___
___ 03:00PM BLOOD ___ PTT-42.7* ___
___ 03:00PM BLOOD Glucose-122* UreaN-38* Creat-1.0 Na-139
K-4.4 Cl-95* HCO3-28 AnGap-20
___ 03:00PM BLOOD ALT-25 AST-48* CK(CPK)-33 AlkPhos-154*
TotBili-0.3
DISCHARGE
___ 06:15AM BLOOD WBC-6.2 RBC-3.48* Hgb-10.6* Hct-32.7*
MCV-94 MCH-30.5 MCHC-32.4 RDW-13.6 RDWSD-46.8* Plt ___
___ 06:15AM BLOOD ___ PTT-40.2* ___
CXR ___
No acute cardiopulmonary abnormality.
CT Head ___
1. Left temporoparietal lobe ill-defined hyperdensity as well
as smaller
focal hyperdensity adjacent to the temporal horn of the left
lateral ventricle are better characterized on MR dated ___. Findings are associated with minimal mass effect and
effacement of adjacent sulci.
2. No evidence of acute hemorrhage or large territorial
infarction.
EEG - ___
This telemetry captured a single pushbutton activation, not
showing evidence of seizures. Otherwise, the posterior
background was normal in the bit disorganized. There was
prominent though intermittent delta slowing in the left
hemisphere, likely related to the report of a mass lesion. There
were a few spikes in the same area, but there were no simple
spike or sharp and slow-wave complexes, and there were no
electrographic seizures.
Brief Hospital Course:
___ year old female with past medical history of hypertension,
prior pulmonary embolism on warfarin, recent diagnosis of L
temporoparietal mass with high grade glioma on biopsy, admitted
___ with seizures, now s/p optimized regimen, planning for
discharge home with hospice
# High-Grade Glioma / Seizures / Acute metabolic encephalopathy
- patient admitted with observed seizures; felt to likely be
secondary to progression of her high grade glioma. She was seen
by Dr. ___ Neuro-oncology, who recommended increasing
lacosamide to 150 BID, starting dexamethasone and continuing
keppra. Given high-grade features of glioma, life expectancy was
felt to be ~2 months. Given her worsening symptoms, and poor
prognosis, patient and daughter opted to pursue home with
hospice. Prior to discharge MOLST form filled out, with opting
to for "do not rehospitalize". Patient discharged home with
hospice, with prescriptions for home medications including
lacosamide 150 BID, Keppra 1500 BID, Dexamethasone 4mg PO daily.
# HISTORY OF PE - Patient on chronic warfarin. As above, given
that patient transitioned care to ___ focused, we discussed
plan for anti-coagulation, at which time, patient and HCP opted
for cessation of coumadin.
#Goals of care: after thorough discussion with patient and her
daughter, patient would like to go home with hospice and
transition towards comfort focused care. Will keep medications
such as anti-seizure meds, steroids as that may improve
functioning, as well as ranitidine given patient report that she
felt it helped to prevent discomfort from heartburn. As above,
stopped coumadin. Patient discharged home with hospice.
# Dysphagia - had previously been on dysphagia diet with pureed
solids, thin liquids; given change in goals of care as above,
can consider allowing patient to eat for comfort.
Other medical issues managed this admission
# ___ - Cr 1.0 on admission from baseline 0.5; resolved with
fluids; given goals of care change above, no further monitoring
prior to discharge
# HTN - Discontinued torsemide as not within goals of care as
above
# Hyperlipidemia - Discontinued pravastatin as not within goals
of care as above
TRANSITIONAL ISSUES
- Discharged home with hospice
- Code status - DNR/DNI confirmed w/ HCP; MOLST form signed
indicating "do not rehospitalize"
- EMERGENCY CONTACT/HCP: daughter ___
___
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Ranitidine 150 mg PO BID
3. Torsemide 20 mg PO DAILY
4. LACOSamide 100 mg PO BID
5. LeVETiracetam 1500 mg PO BID
6. Warfarin 5 mg PO EVERY OTHER DAY
7. Warfarin 6 mg PO EVERY OTHER DAY
8. OLANZapine 2.5 mg PO BID
Discharge Medications:
1. Hospital Bed
Dx: Malignant neoplasm of brain, unspecified C71.9
2. OLANZapine 2.5 mg PO BID
RX *olanzapine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. LACOSamide 150 mg PO BID
RX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. LeVETiracetam 1500 mg PO BID
RX *levetiracetam 750 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN pain, fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
8. Morphine Sulfate (Concentrated Oral Soln) 0.25-5 mg PO
Q3H:PRN pain/SOB
RX *morphine concentrate 20 mg/mL 0.25-5 mg by mouth q3h Disp
#*30 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# High-Grade Glioma
# Seizures
# Acute metabolic encephalopathy
# GERD
# Dysphagia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
___ with seizures. You were seen by neuro-oncologists who
felt that the seizures were most likely from progression of your
cancer. They recommended increasing anti-seizure
medications--we increased your lacosamide to 150mg twice daily,
you were started on dexamethasone once a day, and we kept your
keppra dose the same.
While here, we discussed your goals of care, and you decided
that you wanted to focus on comfort and pursue hospice. You
were set up with a hospice agency, and your medications were
changed so that we would focus on your comfort.
Followup Instructions:
___
|
10763063-DS-19
| 10,763,063 | 26,819,962 |
DS
| 19 |
2147-04-17 00:00:00
|
2147-04-17 08:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cipro / Macrobid
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right Femur Open Reduction Internal Fixation
History of Present Illness:
___ on Coumadin for bilateral pulmonary embolism in ___, s/p
right total hip arthroplasty ___ and right total
knee arthroplasty ___ presents as a transfer from
___ with a right periprosthetic femur fracture
sustained after a mechanical fall. The patient reports she was
making dinner when she fell in her kitchen. She denies
headstrike/loss of consciousness. She was unable to ambulate
afterwards and presented to ___ where XRs were performed
which showed a right periprosthetic femur fracture for which she
was transferred and for which Orthopaedic Surgery was consulted.
Past Medical History:
Hypothyroid
Bilateral PEs on Coumadin
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
Right lower extremity:
- Skin intact
- Shortened and externally rotated
- Soft, non-tender lower leg
- Full, painless AROM/PROM of the ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- Palpable DP pulse
- Foot warm and well-perfused
Exam on discharge:
Vital signs were stable. Patient was afebrile
Patient was comfortable, no acute distress, alert and oriented.
Right lower extremity:
- Wound well approximated without erythema, mild ecchymosis, and
minor serous drainage.
- Skin intact
- Soft, non-tender lower leg
- Painless AROM/PROM of ankle. Minor stiffness for AROM/PROM of
knee/hip
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural
- Palpable DP pulse
- Foot warm and well-perfused
Pertinent Results:
___ 05:30AM BLOOD WBC-4.2 RBC-2.86* Hgb-9.0* Hct-27.7*
MCV-97 MCH-31.5 MCHC-32.5 RDW-15.5 RDWSD-55.3* Plt ___
Brief Hospital Course:
The patient presented to the emergency department from an
outside hospital and was evaluated by the orthopedic surgery
team. The patient was found to have a right periprosthetic femur
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for right
periprosthetic femur open reduction internal fixation, 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 was
given two units of blood due to intra-operative blood loss and
low hematocrit. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the right lower extremity, and will
be discharged on warfarin for DVT prophylaxis. The patient
refused lovenox and therefore will not be bridged. She was
counseled on the increased risk of DVT due to her history,
acknowledged this, and continued to refuse bridging therapy. 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:
Prevacid 30 mg capsule,delayed release oral 1 capsule,delayed
___ Once Daily
Lasix 20 mg tablet oral 1 tablet(s) , as needed
Lotensin 20 mg tablet oral 1.5 tablet(s) Once Daily
Synthroid ___ mcg tablet oral 1 tablet(s) 2x week ___ tab O
Senokot 8.6 mg tablet oral 1 tablet(s) Once Daily
Tylenol -- Unknown Strength 1 tablet(s)
Coumadin 2 mg tablet oral 1 tablet(s) Once Daily2-5mg as
directed
calcium phosphate-vitamin D3 250 mg calcium-500 unit chewable
tablet oral 1 tablet,chewable(s) Once Daily
Bactrim -- Unknown Strength 1 tablet(s)
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
2. Senna 8.6 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H
4. Docusate Sodium 200 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*150 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Vitamin D 400 UNIT PO DAILY
9. Furosemide 20 mg PO ONCE
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Lotensin (benazepril) 30 mg ORAL DAILY
12. Warfarin ___ mg PO DAILY16
13. Bisacodyl ___ID:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery for your right
leg fracture. 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 of right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take warfarin for DVT prophylaxis. You refused a
lovenox shots to help prevent clots as your INR levels are not
therapeautic. As such it is extremely important to monitor your
INR.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills and to monitor your INR
Physical Therapy:
Touch down weight bearing right lower extremity
Treatments Frequency:
-You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10763131-DS-16
| 10,763,131 | 28,463,082 |
DS
| 16 |
2166-01-29 00:00:00
|
2166-01-29 10:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right femur fracture
Major Surgical or Invasive Procedure:
Open reduction, internal fixation, right femur
fracture with application ___ plate and screws.
History of Present Illness:
___ female presents with the above fracture s/p mechanical
fall. She has a history of NIDDM with peripheral neuropathy, and
this morning was walking to the bathroom when, due to decreased
sensation in her feet, she tripped over them, falling to the
floor, noting immediate R distal thigh/knee pain. She denies
pain elsewhere. She denies weakness/dizziness/palpitations/
headache or other medical prodromal symptoms. She was placed in
Hare traction by EMS.
Past Medical History:
OSTEOARTHRITIS
MULTIFACTORIAL GAIT DISORDER
HTN
NIDDM
Elevated cholesterol
Fe deficiency
Hypothyroidism
GERD
R TKR
R THR
Social History:
___
Family History:
NC
Physical Exam:
GEN: NAD, AAOX4
RLE: in unlocked ___ brace. incisions lateral thigh c/d/I
with staples to skin. minimal drainage, no edema or erythema.
SILT s/s/spn/dpn/tn, Fires ___, 1+ distal pulses, toes
wwp.
Pertinent Results:
___ 10:40AM BLOOD WBC-8.6 RBC-2.88* Hgb-8.7* Hct-26.6*
MCV-92 MCH-30.2 MCHC-32.7 RDW-14.6 RDWSD-49.3* Plt ___
___ 05:45AM BLOOD WBC-9.9 RBC-2.97*# Hgb-8.8*# Hct-27.1*
MCV-91 MCH-29.6 MCHC-32.5 RDW-15.4 RDWSD-51.1* Plt ___
___ 06:15AM BLOOD WBC-8.5 RBC-2.33* Hgb-7.0* Hct-22.4*
MCV-96 MCH-30.0 MCHC-31.3* RDW-13.7 RDWSD-47.8* Plt ___
___ 10:29AM BLOOD Neuts-55.9 ___ Monos-8.5 Eos-2.2
Baso-1.0 Im ___ AbsNeut-3.87 AbsLymp-2.22 AbsMono-0.59
AbsEos-0.15 AbsBaso-0.07
___ 10:40AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 06:15AM BLOOD Plt ___
___ 01:35AM BLOOD Plt ___
___ 01:35AM BLOOD Glucose-211* UreaN-19 Creat-0.6 Na-135
K-4.2 Cl-104 HCO3-23 AnGap-12
___ 10:29AM BLOOD Glucose-206* UreaN-19 Creat-0.5 Na-137
K-4.7 Cl-102 HCO3-25 AnGap-15
___ 01:35AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.6
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right interprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the right femur, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the right lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
Medications - Prescription
AMLODIPINE - amlodipine 5 mg tablet. 1 (One) tablet(s) by mouth
once a day - (Prescribed by Other Provider; Dose adjustment -
no
new Rx)
ATORVASTATIN - atorvastatin 40 mg tablet. 1 (One) tablet(s) by
mouth once a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
CEPHALEXIN - cephalexin 500 mg capsule. 4 capsule(s) by mouth
___ minutes prior to dental procedures as needed for ONCE
CITALOPRAM [CELEXA] - Celexa 10 mg tablet. 1 tablet(s) by mouth
daily
DICLOFENAC SODIUM [VOLTAREN] - Voltaren 1 % topical gel. Apply a
small amount of gel ___ times daily to bilateral hands
TID/QID:PRN as needed for Pain
GABAPENTIN - gabapentin 300 mg capsule. 1 (One) capsule(s) by
mouth once a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
GLIMEPIRIDE - glimepiride 2 mg tablet. 1 (One) tablet(s) by
mouth
twice a day - (Prescribed by Other Provider; Dose adjustment -
no new Rx)
LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 (One) tablet(s)
by
mouth once a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
LORAZEPAM [ATIVAN] - Ativan 0.5 mg tablet. tablet(s) by mouth as
needed - (Prescribed by Other Provider: ___
METOPROLOL TARTRATE - metoprolol tartrate 50 mg tablet. 1 (One)
tablet(s) by mouth once a day - (Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 (One)
capsule,delayed ___ by mouth once a day -
(Prescribed by Other Provider; Dose adjustment - no new Rx)
SITAGLIPTIN-METFORMIN [JANUMET] - Janumet 50 mg-1,000 mg tablet.
1 (One) tablet(s) by mouth twice a day - (Prescribed by Other
Provider)
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 (One) tablet,delayed release
(___)
by mouth once a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. 1 (One) capsule(s) by mouth once a day -
(Prescribed by Other Provider; Dose adjustment - no new Rx)
FERROUS GLUCONATE - ferrous gluconate 325 mg (36 mg iron)
tablet.
1 tablet(s) by mouth three times a day do not take with
levothyroxine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
3. Amlodipine 5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Citalopram 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC QPM Duration: 28 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
9. Ferrous GLUCONATE 324 mg PO TID
10. Gabapentin 300 mg PO DAILY
11. glimepiride 2 mg oral DAILY
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Lorazepam 0.5 mg PO Q6H:PRN anxiety
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Metoprolol Tartrate 25 mg PO BID
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
17. Pantoprazole 40 mg PO Q24H
18. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right interprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing in right lower extremity in unlocked
___
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
tdwb rle in unlocked ___ brace
Treatments Frequency:
please monitor wounds for s/s of infection; change dressings prn
Followup Instructions:
___
|
10763516-DS-5
| 10,763,516 | 29,964,607 |
DS
| 5 |
2162-04-06 00:00:00
|
2162-04-08 09:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Arava / Macrobid / clindamycin / codeine / cephalexin
Attending: ___.
Chief Complaint:
LLE critical limb ischemia
Major Surgical or Invasive Procedure:
Left lower extremity diagnostic angiogram
History of Present Illness:
Ms. ___ is a ___
female, former smoker, who was transferred to ___ for
further evaluation of left lower extremity rest pain. She
developed a new numbness sensation of the left foot on ___,
which is about five days ago and this pain has persisted since
onset. She underwent vascular noninvasive studies after
admission to the hospital, which showed discrepant findings on
the left lower extremity. Left lower extremity had a toe
pressure of 28 and evidence of disease throughout the ___
segment. Given these findings, a left lower extremity
angiogram was offered for the patient.
Past Medical History:
PMH:
Rheumatoid arthritis
Hypertension
Hyperlipidemia
Pre-diabetes
PSH:
Right total knee replacement
Open appendectomy (remote)
Social History:
___
Family History:
Family History:
Significant for CAD - 2 brothers died of MI
Physical Exam:
Vitals: 97.7 150-84 95 18 94%/RA
General: NAD, AOx3
Chest: Normal work of breathing on room air
Abd: Soft, nontender, nondistended
Ext: Warm bilaterally
Neuro: Moving all 4 extremities equally, sensation grossly
intact
Pulses: DP and ___ dopplerable bilaterally
Pertinent Results:
Labs-----------
___ 04:06AM BLOOD WBC-14.3* RBC-3.94 Hgb-11.6 Hct-37.2
MCV-94 MCH-29.4 MCHC-31.2* RDW-14.3 RDWSD-49.2* Plt ___
___ 11:48AM BLOOD Neuts-57.2 ___ Monos-14.5*
Eos-0.8* Baso-0.7 Im ___ AbsNeut-6.97* AbsLymp-3.18
AbsMono-1.77* AbsEos-0.10 AbsBaso-0.08
___ 04:06AM BLOOD Plt ___
___ 04:06AM BLOOD Glucose-167* UreaN-13 Creat-0.6 Na-141
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 04:06AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
Diagnostic Angiogram ___--
ANGIOGRAM FINDINGS:
1. Diffusely diseased infrarenal abdominal aorta without
evidence of flow-limiting stenoses.
2. Patent bilateral renal arteries with brisk nephrograms.
3. Patent bilateral common iliac, external and internal iliac
arteries.
4. Heavily diseased left common femoral artery with a
high-grade greater than 90% stenosis in the proximal common
femoral. The left profunda femoris and its branches are
patent. The left SFA is diffusely diseased throughout its
course with multiple areas of high-grade stenoses in the mid
SFA.
5. The above and below-knee popliteal arteries are patent.
6. Further distally, there is three-vessel runoff to the
forefoot, the left anterior tibial and posterior tibial and
peroneal arteries. The left peroneal artery feeds into
posterior collaterals at the level of the ankle.
Brief Hospital Course:
___ was admitted to ___ on ___ after she was
evaluated for a cold and pulseless LLE in the ED and was found
to have acute on chronic LLE ischemia. She was started on a
heparin gtt with initial improvement in her LLE numbness and
distal doppler signals over the next ___ hours. Noninvasive
arterial studies done on ___ showed Left iliac, SFA, and distal
tibial disease. Based on these findings she underwent LLE
diagnostic angiogram on ___ which showed high grade stenosis in
the left Common femoral artery and Left superficial femoral
artery. For full details of the surgical procedure please see
the dictated operative report.
After a brief stay in PACU she was transferred to the vascular
surgery floor where where she remained for the rest of her
admission. He diet was advanced to a house diet which she
tolerated well. She was able to void on her own QS and ambulate
ad lib in her room. She was given PO APAP for any postoperative
discomfort.
Based on the results of her angiogram she will require a
re-admission for an angiogram with intervention and this has
been scheduled for ___. Of note, she was enrolled in the
BEST-CLI study by the research team and has been randomized to
endovascular intervention.
Her heparin gtt was re-started after her angiogram. She was
then transitioned to lovenox prior to discharge on ___.
She will need to continue on lovenox 70mg SC BID until the day
before her surgery when she should take the morning dose but
hold the evening dose. She should also hold the morning dose on
day of surgery.
Patient is discharged home in an improved condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. amLODIPine 2.5 mg PO DAILY
4. Methylprednisolone 4 mg PO BID
5. leflunomide 20 mg oral DAILY
6. olmesartan 20 mg oral DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
8. Furosemide 20 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
11. Ascorbic Acid ___ mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Continue this medication until you are re-admitted for your next
procedure.
RX *enoxaparin 80 mg/0.8 mL 70 mg SC twice a day Disp #*14
Syringe Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. amLODIPine 2.5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
9. Furosemide 20 mg PO DAILY
10. leflunomide 20 mg oral DAILY
11. Methylprednisolone 4 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. olmesartan 20 mg oral DAILY
14. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Critical limb ischemia, peripheral vascular disease
Secondary: Hypertension, rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
peripheral angiogram. To do the test, a small puncture was
made in one of your arteries. The puncture site heals on its
own: there are no stitches to remove. You tolerated the
procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
Peripheral Angiography
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may remove the bandage and shower the day after the
procedure. You may leave the bandage off.
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the first 48 hours:
Do not drive for 48 hours after the procedure
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may
then gradually work back to your full routine.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
For Problems or Questions:
Call ___ in an emergency such as:
Sudden, brisk bleeding or swelling at the groin puncture site
that does not stop after applying pressure for ___ minutes
Bleeding that is associated with nausea, weakness, or
fainting.
Call the vascular surgery office (___) right away if
you have any of the following. (Please note that someone is
available 24 hours a day, 7 days a week)
Swelling, bleeding, drainage, or discomfort at the puncture
site that is new or increasing since discharge from the hospital
Any change in sensation or temperature in your legs
Fever of 101 or greater
Any questions or concerns about recovery from your angiogram
Based on the findings from your angiogram you will require a
repeat Left leg angiogram with intervention in the next several
days. Your procedure is booked for ___. You will be
contacted the night before this procedure by the endovascular
team with your arrival time.
Followup Instructions:
___
|
10763687-DS-17
| 10,763,687 | 28,190,914 |
DS
| 17 |
2205-06-02 00:00:00
|
2205-06-03 22:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o ___ male with h/o dCHF (EF 60% ___,
Afib on warfarin, HTN, DM2 presenting with 1 day h/o SOB and
several months of abdominal distention. History obtained with
help of pt's son who is at the bedside. Pt has had progressive
abdominal distention for several months as well as ___ swelling
which was attributed to lymphedema per recent clinic notes. Pt
awoke this morning with SOB, denies CP, palpitations. + stable
___ pillow orthopnea, denies fever/chills/night sweats,
nausea/vomiting, diarrhea or constipation. Pt has been compliant
with medications with the help of his daughter, no recent
dietary indiscretion.
In the ED, initial vitals were 98.2 65 100/76 18 97%. Labs
significant for negative UA, lactate 3.0, normal Chem 7 with Cr
0.8. Tbili 1.7, lipase 15, proBNP 2738 (___), HCT 34.9,
INR 2.3. CXR showed pulm edema and bilateral pleural effusions,
R>L on initial report. Pt was given lasix 40mg IV x 1 at 1545,
azithromycin and CTX. A foley was placed with 1300mL UOP in ED.
Vitals on transfer 97.6 63 126/69 18 98% RA.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Chronic Diastolic CHF
2. Atrial fibrillation on warfarin
3. Type 2 DM with poor compliance with medications. HgbA1C =
7.6% in ___
4. Hyperlipidemia
5. Benign Hypertension.
6. Status post tib/fib fracture in ___, R leg.
7. Status post open cholecystectomy.
8. History of elevated PSA.
9. Questionable peripheral vascular disease
Social History:
___
Family History:
The patients parents died a long time ago. He does not report
any family history of DM, cancer. He has two siblings who are
alive and he doesn't know about their health.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:T 97.8, 126/72 75 18 97% RA WT 107kg
General- Alert, wheezing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- JVP to mandible @ 30 degrees
Lungs- + wheezes, diminished at bases
CV- irregularly irregular, distant S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, 1+ pitting
edema pannus
GU- foley in place draining clear yellow urine
Ext- cool, 1+ distal pulses, hyperpigmentation of both chins, L
shin with overlying erythema no warmth or tenderness to
palpation; 2+ pitting edema to knees and 1+ pitting lateral
thighs bilaterally
Neuro- motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS: 98.2 96/59 66 18 96%RA
24-hour I/O 1180/1130
Tele: Bradycardia to high ___ for several seconds, asx
General: A&O, NAD. Son translating this morning.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Suppled, no LAD, JVP ~10
Lungs: Crackles bilaterally in lower lung fields
CV: Distant heart sounds. Irregularly irregular, +S1/S2, no
appreciable m/r/g
Abdomen: Distended but soft, non-tender, bowel sounds present,
no rebound/guarding. No fluid wave, but 1+ pitting edema around
pannus
GU: Foley in place draining clear yellow urine
Ext: Cool, 1+ distal pulses, hyperpigmentation of both shins, L
shin with overlying erythema, some warmth, tenderness improved;
1+ pitting edema to knees bilaterally
Neuro: CN II-XII, motor, and sensation grossly normal.
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-9.6 RBC-4.34* Hgb-11.4* Hct-34.9*
MCV-81* MCH-26.3* MCHC-32.7 RDW-16.1* Plt ___
___ 01:20PM BLOOD Neuts-81* Bands-0 Lymphs-12* Monos-5
Eos-2 Baso-0 ___ Myelos-0
___ 01:20PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-1+ Polychr-NORMAL
___ 01:20PM BLOOD ___ PTT-38.8* ___
___ 01:20PM BLOOD Glucose-177* UreaN-10 Creat-0.8 Na-133
K-4.6 Cl-96 HCO3-26 AnGap-16
___ 01:20PM BLOOD ALT-17 AST-27 AlkPhos-124 TotBili-1.7*
___ 01:20PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-2738*
___ 01:20PM BLOOD Albumin-4.0
___ 11:50PM BLOOD Calcium-9.7 Phos-3.4 Mg-2.0
___ 01:34PM BLOOD Lactate-3.0*
PERTINENT LABS:
___ 06:05AM BLOOD WBC-12.3* RBC-4.50* Hgb-11.6* Hct-36.1*
MCV-80* MCH-25.8* MCHC-32.2 RDW-16.2* Plt ___
___ 11:50PM BLOOD Glucose-128* UreaN-10 Creat-0.7 Na-134
K-4.7 Cl-92* HCO3-28 AnGap-19
___ 06:05AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
___ 06:05AM BLOOD WBC-10.7 RBC-4.28* Hgb-11.2* Hct-34.4*
MCV-80* MCH-26.2* MCHC-32.6 RDW-16.2* Plt ___
___ 04:20PM BLOOD Glucose-190* UreaN-12 Creat-0.9 Na-133
K-4.0 Cl-92* HCO3-27 AnGap-18
___ 04:20PM BLOOD Mg-2.2
___ 06:05AM BLOOD WBC-9.9 RBC-4.41* Hgb-11.7* Hct-35.9*
MCV-81* MCH-26.6* MCHC-32.7 RDW-16.4* Plt ___
___ 06:05AM BLOOD Glucose-98 UreaN-12 Creat-1.0 Na-135
K-4.1 Cl-92* HCO3-31 AnGap-16
___ 04:10PM BLOOD Mg-2.3
___ 06:00AM BLOOD WBC-11.1* RBC-4.46* Hgb-11.6* Hct-35.5*
MCV-80* MCH-26.0* MCHC-32.7 RDW-16.1* Plt ___
___ 04:35PM BLOOD Glucose-151* UreaN-16 Creat-1.1 Na-133
K-3.5 Cl-88* HCO3-34* AnGap-15
___ 04:35PM BLOOD Mg-2.3
___ 06:00AM BLOOD WBC-10.0 RBC-4.60 Hgb-12.0* Hct-36.8*
MCV-80* MCH-26.1* MCHC-32.6 RDW-16.0* Plt ___
___ 06:00AM BLOOD WBC-10.0 RBC-4.60 Hgb-12.0* Hct-36.8*
MCV-80* MCH-26.1* MCHC-32.6 RDW-16.0* Plt ___
___ 04:40PM BLOOD Glucose-163* UreaN-18 Creat-0.9 Na-130*
K-4.3 Cl-88* HCO3-33* AnGap-13
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-9.5 RBC-4.61 Hgb-12.1* Hct-36.8*
MCV-80* MCH-26.2* MCHC-32.8 RDW-15.9* Plt ___
___ 12:30PM BLOOD Glucose-300* UreaN-18 Creat-1.0 Na-132*
K-4.5 Cl-88* HCO3-35* AnGap-14
___ 12:30PM BLOOD Mg-2.3
ANTICOAGULATION:
___ 06:05AM BLOOD ___ PTT-39.3* ___
___ 06:05AM BLOOD ___ PTT-39.9* ___
___ 06:05AM BLOOD ___ PTT-41.0* ___
___ 06:00AM BLOOD ___ PTT-38.4* ___
___ 06:00AM BLOOD ___ PTT-38.8* ___
___ 06:00AM BLOOD ___ PTT-38.1* ___
___ 06:05AM BLOOD ___ PTT-36.7* ___
___ 06:00AM BLOOD ___ PTT-36.7* ___
___ 04:50AM BLOOD ___ PTT-36.6* ___
REPORTS:
___ Cardiovascular ECHO
Findings
This study was compared to the prior study of ___.
Intravenous administration of echo contrast was used due to poor
native endocardial border definition.
LEFT ATRIUM: Mild ___. No ___ (best
excluded by TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function. [Intrinsic RV systolic function likely more depressed
given the severity of TR].
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to
moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension. Given
severity of TR, PASP may be underestimated due to elevated RA
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - patient unable to cooperate. The
rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. No left atrial ___
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is mildly dilated with
normal free wall contractility. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The ascending aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation with preserved systolic function. Moderate to severe
tricuspid regurgitation. Pulmonary artery hypertension. Mild
symmetric left ventricular hypertrophy with preserved global
systolic function. Mild-moderate mitral regurgitation. Dilated
ascending aorta.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation has increased.
___BD & PELVIS W/O CON
FINDINGS: There is a moderate pleural effusion on the right and
a trace
effusion on the left with associated atelectasis. The
visualized portions of the heart and pericardium are remarkable
for coronary artery disease and mild cardiomegaly. Diffuse
anasarca is also apparent.
Evaluation of the liver is limited in the absence of intravenous
contrast. However, there is obvious hypertrophy of the caudate
lobe along with a mildly shrunken appearance suggestive of
cirrhosis. The spleen is normal in size. There are no
gastroesophageal varices. The gallbladder is absent. The
pancreas is atrophic. There is no hydronephrosis or
nephrolithiasis. The stomach and small bowel are unremarkable.
Low volume ascites is noted. There is no evidence of
obstruction. There is no free intraperitoneal air.
CT PELVIS: The appendix is not definitely visualized. The
colon, rectum, seminal vesicles, and prostate are normal. The
urinary bladder is collapsed and contains a Foley catheter.
There is no pelvic lymphadenopathy.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for
malignancy. Again seen are anterior wedge deformities of the
lumbar spine and prominent anterior osteophytes.
IMPRESSION: 1. No evidence of obstruction. 2. Low volume
ascites, bilateral pleural effusions, anasarca, and hypertrophy
of the left lobe of the liver are suggestive of hepatic
congestion and chronic liver disease. No splenomegaly.
___ Imaging CHEST (PA & LAT)
FINDINGS: PA and lateral views of the chest. There is a new
large right
pleural effusion with adjacent atelectasis. There is also new
moderate left pleural effusion. There is increased opacity
throughout both lungs, most consistent with pulmonary edema.
The heart is not well evaluated due to the adjacent effusions.
There are aortic knob calcifications. No pneumothorax.
IMPRESSION: New large right and moderate left pleural effusions
with pulmonary edema.
___ Cardiovascular ECG
Atrial fibrillation with ventricular rate of 54 beats per
minute. Inferior wall myocardial infarction of indeterminate
age. Right bundle-branch block. Left axis deviation. Compared to
the previous tracing of ___ atrial fibrillation persists but
the ventricular rate has decreased markedly.
Brief Hospital Course:
Acute-on-chronic diastolic congestive heart failure: The patient
has known diastolic congestive heart failure, and was admitted
for shortness of breath in the setting of increased lower
extremity swelling and abdominal girth. His most recent
outpatient weight was 236.4 lbs on ___. On admission, the
patient was significantly volume-overloaded with pulmonary
edema, pleural effusions, ascites, pitting edema of bilateral
extremities. He denied medication noncompliance and dietary
indiscretion prior during this time. He also denied any chest
pain, palpitations, and syncope. A transthoracic echocardiogram
on ___ was notable for a small hypertrophic left ventricle
and significant tricuspid regurgitation. He was treated by a
furosemide bolus followed by a furosemide drip augmented with
metolazone on several days for a diuresis goal of total body
balance of -3 liters/day. The diuresis was complicated by
asymptomatic hypotension with systolic blood pressures to ___
(see below), and hyponatremia (see below). At the time of
admission, his weight was 107kg. At discharge, his weight was
92kg and he was without shortness of breath and lower extremity
edema.
Shortness of breath: The patient's shortness of breath was
treated by azithromycin and ceftriaxone given a concern of
infection. However, on admission to the Cardiology service, his
shortness of breath with radiologic pulmonary edema and
bilateral pleural effusions was attributed to fluid overload in
the setting of acute-on-chronic congestive heart failure. The
patient was afebrile and without productive cough. The
patient's shortness of breath resolved with diuresis.
Left lower extremity erythema: On admission, the patient was
found to have hyperpigmentation of bilateral lower extremities
consistent with chronic venous stasis dermatitis with overlying
warmth and tenderness over her left lower extremity that was
concerning for cellulitis. For this, he was treated with a 7 day
course of Keflex ___. The erythema and tenderness of
the patient's left lower extremity improved on Keflex and
diuresis.
Atrial fibrillation: The patient has a CHADS2 score of 3, and
was anticoagulated on warfarin on admission. Throughout this
admission, he was continued on his home dose of coumadin, with
therapeutic INRs ___ during this admission. He was continued on
his home metoprolol for rate control, which was held on a few
occasions for low blood pressures during diuresis (see below).
Hypertension: The patient was normotensive on admission, and
home angiotension receptor blocker and beta blocker were
continued. Over the course of diuresis, the patient was
occasionally hypotensive to systolic blood pressures of ___
without any symptoms. His home losartan was discontinued in this
setting.
Abdominal distention/Ascites: The patient had abdominal
distention on admission with an abdominal imaging that showed
new, minimal ascites. This was thought likely due to portal
hypertension in the setting of a congestive heart failure
exacerbation. Throughout the hospitalization, the patient had a
benign abdominal exam and his liver function tests remained
within normal limits. Given the patients minimal ascites,
paracentesis was deferred during this admission.
TRANSITIONAL ISSUES:
- The patient's angiotensin receptor blocker was held during
this admission for low blood pressure in the setting of
diuresis. Please reconsider starting ___ if blood pressure
tolerates.
- No pending results
- ___ Abd CT showed "hypertrophy of the caudate lobe along
with a mildly
shrunken appearance suggestive of cirrhosis."
- The patient remained full code throughout this hospitalization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE 10 mg PO BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metoprolol Succinate XL 100 mg PO QAM
7. Metoprolol Succinate XL 50 mg PO QPM
8. Warfarin 2.5 mg PO DAILY16
9. Losartan Potassium 50 mg PO DAILY
10. Clotrimazole Cream 1 Appl TP BID
Discharge Medications:
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE 10 mg PO BID
3. Clotrimazole Cream 1 Appl TP BID
4. Warfarin 2.5 mg PO DAILY16
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Atorvastatin 20 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO QAM
RX *metoprolol succinate 25 mg 2 tablet extended release 24
hr(s) by mouth Every morning Disp #*60 Tablet Refills:*5
8. Metoprolol Succinate XL 25 mg PO QPM
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth every night Disp #*30 Tablet Refills:*5
9. Torsemide 40 mg PO DAILY Start: ___, First Dose: Next
Routine Administration Time
RX *torsemide 20 mg 2 tablet(s) by mouth Once a day Disp #*60
Tablet Refills:*5
10. Outpatient Physical Therapy
Rolling walker
For gait training/transfer training
For lifetime
Diagnosis: Congestive Heart Failure
Prognosis: Good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute diastolic congestive heart failure
Secondary diagnoses: cellulitis, atrial fibrillation
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 Mr. ___,
It was a pleasure to take care of you during your
hospitalization. You were admitted to ___ for shortness of
breath, leg and abdominal swelling. You were found to
significant excess fluid in your lungs and your body because of
"heart failure," decreased pumping of your heart. You were
treated with intravenous medicines to help you get rid of this
excess fluid. In total, you lost 35 lbs (16kg) of fluid. At
the time of discharge, your weight was 200 lb (91kg). Weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
You also had redness and left lower leg that was concerning for
infection. You completed a 7 day course of antibiotics.
Your medications and follow-up appointments are summarized
below.
Followup Instructions:
___
|
10763687-DS-19
| 10,763,687 | 28,711,626 |
DS
| 19 |
2207-07-16 00:00:00
|
2207-07-16 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending: ___.
Chief Complaint:
Jaundice, anorexia
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mr. ___ is a ___ year old man with dementia, a-fib (no longer
on warfarin), HFpEF (LVEF >60%), IDDM2, history of
cholecystectomy, CBD stricture (s/p stent ___ w/ "atypical"
brushings), HLD and HTN who was brought in by his son for poor
PO intake for 3 days and nausea. Per son, patient has been only
taking minimal PO intake for several days, and has been vomiting
very small amounts of food when he eats. He reports weight loss
over the past few weeks, but is unable to quantify it.
He has had dark urine and light colored loose stools over the
past few days. He denies fevers, chills, abdominal pain, chest
pain, shortness of breath.
10 point review of systems is otherwise negative.
In the ED, VS were 98.3, 80, 102/59, 16, 95% on RA. He was found
to have tbili 12.2, ALT/AST 128/74 and ALP 386. ERCP was
notified of his admission, with plan for ERCP later in the day.
He was given ceftriaxone/flagyl and admitted to medicine.
Past Medical History:
- CBD stricture s/p stent ___ (brushings w/ only "atypical"
cells)
- Heart failure w/ preserved EF
- Atrial fibrillation currently off warfarin
- NIDDM
- Hyperlipidemia
- Hypertension
- Elevated PSA
- Peripheral vascular disease/DVT
- Cataracts
- Memory Impairment
- Sleep Apnea
SURGICAL HISTORY
- Status post tib/fib fracture in ___, R leg.
- Status post open cholecystectomy
Social History:
___
Family History:
The patient's parents died a long time ago. He does not report
any family history of DM, cancer. He has two siblings who are
alive but he does not know about their health.
Physical Exam:
===============
DISCHARGE EXAM:
===============
Vital signs: 98, 113/68, 54, 20, 98% on RA
HEENT: AT/NC, EOMI, R cataract, scleral icterus improved, MMM,
dentures, supple neck, no LAD
Skin: Jaundice improving, warm and well perfused
CV: Distant heart sounds, RRR, normal S1/S2, no audible m/r/g
Lungs: Clear to auscultation bilaterally
Abd: Non-tender, non-distended, no rebound/guarding on deep
palpation, no asterixis
Ext: 1+ edema bilateral lower extremities, 2+ distal pulses
Neuro: Oriented only to self (baseline), no focal deficits
Pertinent Results:
___
---------
BMP:
139 | 99 | 14
--------------< 60
3.8 | 28 | 1.0
Ca: 8.2 Mg: 2.1 P: 3.1
ALT: 47 AP: 363 Tbili: 3.2 Alb: 2.5
AST: 55
CBC:
21.4 > 9.7/30.3 < 695
___: 19.2 PTT: 45.3 INR: 1.7
___
---------
Lactate:1.7
ICTERIC SPECIMEN
BMP:
130 93 28 AGap=17
---|----|---< 194
3.3 23 1.3
CBC: 26.2 > 10.9/33.2 < 485
Ca: 8.7 Mg: 2.0 P: 3.1
ALT: 128 AP: 386 Tbili: 12.2 Alb: 2.9
AST: 74 LDH: Dbili: 9.7 TProt:
___: Lip: 6
___: 20.6 PTT: 30.9 INR: 1.9
RUQ ultrasound:
---------------
1. Metal stent within the common bile duct which measures 11 mm,
unchanged
from prior. There is no intrahepatic biliary dilatation;
however, there is no pneumobilia which raises the possibility of
stent obstruction.
2. 2.5 cm hypoechoic ill-defined lesion within segment 8 of the
liver which is incompletely characterized.
3. Cirrhotic liver morphology with sequela of portal
hypertension including splenomegaly.
4. Large right pleural effusion.
ERCP (___):
---------------
Gastric deformity was noted with a tortuous lumen and J-shape.
Limited exam of the duodenum showed mucosal edema.
Evidence of a previous sphincterotomy was noted in the major
papilla.
A metal stent placed in the biliary duct that migrated distally
was found in the major papilla. It was entirely occluded by
debris and pus. This was removed via snare.
Cannulation of the biliary duct was successful and superficial
with a sphincterotome using a free-hand technique.
On cholangiogram, a single stricture that was 20 mm long was
once again seen at the lower third of the common bile duct with
post-obstructive dilation noted.
An RX Extractor Pro balloon was used to sweep the ducts.
Multiple sweeps were performed which revealed copious debris and
pus.
A ___ Wallflex Fully Covered Metal Stent (REF
___, LOT ___ 10cm by 60mm biliary stent was placed
successfully with excellent biliary drainage noted
endoscopically.
Recommendations:
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Continue with antibiotics for sepsis
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Brief Hospital Course:
Mr. ___ is a ___ year old man with dementia, a-fib (no longer
on warfarin), HFpEF (LVEF >60%), IDDM2, history of
cholecystectomy, CBD stricture (s/p stent ___ w/ "atypical"
brushings), HLD and HTN who was brought in by his son for poor
PO intake for 3 days and nausea, found to have cholangitis due
to migrated biliary stent.
# Cholangitis / hyperbilirubinemia / migrated biliary stent /
bacteremia:
Patient found to have elevated bilirubin and LFTs. Underwent
ERCP that showed metal stent placed in the biliary duct had
migrated distally and was found in the major papilla. It was
entirely occluded by debris and pus. It was removed and replaced
with new metal stent. Course complicated by positive blood
cultures growing citrobacter freundii and strep anginosus. He
will complete a 14 day course of ceftriaxone 2g q24h. His LFTs
improved steadily throughout the admission.
# Leukocytosis:
Patient had a persistent leukcytosis that was only partially
improved at the time of discharge from 26 to 21. Symptoms were
resolved, source control was achieved, and that he was on
appropriate antibiotic therapy. He should have follow-up labs as
an outpatient to ensure his leukocytosis continues to improve.
# Acute renal failure:
Creatinine initially 1.3 up from baseline of 1. Likely in the
setting of decreased PO intake. Resolved with IVF and holding
initial doses of diuretic. His home diuretic was resumed and he
tolerated it well with stable renal function.
# Heart failure with preserved ejection fraction:
Appeared euvolemic on admission.
- Torsemide 60mg qAM, 40mg qPM
- Continued ASA 81
# IDDM2:
Given decreased PO intake on admission, his home glargine dose
was decreased and he was covered with sliding scale insulin. He
can resume his home dose of insulin now that he has an improved
appetite. If his appetite decreases as an outpatient, consider
decreasing glargine dose.
# OSA:
- Continued CPAP.
TRANSITIONAL ISSUES:
[ ] Check CBC, BMP and LFTs at ___ appointment on ___
[ ] Continue ceftriaxone until ___
[ ] Consider outpatient palliative care involvement
[ ] If leukocytosis does not resolve, please evaluate for other
possible sources of infection if appropriate.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO QAM
2. Metoprolol Succinate XL 25 mg PO QPM
3. Multivitamins 1 TAB PO DAILY
4. Torsemide 60 mg PO QAM
5. Aspirin EC 81 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. clotrimazole-betamethasone ___ % topical bid
8. Potassium Chloride 20 mEq PO DAILY
9. Torsemide 40 mg PO QPM
10. Atorvastatin 20 mg PO QPM
11. Glargine 32 Units Breakfast
12. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H Duration: 14 Days
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV Q24H Disp
#*14 Intravenous Bag Refills:*0
2. Aspirin EC 81 mg PO DAILY
3. Glargine 32 Units Breakfast
4. Metoprolol Succinate XL 50 mg PO QAM
5. Metoprolol Succinate XL 25 mg PO QPM
6. Multivitamins 1 TAB PO DAILY
7. Torsemide 60 mg PO QAM
8. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
9. Atorvastatin 20 mg PO QPM
10. clotrimazole-betamethasone ___ % topical bid
11. FoLIC Acid 1 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Torsemide 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Common bile duct stricture
Migrated biliary stent
Cholangitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you. You were admitted with nausea
and elevated bilirubin levels. We found that the stent that had
been placed last year in your bile duct had moved. This caused a
blockage and led to an infection. A new stent was placed in your
bile duct. The infection in your blood is being treated with IV
antibiotics, which you will continue until ___. If you have
any fevers, abdominal pain, or other concerning symptoms, please
contact your doctor or return to the hospital.
Please make sure to follow-up with your physician at your
scheduled visit. You will need to have blood tests checked at
that time.
Thank you for choosing ___ for your care.
___, M.D.
Followup Instructions:
___
|
10764017-DS-23
| 10,764,017 | 24,001,931 |
DS
| 23 |
2188-04-25 00:00:00
|
2188-04-25 20:34:00
|
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, tachycardia
___ Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old young woman discharged on ___
from ___ after a prolonged hospital admission for anoxic brain
injury secondary to EtOH withdrawal seizure with hospital course
complicated by acute renal failure s/p temporary hemodialysis,
hospital acquired pneumonia, urinary tract infection,
tracheostomy and PEG tube placement, c.diff colitis, as well as
cyclical fevers, tachycardia, tachypnea, and hypertension
attributed to paroxysmal autonomic instability with dystonia,
who now presents from her rehabilitation facility with fever and
tachycardia, found to have a new left lower lobe pneumonia.
At the outside facility, she was noted to be progressively
hypoxic with a temperature of 106 (usual is not higher then 103
in setting of autonomic dysfunction), tachycardia to 180. CT
abdomen (performed to assess for complications of C. diff) was
concerning for a new left lower lobe infiltrate consistent with
pneumonia. She was given IV fluids, ativan, and was externally
cooled. She was also started on vancomycin, cefepime, and
ciprofloxacin given her history of multi-drug resistant
enterobacter in the lungs. Labs were notable for lactate 3.3 and
WBC 30.
Per report, HR improved from 180s to 140s and O2 sats were
stable without ventilator.
Of note, Ms. ___ was admitted to ___ from ___ with
severe anoxic brain injury secondary to alcohol withdrawal
seizure. As a result, patient has paroxysmal autonomic
instability with dystonia, causing transient periods of fevers,
tachycardia, hypertension, tachypnea, and diaphoresis.
In the ED, patient was persistently tachycardic and required a
labetolol drip.
In the ED, initial vitals: 98.6 150 132/89 22 96% TM
- Exam notable for: Rhonchi diffusely. No [appreciable]
abdominal pain. Dry mucous membranes
- Labs notable for: WBC 27.3, plts 460, Cl 114
- Imaging notable for: LLL PNA (OSH)
- Pt given: IV LORazepam 1 mg PO/NG Baclofen 10 mg PO/NG
Propranolol 80 mg PO CloNIDine .4 mg PO/NG Acetaminophen 1000 mg
IV Labetalol 20 mg IV CefePIME 2 g IV Vancomycin 1000 mg PO/NG
Baclofen 10 mg PO CloNIDine .4 mg PO Dantrolene Sodium 25 mg
PO/NG Propranolol 80 mg IV Ciprofloxacin 400 mg PO/NG
Acetaminophen 1000 mg IV LORazepam 1 mg IVF NS 1000 mL PO
Dantrolene Sodium 25 mg PO/NG Baclofen 10 mg PO CloNIDine .4 mg
IV CefePIME (2 g ordered) Started IV Ciprofloxacin Started in
Other Location 400 PO/NG Vancomycin Oral Liquid Administered in
Other Location
- Vitals prior to transfer: 99.8 58 101/48 19 100% RA On the
floor, patient appears comfortable. Laying in bed with trach
mask. No increased WOB, not diaphoretic. Not responsive to
voice. Father at bedside, states that current condition is worse
than prior to discharge from ___.
Past Medical History:
Anxiety/Depression
Social History:
___
Family History:
No pertinent family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.8 114 / 66 61 19 100 40% TM
General: Lying in bed, trach mask in place, breathing
comfortably
HEENT: Normocephalic, atraumatic. Trach in place with trach
mask.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation on the anterior surface, no
wheezes, rales, rhonchi
Abdomen: Soft, no appreciable tenderness to palpation,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
Ext: Several severe flexion contractures, worst R elbow, also
significant contractures at bilateral wrists and L elbow. Less
severe involvement of bilateral fingers. Plantar flexion
contractures bilaterally.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Opens eyes to voice, does not track, does not blink to
threat, does not respond to commands, no spontaneous movements
of the upper or lower extremities
DISCHARGE PHYSICAL EXAM:
======================
Vitals: T99.6 O BP 96 / 47 L Lying HR96 RR18 o2100 TM
GENERAL: Young female lying in bed, mouth open. Unable to follow
commands, does not interact.
HEENT: NC/AT, eyes open, not tracking.
CARDIAC: Regular rate and rhythm, S1S2, no murmurs,
LUNGS: coarse transmitted upper airway sounds on anterior exam,
not tachypneic while in room, secretions from trach
ABDOMEN: Soft, +BS, no rebound or guarding. PEG c/d/I.
EXTREMITIES: Warm, no edema, b/l upper extremities flexed and
with increased tone, lower extremities contracted. Pulses
intact.
Pertinent Results:
ADMISSION:
==========
___ 08:40PM BLOOD WBC-27.3*# RBC-3.78* Hgb-12.2 Hct-37.0
MCV-98 MCH-32.3* MCHC-33.0 RDW-12.7 RDWSD-45.1 Plt ___
___ 08:40PM BLOOD Neuts-84.4* Lymphs-8.1* Monos-6.8
Eos-0.0* Baso-0.2 Im ___ AbsNeut-23.02*# AbsLymp-2.21
AbsMono-1.86* AbsEos-0.00* AbsBaso-0.05
___ 08:40PM BLOOD Glucose-104* UreaN-21* Creat-0.6 Na-149*
K-3.6 Cl-109* HCO3-23 AnGap-17
___ 08:40PM BLOOD ALT-33 AST-30 AlkPhos-83 TotBili-0.4
___ 04:35AM BLOOD Calcium-9.4 Phos-2.1* Mg-1.9
___ 04:45AM BLOOD freeCa-1.25
___ 08:40PM BLOOD Lactate-3.4*
DISCHARGE:
==========
___ 04:32AM BLOOD WBC-10.8* RBC-3.70* Hgb-11.7 Hct-35.0
MCV-95 MCH-31.6 MCHC-33.4 RDW-11.9 RDWSD-40.7 Plt ___
___ 04:32AM BLOOD Glucose-108* UreaN-32* Creat-0.4 Na-144
K-4.0 Cl-99 HCO3-30 AnGap-15
___ 04:32AM BLOOD Calcium-12.6* Phos-3.5 Mg-2.3
IMAGING:
========
CXR ___:
There is increased opacification at the left lower lung and
obscuration at the retrocardiac border consistent with left
lower lung pneumonia. Tracheostomy tube is midline trachea and
in place. Cardiomediastinal silhouette is unchanged. There is
no pneumothorax.
CTA CHESTStudy Date of ___
1. No pulmonary embolism.
2. Fluid/debris is noted within the segmental and subsegmental
branches of the right lower lobe.
CHEST (PORTABLE AP) Study Date of ___
Compared to chest radiographs ___ through ___.
New areas of subsegmental atelectasis right lower lobe, could be
due to
aspiration, but there is no good evidence for pneumonia. Heart
size normal. No pleural abnormality. Tracheostomy tube midline.
MICROBIOLOGY:
=============
___ blood culture x1: negative
___ MRSA: negative
___ and ___ sputum cultures: contaminated
___ blood culture x2: negative
___ urine culture: negative
___ blood culture x2: negative
___ 10:00 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
UA
___ 10:00PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD*
___ 10:00PM URINE RBC-46* WBC-12* Bacteri-FEW* Yeast-NONE
Epi-57 TransE-<1
___ 10:00PM URINE CastHy-5*
___ blood culture x2: negative
___ blood culture x1: negative
___ 10:17 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. 10,000-100,000 CFU/mL.
Piperacillin/Tazobactam test result performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- 1 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
UA
___ 10:17AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:17AM URINE Blood-NEG Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 10:17AM URINE RBC-9* WBC-102* Bacteri-MANY* Yeast-FEW*
Epi-1 TransE-<1
___ 10:17AM URINE CastHy-15* CastCel-3*
Brief Hospital Course:
PLEASE NOTE THIS PATIENT JUST HAD AN EXTENSIVE HOSPITALIZATION
___ AND FOR CONVENIENCE THE PREVIOUS HOSPITAL COURSE IS
COPIED BELOW. That discharge summary in its entirety will also
be provided.
CODE STATUS & CONTACT:
======================
FULL
*If change in clinical status, both her Mother and Father should
be called
- Father/GUARDIAN/HCP: Mark ___
- Mother: ___ ___
TRANSITIONAL ISSUES:
====================
[ ] Please discontinue PO vancomycin after ___
[ ] Neurology followup appointment scheduled for ___ 02:30p
with ___ at ___.
[ ] She should have a CBC and Chem 10 performed within the first
3 days of transfer to establish baseline labs, ensure no ___ or
asymptomatic elevation in WBC count.
Respiratory Care:
-----------------
-Tracheostomy care: See attached protocols. Trach is
specifically a Portex Perfit #7
-Suctioning requirements: She has a strong cough but will
require deep suctioning PRN (you will be able to hear wet cough
that indicates need for suctioning. Typically ___ times per day.
-Supplemental oxygen should be mixed with humidification
continuously for patient comfort and to prevent excessive
dryness of oropharynx
-Supplemental oxygen stable at 35% via trach mask
-Respiratory therapy noted her trach/pilot balloon to be stiff,
but found that it was functioning well still. This was discussed
with the respiratory therapy supervisor and IP, and it was felt
appropriate to not exchange it. The only concern is that it may
not form a tight seal if she needs ventilation, which she did
not require at all during this hospitalization.
Nursing Care:
-------------
-Reposition Q2H.
-Skin precautions, she has no significant current skin
breakdown. She has an early pressure sore on her sacrum
-She is completely incontinent. Please do not use briefs as this
will cause skin breakdown. She will require voiding checks w/
cleaning frequently.
-All meds are to be administered crushed through G-tube. NO
PILLS or FEEDING BY MOUTH.
-She requires regular mouth care ___ times a day and more
frequently as necessary
-Please use fan and maintain room at comfortably cool
temperature, to help her regulate body temperature.
Physical Therapy:
------------------
-The most important therapy is ROM exercises with arms and legs
to prevent further contracture.
-Please reposition & move OOB to chair 3x/day w/ overhead lift.
-Please limit sitting time to 1 hour on air cushion as she is
unable to reposition herself independently.
-Apply multi-podus boots to both ___ with
frequent skin checks to prevent foot drop
Diet:
-----
Continuous tubefeeding: Nepro; Full strength
Tube Type: Percutaneous gastrostomy (PEG); Placement confirmed.
Starting rate:40 ml/hr; Do not advance rate Goal rate:40 ml/hr
Residual Check:Q4H Hold feeding for residual >= :200ml
Flush w/ 30 mL water Per standard
Free water amount: 180 mL; Free water frequency:Q6H
Labs:
-----
- She should have a CBC and Chem 10 performed within the first 3
days of transfer to establish baseline labs, ensure no ___ or
asymptomatic elevation in WBC count.
Medication Administration:
****All meds are to be administered crushed through G-tube. NO
PILLS or FEEDING BY MOUTH.****
- Timing of medications is VERY IMPORTANT, because in the past
she has had vital sign abnormalities when medication
administration was delayed.
VERY IMPORTANT CONTINGENCIES FOR THIS PATIENT:
Ms. ___ suffered a very severe brain injury. Secondary to this
she has extreme autonomic dysfunction consistent with a syndrome
called paroxysmal autonomic instability with dystonia (PAID).
She has transient periods of fevers, tachycardia, hypertension,
tachypnea, diaphoresis, and general unwell appearance. It can be
challenging to distinguish these episodes from infection.
A few principles in the way we have managed fevers:
# When she has a fever:
- Start with techniques such as bedside fan, cold wash cloths,
and administer standing Tylenol/Ibuprofen as prescribed. Please
do not give an extra Tylenol outside of her scheduled doses as
in the long term that could cause liver toxicity. If a cooling
blanket is available, that may be a good option for her.
- Assess for severity: She frequently has fevers up to 101,
sometimes to 102, but rarely to 103. Fever 103 or higher tends
to increase our suspicion for infection.
- Assess for frequency: Intermittent fevers, daily or QOD, tend
to not be of concern unless accompanied by other signs of
infection. Consistent fevers greater than 2 days in duration
tend to raise our suspicion for infection even in the absence of
signs/symptoms.
# In addition to fever, other signs that could increase concern
for infection:
- WBC >/= 18k, though this is not always consistent.
- Other abnormal vital signs such as persistent tachycardia out
of proportion to what we expect with her fever
- Diarrhea, grimacing with abdominal palpation
- Hypoxia
# If concerned for infection, would obtain blood cultures, urine
cultures and UA (which may require straight cath), CBC with
differential, and CXR.
OTHER:
- If hypotensive, please note, sometimes due to diaphoresis the
automated cuff is unable to read her blood pressure. In this
case, please try a Doppler or Manual pressure on her arms. She
has not had hypotension or lethargy during this admission, so
these may be signs of infection in her.
- If tachypnea with RR > 40, please suction her. You can give
her 1 mg of Ativan in addition to her scheduled dose which will
help her respiratory rates.
- If hypertensive, consider treatment if systolic blood
pressures > 180. If so, you can give ONE of her blood pressure
medications early (this would be propranolol or clonidine). If
she remains with blood pressures > 180, recommend short-term
anti-hypertensive therapy with labetalol 200mg if her heart rate
will tolerate.
=============================
___ HOSPITAL SUMMARY:
=============================
Ms. ___ is a ___ with h/o ETOH use disorder &
depression c/b one suicide attempt, who suffered possible
cardiac arrest at home and was admitted to the MICU for
post-arrest care. She suffered diffuse anoxic brain injury,
respiratory failure, & anuric renal failure requiring dialysis.
In the MICU, she was treated with targeted temperature
management and empiric midazolam infusion for possible alcohol
withdrawal seizures. She remained comatose and was found to have
diffuse anoxic brain injury. Neurology was consulted for
prognostication and stated that patient had a very limited
chances of making meaningful recovery. Her MICU course was
complicated by multiple infections including HSV-1 infection,
sinusitis, and ventilator-associated pneumonia. Once stabilized,
the patient had a tracheostomy and percutaneous endoscopic
gastrostomy placed and was transferred to the General Medicine
service for further stabilization. Her course was further
complicated by persistent fevers, hypertension, tachycardia, &
tachypnea. She underwent extensive work-up for these episodes
which were ultimately thought to represent the post-anoxic brain
injury syndrome known as paroxysmal autonomic instability w/
dystonia. Neurology was re-consulted for medical management of
this autonomic instability and she was started on multiple
neurologic medications which were titrated in order to achieve
vital sign stability and patient comfort. These medications are
clonidine, propranolol, bromocriptine, baclofen and dantrolene.
She developed diarrhea which tested positive for C. difficile
and she will continue treatment with vancomycin until ___.
Once her vitals had stabilized and there was minimal concern for
ongoing infection aside from C. difficile, it was felt that
___ care should continue at a skilled nursing facility.
ACUTE ISSUES ADDRESSED:
=======================
# Diffuse anoxic brain injury:
# Acute respiratory failure:
# Paroxysmal autonomic instability with dystonia:
Initial presentation of being found down with described acute
respiratory event, concern for possible cardiac arrest (although
unclear if she had a pulse but did reportedly require brief CPR
and no other medications) versus seizure (possibly from delirium
tremens ISO acute ETOH w/d). Following arrest, patient underwent
cooling w/ subsequent re-warming. Neurology was consulted for
prognostication, & initial MRI Head ___ showed diffuse anoxic
brain injury. Repeat MRI on ___ showed progressive worsening of
anoxic brain injury. She notably did have some brainstem
activity (breathing on own, brainstem reflexes present,
nonpurposeful movements of extremities). For further Neurologic
evaluation and prognostication, she underwent multiple EEGs
which initially showed some activity to stimulation, but
increasingly showed persistently diffuse slowing. Once initially
stabilized, she underwent combined tracheostomy-PEG ___ & was
transferred to the General Medicine Service for further
stabilization. Throughout this time, the patient had
intermittent periods of fevers (see below), tachypnea,
tachycardia, diaphoresis, & HTN (see below). Neurology suggested
that this could represent a central process ISO anoxic injury
and could be a manifestation of the post-anoxic brain injury
syndrome known as paroxysmal autonomic instability w/ dystonia
(PAID). Neurology recommended medical management of this
autonomic instability and she was started on multiple neurologic
medications which were titrated in order to achieve vital sign
stability and patient comfort. These medications are clonidine,
propranolol, bromocriptine, baclofen and dantrolene (other
medications trialed include amantadine [stopped b/c of worsening
vital signs] & labetalol [changed to propranol for better BP
control]). Per ___ ___ conversation with mother and father,
they want to pursue all interventions with the hope that she
will gain some responsiveness and be able to recognize them.
Neurology stated that ultimate prognosis is guarded but cannot
be fully known until 6 months - ___ years post injury.
#Fevers: Initially patient febrile in the MICU with concerns for
ongoing infection. She underwent treatment for various
infections as detailed:
-HSV-1: Oral cavity with ulcers and skin breakdown that were
very severe, swab positive for HSV. Treated with acyclovir
___.
-Sinusitis: Treated with clindamycin ___.
-VAP: Initially for MSSA VAP with vancomycin & cefepime ___
___. BAL ___ showed Enterobacter aerogenes, treated w/
meropenem, then ciprofloxacin, (___).
-UTI: Treated w/ nitrofurantoin ___.
-UTI: Treated w/ ciprofloxacin ___.
-C. difficile: Treated w/ vancomycin, to continue until ___.
Ultimately, a thorough FUO work up was performed, including TTE
w/o infection & CT C/A/P w/o source of infection. Following
resolution of the above infections, patient has remained
intermittently febrile w/ unstable vital signs and our
conclusion along with Neurology is that this is a manifestation
of PAID as above.
# Hypertension: Hypertensive with SBPs >180 on admission.
Initially required nitroglycerin drip and transitioned to a
labetalol drip while in the ICU. Her blood pressure labiality is
due to autonomic instability in the setting of anoxic brain
injury. She was ultimately stabilized on a regimen of clonidine,
amlodipine, & propranolol.
# Severe C. difficile colitis: Patient had diffuse diarrhea
___, C. difficile toxin positing ___, started on PO
vancomycin 125mg Q6H ___ - ___ (7 days after
completion of latest course of antibiotic therapy for
pneumonia).
# Anuric renal failure: Initially patient presented with a large
metabolic acidosis and evidence of renal failure thought likely
ATN ___ inciting event. She underwent CVVH and HD per Nephrology
throughout ICU stay. Renal function improved w/ last HD session
on ___ and creatinine recovered and was normal on discharge.
# Hypercalcemia: Non-ionized calcium intermittently > 11.0, PTH
27, VD 17. Ultimately concluded that this was due to
contractures and immobility. Ionized calcium normal. Discussed
case w/ ___ who recommended no intervention (specifically,
no bisphosphonate therapy) w/ intermittent monitoring of ionized
calcium.
# Normocytic Anemia: Monitored, did not require transfusion.
Normal on discharge.
CURRENT HOSPITALIZATION SUMMARY ___:
=============================================
Patient re-presented to OSH soon after discharge to rehab (per
the above summary) with fever of 106, tachycardia to 180s, and
LLL infiltrate on CT, was admitted to the medicine floor on IV
antibiotics.
# HAP:
Rehab staff noted patient to have temperature of 106,
tachycardia to 180. A CT abdomen (performed to assess for
complications of C. diff) was concerning for a new left lower
lobe infiltrate consistent with pneumonia. She was transferred
to ___ for further care and started on IV vancomycin, cefepime
& ciprofloxacin given a history of resistant Enterobacter in
sputum. WBC was 27 on admission. The patient was admitted to the
floor and maintained on IV antibiotics. ID was consulted for
antibiotic recommendations and advice for any other work-up. IV
vancomycin was d/c'd ___ given negative MRSA swab,
ciprofloxacin was d/c'd ___ per ID recommendations. She was
maintained on cefepime until ___ for a 7-day course of
antibiotics for HAP. ID recommended no further work-up.
# PAID/autonomic dysfunction
Given frequent fevers, standing tylenol dosing was increased
initially to 1g Q6H given breakthrough fevers, ultimately
discharged with 800 mg Q6H to ensure a safe long-term dosage.
Ibuprofen was added for further control of fevers and uptitrated
to 600 mg Q6H, briefly discontinued due to ___, and restarted at
400 mg Q8H. She was started on ranitidine for GI protection due
to plan for long-term NSAID use. She had a few episodes of
bradycardia to <40 for which propranolol was held for a brief
period, after which she became tachycardic and it was restarted
with good effect. Dosing was not adjusted. CTA chest was
obtained due to tachycardia, was negative for PE. She will have
neurology followup as an outpatient.
# Severe C. difficile:
Completed a course of PO vancomycin treatment for severe c diff.
___, with last day ___ (7 days post PNA treatment). She
received C diff PPX while undergoing treatment for UTI, to
finish 7 days post-UTI treatment (last day ___.
# UTI
She was noted to have more frequent fevers than typical, with
new leukocytosis to 18. Infectious workup was sent and revealing
for UA consistent with infection. Initially treated with bactrim
and nitrodantin based on previous culture data, narrowed to
Bactrim based on urine culture growing ENTEROBACTER AEROGENES.
She completed an 8 day course (___).
# ___:
Baseline Cr 0.2-0.6. Increased to 1.2 overnight ___. Thought
prerenal i/s/o insensible losses from fevers and inadequate free
water with tube feeds. ___ resolved with 1L IVF and increasing
free water flushes. Had also recently received contrast for CTA
to r/o PE. Ibuprofen was held, restarted upon resolution of ___.
# Nutrition
Per nutrition recommendation, she was transitioned from ___
to ___ tube feeds. She was titrated to goal. Please see above
for current diet regimen.
# Goals of Care
# Disposition
Family meeting was conducted with family, primary medical team
and neurology this admission. Neurology had been consulted for
re-prognostication and felt it was highly unlikely she would
ever function independently, but felt that it would take 6
months to ___ years before definitive prognostication could occur.
Family continues to hope for recovery and she is full code. With
this goal in mind, an extensive search was conducted by case
management to find the most suitable place for the patient given
her complicated needs. LTAC level of care was thought the safest
transition out of the hospital setting, with possibility to
transition to SNF when possible.
Of note, her father is her guardian/HCP.
#Code: Full confirmed
#HCP: Mark ___
Relationship: father
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO HS
2. CloNIDine 0.4 mg PO TID
3. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 17.2 mg PO BID:PRN constipation
6. Thiamine 100 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Acetaminophen 1000 mg PO Q8H
9. Baclofen 10 mg PO TID
10. Bromocriptine Mesylate 5 mg PO BID
11. Dantrolene Sodium 25 mg PO QID
12. Heparin 5000 UNIT SC BID
13. Propranolol 80 mg PO Q6H
14. LORazepam 1 mg PO BID tachypnea
15. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Fish Oil (Omega 3) ___ mg PO BID
2. Ibuprofen 400 mg PO Q8H
3. Ranitidine 75 mg PO BID
4. Acetaminophen 800 mg PO Q8H
5. amLODIPine 10 mg PO HS
6. Baclofen 10 mg PO TID
7. Bromocriptine Mesylate 5 mg PO BID
8. CloNIDine 0.4 mg PO TID
9. Dantrolene Sodium 25 mg PO QID
10. FoLIC Acid 1 mg PO DAILY
11. Heparin 5000 UNIT SC BID
12. LORazepam 1 mg PO BID tachypnea
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Propranolol 80 mg PO Q6H
15. Senna 17.2 mg PO BID:PRN constipation
16. Thiamine 100 mg PO DAILY
17. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
fever
Healthcare associated pneumonia
Sepsis
leukocytosis
urinary tract infection
Secondary Diagnosis:
====================
anoxic brain injury
paroxysmal autonomic instability with dystonia
tachypnea
severe C. difficile
normocytic anemia
thrombocytosis
Acute kidney Injury
Hyponatremia
Hypercalcemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___ Mrs. ___,
___ you for choosing the ___
for your daughter's care.
___ was admitted with a fever and pneumonia.
While she was in the hospital, we gave her IV antibiotics to
treat her pneumonia and continued all of her other medications.
Over the course of admission, she also developed a urinary tract
infection. We gave her separate antibiotics to treat her urinary
tract infection.
Once ___ leaves the hospital, she will transition to an
LTAC. At this facility she will continue to work with therapists
and doctors who ___ continue to evaluate her and try to help
her. We communicated with an accepting physician and the
nursing director and told them about ___ care. We conveyed
our perspectives on aspects of her care that are of particular
concern, including fevers and managing her tracheostomy. She
will be connected to outpatient neurology for after discharge.
We wish your family the best. It was a pleasure caring for
___ and we will miss her.
Your ___ Care Team
Followup Instructions:
___
|
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2131-01-18 00:00:00
|
2131-01-18 13:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
___ RIGHT HUMERAL FRACTURE STATUS-POST OPEN REDUCTION AND
INTERNAL FIXATION
___ LEFT SHOULDER FRACTURE STATUS-POST CLOSED REDUCTION
History of Present Illness:
___ PMHx metastatic lung adenocarcinoma (diagnosed 7 months
prior, thought to be second primary lung cancer) found down and
unresponsive in his home. Last known contact was 16 hours prior.
The patient lives alone and one of his brother entered the
apartment by force when he went to check on the patient. The
brother found the patient moaning and unresponsive with dried,
___, khaki-colored secretions. Initially transported by
EMS to ___ whereupon he was sent to ___ out of
concern for multiple orthopedic trauma given right humerus
fracture and left shoulder fracture. The patient remained
minimally responsive and has no recollection of the events
preceding his loss of consciousness until he was post-op at
___.
Upon arrival to ___, he was found to have HR in the 130s. EKG
showing sinus tachycardia with TWI in lateral leads unchanged
from previous EKG. Labs significant for wbc of 17, hct 27,
platelets 172, Na 149, K 4.2, Cr 1.5, glucose 114. Imaging
significant for CXR showing possible pneumonia, CT head and
C-spine normal, and XR showing acute fracture of right humeral
head.
Upon arrival to ___ ED initial vs were: 98.0 128 127/79 20
100% Non-Rebreather. The patient was noted to be moaning and
not responsive to commands. He was intubated given poor mental
status. Labs were notable for a leukocytosis of 14.9 with 86%
PMNS, Cr of 1.4 from an unknown baseline, CK of 3000, HCT of 26,
lactate of 1.9, negative urine and serum tox screens. Head CT
was negative. CT torso showed bilateral shoulder fractures, and
opacities at the lower aspect of the left lung. Patient given
ceftriaxone, vanc, levoquin.
Review of systems: (Obtained later from the patient and his
family).
Denies alcohol, tobacco, or drug use.
Past Medical History:
Lung adenocarcinoma likely metastatic to the R adrenal
(diagnosed ___, undergoing cisplatin and primetrexed
(alimta) chemotherapy.
Social History:
___
Family History:
Mother- Lung cancer, alive.
Father-Lung cancer, expired.
Physical Exam:
ON ADMISSION:
-----------------
Vitals: 99.4 167/106, 112, 92% on FiO2 40%.
General: intubated and sedated
HEENT: Sclera anicteric, PEARL, OGT in place
Neck: supple, JVP not elevated,
Lungs: course breaths appreciated from anterior lung fields, R>L
CV: sinus tachy, no MMG
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, 1+ pulses, no edema
Access: R port-a-cath: no edema, erythema or discharge from site
Neuro: sedated, withdrawals all extremities from painful stimuli
DISCHARGE PHYSICAL EXAM:
Vitals- 98.5 176/61 81 16 95/RA I/O:1100+/2700
General- awake, alert, NAD
HEENT- OMM, no lesions
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB. No w/r/r.
CV- Regular rate, regular rhythm, no m/r/g appreciated
Abdomen- soft, nontender, BS+, no r/g/r
GU- no foley
Ext- WWP, RUE ACE bandage placed, LUE with immobilizer, both
upper extremities neurovascularly intact
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABS ON ADMISSION:
___ 08:00PM BLOOD WBC-14.9* RBC-2.38* Hgb-8.6* Hct-26.3*
MCV-110* MCH-35.9* MCHC-32.5 RDW-16.5* Plt ___
___ 08:00PM BLOOD Neuts-85.7* Lymphs-8.4* Monos-5.1 Eos-0.6
Baso-0.2
___ 08:00PM BLOOD ___ PTT-26.1 ___
___ 08:00PM BLOOD Glucose-93 UreaN-32* Creat-1.4* Na-134
K-4.6 Cl-103 HCO3-22 AnGap-14
___ 08:00PM BLOOD ALT-32 AST-71* CK(CPK)-3141* AlkPhos-57
TotBili-0.5
___ 08:00PM BLOOD Lipase-9
___ 08:00PM BLOOD Albumin-3.8
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:01PM BLOOD Lactate-1.9
___ 08:39PM BLOOD Type-ART Rates-16/ Tidal V-550 PEEP-5
FiO2-100 pO2-497* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 AADO2-183
REQ O2-40 Intubat-INTUBATED
PERTINENT LABS:
___ 03:33AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.4*
___ 03:33AM BLOOD Triglyc-140
___ 03:33AM BLOOD CK-MB-18* MB Indx-0.3
___ 06:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:20PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:45AM BLOOD calTIBC-161* Ferritn-980* TRF-124*
___ 08:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
URINE:
___ 08:00PM URINE RBC-9* WBC-10* Bacteri-FEW Yeast-NONE
Epi-6 TransE-<1
___ 08:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CSF:
___ 12:39AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 12:39AM CEREBROSPINAL FLUID (CSF) TotProt-27 Glucose-68
___ 12:39AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
MICRO:
BLOOD CX-
URINE CX-NEG
CSF GRAM STAIN/CX-NEG
SPUTUM GRAM STAIN/CX-NEG
IMAGING:
EEG ___:
FINDINGS:
CONTINUOUS EEG: The background consisted of frontocentrally
predominant
___ Hz activity superimposed on admixed irregular diffuse ___
Hz delta/theta activity. Significant low voltage frontally
predominant beta activity is present. There are no epileptiform
discharges or seizures.
SPIKE DETECTION PROGRAMS: There were no automated spike
detections. There
were no epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were no automated seizure
detections. There were no electrographic seizures.
QUANTITATIVE EEG: Trend analysis was performed with Persyst
Magic Marker
software. Panels included automated seizure detection, rhythmic
run detection and display, color spectral density array,
absolute and relative asymmetry indices, asymmetry spectrogram,
amplitude integrated EEG, burst suppression ratio, envelope
trend, and alpha delta ratios. Segments showing abnormal trends
were reviewed and showed no focal asymmetries and no periods of
increased rhythmicity.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: No structured sleep architecture was present.
CARDIAC MONITOR: Showed a regular rhythm with a rate of
approximately 110
bpm.
IMPRESSION: This was an abnormal routine EEG study because of
generalized
background theta/delta slowing without focal features consistent
with a
moderate-severe encephalopathy of non-specific etiology.
Significant admixed frontally predominant beta activity may be
medication side effect. There were no epileptiform discharges or
seizures.
CXR ___:
FINDINGS: Semi-upright portable AP view of the chest was
provided. ETT tip resides approximately 4.6 cm above the
carina. The NG tube courses into the left upper abdomen. The
Port-A-Cath is unchanged with tip in the region of the mid SVC.
There is volume loss in the left lung with evidence of prior
left upper lobectomy with clips in the left mid to upper lung
noted. Scarring in the right upper lung is present. There is
no definite evidence for pneumonia or CHF. No large effusion or
pneumothorax is seen. Cardiomediastinal silhouette is stable.
Bony deformities in the left upper rib cage are unchanged,
reflective of prior surgery.
IMPRESSION: Appropriately positioned ET and NG tubes.
Post-surgical changes in the left upper lung.
CT TORSO ___:
FINDINGS:
CT chest: The visualized thyroid is unremarkable. There is no
supraclavicular lymph node enlargement. The airways are patent
to the subsegmental level. The patient is status post left lower
lobectomy. Surgical clips are noted in the left apex and left
hilum. Severe paraseptal emphysema is noted. A fluid collection
at the left apex measuring 3.4 x 2.5 cm may represent a
postoperative seroma or pleural ___. However, given there is no
prior imaging available is of unclear chronicity. Opacification
in the lower aspect of the left lung with air bronchograms could
represent atelectasis, although infection, aspiration or
malignancy versus post treatment changes are also possibe. If
prior exist for comparison this would be helpful in determining
the stability of this lesion. There is no mediastinal, hilar or
axillary lymph node enlargement by CT size criteria. There is a
small pericardial effusion. No pleural effusion or pneumothorax
is present. An ET tube ends 5 cm above the carina. An enteric
tube is seen with the tip and side hole in thestomach.
CT abdomen: The liver enhances homogeneously without focal
lesions or
intrahepatic biliary dilatation. The gallbladder is unremarkable
and the
portal vein is patent. The pancreas, spleen and left adrenal
gland are
unremarkable. There is a 13 mm nodule in the right adrenal
gland. There is a
15 mm cyst in the lower pole of the right kidney. The kidneys
otherwise
present symmetric nephrograms and excretion of contrast with no
pelvicaliceal dilation or perinephric abnormalities. The
stomach, duodenum and small bowel are unremarkable. The colon is
within normal limits. The appendix is not visualized but there
is no evidence of appendicitis. The intraabdominal vasculature
is unremarkable. There is no mesenteric or retroperitoneal lymph
node enlargement by CT size criteria. No ascites, free air or
abdominal wall hernia is noted.
CT pelvis: Streak artifact from the right hip prosthesis limits
evaluation of the pelvis. The urinary bladder is decompressed
with a Foley. There is no pelvic free fluid. There is no
inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious for
malignancy is present. There is a fracture dislocation of the
right shoulder and a fracture of the left humeral head and left
glenoid.
IMPRESSION:
1. Postoperative changes in the left lung with an 3.5 cm fluid
collection at the lung apex which may represent a postoperative
seroma or pleural fluid. If prior exams for comparison document
stability this would be helpful.
2. Opacities at the lower aspect of the left lung could
represent atelectasis; although, infection, aspiration or
malignancy versus or treatment change are also possible. If
priors exist for comparison it could be helpful to document
stability.
3. 13 mm nodule in the right adrenal gland concerning for
malignancy given
patient's history.
4. Fractures of the bilateral shoulders are partially
visualized.
SHOULDER XR ___:
FINDINGS:
Right shoulder 3 views.
There is a subcapital fracture of the humeral head with the
humeral head
displaced laterally and rotated approximately 180 degrees so
that the
articular surface is oriented inferiorly and laterally. A right
chest wall Port-A-Cath is noted. The visualized right lung is
clear.
IMPRESSION:
Severely displaced and angulated humeral head fracture
FINDINGS:
Left shoulder 3 views.
There is a the posterior bony Bankart fracture (better
appreciated on the CT) as well as a reverse ___
deformity. Osseous fragment is noted inferior to the glenoid.
There is no evidence of dislocation at this time however the
mechanism of injury was likely posterior dislocation. The
visualized left upper lung demonstrates numerous surgical clips.
An ET tube and NG tube are partially visualized.
IMPRESSION:
Posterior bony Bankart's fracture and reverse ___
deformity consistent with a previous posterior dislocation
although no evidence of current dislocation.
WRIST XR ___:
THREE VIEWS, LEFT WRIST:
There is mild ulnar positive variance. The carpal rows are
aligned. There is no fracture or dislocation.
IMPRESSION: No fracture or dislocation.
MR HEAD ___:
FINDINGS:
There is no evidence of hemorrhage or infarction. Ventricles and
extra axial spaces are within normal limits for age. The major
intracranial vessels exhibit the expected signal void related to
vascular flow.
No abnormal enhancement is appreciated. The paranasal sinuses
demonstrate
scattered areas of mucosal thickening most prominent within the
right
maxillary and scattered ethmoid air cells. The mastoid air
cells demonstrate scattered areas of fluid signal and
inflammatory change. The sella turcica, craniocervical
junction, and orbits are unremarkable.
IMPRESSION:
Mild paranasal sinus mucosal thickening and mastoid air cell
fluid. Otherwise normal study.
Brief Hospital Course:
___ PMHx metastatic lung cancer (diagnosed 7 months prior)
found down and unresponsive in his home, likely due to seizure,
found to have rhabdomyolysis; new onset, difficult to control
hypertension; R humeral head fracture s/p ORIF; and L shoulder
posterior dislocation s/p closed reduction.
---------------
ACTIVE ISSUES BY PROBLEM:
#ACUTE ENCEPHALOPATHY: Resolved. Unclear etiology, but most
consistent with seizure evidenced by his post-ictal state and
likely LEFT posterior shoulder dislocation. Alternate etiologies
include 1) ingestions (synergy from alcohol, opiods,
cannabinoids), which is less likely given collateral information
from patient's family who is closely involved in his care,
negative alcohol screen at ___, and absence of
withdrawal symptoms; 2) cardiogenic etiologies, which is less
likely in the absence of arrhythmia on EKG or telemetry. Tox
screen negative, no obvious electrolyte or other metabolic
abnormalities at ___. No obvious masses on head CT or MRI.
LP performed in ED and CSF bland. EEG performed at ___ showed
abnormal routine EEG study because of generalized background
theta/delta slowing without focal features consistent with a
moderate-severe encephalopathy of non-specific etiology.
Significant admixed frontally predominant beta activity may be
medication side effect. There were no epileptiform discharges or
seizures.
- will follow up with Neurology in 1 month (appt is not yet made
on discharge, patient will be called with date and time)
# RIGHT HUMERAL FRACTURE S/P ORIF ___: Subcapital fracture of
the humeral head with the humeral head displaced laterally and
rotated approximately 180 degrees so that the
articular surface was oriented inferiorly and laterally.
- Followup with ___ Trauma for staple removal and post-op on
___
- pain control with tylenol and oxycodone
- non-weightbearing
# LEFT HUMERAL FRACTURE : STABLE. Posterior bony Bankart's
fracture and reverse ___ deformity consistent with a
previous posterior dislocation
- Continue immobilization in a sling and nonweightbearing.
- Outpatient followup with Dr. ___ ___ for operative
intervention.
- pain control with tylenol and oxycodone
# HYPERTENSION: Stable. Remains difficult to control. High
pre-test probability for pheochromocytoma evidenced by
hypertensive episodes which remain difficult to control,
paroxysms of anxiety, paroxysms of sweat, and right adrenal
mass. Alternate diagnoses include 1) primary hypertension, which
is less likely given the acuity of onset in the setting of no
past medical history of hypertension.
- Continue labetolol, clonidine with further titration as needed
- Urine metanephrines and catecholamines, Plasma metanephrine
pending (will follow up)
# ___: Baseline Cr 1.3-1.4. Unclear etiology, most likely
delayed manifestation of nonoliguric ATN in the setting of
rhabdomyolysis. Alternate etiologies include 1) pre-renal
azotemia, which is less likely in the setting of excellent
ongoing positive urine output and overall volume overload.
- Renal dosage, CrCl
# CHEST PAIN: Stable. Multifactorial. Alternate etiologies
include 1) pulmonary parenchymal irritation in the setting of
pneumonia and lung cancer; 2) musculoskeletal pain, evidenced by
the trauma associated with his fall and acute encephalopathic
episode; 3) paroxysms of anxiety; 4) pulmonary embolus, which
is less likely given absence absence of hypoxemia; 5) ACS,
which is less likely given normal ECG and multiple, negative
troponin rule-outs while an inpatient.
- Treat with home oxycodone schedule.
- Outpatient transitional issue: stress echo.
#ASPIRATION PNEUMONIA: chest CT findings of LLL opacities and
cough productive of green sputum, consistent with aspiration
pneumonia.
- Received 1 day of vancomycin and cefepime (___)
- Continue levofloxacin (___), clindamycin (___) for
coverage of anaerobes for 8 days through ___.
#ACUTE ON CHRONIC ANEMIA S/P 1U pRBC INTRAOPERATIVE TRANSFUSION
on ___: STABLE. Baseline Hgb 9.3 on ___. Acute blood
loss anemia attributable to bilateral humeral fractures.
Evidenced by significant ecchymoses. Superimposed on anemia of
chronic disease ___ lung adenocarcinoma evidenced by iron
studies consistent with the same.
# RHABDOMYOLYSIS: RESOLVED. Due to extended period of
unconsciousness during his period of acute encephalopathy. CK
peaked at ___, ran Lactated Ringer's aggressively to reduce
the risk of rhabdomyolysis induced ATN. Cr 1.6 on discharge
(baseline appears to be 1.3-1.5)
- Follow Cr with repeat chem panel on ___
# CONSTIPATION: Patient has not passed stool in 7 days.
Currently receiving senna, decussate, PO polyethylene glycol,
and PR biscodyl.
---------
CHRONIC ISSUES:
#LUNG ADENOCARCINOMA, LIKELY METASTATIC TO THE RIGHT ADRENAL
GLAND: Followed by Dr. ___ (___) at ___
___. Received cycle 5 of palliative cisplatin and
primetrexed (alimta) with good tolerance of regimen and
significant improvement when last staged after cycle 3.
Scheduled for cycle 6 but this is currently on hold given his
current illness.
- Continue to wean dexamethasone to 3 mg x3 days, 2mg x 3 days,
1mg x 3 days then stop
- will follow up with Dr ___ as an outpatient after he is
discharged from rehab
--------
TRANSITIONAL ISSUES:
# POSSIBLE SEIZURE: will need to follow up with neurology, appt
is pending at discharge and the patient will be contacted.
# BILATERAL HUMERAL FRACTURES:
- Right s/p ORIF, needs to follow up with Dr. ___ on
___.
- Left has not been fixated, will follow up with Dr. ___
___.
- He will need to be non-weight bearing in both arms
# CONSTIPATION: Patient has not stooled in 7 days despite bowel
regimen. Escalate bowel regimen as needed.
# HYPERTENSION: will need to continue to monitor and uptirate
medications as needed. SERUM METANEPHRINE AND URINE METANPEHRINE
/ CATECHOLAMINE RESULTS pending on discharge, will be followed
up by inpatient attending.
# CHEST PAIN: intermittent chest pain while hypertensive, should
consider stress testing as an outpatient
# RIGHT ADRENAL MASS: Most likely metastatic disease from lung
primary; however, differential includes pheochromocytoma.
# LUNG ADENOCARCINOMA: Followup with Dr. ___ (aware of
the patient's hospitalization) after completing rehab stay.
Chemo will be on hold until he gets out of rehab. Dexamethasone
is being tapered, as this may have contributed to his
hypertension -- 3 mg x3 days, 2mg x 3 days, 1mg x 3 days then
stop
# RHABDOMYOLYSIS: please check chem 7 on ___ to
ensure Cr remains in baseline range 1.3-1.5
# FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN PAIN
2. FoLIC Acid 1 mg PO DAILY
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Lactulose 15 mL PO DAILY:PRN constipation
5. Dexamethasone 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE KIDNEY INJURY
HYPERTENSION
ASPIRATION PNEUMONIA
ACUTE ENCEPHALOPATHY
ACUTE ON CHRONIC ANEMIA
RIGHT HUMERAL FRACTURE STATUS-POST OPEN REDUCTION AND INTERNAL
FIXATION
LEFT SHOULDER FRACTURE STATUS-POST CLOSED REDUCTION
RHABDOMYOLYSIS
LUNG ADENOCARCINOMA
RIGHT ADRENAL MASS
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 privilege caring for you at ___. You were admitted
because you lost consciousness for several hours and were found
unresponsive by your brother. It is difficult to know with
certainty the cause of your loss of consciousness, but we
believe you sustained a seizure. You underwent an MRI scan of
you brain which did not show masses inside. You underwent an
electrical study of your brain which did not show specific
locations where seizures would start.
You were noted to have new high blood pressure and you were
started on new medications to control these pressures. You will
have followup with your PCP to ensure we continue to learn why
this is the case as there are still some test we sent which will
not return for several more days.
You were noted to have a broken right arm. It was fixed by
surgeons. You will followup in 2 weeks to ensure it is still
healing.
You were noted to have a broken left shoulder. It was put in a
splint, You will followup in 10 days with a different surgeon
who specializes in fixing broken shoulders like these.
You were noted to have some injury to your kidneys, and you
continued to received fluids to prevent this from worsening.
Followup Instructions:
___
|
10764329-DS-11
| 10,764,329 | 26,616,803 |
DS
| 11 |
2143-06-02 00:00:00
|
2143-06-02 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
headache, pituitary lesion
Major Surgical or Invasive Procedure:
Endoscopic endonasal approach to suprasellar pituitary lesion;
resection of pituitary lesion
History of Present Illness:
___ year old male with intermittent headaches for 4 days. He
presented to ___ ED on ___, and reportedly had a
negative NCHCT. He represented on ___ with continued headaches,
and underwent an MRI that was also reported to be negative. On
the morning of ___, he saw his PCP due to continued concern,
who
ordered a second MRI that reportedly showed a pituitary mass at
the optic chiasm with reported bleeding/apoplexy. Therefore he
was referred to ___ for further evaluation.
Past Medical History:
diabetes
hypertension
hyperlipidemia
CLL diagnosed ___
Social History:
___
Family History:
NC
Physical Exam:
EXAM ON DISCHARGE:
GEN: well appearing, NAD
NEURO: A/Ox3, strength ___ throughout, SILT
HEENT: CNII-XII grossly intact, no epistaxis, visual fields full
b/l, no nystagmus, MMM, oropharynx without blood clot, no nasal
packing
CARDS: RRR, S1 and S2 heard throughout
PULM: CTAB b/l
ABD: soft, NTND
Pertinent Results:
CT HEAD: ___
IMPRESSION:
1. Expected post-procedure changes status post resection of
known pituitary adenoma with expected fluid and small amount of
local hemorrhage.
2. No evidence of intracranial hemorrhage or infarctions.
MRI w/ & w/o CONTRAST (___):
IMPRESSION:
1. Expected trans-sphenoidal partial resection of a pituitary
mass with fat packing is identified.
2. There is residual 1.7cm lobulated enhancing tissue along the
posterior
superior aspect of the sella, which may represent any
combination of residual lesion versus postoperative changes.
The infundibulum is deviated to the left, unchanged from prior
exam. The optic chiasm is unremarkable. Long-term followup is
recommended.
3. There is no evidence of intra-axial mass, acute hemorrhage or
infarct.
Brief Hospital Course:
Patient presented to ___ after referral from her PCP when he
was found to have a pituitary lesion that had concern for
apoplexy. He had no neurologic findings on exam and was admitted
to the floor for further workup. He remained stable overnight
into ___ and was awaiting results of endocrine labs and setting
up of visual field testing with neuro-Ophth. He continued to
remain stable in hospital and after receiving visual field
testing was scheduled for the OR on ___ for resection of
his pituitary mass.
On ___, he was brought to the OR and underwent an
endoscopic endonasal approach to resection of his suprasellar
pituitary lesion. He tolerated the procedure well, was extubated
in the OR and sent to the PACU in good condition. Initial frozen
pathology was consistent with pituitary adenoma. Immediately
post-op, he did well - his blood pressure was well controlled,
no focal neurological deficits and his urine output was
<250cc/hr. Visual fields post-operatively were full bilaterally
and epistaxis was controlled with his nasal packing. Follow up
non-contrast head CT imaging did not show any gross residual
tumor and no signs of gross hemorrhage.
On ___, he continued to do well in the PACU awaiting
transfer to the step-down unit. His UOP increased briefly to
>250cc/hr for 2 hours. Serum Na and spec ___ were sent which
came back WNL. His UOP subsequently decreased to 100cc/hr and he
was tolerating a regular diet and IV KVO. . His pain continued
to be well controlled and no signs of continuing epistaxis.
Nasal packing remained in place.
On ___, he underwent a follow MRI w/ & w/o contrast which
demonstrated a small focus of enhanging tissue possibly
representing residual disease. No hemorrhage or other acute
processes. He was otherwise neurologically stable.
On ___, the patient remained neurologically stable. His urine
output remained stable and his foley was removed. His labs were
stable. His nasal packing was removed and there was no drainage
noted from nares. He ambulated in the hallways without
difficulty.
On ___, the patient remained neurological and hemodynamically
stable. He expressed readiness to be discharge home and he was
discharged home in stable conditions. All his discharge
instructions and follow up were given prior to discharge.
Medications on Admission:
metformin, pravastatin, amlodipine, lisinopril
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Pravastatin 20 mg PO QPM
3. Lisinopril 10 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Please do not drive or operate mechanical machinery while taking
narcotics.
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 hrs Disp #*60 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Amlodipine 5 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN Mild Pain/Fever
Please do not exceed more than 4 grams in 24hrs.
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary lesion
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.
¨Clearance to drive and return to work will be addressed at
your post-operative office visit.
¨Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
¨If you have been discharged on Prednisone, take it daily as
prescribed.
¨If you are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨New onset of tremors or seizures.
¨Any confusion or change in mental status.
¨Any numbness, tingling, weakness in your extremities.
¨Pain or headache that is continually increasing, or not
relieved by pain medication.
¨Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
¨It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a dripping
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
¨Fever greater than or equal to 101° F.
¨If you notice your urine output to be increasing, and/or
excessive, and you are unable to quench your thirst, please call
your endocrinologist.
Followup Instructions:
___
|
10764758-DS-8
| 10,764,758 | 28,056,123 |
DS
| 8 |
2133-02-06 00:00:00
|
2133-02-06 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
polytrauma
Major Surgical or Invasive Procedure:
Left Olecranon Fracture ORIF ___
History of Present Illness:
___ ___ s/p fall from 15ft off ladder with
multiple orthopedic injuries.
Past Medical History:
Per medical record: none
Social History:
___
Family History:
NC
Physical Exam:
Per Medical Record:
PHYSICAL EXAMINATION:
In general, the patient is an awake alert ___
Vitals:
AVSS
Right upper extremity:
Skin intact
Right shoulder deformity
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Proximal forearm deep laceration w/ olecrenon seen
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 06:21PM LACTATE-3.5*
___ 06:00PM GLUCOSE-306* UREA N-27* CREAT-1.3* SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ 06:00PM ALT(SGPT)-41* AST(SGOT)-45* ALK PHOS-70 TOT
BILI-0.4
___ 06:00PM CALCIUM-8.8 PHOSPHATE-4.8* MAGNESIUM-1.9
___ 06:00PM WBC-22.2* RBC-4.25* HGB-13.4* HCT-39.7*
MCV-93 MCH-31.5 MCHC-33.7 RDW-12.6
___ 06:00PM NEUTS-87.8* LYMPHS-6.0* MONOS-5.7 EOS-0.3
BASOS-0.2
___ 06:00PM PLT COUNT-258
___ 06:00PM ___ PTT-24.8* ___
___ 02:39PM COMMENTS-GREEN TOP
___ 02:39PM GLUCOSE-245* LACTATE-6.5* NA+-139 K+-3.8
CL--100 TCO2-21
___ 02:30PM UREA N-26* CREAT-1.4*
___ 02:30PM estGFR-Using this
___ 02:30PM WBC-17.4* RBC-4.79 HGB-14.6 HCT-44.9 MCV-94
MCH-30.5 MCHC-32.5 RDW-12.1
___ 02:30PM PLT COUNT-283
___ 02:30PM ___ PTT-24.6* ___
Brief Hospital Course:
The patient was taken to the operating room on ___ for L
olecranon fracture ORIF, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to <<>> was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the operative extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
None
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L olecranon fx, L rib fx ___, L-sided pelvic fractures (L
inferior/superior pubic rami, L anterior column, L sacral ala),
R shoulder anterior dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- WBAT bilateral lower extremities
- NWB bilateral upper extremities
Followup Instructions:
___
|
10764840-DS-17
| 10,764,840 | 29,666,044 |
DS
| 17 |
2122-01-05 00:00:00
|
2122-01-07 20:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Cefazolin /
Vancomycin / Celexa / Cipro Cystitis
Attending: ___
Chief Complaint:
Confusion; incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ with history of ___ disease c/b
dystonia, likely lung CA metastatic to bones who presents with
___ days of confusion. History gathered from chart as patient
not able to provide history and daughter not presents. Per
documentation from patient's nursing home, patient was noted to
be confused on saunday. UA was sent which was negative however
she was started on Macrobid for empiric treatment of UTI. Urine
culture returned negative; since patient continued to be
altered; she was sent to ED. Per documentation, patient is
usually alert and oriented x3, so her current mentation is not
at baseline. Patient is wheelchair bound however recently she
has been having difficulty with taking her pills which is
different from her baseline. She has also been more sleepy than
usual. Currently patient is awake and alert and able to snwer
simple question. She denies any fevers, chills, night sweats,
cough, chest pain, abdominal pain, nausea, vomiting, diarrhea,
dysuria, numbness, focal weakness or headaches.
Per documentation patient was recently placed on hospice care at
the nursing home.
Past Medical History:
- Lung nodules on CT chest in ___ patient did not want further
___ CT scan: ___: Lesions on spine consistent with
bone metastasis; likely lung cancer
- ___ Disease followed by Dr. ___ at ___
- Dystonia secondary to ___ disease
- Polymyalgia Rheumatica and Temporal arteritis: managed by Dr.
___ and PCP
- ___
- HTN
- S/p minor stroke ___ no obvious deficits
- S/p cataract surgery- R eye
- History of hyponatremia on salt tabs
Social History:
___
Family History:
Mother died at ___ from cardiac disease. Father had DM and
cardiac disease.
Physical Exam:
Admission Physical Exam:
Vitals: 98.4 133/43 93%RA
General: Alert, oriented to self only
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, ___
Ext: Warm, well perfused
Neuro: ___ intact, ___ strenght upper/lower extremities,
grossly normal sensation to light touch
Discharge Physical Exam:
Vitals: Tc/Tm BP 92/34, HR71, O297RA
General: lethargic, responds to half of questions before falling
back asleep. Oriented to name and location ("in the hospital")
HEENT: Neck dystonic. Fluid collection lateral to right eye,
nontender.
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, holosystolic murmur
best appreciated at the apex.
Abdomen: mild distention, nontender
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Skin tear over left lower extremity ___,
nonfluctuant with no evidence of purulent drainage.
Pertinent Results:
Lab Results
===============================================================
___ 05:06PM BLOOD ___
___ Plt ___
___ 05:06PM BLOOD ___
___
___ 05:06PM BLOOD ___
___
___ 06:24AM BLOOD ___ LD(LDH)-272* ___
___
___ 06:24AM BLOOD ___
___ 06:24AM BLOOD ___
___ 06:24AM BLOOD ___
___ 04:53AM BLOOD ___
___ Plt ___
___ 05:23AM BLOOD Ret ___
___ 05:05AM BLOOD ___
___
___ 05:05AM BLOOD ___
___ 05:23AM BLOOD ___
Blood cultures drawn ___ and ___ Pending at the time of
discharge
Urine cultures drawn ___ Preliminary growth ___
rods>100,000, enterococcus>100,000
Imaginag Results
=
=
=
=
=
=
=
================================================================
- CHEST (PORTABLE AP) Study Date of ___:
IMPRESSION:
Previously detected right lower lobe pulmonary nodule not
clearly seen. No signs of superimposed pneumonia or edema.
- CT HEAD W/O CONTRAST Study Date of ___:
IMPRESSION:
No acute intracranial process.
- CHEST (PORTABLE AP) Study Date of ___:
IMPRESSION:
As compared to ___ chest radiograph, the lungs remain
hyperinflated
without evidence of focal consolidation to suggest the presence
of pneumonia.
Brief Hospital Course:
Primary Reason for Hospitalization
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
___ with ___ dementia c/b dystonia, hypothyroidism,
T2DM, and likely metastatic lung cancer here with altered mental
status. Hospital course complicated by hypotension likely in the
setting of straining due to constipation; however, infectious
workup revealed UA with bacteria and WBC concerning for UTI, so
was treated with zosyn.
Active Issues
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
#Anemia, normocytic: The patient had a hct drop from 31-->26.3
between ___ and ___. Stool was guaiac positive, suggesting a
likely GI source of bleeding. Hemolysis labs were negative.
Given the patient's move to hospice and desires for no invasive
intervention, no further workup was undertaken for her GI
bleeding. She did not require a blood transfusion, and her
hematocrit improved to 29 on ___.
#Delirium: The patient had waxing and waning mental status
throughout admission, though level of alertness improved
somewhat with holding lorazepam. The patient was found to have a
TSH of 32, and she was maintained on her home dose of
levothyroxine. She had some constipation that resolved with
manual disimpaction. She developed a urinary tract infection
that may have been contributing to her symptoms and was treated
with five days of zosyn; she will not be discharged on any
antibiotics. Workup for other infections including pneumonia was
negative. Blood and urine cultures were pending at discharge.
She did not require any PRN medications for agitation.
# Hypotension: She had some episodes of hypotension to the
___ systolic. These episodes improved with IV fluid
repletion. Possible sources of her hypotension include straining
due to constipation and infection due to urinary tract
infection. She was treated with disimpaction and zosyn as above.
Hypotensive episodes resolved with these interventions. Her home
metoprolol was held.
___ Disease with severe neck dystonia: the patient was
maintained on her home sinement ___ 2 tablets at 7am, 1.5
tablets at 11am, 2 tablets at 4pm, and 1 tablet at 9pm
#Depression: the patient was maintained on her home fluoxetine
and mirtazapine
#Hyponatremia, chronic: the patient was maintained on her home
salt tablets, and her sodium maintained in a normal range
throughout admission. On discharge, as goals of care are focused
on comfort, salt tablets were discontinued.
#Hypothyroidism: As above, the patient's TSH was 32 on
admission, and her family thought that perhaps she had not been
taking her levothyroxine as directed at home. She was maintained
on her home dose of levothyroxine.
#DM2: Blood sugars were ___ throughout admission.
Patient's home actos was held, and she did not require insulin.
#Glaucoma: the patient was maintained on her home eyedrops
throughout admission.
#Wound care: Pt has a traumatic skin tear on her left calf
secondary to hitting her leg on her wheelchair during a transfer
prior to admission. She had no documentation of recent tetanus
vaccine so received the vaccine in the hospital. The wound
remained clean and not infected throughout admission.
Transitional Issues
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
-Please ___ TSH in ___ weeks to ensure that it declines
appropriately with levothyroxine.
-Patient had episodes of hypotension during hospitalization,
likely secondary to straining from constipation thus
preadmission metoprolol was held; may consider restarting if
patient is hypertensive after discharge
-Patient had hypokalemia during hospitalization, likely
nutritional, and received PO potassium supplementation. Please
recheck potassium in 2 days after discharge and replete as
necessary
- the following preadmission medications were discontinued: ASA,
omeprazole, lorazepam, salt tabs.
- was discharged on oxycodone 2.5mg q4hrs PRN; please titrate
pain medication as needed.
- completed a ___ course of Zosyn for UTI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lumigan (bimatoprost) 0.01 % ophthalmic one drop to both eyes
at bedtime
2. Fluoxetine 50 mg PO DAILY
3. ___ 1.5 TAB PO QAM ___
Disease
4. ___ 2 TAB PO BID
5. Pioglitazone 15 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Senna 8.6 mg PO BID:PRN contipation
10. Omeprazole 20 mg PO DAILY
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Lorazepam 1 mg PO BID
13. Mirtazapine 30 mg PO QHS
14. sodium chloride 1 gram oral BID
15. Ibuprofen 600 mg PO Q8H
16. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
17. ___ 1 TAB PO QHS
18. Istalol (timolol maleate) 0.5 % ophthalmic BID Glaucoma
19. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
20. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
2. ___ 1.5 TAB PO QAM ___
Disease
3. ___ 2 TAB PO BID
4. ___ 1 TAB PO QHS
5. Fluoxetine 50 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Senna 17.2 mg PO HS
8. Acetaminophen 1000 mg PO TID
9. Istalol (timolol maleate) 0.5 % ophthalmic BID Glaucoma
10. Lumigan (bimatoprost) 0.01 % ophthalmic one drop to both
eyes at bedtime
11. Mirtazapine 30 mg PO QHS
12. Bisacodyl ___AILY:PRN Constipation
13. Docusate Sodium 100 mg PO BID
14. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q4hrs Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status/ metabolic encephalopathy
Hypothyroidism
Urinary Tract Infection
Constipation with fecal impaction
___ Disease
SECONDARY:
probable lung ca with bone metastasis
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 Ms. ___,
It was a pleasure to care for you while you were a patient at
___. As you know, you were admitted for
confusion. To better understand the causes of your confusion, we
did a thorough investigation of the medications you were taking
prior to admission and did some blood tests looking for
infections and hormone changes that could contribute to your
confusion. We found that you had recently been taking more
lorazepam that you had been previously taking, which may have
contributed to your confusion. Additionally, our lab tests
indicated that your thyroid hormone levels were low. To treat
this, we held your lorazepam and gave you levothyroxine. During
your hospitalization, you became constipated and developed a
urinary tract infection. This was treated with an antibiotic.
You will not need to continue this antibiotic after discharge.
You will not need to take more antibiotics after discharge.
Again, we really enjoyed caring for you while you were a patient
at ___. Please do not hesitate to contact our
team with any questions. We wish you all the best.
Your care team at ___
Followup Instructions:
___
|
10765204-DS-11
| 10,765,204 | 26,964,163 |
DS
| 11 |
2186-09-26 00:00:00
|
2186-09-27 22:08:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Ceftin / Ampicillin / Erythromycin Base
Attending: ___.
Chief Complaint:
Bloody stool
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
this is a ___ year old female ___'s witness with a history of
HTN, Grave's, DCIS s/p radiation in remission, GERD, and HLD who
presents with GI bleeding. She reports one episode of BRBPR
coating her stool 3 days ago. This is the first time this has
happened to her knowledge. She was unable to quantify the
amount of blood, but thinks it was less than a cup. She denies
any history of dark stool. Denies a history of hemorrhoids.
She denies any recent fevers or recent diarrhea. She also
complains of blood "spotting" after urination on toilet paper
over this same period.
Yesterday, she had the onset of bilateral lower abdominal pain
beginning at 0130 AM. It was sharp, non-radiating, and
accompanied by sweats and bloody diarrhea x 3. She denies any
lightheadedness, fevers, or chest pain.
She had a colonscopy in ___ which was normal. Her last
menstrual period was ___ years ago.
She was hemodymically stable in the ED, received antibiotics,
had a CT as detailed below, 1L NS and was transferred to the
medicine floor for evaluation.
Past Medical History:
1. Hypertension.
2. History of Graves' disease.
3. History of DCIS, diagnosed in ___, in remission
4. Pulmonary nodules on chest CT, final follow-up
___ stable.
5. Mildly dilated aortic root on echocardiogram. Stable
follow-up ___.
6. GERD.
7. Hyperlipidemia.
8. osteopenia
Social History:
___
Family History:
mother passed away 4 months ago from
complications of pneumonia and pericardial effusion at age ___.
Siblings and father-hypertension and hyperlipidemia
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: 98.1, 128/.84, 65, 18, 96% RA
GENERAL: pleasant female, NAD
HEENT: PERRL, EOMI
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, TTP over LLQ, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE PHYSICAL EXAMINATION:
VITALS - T 97.7 HR 72 RR 18 BP 110/72 SaO2 100 on RA
GENERAL - Well-appearing middle-aged woman ambulating around the
wards and is in NAD.
HEENT - MMM, sclera nonicteric, PEERL. Conjunctiva pale
CARDIOVASCULAR - III/VI pansystolic murmur heard best over left
sternal border. Regular rate & rhythm. No rubs or gallops.
PULMONARY - CTAB. Moving air well. No accessory muscle use.
ABDOMINAL - BS normoactive. Mild tenderness to palpation of
midepigastrium.
NEUROLOGICAL - A&Ox3. Moving all four limbs. Follows commands.
RECTAL - Full rectal tone. Small nonulcerated external
hemorrhoid seen at 6 o'clock. Normal-appearing rectal mucosa
and surrounding skin.
Pertinent Results:
___ 04:20PM BLOOD WBC-9.1# RBC-4.24 Hgb-12.8 Hct-37.8
MCV-89 MCH-30.2 MCHC-33.8 RDW-12.9 Plt ___
___ 06:45AM BLOOD WBC-8.5 RBC-4.06* Hgb-12.2 Hct-37.1
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.2 Plt ___
___ 08:10AM BLOOD WBC-6.4 RBC-4.17* Hgb-12.6 Hct-37.9
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.0 Plt ___
___ 08:10AM BLOOD Glucose-133* UreaN-6 Creat-0.8 Na-144
K-3.8 Cl-108 HCO3-25 AnGap-15
___ 8:48 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):
VIRAL CULTURE (Pending):
CT ABDOMEN AND PELVIS WITH CONTRAST (___)
================================================
INDICATION: ___ female with left lower quadrant pain
and bloody
stools. Evaluate for diverticulitis.
COMPARISON: CT of the abdomen and pelvis from ___.
TECHNIQUE: Volumetric MDCT images from the lung bases to the
pubic symphysis were acquired following the uneventful
administration of 130 cc of IV Omnipaque. No oral contrast
material was administered. Coronal and sagittal reformats were
performed.
FINDINGS:
The partially imaged lung bases show an unchanged 4-mm ground
glass nodule in the lingula. The partially imaged heart is
unremarkable as well.
CT OF THE ABDOMEN WITH IV CONTRAST:
The liver, spleen, both adrenals, pancreas, and gallbladder are
unremarkable. Scattered hypodensities in both kidneys are
sub-cm in size and too small to accurately characterize. Both
kidneys otherwise are unremarkable. No abdominal,
retroperitoneal or mesenteric lymphadenopathy by CT size
criteria is present. No abdominal free fluid or free air is
present. Abdominal aorta is normal in caliber. Abdominal loops
of small bowel and stomach are normal.
CT OF THE PELVIS WITH IV CONTRAST:
The small bowel loops show fatty replacement within the wall of
the terminal ileum. Also noted is fatty replacement in the
descending colon. No surrounding fat stranding is noted about
the terminal ileum. There is mild wall thickening with
surrounding stranding of the descending colon and sigmoid colon.
Additionally, intramural fat deposition is seen within the
descending colon. No bowel obstruction is present. The rectum is
unremarkable. No pelvic or inguinal lymphadenopathy or pelvic
free fluid is present. The uterus, both adnexa, and bladder are
unremarkable.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or
blastic lesions or fractures.
IMPRESSION:
Mild sigmoid and descending colitis which may be due to
inflammatory or
infectious etiologies. Fatty deposition within the wall of the
terminal ileum and descending colon suggests underlying chronic
inflammatory bowel disease.
COLONOSCOPY (___): Normal colonoscopy to cecum and terminal
ileum.
EGD (___)
- Medium hiatal hernia (biopsy)
- Schatzki's ring
- Erythema and patchy erythema in the antrum and stomach body
(biopsy)
- Erythema, friability and edema in the distal bulb/proximal
second part of the duodenum (biopsy)
(biopsy)
- Otherwise normal EGD to second part of the duodenum
PATHOLOGY:
GI BIOPSIES (___)
A) Gastroesophageal junction:
1. Squamous epithelium with a rare intraepithelial
eosinophil.
2. Cardiofundic-type mucosa with mild chronic, inactive
inflammation.
3. No intestinal metaplasia seen.
B) Antrum:
1. Chronic, focally active gastritis.
2. ___ stain is negative for H. pylori, with a
satisfactory control.
C) Duodenal bulb:
Preservation of villous architecture with focally-increased
intraepithelial lymphocytes. See note.
Note: The findings are mild and non-specific , but can be seen
with certain infections (e.g. H. pylori), as a result of a drug
effect or other immune mediated etiologies such as Celiac
disease. Clinical correlation is suggested.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION
==================================
#) GI BLEED: Has been afebrile, hemodynamically stable, without
leukocytosis, not anemic, and without hematocrit drop during
this admission. Had one further guaiac positive formed stool
here. No frank blood. Colitis seen on CT scan is likely source
of bleed, however no diverticula noted. Previous EGD in ___
showed focally active gastritis, so this could be the source as
well. Etiology inflammatory vs. infectious. Stool cultures
sent, final results pending. Has been hemodynamically stable
and with hct at baseline. Given hemodynamic stability, OK to
follow-up on this as an outpatient.
- Discharged on ciprofloxacion 400mg BID + metronidazole 500mg
TID. Continue for 6 more days.
- Initiated PPI, omeprazole 20mg QD
TRANSITIONAL ISSUES
===================
- Final stool cultures/studies are still pending upon discharge.
Please follow-up on these.
- Consider repeat colonoscopy/EGD given signs of chronic
inflammatory colitis given fat deposition seen on CT and history
of focally active gastritis from EGD in ___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Claritin *NF* 10 mg Oral daily
6. Calcium Carbonate 500 mg PO Frequency is Unknown
Discharge Medications:
1. Simvastatin 20 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Calcium Carbonate 500 mg PO HS:PRN vitamin
5. Claritin *NF* 10 mg Oral daily
6. Hydrochlorothiazide 25 mg PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
9. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroinestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for the evaluation of a
gastrointestinal bleed. We treated you with IV fluids,
antibiotics, and you improved. Your blood levels were normal
and stable throughout your admission, so we were not concerned
for a life-threatening GI bleed. We recommend you call your GI
doctor, ___ ___, to arrange for a follow up
appointment.
Please make the following changes to your medications:
- START: Ciprofloxacin and metronidazole, which are antibiotics
to treat a possible infection that may have led to your GI
bleeding. It is important to not drink alcohol when taking this
medication.
- START: Omeprazole 20 mg by mouth daily to help decrease any
inflammation in your GI tract, specifically your stomach.
Followup Instructions:
___
|
10765488-DS-12
| 10,765,488 | 25,734,954 |
DS
| 12 |
2198-05-28 00:00:00
|
2198-06-02 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CT-guided core biopsy
History of Present Illness:
Mr. ___ is an ___ with a h/o severe AS ___ 0.8cm2 w/plan
for SAVR vs. TAVR), HTN, CAD s/p PCI to LAD ___ who presented
to the hospital on ___ with progressively worsening
substernal chest pain radiating to the back and both shoulders
as well as unilateral leg swelling. Post-PCI placement in
___, he was able to ambulate one-mile pain free. However, one
month prior to admission, he took a walk along the ___ and
suddenly developed an acute episode of dull chest discomfort
without radiation. Since that time, his exercise and functional
capacity has declined significantly. He endorsed generalized
fatigue and difficulty even with ADLs and difficulty walking
across the room and also described recent epigastric pain, a
"squeezy pain" that lasted all day prior to admission. He denied
n/v/f/c and shortness of breath. He endorsed fatigue, weakness,
and presyncopal symptoms of dizziness with exertion without LOC.
Denied PND, orthopnea, ankle edema.
He has had progressive anemia since ___, on dual
antiplatelet. Never had a colonoscopy, denied any blood in
stool. Notes significant constipation.
In the ED, initial vitals were:
T 97.8, HR 60, BP 109/42, RR 17, O2 100% RA. Left blood pressure
108/66 right arm 112/50.
Labs were notable for:
anemia with initial hemoglobin of 8.7, down to 7.8 on recheck 7
hours later (compared to baseline ~ 12). Initial troponin
negative. Cr 2.2 (baseline ~ 1.6-1.8). U/A showed > 182 WBCs.
Blood cultures x2 pending.
Patient was given: 1 x cipro 500 for UTI, ASA 325
CXR showed a new 3.7 cm elliptical opacity in the mid left upper
lung, concerning for an extra pulmonary process located in
either the pleura or chest wall. There was also progression of
loss of height of a mid thoracic compression fracture.
EKG with NSR @ 61 bpm, prolonged PR interval consistent with ___
degree AV block, LAD, TWI in leads III, aVR, and V1.
UA concerning for UTI.
Vitals prior to transfer: 98.4 66 106/52 12 98% RA.
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
Past Medical History:
- Aortic stenosis
- HTN
- HLD
- Hypothyroidism
- BPH
- B12 deficiency
- History of ___ and ___
Social History:
___
Family History:
Family History: Significant for cancer and heart disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 97.5 BP 122/54 HR 65 RR 18 O2Sat 98% RA
GENERAL: Well-appearing male in NAD. Oriented x3. Hard of
hearing even with hearing aid in place. Mood, affect
appropriate.
Speaking full sentences.
HEENT: NCAT. PERRL, EOMI. Scar on bridge of nose s/p BCC. No
xanthelasma.
NECK: Supple, JVP flat.
CARDIAC: RRR, normal S1, diminished S2, ___ SEM with diffuse
radiation to bilateral carotids. No thrills, lifts, No S3 or S4.
PMI located in ___ intercostal space, midclavicular.
LUNGS: Respirations unlabored, no accessory muscle use, CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: WWP, No c/c/e.
PULSES: 2+ DP, ___
NEURO: A&Ox3. CNs grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.2, BP: 126/70, HR: 62, RR: 18, OS=97%
Gen: Well appearing, alert in NAD, talkative and kind
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
LYMPH: No cervical or supraclavicular LAD
CV: Regular rate, normal S1, S2 with III/VI holosystolic murmur,
best heard @ R ___ intercostal space with radiation to b/l
carotids.
LUNGS: No accessory muscle use. Clear to auscultation b/l. No
wheezes, rales, or rhonchi.
ABD: soft, non tender to palpation.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
Pertinent Results:
LABS ON ADMISSION ___ 10:00AM BLOOD WBC-6.4 RBC-3.05* Hgb-8.7* Hct-26.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-16.3* RDWSD-52.2* Plt ___
___ 10:00AM BLOOD Neuts-80.0* Lymphs-8.6* Monos-9.8
Eos-0.8* Baso-0.3 Im ___ AbsNeut-5.12 AbsLymp-0.55*
AbsMono-0.63 AbsEos-0.05 AbsBaso-0.02
___ 10:00AM BLOOD ___ PTT-32.0 ___
___ 05:04PM BLOOD Ret Aut-1.7 Abs Ret-0.05
___ 10:00AM BLOOD Glucose-112* UreaN-49* Creat-2.2* Na-138
K-4.8 Cl-101 HCO3-25 AnGap-17
___ 10:00AM BLOOD cTropnT-<0.01
___ 05:04PM BLOOD cTropnT-<0.01
___ 09:58PM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD Iron-36*
___ 10:00AM BLOOD calTIBC-299 Ferritn-106 TRF-230
LABS ON DISCHARGE:
___ 12:00AM BLOOD WBC-8.0 RBC-3.14* Hgb-9.2* Hct-28.2*
MCV-90 MCH-29.3 MCHC-32.6 RDW-17.1* RDWSD-54.2* Plt ___
___ 12:00AM BLOOD Neuts-83.2* Lymphs-5.5* Monos-9.0 Eos-1.1
Baso-0.1 Im ___ AbsNeut-6.63* AbsLymp-0.44* AbsMono-0.72
AbsEos-0.09 AbsBaso-0.01
___ 12:00AM BLOOD Glucose-131* UreaN-42* Creat-1.7* Na-138
K-4.2 Cl-102 HCO3-28 AnGap-12
___ 12:00AM BLOOD ALT-27 AST-19 LD(LDH)-336* AlkPhos-64
TotBili-0.3
___ 04:15PM BLOOD Calcium-10.5* Phos-2.9 UricAcd-3.9
CXR (___):
1. Interval development of a 3.7 cm elliptical opacity in the
mid left upper lung. The incomplete sharp borders suggest an
extra pulmonary process located in either the pleura or chest
wall. CT is recommended for further evaluation to exclude a
malignant lesion.
2. Interval progression of loss of height of a mid thoracic
compression fracture.
___ ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
CT Chest ___:
IMPRESSION:
1. Multiple pulmonary nodules, pleural based and extrapleural
lesions and retroperitoneal masses/lymphadenopathy consistent
with malignancy such as lymphoma or metastatic disease of
unknown primary. One extrapleural posterior mediastinal lesion
likely involves adjacent T 6 and 7 vertebral bodies.
2. Retroperitoneal mass, which is probably a conglomerate of
para-aortic
lymph nodes, displaces IVC anteriorly and encases the right
renal vascular pedicle and abdominal aorta. Posterior
mediastinal mass/ lymphadenopathy encases distal thoracic aorta.
3. Right hydronephrosis is partially imaged.
5. Splenomegaly.
___ CT-guided biopsy ___:
- Touch prep of core biopsy
- LN workup
FINDINGS: Noncontrast CT performed for preprocedure evaluation
demonstrates a 3.1 x 1.6 cm left anterior pleural-based mass.
This nodule was targeted for biopsy. Additional smaller
pleural-based nodules are identified as well as pulmonary
parenchyma nodules, the largest at the right lung base measuring
3 x 3.1 cm. Trace bilateral pleural effusions with adjacent
atelectasis are noted.
The heart is enlarged. There are dense coronary artery vascular
calcifications. There is soft tissue density around the
thoracic and visualized abdominal aorta, compatible with
metastatic disease.
CT ABD/PELVIS ___:
1. 6.6 x 6.2 x 7.4 cm (AP x TRV x CC) soft tissue mass mass
effaces the lower pole of the right kidney, and obstructs an
upper pole calyx (2:37, 601b:36).
2. Large nodal conglomerate mass in the retroperitoneum
displaces the IVC and encases the abdominal aorta, as described
on the recently obtained CT of the chest from earlier today, as
is extensive upper abdominal lymphadenopathy.
3. Diffuse bladder wall thickening with an enlarged and nodular
prostate gland.
4. Enlarged spleen with hypodense 2 cm mass, as described on
abdominal ultrasound from earlier today.
5. Bilateral pars defects at the L5 level contribute to grade 1
anterolisthesis of L5 on S1.
CT CHEST ___:
1. Multiple pulmonary nodules, pleural based and extrapleural
lesions and retroperitoneal masses/lymphadenopathy consistent
with malignancy such as lymphoma or metastatic disease of
unknown primary. One extrapleural posterior mediastinal lesion
likely involves adjacent T 6 and 7 vertebral bodies.
2. Retroperitoneal mass, which is probably a conglomerate of
para-aortic lymph nodes, displaces IVC anteriorly and encases
the right renal vascular pedicle and abdominal aorta. Posterior
mediastinal mass/ lymphadenopathy encases distal thoracic aorta.
3. Right hydronephrosis is partially imaged.
5. Splenomegaly.
RENAL ULTRASOUND IMPRESSION ___:
1. There is a 7.4 cm mass in the mid right kidney, concerning
for malignancy. There is right upper pole calyceal dilation
consistent with obstruction by tumor.
2. Limited evaluation of spleen shows 2 cm and 0.7cm masses
also concerning for metastasis. There is evidence of additional
metastatic disease in the abdomen including retroperitoneal
masses and a possible deep pelvic mass.
The findings could represent diffuse lymphoma or other diffuse
metastatic disease.
CARDIAC ECHO, ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>65%).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic root, ascending aorta and arch are mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
very severe aortic valve stenosis (Vmax ___ or mean gradient
>=60mmHg; valve area <1.0cm2). Mild [1+] aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: Very severe aortic valve stenosis. Moderate
symmetric left ventricular hypertrophy with preserved regional
and global biventricular systolic function. Mildly dilated
thoracic aorta. Mild aortic regurgitation. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the aortic valve gradient has further progressed and the
estimated PA systolic pressure is now lower.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if a surgical or TAVI
candidate, a mechanical intervention is recommended.
CHEST PORT LINE PLACEMENT ___
There is a new right-sided PICC line with the distal lead tip in
the right atrium. This could be pulled back 3-4 cm for more
optimal placement. Heart size is within normal limits. There
is again noted multiple masses within the left upper lobe which
are pleural based on the recent CT scan. There are no
pneumothoraces. There is atelectasis versus developing
infiltrate at the right base.
MR HEAD W/O CONTRAST
1. Study is moderately degraded by motion.
2. 9 x 18 x 14 mm right frontal extra-axial suppressed and 9 x 6
x 9 mm left middle cranial fossa masses as described.
Differential considerations include meningioma and dural
metastatic lesion. Recommend clinical correlation and attention
on followup imaging. If clinically indicated, CT of the head
may be obtained for evaluation for osseous involvement.
RECOMMENDATION(S):
1. 9 x 18 x 14 mm right frontal extra-axial suppressed and 9 x 6
x 9 mm left middle cranial fossa masses as described.
Differential considerations include meningioma and dural
metastatic lesion. Recommend clinical correlation and attention
on followup imaging. If clinically indicated, CT of the head may
be obtained for evaluation for osseous involvement.
Brief Hospital Course:
Mr. ___ is an ___ w/severe aortic stenosis ___ 0.8),
HTN, CAD s/p DES to LAD ___ who p/w substernal CP found on
admission to have metastatic disease ___ DLBCL, final pathology
from a L subpleural nodule core bx pending.
# DLBCL: Patient presented with newly discovered mass in LUL on
CXR, which revealed a 3.7 cm elliptical opacity in the mid left
upper lung. CT chest on ___ revealed multiple pulmonary nodules
with many pleural and extrapleural lesions and retroperitoneal
masses/LAD c/w lymphoma vs metastatic disease. Also notes one
posterior mediastinal lesion likely involving T6 and 7 vertebral
bodies. Abdominal CT also on ___ revealed splenomegaly, a
8.1x7.9 cm retroperitoneal mass encasing the abdominal aorta,
and a posterior mediastinal mass/ lymphadenopathy encasing
distal thoracic aorta. The CT also revealed a 7.2x 6.4 mass in
the R kidney and 2.0cm splenic lesion. Patient underwent CT
guided pleural biopsy of a lung nodule, pathology consistent
with Diffuse Large B cell lymphoma. Given patient's
co-morbidities, mini-CHOP was chosen as treatment. Brain MRI on
___ revealed extra-axial lesions concerning for most likely
meningioma.Patient started on Prednisone on ___, day 1 of
chemotherapy was ___. The patient received three days of mini
chop and five days of prednisone.
# Hypercalcemia: Corrected calcium on admission 13.7. Likely
secondary to lytic bone metastasis vs paraneoplastic. PTH 9
appropriately low. Patient symptomatic with constipation.
Received 60 iv pamidronate ___ and 1L NS @ 150cc/r w/ 20 iv
lasix given severe AS. PTHrP was within normal limits.
Hypercalcemia closely monitored on ___ service and improved with
prednisone and chemotherapy treatment.
# AoCKD Stage III: Creatinine 2.4 on admission, up baseline of
1.5. Likely multifactorial from renal mass causing R
hydronephrosis, hypercalcemia, potential pre-renal. Urine lytes
from ___ w/ FeNa 1.3%, FeUrea 41.7% inconsistent with pre-renal
etiology. Urology consulted, did not think patient a candidate
for ureteral ___. Creatinine improved with Prednisone therapy,
and was 1.7 on discharge.
# Hyperuricemia: Uric acid ~11 on admission. Patient presented
with hyperuricemia in the setting ___ on CKD, but may have
been exacerbated by urate nephropathy or tumor lysis syndrome,
though electrolytes did not meet ___ criteria (Uric
acid>8 (his:11s), K>6 (his:5.0), Phos>4.5(his:3.3), Ca<7
(his:12s). Treated with allopurinol ___ QD with excellent
effect. Uric acid was 4.2 upon admission and we increased the
allopurinol to 200 daily upon discharge.
# R Hydronephrosis: Worsening renal function likely related to
hydronephrosis found on CT in the setting of metastasis and CKD
stage III. ___ also have a cardiorenal component. Cr 2.4
(baseline 1.5, uptrending since ___. Renal ultrasound revealed
right upper pole calyceal dilation consistent with obstruction
by tumor. Urology consulted, weighed in on his R hydronephrosis
___ obstruction with uptrending Cr, but because patient was
making adequate urine, with significant ureter obstruction,
determined patient not a candidate for ___. Percutaneous
approach contraindicated in the setting of dual antiplatelet
agents for his ___.
# Anemia: s/p transfusion ___ with 1U PRBCs well tolerated.
Patient reported profound generalized fatigue and progressive
anemia since ___ while on dual antiplatelet agents. H/H
7.8/23.5 (down from 8.7/26.9) on admission. Likely ___
malignancy with a component of CKD (Cr 2.2). Could also be
related to ___ syndrome, given combination of severe AS and
anemia. No BRBPR, hematochezia, or melena. Guaic negative in ED,
though guaic positive on the floor. Iron studies: Fe 36 (low),
ferritin 106, TRF, B12 wnl 645. H/H was stable at 9.2 upon
discharge. Still anemic likely secondary to chemotherapy effect.
# Severe Aortic Stenosis ___ 0.8cm2): Last saw Dr. ___
___ with plan to discuss options with family. Patient
intermediate risk for SAVR, but given his metastatic disease,
his evaluation for this procedure was placed on hold.
Disqualified for SURTAVI Trial. Likely considering balloon
valvuloplasty for palliation if chest pain worsens. Patient
presented with progressively worsening substernal chest pain
radiating to the back and shoulder with minimal exertion and
increasing frequency. His worsening AS was likely a contributor
to his chest pain, though he had no episodes of CP while
inhouse. Workup negative for a cardiac etiology, with negative
CEx2 and EKG without significant changes from ___. In the
setting of significant pulmonary and per-aortic metastasis,
likely chest pain related to his significant tumor burden. ___
recommended holding off while patient undergoes treatment for
metastatic disease. ___ consider balloon valvuloplasty if
patient's conditions worsens during treatment for his lymphoma.
# Hypothyroidism: TSH 42 ___. T3, FREE 1.2 (low). T4, FREE 1.2
(wnl). Repeat TSH 27. Continued on home dose of Levothyroxine.
Labs should be repeated as an outpatient given the patient's
acute illness in the hospital making TFTs more diffciult to
interpret.
# CAD s/p DES to LAD: PCI placed ___, and patient tolerated
well with significant improvement in functional and exercise
capacity. Patient continued on clopidogrel, atorvastatin,
amlodipine, metoprolol and ASA. Plavix was stopped prior to
initiation of treatment with mini-CHOP, and aspirin was stopped
before the patient was discharged. Pt had no CP during
admission.
# UTI: Patient afebrile and asymptomatic on presentation, but UA
showed pyruia, positive nitrite, and few bacteria. Received
cipro x 1 in ED. Completed course of Ceftriaxone (D1: ___ -
___. UCx w/ pansensitive E coli.
# Left lower extremity edema: LENIs negative. Patient presented
with acute onset, no calf tenderness, asymmetric swelling
compared to right side. Given progressively limited functional
capacity over the past month, h/o malignancy, concern for DVT.
Patient given SQH for ppx while inpatient.
TRANSITIONAL ISUSES:
- Patient had urinary retention during admission when tamsulosin
was held; please confirm patient is urinating well at outpatient
appointments and obtain PVR if concern for continued retention
- He was started on colace and senna given constipation. Should
be titrated as needed
- Plavix and Aspirin stopped given expected platelet drop
- He was started on acyclovir, allopurinol and bactrim ss for
ppx. Outpatient providers should adjust as necessary.
- Patient will follow up in clinic for Neulasta on ___
- Please follow Cr (discharge Cr 1.7)
- MRI brain imaging showed a 9 x 18 x 14 mm right frontal
extra-axial suppressed and 9 x 6 x 9 mm left middle cranial
fossa masses as described felt most likely meningioma versus
dural metastatic disease per report
- final tissue from core biopsy and immunphenotyping pending
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Lorazepam 0.5 mg PO QHS:PRN Anxiety, insomnia
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth q 12 Disp #*30 Tablet
Refills:*0
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 0.5 (One half)
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Loratadine 10 mg PO DAILY Duration: 2 Days
Please take this medication on ___ and ___
(___).
RX *loratadine 10 mg 1 tablet(s) by mouth one pill on ___.
one pill on ___. Disp #*2 Tablet Refills:*0
4. Amlodipine 5 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Lorazepam 0.5 mg PO QHS:PRN Anxiety, insomnia
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
11. Atorvastatin 80 mg PO QPM
12. Senna 17.2 mg PO QHS
Please hold if you develop loose stools.
RX *sennosides [senna] 8.6 mg 2 capsules by mouth 1 time in the
evening Disp #*28 Capsule Refills:*0
13. Docusate Sodium 100 mg PO BID
Hold for loose stools.
RX *docusate sodium 100 mg 1 capsule(s) by mouth two times per
day Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Diffuse Large B Cell Lymphoma
Secondary Diagnoses
Severe aortic stenosis
Acute on Chronic Kidney Disease
Coronary Artery Disease
Hypercalcemia
Hyperuricemia
Hypothyroidism
Discharge Condition:
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 on ___ with chest pain and leg swelling. During
your work-up, we discovered abnormalities in your lung and
abdomen. Because of this, we took a biopsy of one of the masses
in your lungs, and the pathology is consistent with Diffuse
Large B Cell Lymphoma. Your chemotherapy regimen was started
with five days of prednisone followed by three days of
chemotherapy before discharge.
Some of your medications have changed. Please make sure you
follow the new medication list. You will need to return to
clinic tomorrow for an injection of a medication to help your
bone marrow.
Please take the medication called loratadine on ___ morning
before coming to clinic and then again on ___ morning.
Again, it was a pleasure participating in your care.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10765488-DS-13
| 10,765,488 | 25,807,675 |
DS
| 13 |
2198-07-25 00:00:00
|
2198-07-26 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with PMH of DLBCL on R-CHOP, CAD s/p stent,
severe aortic stenosis, who presented with increasing dyspnea on
exertion.
Patient's symptoms has been going on for 2 weeks, but appeared
to be progressing. He stated dyspnea walking from car to home,
and sometimes even from bed to bathroom. Symptom started 2 weeks
ago. He sleeps in recliner and does not typically lie flat. He
denies chest pain, diaphoresis, nausea, vomiting. He did not
notice weight gain.
While in the ___ clinic, pt was noted to have worsening
anemia, and was given 1 u pRBC. He also received 20 mg iv lasix.
Lab was notable for neutropenia (___ 112), BNP 19826, normal
cardiac markers. CXR in the clinic showed b/l effusions with
possible R sided hilar infiltrate.
He was referred to the ED, given the lack of immediate bed
openning. Initial VS in the ED were: 97.7 82 119/70 18 99% RA.
Patient was also given vancomycin and cefepime, as well as
repeat 20 mg lasix.
Past Medical History:
- Aortic stenosis
- CAD s/p DES to LAD (___)
- HTN
- HLD
- Hypothyroidism
- BPH
- B12 deficiency
- History of ___ and ___
Social History:
___
Family History:
Brother with lymphoma.
another brother with pacemaker placement and sudden death.
Daughter with breast cancer.
Physical Exam:
=============================
ADMISSION PHYSICAL EXAM:
=============================
VS: 97.4 88 127/70 18 98% on RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, ___ systolic ejection murmur, ___ heart @ LSB,
very faint S2, radiation to carotids
LUNG: Clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: 2+ pitting edema to thigh
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and dry, without rashes
=============================
DISCHARGE PHYSICAL EXAM:
=============================
Vitals: 98.1 F, HR ___, BP 90-140/60-80, RR 18, 96% RA
General: NAD, hard of hearing, pleasant
HEENT: NCAT, MMM, JVP 5-6 cm at clavicle
Lungs: CTAB
CV: loud mechanical-sounding holosystolic murmur, normal rate
Abdomen: + BS, NT ND
Ext: warm, well perfused, no edema
Pertinent Results:
=====================
ADMISSION LABS:
=====================
___ WBC-0.6*# RBC-2.35* Hgb-7.5* Hct-22.6* MCV-96 MCH-31.9
MCHC-33.2 RDW-19.1* RDWSD-67.7* Plt Ct-84*#
___ Neuts-23* Bands-5 ___ Monos-13 Eos-11* Baso-3*
___ Myelos-1* AbsNeut-0.17* AbsLymp-0.26*
AbsMono-0.08* AbsEos-0.07 AbsBaso-0.02
___ Glucose-151* UreaN-28* Creat-1.1 Na-140 K-4.0 Cl-110*
HCO3-21* AnGap-13
___ ALT-13 AST-12 LD(LDH)-205 CK(CPK)-55 AlkPhos-63
TotBili-0.6
___ TotProt-5.8* Albumin-4.0 Globuln-1.8* Calcium-8.7
Phos-2.5* Mg-1.9
========================
PERTINENT RESULTS:
========================
___ cTropnT-0.01 ___
___ cTropnT-0.02*
___ CK-MB-4 cTropnT-0.02*
___ Lactate-1.3
___ 05:28AM BLOOD WBC-1.0* RBC-2.79* Hgb-8.8* Hct-25.9*
MCV-93 MCH-31.5 MCHC-34.0 RDW-18.8* RDWSD-63.8* Plt ___
___ 06:15AM BLOOD WBC-2.4*# RBC-2.69* Hgb-8.5* Hct-24.7*
MCV-92 MCH-31.6 MCHC-34.4 RDW-18.6* RDWSD-62.0* Plt Ct-95*
___ 05:47AM BLOOD WBC-4.2# RBC-2.52* Hgb-8.1* Hct-23.3*
MCV-93 MCH-32.1* MCHC-34.8 RDW-18.3* RDWSD-60.6* Plt Ct-97*
___ 05:20AM BLOOD WBC-6.8# RBC-2.52* Hgb-8.0* Hct-23.5*
MCV-93 MCH-31.7 MCHC-34.0 RDW-18.7* RDWSD-62.2* Plt Ct-99*
___ 12:04AM BLOOD WBC-10.6*# RBC-2.64* Hgb-8.3* Hct-24.8*
MCV-94 MCH-31.4 MCHC-33.5 RDW-19.3* RDWSD-64.3* Plt ___
___ 05:10AM BLOOD WBC-12.7* RBC-2.71* Hgb-8.4* Hct-25.7*
MCV-95 MCH-31.0 MCHC-32.7 RDW-19.7* RDWSD-65.7* Plt ___
___ 05:20AM BLOOD WBC-11.4* RBC-2.64* Hgb-8.1* Hct-25.2*
MCV-96 MCH-30.7 MCHC-32.1 RDW-19.8* RDWSD-67.1* Plt ___
___ 05:19AM BLOOD WBC-10.4* RBC-2.47* Hgb-7.7* Hct-23.7*
MCV-96 MCH-31.2 MCHC-32.5 RDW-19.9* RDWSD-68.0* Plt ___
___ 05:47AM BLOOD Neuts-78* Bands-2 Lymphs-11* Monos-7
Eos-1 Baso-0 ___ Myelos-1* AbsNeut-3.36
AbsLymp-0.46* AbsMono-0.29 AbsEos-0.04 AbsBaso-0.00*
___ 05:20AM BLOOD Neuts-83* Bands-0 Lymphs-12* Monos-2*
Eos-1 Baso-1 ___ Myelos-1* AbsNeut-5.64
AbsLymp-0.82* AbsMono-0.14* AbsEos-0.07 AbsBaso-0.07
___ 06:00PM BLOOD cTropnT-0.02*
___ 05:28AM BLOOD CK-MB-4 cTropnT-0.02*
___ 05:20AM BLOOD CK-MB-4 cTropnT-0.03*
___ 12:04AM BLOOD CK-MB-4 cTropnT-0.02*
===
CXR (___): Mild interstitial pulmonary edema and bilateral
pleural effusions increased since ___, representing volume
overload. Opacity in the right infrahilar region may represent
vascular congestion, however superimposed pneumonia cannot be
ruled out.
===
CXR (___): A right chest port is again seen in stable
position with distal tip projecting over the right atrium. Again
seen are low lung volumes by suboptimal inspiratory effort.
There is unchanged mild enlargement of the cardiac silhouette.
Diffuse, centrally predominant interstitial prominence is
compatible with pulmonary vascular congestion and likely mild
pulmonary edema. A small to moderate right pleural effusion is
again noted. A trace left
pleural effusion is difficult to exclude. Retrocardiac
opacification is unchanged, likely reflective of relaxation
atelectasis. There is no pneumothorax.
===
CT ___: Interval development of relatively extensive
bilateral pleural effusions, right more than left and subsequent
areas of lobar collapse. The known posterior mediastinal mass is
unchanged in size. Unchanged up to 6 mm large lung nodules.
Evidence of mucous plugging at the level of the left lower lobe.
===
CT Abdomen/Pelvis (___): Interval decrease in disease
burden, including decrease in size of a known right renal lesion
and retroperitoneal and mesenteric lymphadenopathy, reflecting
therapeutic response. No new focus of disease or new
lymphadenopathy. Splenomegaly.
Diverticulosis. Please see the chest CT dictation regarding
intrathoracic findings.
===
___ (___): The left atrial volume index is severely
increased. Color-flow imaging of the interatrial septum raises
the suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is moderate global left ventricular hypokinesis
(LVEF = 35 %). The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with normal free wall
contractility. The aortic arch is mildly dilated. There are
focal calcifications in the aortic arch. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area = 0.6cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___, the
left ventricular ejection fraction is markedly reduced.
===
CXR (___): Small right pleural effusion is smaller. Small
left pleural effusion is the same or larger and mild
interstitial pulmonary edema is the same. Heart size top-normal.
Right hilar enlargement appears vascular and probably reflects
biventricular cardiac decompensation. There is no good evidence
of adenopathy in the mediastinum. Right supraclavicular central
venous infusion port ends in the upper right atrium, as before.
=====================
DISCHARGE LABS:
=====================
___ 06:17AM BLOOD WBC-10.9* RBC-2.97* Hgb-9.3* Hct-28.5*
MCV-96 MCH-31.3 MCHC-32.6 RDW-20.1* RDWSD-69.8* Plt ___
___ 12:04AM BLOOD Neuts-81* Bands-4 Lymphs-5* Monos-2*
Eos-4 Baso-2* ___ Myelos-2* AbsNeut-9.01*
AbsLymp-0.53* AbsMono-0.21 AbsEos-0.42 AbsBaso-0.21*
___ 12:04AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-1+ Acantho-1+
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-109* UreaN-17 Creat-1.2 Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 06:17AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ man with DLBCL on cycle 3 of
R-CHOP, CAD s/p DES, and severe aortic stenosis who presented to
the Bone Marrow Transplantation service with increasing dyspnea
on exertion. BNP was elevated to ___ from 3247 in ___ and the
patient was hypervolemic on exam. Imaging showed bileratal,
right greater than left, pleural effusions. He was transferred
to ___ (cardiology service) For further management of diuresis.
===================
ACTIVE ISSUES:
===================
# Acute on Chronic Systolic Heart Failure: The patient presented
from ___ clinic with two weeks of progressively
worsening dyspnea on exertion. In clinic, the patient was noted
to have worsening anemia, and was transfused 1 unit pRBCs
followed by Lasix 20 mg IV. CXR in the clinic showed bilateral
effusions with possible right-sided hilar infiltrate. The
patient was started on empiric therapy with Vancomycin
(___) and cefepime (___). On admission, BNP was
elevated to ___ from 3247 in ___ and the patient was
hypervolemic on exam. Imaging showed bileratal, right greater
than left, pleural effusions. Cardiology was consulted, and the
patient was gently diuresed with Lasix 20 mg IV daily initially,
and then Lasix 10 mg PO daily, with symptomatic improvement. ___
showed LVEF of 35% from 65% on ___ on ___, with possible
apical wall motion abnormality. EKG was without ST or T wave
changes; troponins were 0.02 with flat MB. His amlodipine was
discontinued. He was continued on metoprolol 150 mg daily.
Worsening systolic dysfunction was attributed to possible
anthracycline toxicity vs. stent restenosis. He was then
transferred to ___ for further management. Weight on day of
transfer: 136.2 lbs. He was diuresed with 20 mg IV lasix on his
first day, and transitioned to 20 mg Lasix BID with good output.
==
# Aortic stenosis: Patient has severe AS ___ 0.6cm2 on ___
___ with initial plan for SAVR vs. TAVR. However patient
was admitted to the hospital on ___ for chest pain and
shortness of breath and subsequently found to have a new lung
mass and diagnosed with DLBCL. At that time, cardiac surgery
recommended holding off intervention while patient undergoes
treatment for metastatic disease. He is not considered a
candidate for balloon valvuloplasty at the moment because he is
responding to diuresis, and given that he is doing well on
diuretics already, the risks of bleeding in a patient on Plavix
and ASA would be high.
==
# DLBCL: Diagnosed in ___. C3D13 R-CHOP. Continued
allopurinol, acyclovir prophylaxis. CT on ___ showed
interval decrease in disease burden. The pt will f/u with his
oncologist to discuss new chemo regimen given that he is thought
to have chemo-induced cardiotoxicity.
==
# CAD s/p DES to LAD: Cardiac catheterization done in ___
noted 2VD with mLAD 85% and OM4 50% stenosis. Coronary
intervention to LAD was performed with DESx1 on ___.
Continued aspirin and plavix. Continued atorvastatin 80 mg qd.
Continued metoprolol 150 mg qd.
===================
CHRONIC ISSUES:
===================
# Hypothyroidism: Continued levothyroxine 112 mcg qd.
=========================
TRANSITIONAL ISSUES:
=========================
- onc follow up: Patient will follow up with Dr. ___ on
___. He is not a candiate for balloon valvuloplasty at the
moment because he responds to diuresis, and because
valvuloplasty would carry a high risk of bleeding and 2-3%
chance of periprocedure stroke. Should he become volume
overloaded during chemotherapy and not responding diuretics, we
can consider valvuloplasty at that time. He should continue to
take his Plavix and aspirin. He needs to discuss a new
chemotherapy regimen with Dr. ___ his acute
doxorubicin cardiomyopathy. Given EF < 40% we recommend against
further doxorubicin.
- diuresis: he will get a 20 mg lasix BID prescription to take
at home.
- recommend repeat ___ in ___ weeks
- pacemaker: given his new low EF of 35%, the pt may need EP
followup to discuss ICD placement (he does have a RBBB). This
can be discussed after repeat ___.
===
CODE: Full (confirmed)
EMERGENCY CONTACT HCP: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Lorazepam 0.5 mg PO QHS:PRN insomnia
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Acyclovir 400 mg PO Q12H
10. Tamsulosin 0.4 mg PO QHS
11. Allopurinol ___ mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Levothyroxine Sodium 112 mcg PO DAILY
9. Lorazepam 0.5 mg PO QHS:PRN insomnia
10. Senna 8.6 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
12. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
13. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
14. Metoprolol Succinate XL 150 mg PO DAILY
15. Amlodipine 5 mg PO DAILY
16. Outpatient Lab Work
Check CBC, Chem 10 on ___
Please fax results to Dr. ___: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- Acute Systolic Heart Failure
- Aortic Stenosis
Secondary Diagnoses:
- Diffuse Large B-Cell Lymphoma
- Pancytopenia
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to us because you were having shortness of breath. We
found that your heart was not beating as strongly as it was
before, and that you had fluid on your lungs. We gave you a
water pill to help you get rid of the extra fluid.
You will need to follow up with Dr. ___ to discuss what
your new chemotherapy regimen should be. You will also follow up
with Dr. ___ of our heart failure specialists, in clinic
(we will call to make an appointment for you, but if you don't
hear back by next ___, please call the number listed
below).
It was a pleasure taking care of you and we wish you the ___!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10765596-DS-4
| 10,765,596 | 24,666,496 |
DS
| 4 |
2122-03-08 00:00:00
|
2122-03-09 23:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of gestational hypertension who presents with
shortness of breath, found to have hypertensive emergency.
Patient developed acute onset dyspnea around 7PM yesterday and
presented to the ED. Notes headache, but denies vision changes.
Moved from ___ 2 months ago. Takes no medications at home.
No drug use or supplements. Has not checked blood pressure in
years, but had gestational HTN while pregnant with her son ___
years ago.
In the emergency department, vitals notable for heart rate of
128
and BP 239/158, satting 99% on 2 L NC on arrival. Her labs are
notable for WBC 14.4, Hb 10.0, BMP notable for creatinine 1.3.
Normal LFTs. proBNP 7623. Troponin undetectable x1. D-dimer
1352. VBG pH 7.40 PCO2 35. EKG showing sinus tachycardia at
131
bpm. Chest x-ray showing pulmonary vascular congestion,
moderate
pulmonary edema, small left pleural effusion, no focal
consolidations. CTA chest negative for PE, notable for
cardiomegaly with moderate pulmonary edema and right greater
than
left nonhemorrhagic pleural effusions. Enlarged pulmonary
artery. She was placed on a nitroglycerin drip, currently at 5
mcg/kg/min. Also received 1 g Tylenol, 20 mg IV Lasix, Ativan
0.5 mg. Blood pressures improved on nitro drip, currently
160/106, heart rate 105, 98% RA.
On the floor, patient on nitro drip at 5 mcg/kg/min. She reports
her symptoms have improved. She says she has had these symptoms
on and for for the past month, came for evaluation as symptoms
have progressed. She was unable to lie flat while she was at
home
for the past month, and this is the first time she is able to
lie
down. In fact she has been sleeping sitting up for the past
month. Denies peripheral edema. No palpitations. When she was
pregnant ___ years ago she did have preeclampsia, says she spent
a
lot of time in the hospital. She denies any heart problems
during
the time of and after that pregnancy. She reports that she does
have significant family history of heart disease. Mother died of
MI in ___, ___ year old cousin with ?genetic heart condition now
s/p transplant doing well (not sure what condition).
She reports recent onset of bilateral leg pain in her calves and
hamstrings. She also notes headache since being on nitro gtt.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope, or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS
Hx gestational hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Social History:
___
Family History:
As above - mother died of MI in ___. Grand mother MI in ___.
Great grandmother died of MI as well unsure what age. ___ yo
cousin
w/ apparent genetic heart failure condition now doing well s/p
heart transplant.
Physical Exam:
ADMISSION EXAM:
================
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm
CARDIAC: Rapid regular rhythm, normal S1, S2. Difficult to
ascertain in the setting of tachycardia but possible systolic
murmur. Thrill present over PMI at ___ intercostal space,
midclavicular. S3 less noticeable than before.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: Mild lower extremity edema, minimal
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
===============
VITALS: 24 HR Data (last updated ___ @ 1117)
Temp: 97.6 (Tm 99.9), BP: 108/76 (99-119/63-83), HR: 71
(69-86), RR: 18 (___), O2 sat: 99% (99-100), O2 delivery: Ra
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: JVP 8 cm
CARDIAC: Rapid regular rhythm, normal S1, S2. ___ harsh
holosystolic murmur heard throughout but best at the LLSB.
Hyperdynamic precordium.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: No lower extremity edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
===============
___ 09:00PM BLOOD WBC-14.4* RBC-4.75 Hgb-10.0* Hct-34.2
MCV-72* MCH-21.1* MCHC-29.2* RDW-16.7* RDWSD-42.5 Plt ___
___ 09:00PM BLOOD Neuts-76.8* Lymphs-16.8* Monos-3.8*
Eos-1.6 Baso-0.6 Im ___ AbsNeut-11.04* AbsLymp-2.42
AbsMono-0.55 AbsEos-0.23 AbsBaso-0.09*
___:07PM BLOOD D-Dimer-1352*
___ 04:20PM BLOOD Ret Aut-1.6 Abs Ret-0.07
___ 09:00PM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-135
K-3.7 Cl-100 HCO3-20* AnGap-15
___ 09:00PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.8 Mg-1.9
___ 09:00PM BLOOD ALT-17 AST-22 AlkPhos-69 TotBili-0.5
___ 09:00PM BLOOD proBNP-7623*
___ 09:00PM BLOOD cTropnT-<0.01
___ 10:25PM URINE Color-Straw Appear-Hazy* Sp ___
___ 10:25PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 10:25PM URINE RBC-1 WBC-20* Bacteri-NONE Yeast-NONE
Epi-13 TransE-<1
___ 11:24PM URINE Hours-RANDOM Na-<20 K-16
___ 11:24PM URINE Osmolal-194
___ 10:25PM URINE UCG-NEGATIVE
___ 11:24PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS
==============
___ 06:40AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-2+*
Microcy-1+* Echino-1+* Ellipto-2+* RBC Mor-SLIDE REVI
___ 04:20PM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8 Iron-21*
___ 08:20AM BLOOD %HbA1c-5.2 eAG-103
___ 08:20AM BLOOD Triglyc-88 HDL-58 CHOL/HD-3.0 LDLcalc-100
___ 04:20PM BLOOD TSH-1.5
___ 08:20AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:20AM BLOOD PEP-NO SPECIFI IgG-1521 IgA-285 IgM-120
IFE-NO MONOCLO
___ 06:30AM BLOOD FreeKap-32.7* FreeLam-31.5* Fr K/L-1.0
___ 06:27AM BLOOD HIV Ab-NEG
___ 08:20AM BLOOD HCV Ab-NEG
PERTINENT IMAGING
==================
CTA Chest ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality
2. Cardiomegaly with moderate pulmonary edema and bilateral,
right greater than left, nonhemorrhagic pleural effusions
3. The main pulmonary artery is enlarged, suggestive of
pulmonary
artery hypertension
___ Duplex Renal Ultrasound
Normal renal ultrasound. No evidence of renal artery stenosis.
___ TTE Report
LVEF 30%. severe concentric left ventricular hypertrophy with
moderate-to-severe left
ventricular systolic dysfunction with regional variation
(inferior and posterior walls worst)
___ Bilateral Doppler US for DVT
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. No focal fluid collection.
___ Cardiac MRI
Moderate left ventricular hypertrophy with severely increased
mass index. Severely dilated left ventricle and severe global
systolic dysfunction with preservation of function of the apical
segments (see schematic). No late gadolinium enhancement c/w
absence of focal fibrosis/scar. Normal right ventricular cavity
size with mild global systolic dysfunction. Mild aortic and
mitral regurgitation.
Given the presence of significant left ventricular hypertrophy
and absence of gadolinium enhancement, the CMR findings are most
suggestive of a hypertensive cardiomyopathy.
DISCHARGE LABS
===============
___ 06:40AM BLOOD Glucose-91 UreaN-27* Creat-1.3* Na-138
K-4.4 Cl-100 HCO3-22 AnGap-16
___ 06:40AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.2
___ 06:40AM BLOOD proBNP-130
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] Hepatitis non-immune. Encourage vaccination as outpatient
[ ] Consider genetic counseling as outpatient given young age
and presentation with HF and HTN
[ ] Plans to return to ___ in ___, please consider
this with relevant testing
[ ] Repeat Metanepherine urine testing pending, if positive or
for questions contact endocrine fellow ___, she saw
patient inpatient from endocrine
[] Patient provided with financial services information to
assist her in affording appointments. Please keep her lack of
insurance in mind when prescribing new medications, setting up
appointments etc
SUMMARY STATEMENT:
====================
___ from ___ 2 months prior to admission presented with
dyspnea, found to have heart failure exacerbation and
hypertensive emergency. She initially required a nitro drip and
IV diuresis improving prior to discharge. Her heart failure
etiology was thought to be ___ hypertension. Extensive secondary
hypertension evaluation showed elevated metanephrines in her
urine for which endocrine was consulted and recommended repeat
testing.
# CORONARIES: unknown
# PUMP: 30%
# RHYTHM: sinus tach
ACTIVE ISSUES:
==============
# Acute Heart Failure with reduced EF
New diagnosis. Extensively laboratory eval as below w/o
findings. MRI w/o infiltrative disease. She did have elevated
urine metanephrines in the setting of her hypertensive episode.
Notably a pheochromocytoma can cause a cardiomyopathy. Endocrine
was consulted as below.
She was iron deficient and received IV iron and goal directed
heart failure management with lisinopril, spironolactone, and
carvedilol.
Work up: HIV neg, ferritin 21 wnl, TSH 1.5 wnl, Hep B
neg/unvaccin, HCV b neg, urine tox negative, SPEP/UPEP, free
kappa/lambda light chains (elevated, normal ratio) Considered
lyme (no conduction abnormality noted but prolonged QT).
# Hypertensive emergency
# Elevated urine metanephrines
Given severe elevation in this patient with history of
gestational hypertension secondary HTN work up initiated. Sent
renin/aldosterone ratio, 24 hour urine fractionated
metanephrines & catechols, serum metanephrines. Urine
metanephrines were positive, but this was during hospitalization
when she was hypertensive which can raise the levels in any
patient. We repeated testing inpatient prior to discharge. If it
remains elevated she will likely require abdominal imaging. A
renal artery ultrasound w/ doppler was negative. Pt was weaned
off nitro gtt and uptitrated GDMT per above. She also was
started on amlodipine, which was later d/c'd in favor of ACE
inhibitor and carvedilol for goal directed medical therapy.
# Microcytic anemia, iron deficiency
No evidence of bleeding. Unclear cause given pt history.
Possibly menorrhagia, as it is the most common cause and patient
recounts myomectomies. Sent iron studies, retic count, hemolysis
labs, and started IV iron given iron deficiency seen on labs.
# Prolonged QT
Pt found to have prolonged QT so we avoided QT prolonging agents
# Leg pain
Patient reporting bilateral leg pain. No edema, no skin changes;
low concern for DVT but given reoccurred got doppler US of LEs
that was negative. Pain may be a side effect of diuretic, and
has resolved.
# ___
Likely cardiorenal given improvement following diuresis.
Diuresed per above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed for pain Disp #*180 Tablet Refills:*3
2. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
3. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
4. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
5. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute heart failure exacerbation with reduced ejection fraction
Hypertension
SECONDARY DIAGNOSIS:
Anemia
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 ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were short of
breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital you were found to have new heart failure. We
did many blood and imaging tests and think your heart failure is
because of high blood pressure.
- We did a work up to find out why your blood pressure is so
high. Some of the tests indicate you may be producing too much
adrenaline. This can also happen when your blood pressure is
high so we repeated the test before you were discharged.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below. We are
providing you with information from financial services to help
you since you do not have insurance.
- If your weight goes up or down by more than 3 lbs (discharge
weight 93.8 kg or 207 lbs), please call the cardiology office
for instructions (___)
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10765746-DS-10
| 10,765,746 | 28,051,876 |
DS
| 10 |
2156-01-09 00:00:00
|
2156-01-09 16:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ left-handed man with a
history of alcoholism, CAD, NIDDM, peripheral neuropathy, and
hyperlipidemia who presents with left-sided weakness started at
4
___ on ___. He was at home yesterday afternoon sitting at a
table. He says he put his ___ down to take a nap, and awoke
~15
minutes later and discovered he had difficulty using his left
arm. He tried to get up and discovered his left leg was weak
and
he could not walk. He minimized his symptoms to his wife over
the
subsequent hours, and refused to go to the hospital. His adult
son came home ~9PM, and during the subsequent hours as they had
to carry him around, to the bathroom, etc, they eventually
convinced him he needed to go to the hospital. They arrived in
the ED at ~2:20AM on ___, about 10 hours after last known well.
He was far out of the window for tPA. CTA was done which showed
no vessel cutoffs, particularly in any areas which would be
amenable to endovascular intervention this many hours
post-ictus.
He was recently admitted in the ED (observation) from ___
for
vomiting, diarrhea, and hyperglycemia related to poor medication
compliance and heavy alcohol use. He had previously been taken
off of insulin due to concerns for hypoglycemia given his
drinking. According to his son, he drinks "all the time", ___ to
an entire bottle of liquor at a time. He takes his metformin
inconsistently. His compliance with his other medications is
questionable. His son says it is difficult to believe anything
he
says. His son does say that he has been drinking less alcohol
following the ED admission earlier this month, though he did
drink heavily last ___.
His son notes that he has not been eating much in the last
month,
and has lost weight in the last year. He does not weigh
himself,
but his son says he looks much thinner than he did ___ year ago.
Past Medical History:
- DM2: last HbA1C 8.3, on Metformin 500mg BID which he takes
faithfully
- Dyslipidemia
- Hypertension
- Past tobacco abuse
- Alcohol abuse
Social History:
___
Family History:
Multiple family members with DM
Father died of snake bite
Mother and eldest brother died of complications of diabetes
5 children all health
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
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 without difficulty. Speech is fluent with full
sentences,
intact repetition, and intact verbal comprehension. Naming
intact
to items on stroke card. No paraphasias. No dysarthria on
"pa-ma-ta-ka-ga". 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 confrontation.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
speech. Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 4 5 5 4 4 4- 2+ 4 4- 4 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes: Brisk
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 2+ 0
Plantar response mute on left, extensor on right.
- Sensory: No deficits to light touch, proprioception, or cold
sensation. No extinction to DSS.
- Coordination: On left, mild dysmetria on FNF and slowed
repetitive finger tapping, however both appear in proportion to
weakness.
- Gait: Not able.
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, lying in bed 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 ___ edema.
Skin: no rashes or lesions noted.
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, place, and
date. Able to relate
history without difficulty. Speech is fluent with full
sentences,
intact repetition, and intact verbal comprehension. Naming
intact
to items on stroke card. No paraphasic errors. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 2->1 brisk. VF full to confrontation.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
speech. Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No tremor or asterixis.
[___]
L 4+ 5 5- 4+ 4 4 4- 5 4 4+ 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 2+ 0
Plantar response mute on left, extensor on right.
- Sensory: No deficits to light touch, proprioception, or cold
sensation. No extinction to DSS.
- Coordination: On left, + dysmetria on FNF and slowed finger
tapping
- Gait: Not able.
Pertinent Results:
___ 06:25AM BLOOD WBC-5.2 RBC-4.33* Hgb-14.4 Hct-38.7*
MCV-89 MCH-33.3* MCHC-37.2* RDW-13.2 RDWSD-43.2 Plt ___
___ 02:37AM BLOOD WBC-6.6 RBC-4.32* Hgb-14.6 Hct-39.4*
MCV-91 MCH-33.8* MCHC-37.1* RDW-13.3 RDWSD-45.1 Plt ___
___ 06:25AM BLOOD ___ PTT-30.4 ___
___ 02:37AM BLOOD ___ PTT-26.9 ___
___ 06:25AM BLOOD Glucose-118* UreaN-18 Creat-1.5* Na-134
K-4.1 Cl-97 HCO3-23 AnGap-18
___ 02:37AM BLOOD Glucose-287* UreaN-25* Creat-2.3*#
Na-131* K-6.3* Cl-95* HCO3-20* AnGap-22*
___ 04:17AM BLOOD ALT-17 AST-14 AlkPhos-80 Amylase-80
TotBili-0.3
___ 04:17AM BLOOD Lipase-105* GGT-44
___ 06:25AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.1
___ 02:37AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.2
___ 04:17AM BLOOD Albumin-4.0 Cholest-138
___ 05:44AM BLOOD %HbA1c-8.4* eAG-194*
___ 04:17AM BLOOD Triglyc-198* HDL-36 CHOL/HD-3.8
LDLcalc-62
___ 04:17AM BLOOD TSH-1.2
___ 02:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
- ___ CTA ___ & Neck
1. Acute infarcts in the right pons and medulla seen on
subsequent MRI are not well visualized on this CT. No
hemorrhage. Extensive bilateral white matter changes suggestive
of chronic small vessel ischemic disease.
2. High-grade focal narrowing at the origin of the basilar
artery. Otherwise, unremarkable ___ CTA aside from scattered
atherosclerotic disease.
3. Mixed soft and calcified plaque at the carotid bifurcations
does not result in significant luminal narrowing of the internal
carotid arteries by NASCET criteria.
4. Mild multifocal atherosclerotic plaque along the course of
the vertebral arteries without appreciable luminal narrowing.
5. Filling defect in a subsegmental left upper lobe pulmonary
artery is suspicious for pulmonary embolism. Dedicated CTA
chest is recommended for confirmation.
6. Diffuse esophageal wall thickening likely representing
nonspecific
esophagitis.
7. 3 mm right upper lobe pulmonary nodule.
___ Chest
1. Re-demonstration of left upper lobe subsegmental pulmonary
embolus. No other pulmonary emboli visualized. No signs of
right heart strain.
2. Mild, left greater than right bilateral lower lobe
atelectasis.
3. Moderate coronary calcific atherosclerosis.
4. Cholelithiasis.
___ ___ w/o
1. Focus of late acute infarction involving the right anterior
pons and right upper medulla.
2. Extensive white matter changes, suggestive of chronic small
vessel ischemic disease and chronic lacunar infarcts in the left
cerebellum, left thalamus, and bilateral basal ganglia.
3. No hemorrhage.
Brief Hospital Course:
Pt presented to ___ with new onset of left hand and leg
weakness although was seen to be outside of tPA window and not a
thrombectomy candidate. He was admitted to the Neurology Stroke
Service and was monitored on telemetry. On imaging, he was seen
to have basilar artery narrowing on CTA as well as acute infarct
in right anterior pons and upper medulla on MRI, suggestive of
large vessel disease producing infarct in small vessel
territory. He was also noted to have a subsegmental pulmonary
embolism on CTA Chest and per discussion with Medicine was
started on Eliquis as anticoagulation therapy for 3 months. He
was continued on his home statin and underwent Echocardiogram.
While admitted, his diabetes regimen was adjusted per ___
Diabetes Team although pt did not want to start insulin and
wished to remain on home PO diabetes medications. He was
evaluated by ___ and deemed candidate for acute 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 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 = 62 ) - () 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 if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
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: ()
Antiplatelet - (X) 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. Aspirin 81 mg PO DAILY
2. Gabapentin 200 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. amLODIPine 10 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID
Take twice daily for 7 days followed by 5mg twice daily for 3
months
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*2
2. amLODIPine 10 mg PO DAILY
3. Gabapentin 200 mg PO DAILY
4. GlipiZIDE 10 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Rosuvastatin Calcium 40 mg PO QPM
10. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until completion of three month therapy of
Eliquis and PCP agrees
Discharge ___:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke in R anterior pons and upper medulla
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of left sided weakness
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
Coronary artery disease
Diabetes Mellitus
We are changing your medications as follows:
Please continue taking Eliquis 10mg twice daily for 7 days.
Then, take 5mg twice daily for 3 months to treat blood clot in
lungs. After completion of this therapy, start taking Aspirin
81mg daily.
Please take your other medications as prescribed.
Please followup with your primary care physician and obtain
referral to see a neurologist. Please call Nephrology at ___
___ to schedule appointment per your PCP's recommendations.
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:
___
|
10765746-DS-11
| 10,765,746 | 26,589,808 |
DS
| 11 |
2156-01-15 00:00:00
|
2156-01-16 07:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Extremity stiffness / weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman witha PMHx
of recent right pontine and medullar infarcts
(admitted___, residual left ___ weakness in UMN
pattern and LUE dysmetria), HTN, HL, DM, tobacco use, and active
alcohol use disorder who presented with acute worsening of his
weakness at 1pmthe day PTA and left sided stiffness that started
at 12:30pm on day of admission and has been improving since
then.
The patient was recently discharged to ___ from
the neurology stroke service on ___. He had residual left-sided
weakness on discharge, but felt that his weakness had been
improving since presentation on ___ (although not full
strength). He notes that he first experienced worsening of his
new baseline yesterday (___) at 1:00pm. However, per
his son who was at the bedside,
this first took place on ___ at 1:00pm. At that time, the
patient was sitting up in a wheelchair and watching television
when he developed left arm and leg stiffness and was unable to
move those limbs. He also had paresthesias in his left
fingertips. He denied any numbness, headache, dysarthria,
aphasia, or facial droop. His symptoms resolved after a few
hours and then he returned to his recent baseline. The following
day (___), at 1:00pm, he had the same symptoms as above. He
was again sitting in a wheelchair watching television. These
symptoms persisted until 9:00pm, at which time they
spontaneously resolved. On the morning of presentation
(___), he was able to participate with ___ at 10:00am and do
exercises with his left side and ambulate. However, at 12:30pm
(note: patient initially said it startedtoday at 5:25pm but
later changed the timeframe), again while sitting in a
wheelchair watching television, he experienced the
same symptoms as above. On EMS arrival, his stiffness began to
improve but he still had trouble lifting his left arm and leg
up. Notably, the patient has a longstanding history of active
alcohol use disorder. However, he denies any alcohol intake in
rehab. At baseline, he has been drinking 0.5-1 bottles of
alcohol(usually whisky) daily for the last ___ years. Also, of
note, the patient notes that his voice becomes hoarse in the
afternoons; this has been going on for 6 months.
In the emergency room he was seen by neurology who initially
recommended inpatient MRI and to resume home apixaban, hold home
antihypertensives and perform strict glycemic control.
He was given 2L NS in the ED.
On arrival to the floor, patient stated that he felt he was
moving better and confirmed story as above.
On ROS, the pt denies headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus, and hearing difficulty. Denies difficulties producing
or comprehending speech. No bowel or bladder incontinence or
retention. +Recent weight loss over last year Denies recent
fever or chills. No night sweats. 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:
- pontine and medullar infarcts (admitted ___
- DM2
- Dyslipidemia
- Hypertension
- Past tobacco abuse
- Alcohol abuse
Social History:
___
Family History:
Multiple family members with DM
Father died of snake bite
Mother and eldest brother died of complications of diabetes
5 children all health
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.5 164/91 76 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, 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: CNIII-XII intact with the exception of mildly decreased L
face sensation, ___ LUE and LLE strength ___ shoulder and elbow
flexion/extension, ___ ankle dorsiflexion, ___ ankle
plantarflexion, ___ hip flexion)
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: T 97.5 BP 146/74 HR 74 RR 18 O2Sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, 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: CNIII-XII intact with the exception of mildly decreased L
face sensation, ___ LUE and LLE strength ___ shoulder and elbow
flexion/extension, ___ ankle dorsiflexion, ___ ankle
plantarflexion, ___ hip flexion)
Pertinent Results:
ADMISSION LABS
==============
___ 06:50PM BLOOD WBC-6.2 RBC-4.45* Hgb-14.9 Hct-39.8*
MCV-89 MCH-33.5* MCHC-37.4* RDW-13.4 RDWSD-43.8 Plt ___
___ 06:50PM BLOOD Neuts-61.0 ___ Monos-12.0 Eos-1.9
Baso-1.0 Im ___ AbsNeut-3.76 AbsLymp-1.47 AbsMono-0.74
AbsEos-0.12 AbsBaso-0.06
___ 06:50PM BLOOD ___ PTT-31.4 ___
___ 06:50PM BLOOD Glucose-202* UreaN-25* Creat-1.9* Na-132*
K-4.7 Cl-94* HCO3-21* AnGap-22*
___ 06:50PM BLOOD CK(CPK)-100
___ 06:50PM BLOOD CK-MB-4
___ 06:50PM BLOOD cTropnT-<0.01
___ 08:05AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:50PM BLOOD Calcium-10.2 Phos-4.0 Mg-2.1
___ 07:14PM BLOOD Glucose-194* Lactate-4.0* Na-132* K-4.5
Cl-98 calHCO3-20*
PERTINENT LABS
==============
___ 10:35PM BLOOD Lactate-2.1*
___ 08:40AM BLOOD Lactate-2.0
PERTINENT STUDIES/IMAGING/MICRO
===============================
___ 10:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 6:50 pm BLOOD CULTURE STROKE.
Blood Culture, Routine (Pending):
CT HEAD ___:
FINDINGS:
There is no evidence of no evidence of vascular territorial
acute infarction, hemorrhage, edema, or mass. Prominent
ventricles and sulci is suggestive of cerebellar atrophy.
Periventricular and subcortical confluent white matter
hypodensities is likely secondary to chronic small vessel
ischemic disease.
Chronic bilateral thalamic lacunar infarcts are again noted.
Old left
cerebellar infarcts are also noted. There is preservation of
gray-white
matter differentiation. The basal cisterns remain patent.
No osseous abnormalities seen. A mucous retention cyst is seen
in the left maxillary sinus. The remainder of the paranasal
sinuses, mastoid air cells, and middle ear cavities are
essentially clear. The orbits are unremarkable.
IMPRESSION:
No evidence for acute intracranial process.
Extensive white matter hypodensities which are likely sequela of
chronic small vessel disease. If persistent clinical concern
for an acute infarct, MRI may prove to be of use.
CXR ___:
FINDINGS:
The lungs are clear without lobar consolidation, pleural
effusion,
pneumothorax, or pulmonary edema. Left streaky retrocardiac
airspace opacity is noted, similar to prior and likely
representing atelectasis. The cardiomediastinal contours are
unchanged.
IMPRESSION:
Left lower lobe atelectasis. Otherwise, no evidence for acute
cardiopulmonary process.
DISCHARGE LABS
==============
___ 07:50AM BLOOD WBC-4.7 RBC-4.45* Hgb-14.5 Hct-39.6*
MCV-89 MCH-32.6* MCHC-36.6 RDW-13.2 RDWSD-43.4 Plt ___
___ 07:50AM BLOOD Glucose-173* UreaN-24* Creat-1.6* Na-136
K-4.3 Cl-98 HCO3-23 AnGap-19
___:50AM BLOOD Calcium-10.0 Phos-4.8* Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ gentleman with h/o CAD,
NIDDM, peripheral neuropathy, hld, EtOH abuse discharge on
___ from neurology with basilar artery narrowing and R
anterior pons/upper medulla stroke along with incidental
subsegmental PE started on apixaban who presented with concern
for repeat stroke symptoms likely due to recrudescence in the
setting of toxic-metabolic insult with acute kidney injury and
lactic acidosis related to metformin, vs muscle spasm in setting
of recent stroke. Antihypertensives were initially held due to
concern for stroke but neurology recommended restarting. He was
also complaining of intermittent stiffness thought due to muscle
spasm per neurology. His stroke symptoms improved back towards
his recent post-discharge baseline after fluid resuscitation and
discontinuation of metformin. Neurology saw the patient and
thought there was no concern for new or repeat stroke so repeat
MRI was not performed. As he improved back towards his recent
baseline and remained clinically stable he was cleared for
discharge back to rehab.
ACTIVE ISSUES:
# Stroke symptoms: Thought to be likely recrudescence in setting
of toxic/metabolic insult with ___ and metformin-related lactic
acidosis. No evidence of infection or acute intracranial process
was found. Neurology felt there was not significant concern for
new or repeat stroke so repeat MRI was not performed. He was
continued on his home rosuvastatin. His home antihypertensives
were restarted with the exception of lisinopril which was held
given ___. He was continued on his home apixaban and restarted
on aspirin 81mg daily.
# Extremity stiffness: Likely due to post-stroke muscle spasm
per neurology. Patient did not find it bothersome enough to
start medication. Neurology's recs as below:
-If significant symptoms can start baclofen 5mg PO TID and
uptitrate as needed
# Acute kidney injury, improving: Cr down to 1.5 on ___ after
fluid administration though baseline is likely 1.2. Likely at
new baseline after repeat insults. Discontinued metformin given
Cr and lactic acidosis. Held lisinopril. Will need ongoing
monitoring as an outpt.
# Lactic acidosis, resolved: Lactate 4.0 on admission down to
2.1 with hydration. Thought due to metformin administration with
___. Resolved after fluid resuscitation and discontinuing
metformin.
# Subsegmental PE: Incidentally found on previous admission as
part of diverticulitis workup. He is getting a therapeutic
course of apixaban. Continue home apixaban (in the midst of 10mg
BID x7 days through ___ change to 5mg PO BID on ___ plan
for 3 months anticoagulation)
# Hyperlipidemia:
-continued home rosuvastatin 40mg
# Diabetes mellitus:
-Humalog SS AC and HS while in house
-held home glipizide in-house, restarted on discharge
-discontinued metformin given Cr
-Appointment set up for ___ follow up on discharge
# Coronary artery disease
-3VD, recommended medical therapy on cardiac cath ___
-restarted home aspirin at 81mg daily
-continued metoprolol at home dose
# Hypertension
-restarted home antihypertensives (amlodipine, HCTZ) after
briefly being held, but continued to hold lisinopril given ___
-If persistently hypertensive, would recheck Cr and if stable
(1.5), or improved, would consider restarting lisinopril
# Alcohol use disorder
-last drink ___
-multivitamin
TRANSITIONAL ISSUES
===================
[ ] HELD lisinopril in setting of recent ___. Cr 1.6 on
discharge (baseline 1.5-1.6). Please repeat chem 7 in ___ days
to ensure stability and restart lisinopril at that time.
[ ] Continue home apixaban (changed to 5mg PO BID on ___ plan
for 3 months anticoagulation to end ___
[ ] Restarted on reduced dose aspirin 81mg daily.
[ ] If persistent muscle spasm symptoms can consider starting
baclofen 5mg PO QHS and uptitrate to TID as needed.
[ ] Patient scheduled with Neurology for stroke, please ensure
attendance at this appointment
[ ] Patient continuing to refuse insulin, discharged on PO
glipizide, please continue to address diabetes education,
potential need to start insulin
# CODE: full (confirmed)
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 10 mg PO BID
2. GlipiZIDE 5 mg PO BID
3. Gabapentin 200 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Metoprolol Succinate XL 100 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Apixaban 5 mg PO BID
last dose of ___
3. amLODIPine 10 mg PO DAILY
4. Gabapentin 200 mg PO DAILY
5. GlipiZIDE 5 mg PO BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until discussing with your doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Recrudescent stroke
Muscle spasm
Acute kidney injury
SECONDARY DIAGNOSIS
===================
Hypertension
Coronary artery disease
Alcohol use disorder
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 brought to the hospital because you were having
stiffness in your arm and leg. You were seen by neurology who
thought that these symptoms were due to muscle spasms and not a
new or repeat stroke. You also had some kidney damage which made
it unsafe for you to be on your metformin, so this medication
was stopped. You were feeling closer to how you felt when you
last left the hospital so you were able to be discharged back to
rehab to help you regain your strength after your stroke.
It is important that you follow up with your doctors and
continue to take your medications as directed.
It was pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10765746-DS-12
| 10,765,746 | 21,456,554 |
DS
| 12 |
2156-11-01 00:00:00
|
2156-11-02 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
referral from outpatient nephrologist for worsening
creatinine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with ___ CAD, DM2 c/b peripheral neuropathy and
nephropathy, CVA who was referred by outpatient nephrologist for
worsening creatinine.
Outpatient At___ nephrologist Dr. ___ him to come
to the ED for admission and expedited work-up with nephrology
referral. Dr. ___ a creatinine 1.6 in ___, ~2.0
in ___ and then 2.5 in ___. A TTE had been
ordered given low BP, rising Cr and worsening edema. Dr.
___ stated he would reach out to inpatient renal
team.
Otherwise amlodipine was recently reduced to 2.5mg, he continues
on torsemide 5mg daily. He noted mild swelling in both ankles,
no orthopnea and variable weight but no notable recent gain.
In the ED, initial vitals: T: 98.5 HR: 65 BP: 134/72 RR:16
SO2: 97% RA
- Exam notable for: none documented
- Labs notable for: creat 2.2
- Imaging notable for: none ordered
- Patient was given: 1L NS
- Consults: none
- Vitals prior to transfer: T: 97.5 HR: 70 BP: 134/58 RR: 16
SO2: 99% RA
Notably patient is on aspirin 325 mg given history of stroke,
typically this would be held for seven days prior to renal
biopsy. I discussed this with the ED team, who requested
admission based on outpatient request rather then renal
ultrasound with nephrology consult and discharge.
On arrival to the floor, patient confirms he is asymptomatic.
Denies recent medication changes, no change in urination, no
frothy/bubbly urine, no new back pain, no n/v/itching, no chest
pain.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
- pontine and medullar infarcts (admitted ___
- DM2
- Dyslipidemia
- Hypertension
- Past tobacco abuse
- Alcohol use disorder
Social History:
___
Family History:
Multiple family members with DM
Father died of snake bite
Mother and eldest brother died of complications of diabetes
5 children all health
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 0234 Temp: 98.0 PO BP: 140/74 HR: 73 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: mucosa moist, no JVD
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, 2+ edema to shins
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact other than delayed
activation of left facial, motor LUE and LLE 4+/5 vs ___ on
right
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
VITALS: 97.7PO132 / 76 R SittingHR 71 RR18POx 97%Ra
GENERAL: standing up arranging his breakfast, friendly, NAD
HEENT: mucosa moist, no JVD
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, 1+ pitting edema to shins
NEURO: Alert, oriented, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS
===============
___ 10:41PM BLOOD WBC-7.4 RBC-4.97 Hgb-14.9 Hct-41.0 MCV-83
MCH-30.0 MCHC-36.3 RDW-13.9 RDWSD-41.3 Plt ___
___ 10:41PM BLOOD Neuts-58.8 ___ Monos-12.3 Eos-2.2
Baso-1.5* Im ___ AbsNeut-4.33 AbsLymp-1.85 AbsMono-0.91*
AbsEos-0.16 AbsBaso-0.11*
___ 10:41PM BLOOD Glucose-325* UreaN-19 Creat-2.2* Na-137
K-4.2 Cl-96 HCO3-24 AnGap-17
___ 10:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
URINE
=======
___ 10:26PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:26PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 10:26PM URINE RBC-4* WBC-2 Bacteri-FEW* Yeast-RARE*
Epi-0 TransE-<1
___ 10:26PM URINE CastGr-9* CastHy-8* CastWBC-1*
___ 08:30AM URINE Color-Straw Appear-Clear Sp ___
___ 08:30AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:30AM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 08:30AM URINE Hours-RANDOM Creat-76 Na-130 Cl-106
TotProt-60 Prot/Cr-0.8*
PERTINENT INTERVAL AND DISCHARGE LABS
===================================
___ 05:43AM BLOOD WBC-7.3 RBC-4.48* Hgb-13.4* Hct-36.9*
MCV-82 MCH-29.9 MCHC-36.3 RDW-13.9 RDWSD-41.1 Plt ___
___ 05:17AM BLOOD Glucose-92 UreaN-20 Creat-2.2* Na-141
K-3.3* Cl-99 HCO3-28 AnGap-14
___ 05:17AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.6
___ 05:43AM BLOOD Albumin-3.8
___ 05:43AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*
___ 05:43AM BLOOD HCV Ab-NEG
IMAGING AND STUDIES
===================
___ RENAL US
No hydronephrosis.
2.8 cm right renal cyst.
___ CXR
In comparison with the study of ___, there are slightly lower
lung volumes.
There is increased prominence of the cardiac silhouette with
indistinctness of
pulmonary vessels, consistent with the clinical diagnosis of
elevated
pulmonary venous pressure. No evidence of acute focal pneumonia
or pleural
effusion.
___ ECHO (TTE)
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. There is severe symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>65%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Marked symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function. No
valvular pathology or pathologic flow identified. Increased
PCWP.
In the absence of a prominent history fo hypertension, an
infiltrative process (e.g., early amyloid) or primary HCM should
be considered.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ year old man with PMH CAD, DM2 c/b peripheral neuropathy and
nephropathy, CVA who was referred by outpatient nephrologist for
worsening creatinine.
ACTIVE ISSUES:
# Acute on chronic kidney disease
Patient has had ongoing worsening creatinine over the past
several months, most recently found to be 2.5. On admission, Cr
found to be 2.2 with no other electrolyte abnormalities. He was
given 1L of NS, and Cr remained stable at 2.2. Renal was
consulted. A renal ultrasound was done, showing normal kidneys
and no evidence of hydronephrosis. A chest x-ray should no
evidence of pulmonary edema. Hepatitis serologies were
significant for evidence of a previous Hep B infection.
Otherwise, remained stable. TTE showed LV hypertrophy, unchanged
from prior ECHO in ___. Given no plan for renal biopsy, was
able to be discharged home. A UPEP, which was drawn as an
outpatient, is pending and will require follow-up. Plan for
patient to follow-up with renal outpatient.
# Diabetes mellitus type 2
Uncontrolled most recent A1c of 9.4 ___. Patient was
continued on basal standing 36U, Humalog 6U with meals and HS.
Held home sitagliptin while inpatient.
# Hyperlipidemia: Continued home rosuvastatin 40mg
# Hypertension: Continued home amlodipine. Held home HCTZ,
lisinopril given concern for ___ and normotension.
# Coronary artery disease: h/o 3VD on cardiac cath ___.
Continued on aspirin 325 (on full dose given stroke),
metoprolol, and statin.
# h/o CVA: On full dose aspirin and statin.
# Alcohol use disorder: Reportedly no use 8 days prior to
admission. No evidence of withdrawal while in house.
============================================
TRANSITIONAL ISSUES
============================================
[] Recommend Cr be checked later this week to trend
[] Given ECHO showed LV hypertrophy, further w/u for
infiltration process should be considered if patient does not
have history of poorly controlled hypertension.
[] Home HCTZ and Lisinopril were held given concern for
worsening Cr - could consider restarting if remains stable on
recheck
[] Torsemide was increased to 10mg daily per renal
recommendations
[] Would continue to work with patient on strategies for weight
loss, exercise, and diabetes management
[] Hep serologies are significant for evidence of past
infection. ___ require followup and treatment prior to any
future chemotherapy or immunosuppressive regimen
# Contact: ___ ___
# Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Aspirin 325 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Gabapentin 200 mg PO DAILY
8. Glargine 35 Units Bedtime
9. Torsemide 5 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. SITagliptin 50 mg oral DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Glargine 35 Units Bedtime
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Gabapentin 200 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. SITagliptin 50 mg oral DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until your doctor
tells you it is safe to do so.
12. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you it is safe
to do so.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- acute on chronic renal failure
Secondary Diagnoses:
- diabetes type 2
- hypertension
- prior stroke
- coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
because your kidneys are not working very well. You were seen by
the kidney doctors. We also did an ultrasound of your kidneys,
which looked fine. We did an ultrasound of your heart, which
showed that the muscles in your heart are enlarged, and will
need to be looked at further. Your primary care doctor will be
able to arrange this for you. You were then able to be
discharged home.
We think it will be important that you continue to work with
your doctor to see if you need to make any changes to your diet
or exercise routine.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10765748-DS-14
| 10,765,748 | 20,758,998 |
DS
| 14 |
2172-02-09 00:00:00
|
2172-02-09 13:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Worsening Back Pain
Major Surgical or Invasive Procedure:
___: T11 laminectomy with T9-L2 fusion
___: T11 Corpectomy with placement of cage and right T9
screw revision
History of Present Illness:
___ with known oligometastatic HCC lesion to T11 re-presents to
the ___ ED on ___ with worsening back pain and bilateral
lower extremity weakness. He is known to Dr. ___
Oncology for this lesion, in which surgical excision was
recommended for pain control. At time of presentation, he is
scheduled for T11 corpectomy on ___ with Dr. ___. The
patient reports that over the previous two days leading up to
admission he declined from being able to use a walker to
requiring assistance from two people for ambulation. He denies
bladder or bowel incontinence.
Past Medical History:
HCV cirrhosis s/p harvoni with SVR c/b HE, HCC, ascities and 3
cords of grade I varices on nadolol.
DMII
Depression
Anxiety
Social History:
___
Family History:
Father: ___ (Lung CA)
Mother: ___ (Lung CA)
Brother: ___ (Sudden cardiac death in ___
Sister: Living, multiple medical issues.
Physical Exam:
ON ADMISSION:
*************
PHYSICAL EXAM:
Temp: 97.2 °F, Pulse: 52, RR: 16, BP: 146/79, O2 sat: 99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
NO Clonus
NO ___
[x]Sensation intact to light touch
Skin: Erythema noted bilaterally across lower thoracic and
lumbar
spine from prolonged hot pack usage.
========================================================
ON DISCHARGE:
************
General:
___
Temp: 99.0 PO BP: 89/54 HR: 69 RR: 16 O2 sat: 96% O2 RA
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
Right5 5 5 5 5
Left5 5 5 5 5
IP Quad Hams AT ___ ___
Right4+ 5 5 5 4+ 5
Left 4 5 4- 5 4+ 5
[x]Sensation intact to light touch
Surgical Incision:
[x]Clean, dry, intact
Staining noted on pillow; no active or expressible drainage.
[x]Staples
Drain Site:
[x]Clean, dry, intact
[x]Sutures
Pertinent Results:
Please see OMR for pertinent imaging and lab results
Brief Hospital Course:
#T11 metastatic lesion
___ is a ___ year old male with history of HCC and known
T11 lesion. Patient was schedule for surgery on ___
___, but presented to ED on ___ with worsening back
pain and lower extremity pain. Patient was admitted to the
neurosurgery service for pain control and to preop for already
scheduled surgical intervention. A CT spine was obtained to
evaluate for any acute interval changes in spine since last MRI
on ___. CT showed stable T11 lesion. Upon return to his room
after CT RN noted worsening weakness and the patient was also
noted to have new ___ decreased sensation. He went to the OR for
urgent decompression at T11 with T9-L2 fusion. He was then
brought to the operating room for the previously scheduled T11
corpectomy with placement of cage. At that time the R T9 pedicle
screw was also revised slightly. For further details about the
surgical procedures, please see the separately dictated
operative reports. On ___, a T-spine CT scan was ordered to
assess the cage, which showed good placement. Surgical drain was
removed on ___ without complications. At the time of
discharge, he has made significant progress with return of his
strength. In collaboration with ___, it was decided that he would
be best ___ for a short rehabilitation stay where he would
continue to improve his strength and conditioning.
At request of patient's oncologist, Dr. ___ patient had
a CT torso which showed increased ascites, see below. AFP was
446.9. There was however, no evidence of distant disease.
Therefore, it was decided that the patient would not need
chemotherapy until after he recovered from his surgery. His
oncology team will be in contact with him to set up outpatient
follow-up.
#Ascites
CT torso ___ revealed increased ascites. Patient denied any
abdominal pain. Hepatology was consulted and ___ guided drainage
was recommended. Cell count was not suggestive of infection.
Cultures had not finalized at the time of discharge. 4.7L was
removed and patient was given 37.5 g IV albumin x1.
#Aphasia
On the evening of ___, the patient had new onset expressive
aphasia and a code stroke was called. CT/CTA was negative for
stroke. HemeOnc and Hepatology were consulted and felt aphasia
was likely hepatic encephalopathy, see below.
#Hepatic encephalopathy
Consults were placed to HemeOnc and Hepatology, both of which
believed the new onset expressive aphasia and change in mental
status were due to hepatic encephalopathy. The patient had not
had a BM or been given his prescribed Lactulose since admission.
His Lactulose was resumed on overnight on ___, and was changed
to on ___ and titrated back to ___ BMs per day. No expressive
aphasia was noted during the patient's neurological exam the
morning of ___. Per Hepatology, lactulose was changed to
titrate to ___ BMs per day. Per hemeonc, patient was restarted
on Romiplostim, which he received evert ___.
#Anemia
The patient's H+H was low and remained stably low
postoperatively. Stool guaiac was sent and was positive on
___. Medicine was consulted given concern for a GI bleed
and deferred to Hepatology. Hepatology was consulted and
recommended sending labs, continuing the PPI, and follow-up in
the Liver Clinic. Hepatology recommended outpatient follow up
with endoscopy. Medicine recommended starting on ferric
gluconate IV x4 days followed by daily ferrous gluconate after 4
days or at time of discharge. At the time of discharge, his
hematocrit had been stable for several days.
#Elevated BUN
The patient's BUN became elevated postoperatively. Medicine was
consulted and deferred to Hepatology given that it could be
related to a GI bleed. Hepatology noted that it is possible that
this elevation is related to a small GI bleed, but thought that
it was more likely related to dehydration. BUN started to down
trend on ___.
#Hypocalcemia
The patient's calcium was low and was repleted as needed. Per
Medicine, the patient's albumin is low, so his corrected calcium
is actually appropriate.
#Suicidal Ideation
The patient expressed suicidal ideation, and Psychiatry was
consulted. The patient was briefly put under a ___ with
suicide precautions and a 1:1 sitter. Psychiatry later
re-evaluated the patient and cleared him for discharge. Social
work continued to follow the patient.
#T2DM
Patient has T2DM managed on Insulin at home. He was ordered for
his home insulin regimen on admission. When patient was made NPO
for surgery, his Insulin was adjusted according to protocol and
sugars were monitored closely.
#Disposition
___ and OT evaluated the patient and recommended rehab.
Medications on Admission:
* Lantus 100 unit/mL subcutaneous solution
16 units once daily am
* Xifaxan 550 mg tablet
1 tablet(s) by mouth po bid
* furosemide 20 mg tablet
1 tablet(s) by mouth daily
* hydromorphone 2 mg tablet
___ tablet(s) by mouth every four (4) hours as needed
* magnesium 200 mg tablet
2 (Two) tablet(s) by mouth once daily
* nadolol 20 mg tablet
1 tablet(s) by mouth once daily in addition to the 40mg
tablet to take a total dose of 60 mg daily
* nadolol 40 mg tablet
1 tablet(s) by mouth daily at night total dose 60 mg daily
* pantoprazole 20 mg tablet,delayed release
2 tablet(s) by mouth once daily
* spironolactone 50 mg tablet
1 (One) tablet(s) by mouth every other day as needed
* ursodiol 500 mg tablet
1 tablet(s) by mouth twice a day
* insulin lispro (U-100) 100 unit/mL subcutaneous pen
subcutaneous 1 insulin pen(s) sliding scale
* OxyContin 60 mg tablet,crush resistant,extended release oral
1 tablet,oral only,ext.rel.12 hr(s) Three times daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
No more than 4000mg of acetaminophen (Tylenol) total daily.
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
3. Docusate Sodium 100 mg PO BID
4. Ferric Gluconate 250 mg IV DAILY Duration: 4 Doses
Please stop after 4 doses total which will occur ___
5. Ferrous GLUCONATE 324 mg PO DAILY
Initiate after final dose of ferric gluconate
6. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Lidocaine 5% Patch 2 PTCH TD QAM
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
9. Furosemide 20 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
12. Lactulose ___ mL PO BID
13. LORazepam 0.5 mg PO BID:PRN Anxiety
14. Magnesium Oxide 400 mg PO DAILY
15. Nadolol 40 mg PO QPM
16. Nadolol 20 mg PO QAM
17. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
18. Pantoprazole 40 mg PO Q24H
19. Rifaximin 550 mg PO/NG BID
20. Romiplostim 67 mcg SC 1X/WEEK (TH)
21. Spironolactone 50 mg PO EVERY OTHER DAY
22. Ursodiol 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T11 metastatic Lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Spinal Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples. You also have sutures at
the site where your surgical drain was. You will need suture and
staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
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.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
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:
___
|
10765748-DS-15
| 10,765,748 | 29,224,743 |
DS
| 15 |
2172-09-13 00:00:00
|
2172-09-16 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ with history of HCV cirrhosis c/b metastatic
HCC to T11 (s/p RFA ___, TACE ___, SBRT ___,
cryoptherapy ___, vertebroplasty ___, T11 laminectomy and
coprectomy with cage ___, RT ___, 4 cycles of nivolumab,
and most recently C1 levatinib ___ who presents with acute
encephalopathy.
Per history obtained in the ED, the patient is typically
coherent
at baseline. About three weeks ago, he stopped taking his
rifaximin due to high copays. He continued taking his lactulose
BID and had been stooling ___ with this regimen. On
___, the patient's family noticed that he was becoming
increasing somnolent/confused. He endorsed a new cough
productive
of yellow sputum, though his family notes this is chronic for
him
due to his active tobacco use. He also reports decreased
appetite
and intermittent nausea/vomiting over the past week since
starting levatinib.
In the ED, initial vitals were: T 98.2 BP 160/80 HR 50 RR 18 O2
98% RA
Exam was notable for:
- Neuro: A&Ox2.5 (knows it is ___ but thinks it is ___. Can
recite ___ forward but not backward. +Asterixis
Labs were notable for:
- WBC 5.8, Hgb 14.6
- INR 1.5
- BUN 21, Cr 1.0
- ALT 23, AST 57, AP 124, Tbili 2.9, Alb 3.5
- Lactate 2.6
- Serum acetaminophen level 6
Studies were notable for:
- ___ CXR
1. No radiographic evidence of pneumonia.
2. 1.8 cm round opacity left lung base was seen previously,
worrisome for metastasis.
The patient was given:
- Lactulose 30mL x3, Rifaximin 550mg, Ursodiol 500mg
- Amlodipine 10mg
Consults:
- Hepatology: Admit to ET, re-start lactulose/rifaxamin,
consider
CT head if new neuro deficits, pan culture
On arrival to the floor, patient is unable to provide much
additional history but feels that he has been somewhat more
confused at home. He believes he has been taking his lactulose.
He denies fevers, chills, abdominal pain, nausea, vomiting,
cough, shortness of breath, or dysuria.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
- HCV cirrhosis s/p harvoni with SVR c/b HE, HCC, ascities and 3
cords of grade I varices on nadolol
- DMII
- HTN
- Depression
- Anxiety
ONCOLOGIC HISTORY:
==================
- ___: surveillance MRI showed a 1.2 x 0.9 cm segment VI
OPTN ___ lesion.
- ___: Repeat imaging showed that lesion, and more
anteriorly, a second area of arterial enhancement measuring 1.2
x
1.6 cm. Both meeting criteria for HCC.
- ___: RFA to segment VI lesion
- ___: TACEx2 to segment VI lesions
- ___: MRI without new liver lesions, but incidentally
found
2 x 1.5 cm focus of arterial enhancement in the right lateral
aspect of the T11 vertebral body concerning for metastasis.
- ___: Bone Bx showed metastatic HCC
- ___: SBRT (2700 cGy in 3 fx)
- ___: AFP rising to 80 from ___
- ___: MRI showed 2.6 x 1.7 x 1.8 cm right T11 lesion that
was stable, however there was a new 1.3 x 0.7 cm posterior
nodule
consistent with disease progression
- ___: cryotherapy of the new area of disease recurrence.
Bx
showed metastatic HCC
- ___: vertebroplasty, completing therapy
- ___: MR showed progression of disease at T11
- ___: started romiplostim
- ___: CT Torso without other evidence of disease, growth
of
T11 lesion
- ___: T11 laminectomy with T9-L2 fusion
- ___: T11 Corpectomy with placement of cage and right T9
screw revision
- ___: RT at ___ 3500 cGy in 10 fx to T10-12
- ___: C1 nivolumab
- ___: C2 nivolumab
- ___: C3 nivolumab
- ___: C4 nivolumab (delayed a week). Concern for
progression in the spine, discuss lenvatinib
- ___: Start lenvatinib
Social History:
___
Family History:
Father: ___ (Lung CA)
Mother: ___ (Lung CA)
Brother: ___ (Sudden cardiac death in ___
Sister: Living, multiple medical issues.
Physical Exam:
ADMISSION EXAM
==============
VITALS: Temp: 97.8 PO BP: 181/85 R Lying HR: 48 RR: 18 O2 sat:
98% O2 delivery: Ra
GENERAL: Well-appearing, laying in bed comfortably, in NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: Alert, oriented to person/place, slow speech, CN
II-XII intact, ___ strength in bilateral upper/lower extremities
with normal sesnsation, subtle asterixis
DISCHARGE EXAM
==============
VITALS: ___ 0736 Temp: 97.9 PO BP: 160/86 L Lying HR: 59
RR:
17 O2 sat: 97% O2 delivery: Ra FSBG: 143
___ Total Intake: 360ml PO Amt: 360ml
___ Total Output: 0ml Urine Amt: 0ml
GENERAL: Thin and chronically ill appearing, laying in bed
comfortably, in NAD.
HEENT: NC/AT, EOMI, R pupil is slightly smaller than L (4mm vs.
5mm), dermatochalasis on R, MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: Alert, oriented to person/place, slow speech, CN
exam notable for anisocoria as above, ___ strength
in bilateral upper/lower extremities with normal sensation, no
dysmetria, subtle asterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 07:40PM BLOOD WBC-5.8 RBC-4.71 Hgb-14.6 Hct-43.7 MCV-93
MCH-31.0 MCHC-33.4 RDW-16.2* RDWSD-52.1* Plt Ct-43*
___ 07:40PM BLOOD Neuts-60.0 Lymphs-17.8* Monos-10.3
Eos-10.9* Baso-0.7 Im ___ AbsNeut-3.48 AbsLymp-1.03*
AbsMono-0.60 AbsEos-0.63* AbsBaso-0.04
___ 07:40PM BLOOD ___ PTT-23.1* ___
___ 06:32PM BLOOD Glucose-163* UreaN-21* Creat-1.0 Na-136
K-5.1 Cl-100 HCO3-25 AnGap-11
___ 06:32PM BLOOD ALT-23 AST-57* AlkPhos-124 TotBili-2.9*
___ 06:32PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.5 Mg-2.4
___ 07:40PM BLOOD Calcium-8.5 Phos-3.6 Mg-2.4
___ 06:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Tricycl-NEG
DISCHARGE LABS
==============
___ 04:51AM BLOOD WBC-5.1 RBC-4.05* Hgb-12.4* Hct-36.7*
MCV-91 MCH-30.6 MCHC-33.8 RDW-17.0* RDWSD-53.6* Plt Ct-35*
___ 04:51AM BLOOD Neuts-67.7 Lymphs-16.5* Monos-8.1 Eos-6.9
Baso-0.4 Im ___ AbsNeut-3.45 AbsLymp-0.84* AbsMono-0.41
AbsEos-0.35 AbsBaso-0.02
___ 04:51AM BLOOD Plt Ct-35*
___ 04:51AM BLOOD ___ PTT-30.9 ___
___ 04:51AM BLOOD Glucose-151* UreaN-29* Creat-1.3* Na-139
K-4.6 Cl-104 HCO3-23 AnGap-12
___ 04:51AM BLOOD ALT-15 AST-28 LD(LDH)-264* AlkPhos-108
TotBili-2.1*
___ 04:51AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1
NOTABLE LABS
============
___ 06:02AM BLOOD Anisocy-1+* Polychr-1+* Spheroc-1+*
Acantho-1+* RBC Mor-SLIDE REVI
___ 06:02AM BLOOD ___ 06:02AM BLOOD Ret Aut-3.5* Abs Ret-0.15*
___ 04:51AM BLOOD Hapto-<10*
___ 06:02AM BLOOD calTIBC-263 Hapto-<10* Ferritn-149
TRF-202
___ 07:48PM BLOOD Lactate-2.6*
STUDIES/IMAGING
===============
CXR ___
IMPRESSION:
1. No radiographic evidence of pneumonia.
2. 1.8 cm round opacity left lung base was seen previously,
worrisome for
metastasis.
RUQUS ___
IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhotic morphology of the liver with sequela of portal
hypertension
including small volume ascites and marked splenomegaly. The
previously seen ablation cavity in the right hepatic lobe is not
well seen on the current study.
3. The gallbladder contains sludge without wall thickening or
edema.
CTA H/N ___
IMPRESSION:
1. No acute intracranial findings.
2. Mild-to-moderate narrowing bilateral cavernous, supraclinoid
ICA.
3. No significant ICA or vertebral artery narrowing in the neck.
4. Two separate 2 mm right upper lobe solid pulmonary nodules.
No imaging follow-up is indicated.
5. Severe biapical paraseptal and moderate centrilobular
emphysema.
6. Severe cervical spine degenerative changes..
7. Nasal septAl perforation.
RECOMMENDATION(S): For incidentally detected nodules smaller
than 6mm in the setting of an incomplete chest CT, no CT
follow-up is recommended.
Brief Hospital Course:
Patient is a ___ with history of HCV cirrhosis c/b metastatic
HCC to T11 (s/p RFA ___, TACE ___, SBRT ___,
cryotherapy ___, vertebroplasty ___, T11 laminectomy and
corpectomy with cage ___, RT ___, 4 cycles of nivolumab,
and most recently C1 levatinib ___ who presented with acute
encephalopathy, now with significant hypertension likely a side
effect of lenvatinib, course also complicated by possible new
metastatic brain lesion and laboratory signs of hemolysis.
Patient was quite hypertensive upon arrival, SBPs 180-200s,
responsive to initiation of hydralazine. HRs remained 40-50s on
nadolol. Severe HTN was likely ___ lenvatinib, which was held.
Given initial concern for HE, lactulose frequency was increased
and patient was noted to have some improvement in mental status
though continued to have mild asterixis (AOx3 and able to do the
days of the week forwards/backwards on discharge). Patient's
wife was able to confirm that patient will be able to get
rifaximin as an outpatient. Infectious/bleeding work-ups were
NEGATIVE, patient did not submit a urine sample prior to
discharge. Sedating meds were held other than lorazepam.
Given concern for anisocoria and R ptosis on admission, patient
underwent CTA H/N, which did not show any acute bleeding (final
read still pending). Neurology was consulted and confirmed that
patient has physiologic anisocoria (L>R) and dermatochalasis. Of
note, neurology was concerned for frontal lesion, patient was
ordered for MRI brain to assess for metastatic disease. This was
not performed prior to discharge as patient and his wife wanted
to be at home as quickly as possible.
Labs were otherwise notable for normocytic anemia and acute on
chronic thrombocytopenia with signs of hemolysis. No
schistocytes on RBC morphology. Fibrinogen 159. Coombs NEGATIVE.
Possibly related to hypertension. Hb relatively stable at time
of discharge.
Iso increased BM ___ lactulose, patient was noted to have acute
kidney injury, Cr 1.3 ___. He was given 37.5g 5% albumin.
Patient will have close outpatient follow-up with his oncologist
___.
TRANSITIONAL ISSUES
===================
- Lenvatinib was held
- Patient was initiated on hydralazine, continue to monitor
blood pressures
- Outpatient rifaximin prescription was confirmed, patient will
be able to take without issue
- Repeat BMP to ensure resolution ___
- Repeat CBC to ensure stability of Hb/plts
- Continue to work-up for hemolysis
- Order MRI brain to assess for metastatic disease
- f/u UA/UCx
- Furosemide was held given ___, restart as needed
- Restart oxycontin/dilaudid/gabapentin as needed, patient did
not have any pain issues this admission
- Patient should have referral to palliative care
- Patient confirmed DNR/DNI
- Patient should be assessed for home services including ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ursodiol 500 mg PO BID
3. Spironolactone 50 mg PO EVERY OTHER DAY
4. Pantoprazole 40 mg PO Q24H
5. OxyCODONE SR (OxyCONTIN) 80 mg PO Q12H
6. LORazepam 0.5 mg PO Q8H:PRN anxiety, insomnia
7. HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN Pain - Moderate
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Nadolol 60 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. Furosemide ___ mg PO DAILY
12. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
13. Lactulose ___ mL PO BID
14. Rifaximin 550 mg PO/NG BID
Discharge Medications:
1. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose ___ mL PO BID
6. LORazepam 0.5 mg PO Q8H:PRN anxiety, insomnia
7. Nadolol 60 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO EVERY OTHER DAY
11. Ursodiol 500 mg PO BID
12. HELD- Furosemide ___ mg PO DAILY This medication was
held. Do not restart Furosemide until you are told to do so by
your doctor.
13. HELD- Gabapentin 300 mg PO BID This medication was held. Do
not restart Gabapentin until you are told to do so by your
doctor.
14. HELD- HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN Pain -
Moderate This medication was held. Do not restart HYDROmorphone
(Dilaudid) until you are told to do so by your doctor.
15. HELD- OxyCODONE SR (OxyCONTIN) 80 mg PO Q12H This
medication was held. Do not restart OxyCODONE SR (OxyCONTIN)
until you are told to do so by your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
=================
Acute encephalopathy
Hypertension
Secondary Diagnoses
===================
Cirrhosis with hepatocellular carcinoma
Hemolytic anemia
Acute kidney injury
Thrombocytopenia
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were confused at home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given more lactulose and your mental status improved.
- The neurologists evaluated you and did not feel that you were
having a stroke.
- You had a CT scan of your head, which did not reveal any
bleeding.
- Some of your sedating medications were stopped so as not to
make you more confused.
- Your cancer medication (lenvatinib) was stopped because your
blood pressure was quite elevated. You were started on a new
medication to help treat your high blood pressure.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10765786-DS-16
| 10,765,786 | 24,983,535 |
DS
| 16 |
2113-07-19 00:00:00
|
2113-07-20 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
ETT-MIBI (Exercise Stress Test)
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr ___ is a ___ y/o M with PMH significant for CAD (s/p DES to
___ LAD in ___, HTN, HLD, who presents for chest pain.
Of note, this is a patient of Dr ___. In ___ he suffered
an NSTEMI with angiography showing total occlusion of the
proximal LAD which was stented successfully with a 3.0 x 12 mm
Promus drug-eluting stent. Otherwise there was 50% disease in
the
circumflex, ramus and less in the right coronary.
Echocardiography initially showed anteroapical akinesis with an
ejection fraction of 31%. A subsequent echocardiogram on
___ showed persistence of anteroseptal and lateral
hypokinesis and apical akinesis but with ejection fraction
increased to 55%. He has had occaisonal chest pain since this
time, and underwent cardiac cath in ___ which showed patent
stent and otherwise stable disease.
Patient notes that for the last few months he has had occasional
on and off chest pain. The pain is described as in his upper
chest especially on the left side. It is a dull aching
pressure.
It is not clearly induced by activity and does not clearly go
away with rest. Episodes last for hours. Is better over the
last 2 weeks, however and within last 24 hours it started he
once
again and this time radiated into his back. Given his ongoing
symptoms, he presented to the emergency room. An EKG did not
reveal any evidence of acute ischemia. Troponins x2 were
negative. Patient was then discussed with the cardiology
fellow,
and is ultimately admitted for stress test.
Past Medical History:
- HTN
- HLD
- CAD s/p PCI (DES to LAD on ___
- HCV s/p interferon
Social History:
___
Family History:
- Father with pacemaker and colon CA
- Mother with breast CA
- No family history of early MI, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
GEN: Well appearing, NAD
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD.
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: No edema. WWP.
SKIN: No rashes.
NEURO: AOx3.
Pertinent Results:
Admission Labs
==============
___ 07:45AM BLOOD WBC-7.4 RBC-4.87 Hgb-14.5 Hct-43.8 MCV-90
MCH-29.8 MCHC-33.1 RDW-12.9 RDWSD-41.9 Plt ___
___ 07:45AM BLOOD Neuts-68.5 Lymphs-18.7* Monos-10.4
Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.09 AbsLymp-1.39
AbsMono-0.77 AbsEos-0.12 AbsBaso-0.03
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-103* UreaN-17 Creat-1.0 Na-140
K-5.0 Cl-104 HCO3-25 AnGap-11
___ 07:45AM BLOOD cTropnT-<0.01
Discharge Labs
==============
___ 06:47AM BLOOD WBC-6.2 RBC-5.03 Hgb-15.0 Hct-46.3 MCV-92
MCH-29.8 MCHC-32.4 RDW-13.1 RDWSD-43.7 Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD ___ PTT-37.6* ___
___ 06:47AM BLOOD Glucose-106* UreaN-18 Creat-0.9 Na-140
K-4.1 Cl-101 HCO3-27 AnGap-12
___ 06:47AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
Exercise Stress Test
INTERPRETATION: This ___ year old man with h/o CAD s/p MI and LAD
stent in ___ was referred to the lab for evaluation of chest
discomfort. He exercised for 10 minutes and 30 seconds on
modified ___
protocol and stopped for fatigue. The peak estimated MET
capacity is
8.7, which represents an average exercise tolerance for his age.
No
chest, arm, neck or back discomfort reported. No significant ST
segment
changes noticed. Rhythm was sinus with frequent isolated APBs
and rare
atrial couplets in early recovery. Appropriate HR and BP
response to
exercise and recovery.
IMPRESSION : No anginal symptoms or ischemic EKG changes to the
achieved
workload. Nuclear report sent separately.
Brief Hospital Course:
Patient Summary
===============
Mr ___ is a ___ y/o M with PMH significant for CAD (s/p DES to
___ LAD in ___, HTN, HLD, who presented for chest pain and
underwent an ETT-MIBI which showed: EF 46%, no symptoms or ECG
changes, large fixed perfusion defect in mid/apical segment in
LAD territory (consistent with old infarct in ___. Hypokinesis
of anterior wall, akinesis of apex.
Acute Issues
============
# CAD (s/p DES in ___ to ___ LAD)
Pt presented with several months of atypical chest pain that
acutely worsened on ___ evening. The pain is not reproduced
with activity or relieved with rest. His EKG does not show any
evidence of active ischemia and his troponins were negative x2.
However, given his significant coronary artery disease history,
he was admitted to undergo cardiac stress testing. His home
aspirin and atorvastatin were continued. He had an exercise
stress test which showed no new changes from prior.
Chronic Issues
==============
#Hypertension
Home lisinopril and carvedilol were continued.
#Hyperlipidemia
Home atorvastatin was continued.
Transitional Issues
===================
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. CARVedilol 3.125 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 3.125 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Unstable Angina
Coronary Artery Disease
Secondary Diagnosis
===================
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had intermittent
chest pain. Please see below for more information on your
hospitalization. It was a pleasure participating in your care!
What happened while you were in the hospital?
- You had a stress test which was to assess how your heart
functioned under stress. It showed EF 46%, no symptoms or ECG
changes, large fixed perfusion defect in mid/apical segment in
LAD territory (consistent with old infarct in ___. Hypokinesis
of anterior wall, akinesis of apex. There was no need for any
intervention, so you were discharged home. All of your home
medications were continued in the hospital.
What should you do after leaving the hospital?
- Please take your medications as listed below and follow up at
the listed appointments.
We wish you the best!
- Your ___ Healthcare Team
Followup Instructions:
___
|
10765994-DS-16
| 10,765,994 | 22,815,090 |
DS
| 16 |
2114-05-15 00:00:00
|
2114-05-17 23:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
Mr. ___ is a ___ manwith a history of extensive
stage small cell lung cancer, statuspost four cycles of
cisplatin and etoposide (completed ___ concomitant
palliative radiation to the chest (completed
___ who has since developed brain metastases, status
postwhole brain radiation and a CyberKnife radiation on ___.
Herestarted chemotherapy with cisplatin and irinotecan and is
now s/p 6 cycles with a response seen on CT scan.
He was recently seen in ___ clinic follow-up and at that time,
started on levofloxacin for possible pneumonia. He presented to
the ED on ___ with persistent cough and bronchitis symptoms;
abx were switched to doxycycline as he couldn't afford the
levofloxacin.
This morning, while at home watching the news, he experienced
his first seizure. He was found by his wife to be in the chair,
gasping for air, shaking, and eyes rolling back. This lasted
for approximately ___ minutes and resolved when EMS arrived.
He was confused after but returned to his baseline mental status
by the time he came to the ED. In the ED, VSS; CT head
demonstrated a new hyperdense area near the left parietal mets
(?blood) with increased edema. He was loaded with 1 gm keppra
and admitted to medicine for further management.
Currently, he denies any c/o or complaints except for being
tired. No headache, lightheadedness, dizziness, shortness of
breath, CP, abd pain, n/v, urinary or bowel symptoms.
12-pt ROS otherwise negative in detail except for as noted
above.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Presented in ___ with left upper quadrant pain, which had
been present for six months. Abdominal CT showed lower lung
mass. Chest CT on ___ revealed a left lower lobe lung
mass and mediastinal lymphadenopathy.
- ___: bronchoscopy with lymph node biopsy was done.
Lymph nodes 4L, 4R, and 7 were sampled, all with small cell
carcinoma.
- ___: PET scan showed left lower lobe FDG avid mass as
well as an area of avidity in the left upper lobe and right
middle lobe. He also had lymphadenopathy in the mediastinum and
bilateral hila.
- ___: MRI of the head showed no metastatic disease in
the
brain.
- ___: cycle one of cisplatin and etoposide.
- ___: cycle two Cisplatin/Etoposide
- ___: cycle three Cisplatin/Etoposide
- ___: cycle four Cisplatin/Etoposide
- ___: chest radiation 3500 cGy in 14 fractions
- ___: whole brain radiation due to metastatic
disease in the left parietal lobe.
- ___: MRI Head with L parietal lobe mass 1.7 cm in size
with
surrounding edema. CT Chest with increasing mediastinal
lymphadenopathy.
- ___: CK to L parietal lesion
- ___: bone marrow biopsy done for thrombocytopenia showed
hypocellular marrow with dysplasia; no carcinoma seen.
- ___: Cycle 1 Cisplatin 30 mg/m2 + Irinotecan 65 mg/m2
given
on days 1 and 8 of a 21 day cycle.
- ___: Cycle 2 Cisplatin/Irinotecan days 1 and 8
- ___: Cycle 3 Cisplatin/Irinotecan days 1 and 8
- ___: Cycle 4 Cisplatin 22 mg/m2 (dose reduced due to
pancytopenia) and Irinotecan 50 mg/m2 (dose reduced due to
pancytopenia)
- ___: Cycle 5 Cisplatin 22mg/m2, Irinotecan 50 mg/m2 on day
1; day 8 dose was held due to pancytopenia
- ___: CT chest without evidence of progression.
- ___: Cycle 6 Cisplatin 15 mg/m2, Irinotecan 40 mg/m2 on
days 1 and 8.
Other medical history:
1. C-spine fracture in ___, currently maintained on methadone.
2. Coronary artery disease status post MI in ___ with stent
placed at ___.
3. Past history of alcoholism and drug abuse, sober now for ___
years.
Social History:
___
Family History:
Father with history of non-Hodgkin's lymphoma
Physical Exam:
VS: T 98, BP 120/70, HR 85, RR 16, SaO2 95/RA
General: Comfortable-appearing male in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. MM sl dry, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e/, wwp
Neuro: AO x3, CN II-XII intact, MS ___ except in RUE which was
___ with flexion and abduction (chronic); sensation grossly
intact to light touch
Skin: warm, dry
Pertinent Results:
___ 06:10AM PLT COUNT-104*
___ 06:10AM NEUTS-74.1* LYMPHS-15.6* MONOS-8.4 EOS-1.6
BASOS-0.3
___ 06:10AM WBC-4.8 RBC-2.91* HGB-9.7* HCT-27.8* MCV-96
MCH-33.3* MCHC-34.8 RDW-18.3*
___ 07:24AM ___ PTT-36.1 ___
___ 01:10PM PLT COUNT-109*
___ 01:10PM WBC-5.0 RBC-2.47* HGB-8.2* HCT-23.0* MCV-93
MCH-33.4* MCHC-35.9* RDW-17.7*
___ 01:10PM OSMOLAL-271*
___ 01:10PM GLUCOSE-97 UREA N-12 CREAT-1.2 SODIUM-134
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-11
.
___ head CT:
IMPRESSION:
1. Hyperdense material surrounding the known left parietal lobe
metastasis is concerning for blood.
2. New hyperdensities in the white matter of the left parietal
lobe and right
occipital lobe may represent edema radiation changes.
These findings were discussed with Dr. ___ at 6:50
a.m. on ___ by telephone.
ATTENDING NOTE: The hyperdensity surrounding calcified lesion
likely blood
product or mass. There is increased surrounding edema. No acute
hematoma.There
are hypodensities in both occipital lobes. The right occipital
hypodensity
appears slightly more pronounced and the left occipital
hypodensity is new
since previous CT.
.
___ MRI spine:
IMPRESSION:
1. Three foci of high STIR signal with mild enhancement
involving T2, T4 and
T6, while the end plate abnormalities may represent degenerative
changes,
metastatic disease cannot be excluded. Followup examination or
a whole-body
bone scan could be helpful for further evaluation.
2. Small loculated left pleural effusion. Correlate with CT
torso of ___
for additional details.
3. Diffuse fatty infiltration throughout the cervical,
thoracic, and lumbar
vertebral bodies, probably related to prior therapy.
.
___ MRI head:
1. Interval significant increase in size and surrounding edema
of the
previously seen metastatic left superior parietal lesion as well
as new
lesions seen involving the right occipital, right temporal,
right cerebellum
and left inferior parietal lobe when compared to the prior
examination of
___.
2. No acute infarct.
Brief Hospital Course:
___ y/o male with small cell CA with mets to the brain, p/w
new-onset seizure. His course is summarized by problem below:
.
Seizure - Head CT with ?new blood around known mets. MRI of the
head demonstrated new mets as well as increased edema around the
left parietal metastasis. He was started on keppra 1 gm bid and
decadron per neurology; no further seizures occured during his
hospitalization. Due to the new brain mets, an LP was performed
on ___ to evaluate for CSF extension of the mets - prelim
cytology was negative; however this was PENDING upon discharge
and will be followed up by his neuro-oncologist, Dr. ___, as an
outpatient. The patient will be seeing Dr. ___ on ___,
___, to discuss further treatment options for the new brain
mets.
.
Small cell lung CA, metastatic - CT torso done in-house
demonstrated slight increase in the burden of disease and an MRI
of the spine demonstrated several foci of possible mets (could
not be ruled out definitively). A bone scan can be considered
and this was discussed with the patient and his primary
oncologist, who will follow-up with the patient on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Citalopram 20 mg PO DAILY
3. Methadone 25 mg PO TID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Terazosin 5 mg PO HS
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Citalopram 20 mg PO DAILY
3. Methadone 25 mg PO TID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
8. Terazosin 5 mg PO HS
9. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg One tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
10. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg One tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Small cell lung CA with metastatic disease, brain mets
Chronic cervical pain
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after having a new-onset seizure. This was
felt to be secondary to increased swelling around one of the
lesions. You were started on an anti-seizure medication and a
steroid, both which you will need to continue taking unless told
otherwise. As you know, the MRI of your head demonstrated
increased lesions. You underwent a lumbar puncture, results of
which are still PENDING.
You also underwent an MRI of the spine, which did not show
obvious lesions but could not rule out metastatic spread
definitively. It is recommended you undergo a body scan, which
can be discussed with your ___.
Please follow-up with Dr. ___ on ___ and Dr. ___ on
___.
No other changes were made to your medications.
Followup Instructions:
___
|
10766131-DS-11
| 10,766,131 | 22,925,978 |
DS
| 11 |
2137-07-01 00:00:00
|
2137-07-01 21:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, hypotension, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o ___ woman presenting
with concern for weakness. Patient is a poor historian
presenting from adult day care with hypotension and weakness.
Patient was at her daycare where she was complaining of
generalized weakness and was found to have systolic pressures in
the ___. She also noted rectal pain and nausea with no bowel
movements in several days. With interpreter at bedside in the
ED, patient denied abdominal pain, vomiting, urinary symptoms,
fevers, chills, BRBPR, melena, chest pain, cough, or shortness
of breath. There was also a question of chest heaviness per the
patient.
Upon presentation in the ED, VS: Labs significant for WBC 3.9
(baseline), Plt 106 (previously 170-200's), Cr 1.8 (baseline
___ with BUN 23, INR 1.6, trop <0.01, and a negative UA.
Blood and urine cx were drawn. On rectal exam, patient had no
stool in the vault and was heme negative. Abdomen was benign but
patient did complain of abdominal pain and a CT abd/pelvis was
ordered, which showed a celiac artery calcification but no acute
processes. She was given 1L fluid before and after imaging due
to ___. CXR no acute processes, EKG with more pronounced lateral
TWI and mild inferior STD's. VS on transfer: 97.4 70 106/66 14
100% RA.
Of note, the patient's Coumadin is monitored through ___.
On the floor, an interpreter was paged but the patient was only
able to give vague answers to questions. She said that her low
back hurt and her R leg felt "heavy" but said these problems
have been going on "for a long time". She denied chest pain or
difficulty breathing. She also initially denied abdominal pain,
but then said her abdomen felt "not quite right".
Past Medical History:
Hypertension
Hyperlipidemia
PAF on coumadin
hypothyroidism, post-radioactive iodine ablation for
hyperthyroidism in ___.
Deep venous thrombophelbitis
Peripheral Vascular Disease.
Social History:
___
Family History:
Mother and father died of MI.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals - T98.4 137/70 98 18 100 ra.
GENERAL: Patient lying in bed, occasionally grimacing with
movement.
HEENT: AT/NC
NECK: nontender
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, soft, +BS, patient grimacing when abdomen
palpated around the umbilicus.
EXTREMITIES: no cyanosis, clubbing or edema. Some tenderness to
palpation of the bilateral legs.
PULSES: 2+ DP pulses bilaterally
NEURO: Difficult to assess mental status even with interpreter
present. Patient answered some questions but appeared confused
when asked to follow commands. Fine touch sensation intact in
the groin region and patient able to lift both legs off the bed
with effort. Unable to comprehend other strength-testing
exercises for the legs. Grip strength equal bilaterally.
SKIN: warm and well perfused, some scars on legs.
PHYSICAL EXAM ON DISCHARGE:
T 98.8 106-148/83-83, HR 70, 100%RA , wt ___ 58.9kg
Gen: AOx3, comfortable,
Lungs: CTAB
Abd: Soft nt/nd
Ext: Trace edema bilat.
Pertinent Results:
LABS ON ADMISSION:
-----------------
___ 11:45PM cTropnT-<0.01
___ 08:30PM ___ PTT-31.1 ___
___ 08:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:45PM GLUCOSE-123* UREA N-23* CREAT-1.8* SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
___ 04:45PM cTropnT-<0.01
___ 04:45PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.2
___ 04:45PM WBC-3.9* RBC-4.06* HGB-12.9 HCT-39.9 MCV-98
MCH-31.7 MCHC-32.3 RDW-13.3
___ 04:45PM NEUTS-56.7 ___ MONOS-5.6 EOS-2.7
BASOS-0.7
___ 04:45PM PLT COUNT-106*
RELEVANT LABS:
--------------
___ 05:13AM BLOOD Neuts-46.8* Lymphs-44.0* Monos-6.2
Eos-2.6 Baso-0.3
___ 04:23AM BLOOD ___ PTT-28.7 ___
___ 05:13AM BLOOD ALT-19 AST-24 CK(CPK)-129 AlkPhos-51
TotBili-0.5
___ 05:13AM BLOOD TSH-35*
___ 03:56AM BLOOD Lactate-1.1
LABS ON DISCHARGE:
------------------
MICROBIOLOGY:
---------------
__________________________________________________________
___ 8:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:10 pm URINE STRAIGHT CATHETER PLAIN RED.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
-----------
___ CT abd/pelvis
IMPRESSION:
1. No small bowel obstruction.
2. Dense calcification at the origin of narrowed but patent
celiac axis
___ CXR
FINDINGS:
Left chest wall dual lead pacing device is again noted. The
lungs are clear without consolidation, effusion, or vascular
congestion. Cardiac silhouette is enlarged, unchanged. No acute
osseous abnormalities.
IMPRESSION:
Cardiomegaly without acute cardiopulmonary process.
___ EKG ECG-> a paced, lateral TWI (new, more pronouced
than previous), mild inferior STDs
Discharge Labs:
___ 07:40AM BLOOD WBC-3.7* RBC-3.99* Hgb-12.9 Hct-38.5
MCV-96 MCH-32.3* MCHC-33.5 RDW-13.5 Plt ___
___ 07:40AM BLOOD ___ PTT-32.7 ___
___ 07:40AM BLOOD Glucose-107* UreaN-19 Creat-1.0 Na-141
K-4.3 Cl-107 HCO___-25 AnGap-13
Brief Hospital Course:
Ms. ___ is a ___ y/o ___ woman presenting
with concern for weakness and hypotension. She also had other
vague complaints including back pain, abdominal pain,
questionable chest heaviness, found to have ___ and
hypothyroidism. ___ was prerenal in etiology due to dehydration;
Cr on discharge 1.1. Pt's TSH on admission was 35 and she is on
levothyroxine 125mcg on discharge (was on 100mcg at home but
unclear whether she was compliant). She was hypotensive on
admission most likely due to hypovolemia in the setting of
dehydration and it resolved on discharge and home
anti-hypertensives and diuretics were resumed.
ACTIVE MEDICAL ISSUES:
#Hypotension: likely in the setting of poor fluid intake as
responded to volume in the ED. She also has a history of labile
blood pressures and is alternatively hyper and hypotensive.
ACE-in was restarted on ___ after ___ resolved.
___: patient w/ Cr increase from baseline Cr ___ to 1.8 on
admission. Resolved with fluids. Likely pre-renal in setting of
poor PO intake at home.
#Weakness/lethargy: Likely secondary to hypothyroidism as TSH
found to be 35. Family states she has been taking her synthroid
although does not appear to have been filled recently at
pharmacy. Her levothyroxine dose was increased from 100 mcg to
125 mcg. Other possibly etiologies which were ruled out include
infection (UA neg, blood cx NGTD). ___ consulted and recommended
rehab
#Abdominal pain: Difficult to assess the extent of the patient's
pain, as she grimaces upon exam but does not endorse significant
pain upon questioning. CT abdomen showed a calcification at the
level of the celiac axis, raising concern that poor perfusion
may be contributing to her pain. Lactate wnl which is reassuring
against mesenteric ischemia. Otherwise, no acute findings on CT.
Likely secondary constipation in setting of hypothyroidism. Per
family, it is usual for her to go ___ weeks w/o BM. Her BM
regimen was increased
#Back and leg pain: per patient, chronic in nature. No red flags
on physical exam. Rectal wnl on admission. Gait intact (walks
with walker at baseline). Pain was controlled with tylenol
(standing) and prn oxycodone as needed
#Chest heaviness: the patient reportedly had chest heaviness in
the ED but denied chest discomfort on the floor. Two trops
negx3. EKG with lateral TWI (new, more pronouced than previous),
mild inferior STDs. Her symptoms later resolved, although she
had a mild episode night of ___, EKG without changes, self
resolved.
#Thrombocytopenia: below patient's baseline on admission,
unclear etiology. Resolved
#A-fib on coumadin: INR subtherapeutic on admission. Coumadin
dosing increased per pharmacy recommendations.
#CHF: Pt on 10 mg lasix started by her cardiologist for volume
overload. Last ECHO in ___ with preserved EF. Pt appeared more
euvolemic on exam and was dry on admission, therefore lasix was
held
#HLD: Pt continued atorvastatin
TRANSITIONAL ISSUES:
===================
[] monitor INR daily as pt on coumadin for AF
[] check TSH six weeks after discharge which would be around
___ and adjust levothyroxine dose as necessary
[] monitor volume status and restart lasix dose as appropriate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Furosemide 10 mg PO DAILY
3. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID:PRN
irritation
4. Lactulose 15 mL PO BID:PRN constipation
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 30 mg PO DAILY
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN skin
irritation
8. Warfarin 6 mg PO 2X/WEEK (___)
9. Warfarin 4 mg PO 5X/WEEK (___)
10. Docusate Sodium 100 mg PO BID
11. Acetaminophen 1000 mg PO BID:PRN pain
12. Bisacodyl 5 mg PO DAILY:PRN constipation
13. Omeprazole 20 mg PO DAILY
14. Senna 8.6 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID:PRN
irritation
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lisinopril 30 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN skin
irritation
11. Warfarin 6 mg PO DAILY16
12. Warfarin 4 mg PO 5X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE DIAGNOSES:
1. hypothyroidism
2. ___
3. hypotension
CHRONIC DIAGNOSES:
1. atrial fibrillation
2. CHF
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 here at ___. You
presented to us with weakness and you were found to be
dehydrated, resulting in low blood pressures and kidney
dysfunction. We believe your weakness is most likely due to low
thyroid hormone levels, and you are being treated for it. You
are now being discharged to rehab in order to regain your
strength.
Please take all your medications as instructed. Please attend
all your follow up appointments.
Best,
Your ___ team
Followup Instructions:
___
|
10766131-DS-14
| 10,766,131 | 23,740,277 |
DS
| 14 |
2139-02-16 00:00:00
|
2139-02-17 22:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old ___ woman who presented
to ___ ED as a trauma for a fall from standing at 1pm on
___. She is on home Xarelto, which was held on admission.
She states she felt dizzy before falling. She did not have any
chest pain or palpitations at the time. On imaging, she was
found to have a small subarachnoid hemorrhage, a small subdural
hematoma, and L zygomaticomaxillary complex fractures.
Neurosurgery has cleared her for outpatient followup and plastic
surgery has also decided on non-operative management of the
facial fractures and follow up outpatient.
She has been persistently hypertensive while on home
medications. A syncopal workup has been initiated, with ECHO
within normal limits. UA and urine culture has been ordered.
T-spine tenderness to palpation was observed on tertiary trauma
survey and a CT T-spine has been ordered
Past Medical History:
Hypertension
Hyperlipidemia
PAF on rivoraxaban
hypothyroidism, post-radioactive iodine ablation for
hyperthyroidism in ___.
Deep venous thrombophelbitis
Peripheral Vascular Disease
Social History:
___
Family History:
Mother and father died of MI.
Physical Exam:
ADMISSION EXAM
=================
Vital signs: 98, 69, 158/72, 15, O2sat100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMI
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Back: denies TTP, no step offs; left gluteal decubitus ulcer,
clean, with wick/dressing intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and place only, baseline per
family.
Language: ___ Creole speaking only.
CN ___ intact
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
DISCHARGE EXAM
=================
Vitals: 98.3, 155/83, 69, 16; 100% RA
GENERAL - Awake, alert, oriented to person, place (not to year,
at baseline)
HEENT - PERRLA, EOMI with the exception of upward gaze
(baseline), minimal ___ swelling and residual
ecchymosis
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Soft/NT/ND, +bowel sounds
EXTREMITIES - WWP, 2+ peripheral pulses, no edema
NEURO - CNII-XII intact. Lifts upper and lower extremities to
gravity. Sensation intact.
Pertinent Results:
ADMISSION LABS
=====================
___ 08:20PM BLOOD WBC-11.5*# RBC-4.45 Hgb-13.8 Hct-41.4
MCV-93 MCH-31.0 MCHC-33.3 RDW-12.2 RDWSD-41.8 Plt ___
___ 08:20PM BLOOD Neuts-88.3* Lymphs-7.9* Monos-3.3*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.17*# AbsLymp-0.91*
AbsMono-0.38 AbsEos-0.00* AbsBaso-0.01
___ 08:20PM BLOOD ___ PTT-28.5 ___
___ 07:15PM BLOOD Glucose-143* UreaN-13 Creat-0.7 Na-136
K-3.7 Cl-100 HCO3-22 AnGap-18
___ 07:15PM BLOOD ALT-13 AST-21 AlkPhos-66 TotBili-0.7
___ 07:15PM BLOOD cTropnT-<0.01
___ 01:45AM BLOOD cTropnT-<0.01
___ 04:56PM BLOOD cTropnT-<0.01
___ 07:15PM BLOOD Albumin-3.8
___ 01:45AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.8
DISCHARGE LABS
=====================
___ 07:52AM BLOOD WBC-6.0 RBC-4.08 Hgb-12.7 Hct-39.6 MCV-97
MCH-31.1 MCHC-32.1 RDW-13.5 RDWSD-47.8* Plt ___
___ 07:52AM BLOOD ___ PTT-25.6 ___
___ 07:52AM BLOOD Glucose-105* UreaN-19 Creat-0.7 Na-139
K-5.4* Cl-103 HCO3-25 AnGap-16
___ 07:52AM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0
___ 12:35AM BLOOD TSH-23*
___ 01:01AM BLOOD ___ pO2-209* pCO2-41 pH-7.43
calTCO2-28 Base XS-3 Comment-GREEN TOP
IMAGING
======================
CXR ___
NO No discrete fracture identified.
CT HEAD W/O CONTRAST ___
1. Small volume acute subarachnoid hemorrhage in the left
sylvian fissure and tiny acute subdural hematoma along the left
inferior temporal lobe. No mass effect.
2. Left facial fractures, described in further detail on
dedicated facial bone CT exam.
CT MAXILLOFACIAL ___
Left zygomaticomaxillary complex fracture pattern: Complex
fracture involving the left maxillary sinus along the medial,
post oral lateral and anterior walls. The posterior fracture
extends to the level of the base of the left pterygoid plate.
The anterior fractures extend to the left orbital floor with
mild associated extraconal hematoma along the left orbital
floor. No signs of muscle entrapment. The left globe appears
intact. Left maxillary hemo sinus is noted. There is a subtle
fracture involving the left lateral orbital wall with small
amount of adjacent extraconal hematoma. Also noted is an acute
fracture of the left zygomatic arch which appears segmental and
mildly depressed. Nasal bones appear intact. The mandible
appears intact. The patient is edentulous. Partial
opacification of the right inferior mastoid air cells.
CT C-SPINE ___
No fracture or malalignment.
XRAY LEFT KNEE ___
AP, lateral, obliques views of the left knee provided. There is
no acute fracture or dislocation. No signs of joint effusion.
There is no significant degenerative disease. Diffuse
osteopenia noted. Vascular calcification is seen.
ECHO ___
IMPRESSION: Suboptimal image quality. Normal biventricular
regional/global systolic function.
No atrial septal defect is seen by 2D or color Doppler. Normal
left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 73 %). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
REPEAT CT HEAD ___
1. Interval increased conspicuity of subarachnoid hemorrhage
layering along the anterior left temporal lobe and posterior
aspect of the sylvian fissure. Extension of subarachnoid
hemorrhage along the left parietal lobe is not seen on prior
examination.
2. There is a subtle 2 mm thick subdural hematoma along the
posterior aspect of the left temporal lobe.
3. No definite parenchymal contusion is identified. Additional
findings as described above.
CT T-SPINE ___
1. No evidence of fracture or subluxation.
2. Diffuse demineralization.
3. Enlargement of the main pulmonary artery suggests pulmonary
arterial
hypertension.
4. Bilateral renal cysts.
5. A 4 mm perifissural nodule in the right middle lobe.
The ___ pulmonary nodule recommendations are
intended as
guidelines for follow-up and management of newly incidentally
detected
pulmonary nodules smaller than 8 mm, in patients ___ years of age
or older. Low risk patients have minimal or absent history of
smoking or other known risk factors for primary lung neoplasm.
High risk patients have a history of smoking or other known risk
factors for primary lung neoplasm.
CT HEAD W/O CONTRAST ___
1. Possible 3-mm left frontal lobe contusion now with new
hemorrhage.
2. Enlargement of the left convexity subdural fluid collection
since the prior examination.
3. Evolving intraparenchymal hematoma at the depth of the left
sylvian
fissure.
4. Multiple comminuted left fractures and hemorrhage in left
maxillary sinus.
CXR ___
In comparison with the study of ___, there is little change
and no
evidence of acute cardiopulmonary disease. Continued
enlargement of the
cardiac silhouette with dual channel pacer and leads extending
to the right atrium and apex of the right ventricle. No
vascular congestion or pleural effusion or acute focal
pneumonia.
___ ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Head CT (___):
IMPRESSION:
1. Expected evolution of multi compartmental intracranial
hemorrhage, as described above.
2. No new foci of intracranial hemorrhage.
3. No acute large vascular territorial infarction.
CXR (___):
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Enlarged cardiac silhouette, unchanged.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=============================
Ms. ___ is an ___ year old ___ female with a
history Afib on rivoraxaban and sinus node dysfunction s/p PPM
found to have subdural hemorrhage, subarachnoid hemorrhage,
intraparenchymal hemorrhage, and left facial fracture s/p fall.
She was initially managed in the trauma ICU, where she had a
stable neurologic exam without focal deficits. Her blood
pressure was frequently elevated above goal SBP < 160 per
neurosurgery, requiring PRNs. She was transferred to the
medicine floor, where her home lisinopril was uptitrated from
10mg lisinopril to 40mg lisinopril. She was also started on
amlodipine 5 mg at night. At the time of discharge, she was not
requiring PRN medications to maintain SBP < 160. Her neuro exam
was without focal deficits.
DETAILED HOSPITAL COURSE
=============================
#SDH, SAH, IPH: Likely secondary to fall with headstrike given
multiple bleeds and facial fracture, though primary hemorrhagic
CVA as inciting event for fall cannot be definitively ruled out.
Per neurosurgery, goal systolic BP < 160. She was initially
managed in the trauma ICU, where she had a stable neurologic
exam without focal deficits. Her blood pressure was frequently
elevated above goal SBP < 160, requiring PRNs. She was
transferred to the medicine floor, where her home lisinopril was
uptitrated from 10 mg lisinopril to 40 mg lisinopril. She was
also started on amlodipine 5 mg at night. During one episode of
hypertension with SBP > 160, she developed a new left facial
droop. STAT head CT showed new 3mm bleed in left frontal lobe
and interval increase in SDH. Per neurosurgery, she did not need
change in treatment plan or surgical intervention. Her facial
droop resolved the next day. At discharge, she had no focal
neuro deficits on exam and her blood pressures were SBP < 160
without PRNs. She received Keppra 500mg BID seizure prophylaxis
for 7 days during admission. Rivoraxaban was restarted on ___
(10 days after her fall). She will follow up with Dr. ___ in
8 weeks with a repeat head CT.
#Fall: Given that patient reported she was amnestic of the
event, it was difficult to assess the cause of the fall however
most likely etiology is mechanical fall i/s/o peripheral
neuropathy and deconditioning v. orthostatic syncope i/s/o
hypovolemia. Infection was less likely given UA and CXR were
unremarkable. UCx was c/w contamination. Her chronic pressure
ulcer had no surrounding erythema or purulent exudate. Cardiac
event is less likely given TTE showed normal valves and
biventricular regional/global systolic function, PPM
interrogation showed no malfunction, troponins x3 were negative.
CT head showed no e/o structural brain abnormalities. Her
hemorrhages are more likely secondary to headstrike given her
facial fracture than CVA inciting fall, though this cannot be
definitively ruled out.
#Pressure ulcer, chronic and present on admission: Patient has
pressure ulcer on left buttock, which has been cared for by ___
at home. Per wound nurse, it tracks 3cm upward from the base of
the wound. There was no surrounding erythema or purulent exudate
concerning for infection. It was dressed per wound care
recommendations.
#Facial fractures: Found to have L zygomaticomaxillary complex
fx. Per plastics, there was no indication for surgery, so she
was kept on sinus precautions. She will follow-up with plastics
as outpatient.
Chronic issues:
=================
#Paroxysmal AFib: Initially held rivoraxaban in the setting of
intracranial hemorrhages. This was restarted on ___.
#Sinus node dysfunction s/p PPM:
-PPM interrogation showed functioning device
#Hypertension, uncontrolled
-Blood pressure medications as above
-Goal SBP < 160 per NSGY
Resolved issues:
=================
#New left sided facial droop: Resolved. Was observed on ___ in
the setting of systolic blood pressures of 190s in the early AM,
with improvement after hydralazine. CT showed new 3mm left
frontal lobe hemorrhage and small increase in prior SDH. Facial
droop resolved the next day and exam remained stable through
remainder of admission. ___ have been secondary to facial
swelling i/s/o her facial fractures.
#Dyspnea: Resolved. Patient endorsed new dyspnea during
admission. LENIs were negative and CXR showed no e/o PNA, edema,
atelectasis or other abnormalities to explain her dyspnea. Was
likely secondary to deconditioning and minimal activity during
admission. Dyspnea resolved the next day without intervention.
#Yeast infection: Patient was noted to have vaginal swelling and
discharge, concerning for a vaginal yeast infection. Treated
with 150mg fluconazole x1
#FEN: Per speech and swallow, she was initially kept NPO given
concern for aspiration risk on their exam. Her diet was advanced
per their recommendations, and she was tolerating puree solids
and nectar thick liquids safely.
Transitional issues:
-Her lisinopril was increased to 40 mg qAM and we added
amlodipine 5 mg qPM to control her elevated blood pressures.
Goal SBP<160. Amlodipine can be uptitrated if necessary.
-She needs follow-up neurosurgery appointment with Dr. ___
in 6 weeks with a repeat head CT prior to that appointment.
-She needs to follow-up with plastic surgery for her facial
fracture in 1 week.
-An incidental 4 mm lung nodule was found on her PE-CT. Per
___ pulmonary nodule recommendations, she does
not need follow-up for this since nodule size <= 4 mm and she
is a never-smoker, making her low risk.
-She should not drink through a straw or blow her nose until
she sees the plastic surgeons in clinic, per sinus precautions.
-Patient is being discharged home with services and 24h care.
She is a ___ person assist and should not be moved without the
help of two people. She needs a ___ lift for transfers.
-Patient noted to be orthostatic during her stay, likely
secondary to severe deconditioning. She should continue to work
with ___.
-Patient had elevated TSH to 23, which is difficult to
interpret in the setting of known hypothyroidism and current
illness. Please re-check in 6 weeks to assess whether she may
need titration of her levothyroxine.
-CODE: Full (confirmed with interpreter at bedside)
-COMMUNICATION:
___ (niece - ___ speaking) - ___,
___ (health care proxy and daughter - not ___
speaking)- ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Rivaroxaban 15 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO HS
RX *amlodipine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Rivaroxaban 15 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8.DME
Hoyer lift and sling
Length of need: 99
ICD-10: Z74.01
___ bed
Length of need: 99
ICD-10: Z74.01
10.DME
Alternating pressure pad for hospital bed
Length of need: 99
ICD-10: Z74.01
11.DME
Roho Cushion
Length of need: 99
ICD-10: Z74.01
12.DME
Standard Wheelchair
Length of need: 99
ICD-10: Z74.01
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Subdural hematoma, Subarachnoid hemorrhage, Left
zygomaticomaxillary complex fracture
Secondary: Uncontrolled benign essential hypertension, Pressure
ulcer present on admission, Hypothyroidism, Paroxysmal Atrial
fibrillation, Sinus Node Dysfunction s/p PPM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after
falling at home and injuring your head. The bleeding in your
head was evaluated by neurosurgery, and they said you did not
need surgery. You will get a repeat CAT scan of your head to see
how the bleeding is healing, and the neurosurgeons will see you
again in 6 weeks. The plastic surgeons will see you in 1 week
for your broken facial bones. During your hospital stay, we
monitored your blood pressures to make sure they did not get too
high. We are sending you home on new blood pressure medicines
which you should take every day. This is VERY important to make
sure you brain bleeds do not get worse. You are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
New medicines:
1. We increased your lisinopril to 40 mg. Please take it every
morning.
2. Take amlodipine 5 mg every night before you sleep.
Please get plenty of rest, continue to walk several times per
day with assistance, and drink adequate amounts of fluids.
Please attend all of your follow-up appointments (listed below).
It was a pleasure to participate in your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10766131-DS-16
| 10,766,131 | 25,184,449 |
DS
| 16 |
2139-12-01 00:00:00
|
2139-12-01 19:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
elevated Cr
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ woman with history of HFpEF, AF on
rivaroxaban, s/p PPM, prior traumatic SAH/SDH, nonverbal at
baseline presenting w/ lethargy, and pink/orange urine found to
have acute renal failure. Family notes that she has been
increasingly lethargic and had recently moved from rehab back
home with the family. Her urine has become a pink/orange color
over the past 24 hours. No fever/chills. No change in PEG
intake. +cough which is chronic. OR debridement of sacral and
scapula ulcers on ___ PEG placed ___ and PICC in place for IV
antibiotics (end date ___.
Of note, she was recently admitted to ___ from ___ to
___ w/ infected pressure ulcers on her sacrum and right
scapula from which cultures grew multiple organisms including
staph epi, proteus m., bacteroides, pseudomonas. She was
switched to vanc/flagyl/cefepime for a 4 week course (d1 = ___
- ___, to be followed by ID OPAT. She also had an NSTEMI w/ Tn
peak 0.13 and EKG unchanged, likely representing a type II
demand ischemia (in setting of significant sacral infection) or
small branch vessel disease. Further testing was deferred
(stress, cath) as she is a poor candidate for antiplatelet
therapy given her recent SDH/SAH
and overall is chronically ill. PEG placement was undertaken on
___ malnutrition. A Foley catheter was placed because of
the location of the decubiti and incontinence.
Notably, on ___ OPAT labs were Vanco: 18.4 BUN: 45 Creat: 0.7
WBC: 11.1 Neuts%: 69.3 Eos: 2.7. On ___ vanco level was 22.7
so on ___, dose was reduced to 750mg IVQ24 hours. On ___ one
of the ID fellows received a phone call from outside facility
regarding her vanco trough being 35; the level was drawn at 9.30
am and vanco was given at 10. They asked her nurse to
discontinue IV vancomycin and check BUN, Cr; vanco random will
be checked again on ___ around
___ am.
In the ED, initial vitals were: 97.1 146/89 78 18 100%RA
- Exam notable for:
Abd: benign
Rectal: solid dark brown stool, heme +
Foley with pink urine
Large sacral stage 4 decub, right shoulder stage 4 decub
- Labs notable for:
UA with >182 RBC, 92WBC, few bacteria, few yeast, no epis, 300
protein, normal specific gravity
13.5>7.5/___.8<279 with 85%N
___
-----------<140
4.5/___/3.2
phos 6.5
troponin 0.7 @2150, CK 40 MB 5
INR 1.8
lactate 1.8
- Imaging was notable for:
CXR (portable): Right PICC seen at the level of the upper SVC.
Tip obscured by transvenous pacing wires which end in the right
atrium and right ventricle. Mild cardiomegaly is unchanged. No
pneumothorax. There is increasing left basilar airspace opacity
with obscuration of the left costophrenic angle.
- Patient was given: ceftriaxone 1g and started on NS at
150cc/hr
- Vitals prior to transfer: 113/79 74 17 94%RA
Past Medical History:
Hypertension
Hyperlipidemia
PAF on rivoraxaban
hypothyroidism, post-radioactive iodine ablation for
hyperthyroidism in ___.
Deep venous thrombophelbitis
Peripheral Vascular Disease
Social History:
___
Family History:
per OMR, mother and father died of MI.
Physical Exam:
Admission PHYSICAL EXAM:
Vital Signs: 97.4 153 / 80 70 97RA
General: Laying in bed, eyes closed, NAD
HEENT: Sclerae anicteric, MMM
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
GU: + foley
Skin: Large 5X5 wound, few mm deep, pink/red in sacral region,
non purulent, but very open with some granulation tissue, small
~3X2 wound near R shoulder, also non-purulent but very open
pink/red w/ some granulation tissue, R sided PICC
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to RLE,
1+ to LLE, 2+ pitting edema to R hand, none on L hand
Neuro: non-verbal on exam, does not open eyes, does not follow
commands, per reports, pt is somewhat more responsive when
family asks questions
DISCHARGE EXAM:
VITALS: No vitals. RR ___
GENERAL: Opens eyes, does not follow commands
CV: RRR
Pertinent Results:
Day of Admission Labs:
======================
___ 09:51PM BLOOD WBC-13.5*# RBC-2.39* Hgb-7.5* Hct-23.8*
MCV-100*# MCH-31.4 MCHC-31.5* RDW-20.0* RDWSD-71.1* Plt ___
___ 07:00AM BLOOD WBC-11.1* RBC-2.33* Hgb-7.2* Hct-23.6*
MCV-101* MCH-30.9 MCHC-30.5* RDW-19.9* RDWSD-73.1* Plt ___
___ 09:51PM BLOOD Neuts-84.6* Lymphs-6.4* Monos-7.0 Eos-1.1
Baso-0.2 Im ___ AbsNeut-11.41* AbsLymp-0.86* AbsMono-0.95*
AbsEos-0.15 AbsBaso-0.03
___ 09:51PM BLOOD ___ PTT-28.2 ___
___ 07:00AM BLOOD ___ PTT-74.8* ___
___ 09:51PM BLOOD Glucose-140* UreaN-143* Creat-3.2*#
Na-139 K-4.5 Cl-101 HCO3-16* AnGap-27*
___ 07:00AM BLOOD Glucose-104* UreaN-142* Creat-3.3* Na-139
K-4.3 Cl-103 HCO3-15* AnGap-25*
___ 11:37AM BLOOD Glucose-108* UreaN-137* Creat-3.3* Na-142
K-4.2 Cl-104 HCO3-15* AnGap-27*
___ 07:00AM BLOOD ALT-15 AST-29 LD(LDH)-441* CK(CPK)-36
AlkPhos-70 TotBili-0.2
___ 09:51PM BLOOD CK-MB-5 cTropnT-0.70*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.48*
___ 11:37AM BLOOD CK-MB-5 cTropnT-0.52*
___ 09:51PM BLOOD Albumin-2.7* Calcium-8.5 Phos-6.5*
Mg-3.3*
___ 11:37AM BLOOD Calcium-8.3* Phos-6.8* Mg-3.2*
___ 09:51PM BLOOD Vanco-31.2*
___ 01:15AM BLOOD Lactate-1.6
___ 01:13PM BLOOD Lactate-2.2*
Other significant labs:
___ 09:51PM BLOOD CK-MB-5 cTropnT-0.70*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.48*
___ 11:37AM BLOOD CK-MB-5 cTropnT-0.52*
___ 09:51PM BLOOD Vanco-31.2*
___ 02:05AM BLOOD Vanco-25.3*
___ 02:40AM BLOOD Vanco-24.6*
___ 05:42PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:42PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 05:42PM URINE RBC-10* WBC-55* Bacteri-FEW Yeast-NONE
Epi-0 TransE-1
___ 12:05AM URINE Hours-RANDOM UreaN-464 Creat-25 Na-<20
___ 12:05AM URINE Osmolal-358
Micro:
___ CULTURE-FINALINPATIENT
___ Urinary Antigen
-FINALINPATIENT
___ STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ Urinary Antigen
-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTURE-FINAL {YEAST}EMERGENCY
WARD
Discharge Labs:
- No labs performed
Imaging:
CXR ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous left lower lobe consolidation has substantially
cleared. Small left
pleural effusion is unchanged for at least a month. Moderate
cardiomegaly is
chronic. Right lung clear. No pneumothorax.
Right PIC line ends in the right brachiocephalic vein just above
the origin of
the SVC, no less than 7 cm from the estimated location of the
superior
cavoatrial junction. Indwelling atrial ventricular pacer leads
are continuous
from the left pectoral generator.
CT Head ___
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, or mass.
The
ventricles and sulci are prominent consistent with involutional
changes.
Periventricular white matter hypodensities stable in appearance,
nonspecific,
in a pattern suggestive of chronic small vessel ischemic
changes. Hypodensity
in the left corona radiata consistent with chronic infarct
appears unchanged.
No new hypodensities are identified.
No acute osseous abnormalities seen. The paranasal sinuses, left
mastoid air
cells, and middle ear cavities are clear. Partial opacification
of the right
mastoid air cells are nonspecific and possibly due to prolonged
supine
positioning, and unchanged in appearance from prior examination.
The orbits
are unremarkable.
IMPRESSION:
No acute intracranial process.
Renal U/S ___
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 10.9
cm. There is
no hydronephrosis. There is a 3.1 cm simple cyst in the right
kidney. Normal
corticomedullary differentiation is seen in the right kidney.
Views of the
left kidney are limited.
Foley seen within a decompressed bladder.
IMPRESSION:
Limited views of the left kidney, but no hydronephrosis
bilaterally.
Brief Hospital Course:
___ yo ___ woman with history of HFpEF, AF on
rivaroxaban, s/p PPM, prior traumatic SAH/SDH, and recent
admission for infected sacral and R scapular decubitus ulcers
s/p 4 week course of vanc/cef/flagyl for polymicrobial
infection, who was admitted on ___ for acute renal failure and
found to be in septic shock and in afib with RVR. Patient was
transitioned to ___-based care after extensive discussion
with patient's family and health care proxy given her
significant comorbidities and poor prognosis. Tube feeds were
stopped given goals of care discussion and patient was started
on oral care regimen. Patient's symptoms were controlled with
dilaudid liquid administered through PEG tube, Ativan for
anxiety (which she did not require), and glycopyrlate for
secretions. Her symptoms were well controlled and she stabilized
for transition to home-based care. She will be followed by a
palliative ___ after discharge with follow up with palliative
care doctor/hospice per family wishes. Hospice saw patient in
the hospital, but patient's family declined hospice in favor of
___.
#Goals of care: Patient with multiple serious comorbidities
including end stage dementia, multiple severe skin ulcers, acute
renal failure, and serious infection. After extensive discussion
with family regarding the patient's poor quality of life over
the last month and potential for pain with further
interventions, her family felt it appropriate to focus care on
comfort. Her tube feeds were stopped and her symptoms were
controlled with dilaudid, lorazepam, zofran, and glycopyrollate.
Per family wishes, she will be discharge with palliative ___
instead of hospice. Family was concerned regarding nutrition
status of patient, but reiterated that tube feeds were not
helping patient given multi-organ failure and poor prognosis
even with treatment and were not well tolerated.
#Septic Shock ___ pneumonia
#UTI:
CXR at admission showed LLL infiltrate. Patient with multiple
chronic decubitus ulcers, but these were not thought to
represent the souce of infection per infectious disease. She had
been previously treated with 4 week course of
vanc/cefepime/flagyl which ended ___. She was started on
meropenem at admission which was discontinued after ___
discussion on ___.
#Acute Renal Failure:
Presented with Cr increased to 3.3 from baseline of 0.5. Likely
in the setting of hypovolemia from infection with possibly
contribution from supratherapeutic vancomycin levels. Stopped
trending based on GOC.
#Anemia: Worsening anemia without clear course of bleed. Likely
bone marrow suppression in setting of critical illness and
nutritional deficiency. Stopped monitoring.
#Acute toxic-metabolic encephalopathy on chronic vascular
dementia
Baseline bedbound, A+Ox ___. Persistently somnolent and not
following commands. Intermittently opens eyes, but no further
interaction. CT head negative for acute bleed. This remained
throughout course and likely in setting of infection, kidney
failure, and metabolic derangements.
#NSTEMI (type 2): Trop peak at 0.7, with flat CK-MB. Likely
demand in setting of renal failure and hypovolemia in setting of
Afib with RVR.
#Afib with RVR.
RVR occurred in setting of sepsis/hypovolemia. Converted back to
sinus rhythm after volume resuscitation and broadening
antibiotics. Likely precipitated by hypovolemia and underlying
infection.
#HFpEF: LVEF >55% in ___. Moderate edema may be from low
albumin vs. HF. Did not diurese after GOC dission.
#Sacral decubitus ulcer
#R upper back pressure ulcer
No signs of new acute infection and has completed 4 week broad
abx course for polymicrobial infection.
#Severe malnutrition
PEG tube placed last admission on ___ secondary malnutrition
and inability to take PO. Patient continued with low albumin
despite initiation. After extensive discussion with family
regarding poor prognosis, multi-organ failure, and inability to
tolerate feeds, decided to stop tube feeds and focus on comfort
based care. She continued to receive medications through G-tube.
#HTN: Held lisinopril.
#Constipation: Held lactulose BID, docusate, and bisacodyl PRN.
Will give bicacodyl PR for use after discharge if pain.
#Hypothyroidism: Held home levothyroxine after CMO.
Transitional Issues
===================
[] Transitioned to comfort-based care during this
hospitalization. Will be discharged with palliative ___ per
patient's family preferences instead of hospice.
[] Palliative ___ will refer patient to palliative care MD
depending on how she does after discharge with reconsideration
of hospice referral.
[] Filled out MOLST forming prior to discharge indicating no
further hospitalizations and CMO
[] Started morphine PO to be given through PEG tube for
discomfort and respiratory distress
[] Started lorazepam PRN for anxiety. Patient did not require
this medication during hospitalization
[] Started scopolamine patch to be given for excess secretions
q72 hours
[] Tube feeds will not be continued after discussion with
patient's family. She will only use PEG tube for medications to
control symptoms and improve comfort.
[] All other medications were discontinued that did not directly
improve comfort.
# CMO
# CONTACT: Proxy name: ___
Relationship: son Phone: ___
Comments: alternate ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO BID
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Rivaroxaban 15 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Aquaphor Ointment 1 Appl TP TID:PRN wound care
11. Ascorbic Acid ___ mg PO DAILY
12. CefePIME 2 g IV Q8H
13. MetroNIDAZOLE 500 mg PO Q8H
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Vitamin A ___ UNIT PO DAILY
16. Zinc Sulfate 220 mg PO DAILY
17. Bisacodyl 5 mg PO DAILY:PRN constipation
18. Vitamin D 800 UNIT PO DAILY
19. TraMADol 25 mg PO Q6H:PRN pain
20. amLODIPine 5 mg PO DAILY
21. Lisinopril 40 mg PO DAILY
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
23. Aspirin 81 mg PO DAILY
24. Metoprolol Tartrate 6.25 mg PO BID
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl [Bisac-Evac] 10 mg 1 suppository(s) rectally once
a day Disp #*12 Suppository Refills:*0
2. LORazepam 0.25 mg PO Q4H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) tablet(s) by mouth
every four (4) hours Disp #*10 Tablet Refills:*0
3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN Pain - Moderate
RX *morphine concentrate 20 mg/mL ___ mg by mouth every 2 hours
as needed Disp #*50 Syringe Refills:*0
4. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
Apply behind ear
RX *scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over
3 days) Apply behind ear Q72H Disp #*10 Patch Refills:*0
5. Acetaminophen 1000 mg PO Q8H
6. Aquaphor Ointment 1 Appl TP TID:PRN wound care
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Septic shock secondary to pneumonia
Acute renal failure
Severe malnutrition
Secondary Diagnosis
===================
Atrial fibrillation with rapid ventricular response
Sacral decubitus ulcer
Hypertension
Constipation
Hypothyroidism
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic and not arousable.
Mental Status: Confused - always.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you had severely infected
skin wounds on your back, kidney failure, and a very fast heart
rate. You were treated with antibiotics, but your condition
continued to worsen.
After an extensive conversation with your family, we switched
you to comfort-based care. We started medications to control
your symptoms. You were seen by our hospice team for control of
your symptoms, but you family declined hospice care at this
time. You will be followed by a palliative care visiting nurse
after discharge.
Your family was provided with instructions on administering pain
and anxiety medications through your PEG tube. Your family
should ask the visiting nurse if they have any questions
regarding use of the PEG tube or inadequate control of your
symptoms.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team.
Followup Instructions:
___
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10766212-DS-9
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2111-12-07 00:00:00
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2111-12-07 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Bilateral infected heel ulcers with necrotizing infection of
right lower leg
Major Surgical or Invasive Procedure:
___ Right Below the Knee Amputation Site Closure
___ Right Guillotine Below the Knee Amputation
___ Right foot and lower extremity debridement
History of Present Illness:
___ year old male who presents to the ED with foot ulcerations.
Patient's friends had called EMS after the patient stated his
feet were bleeding and he smelled a foul odor from his feet.
Past Medical History:
Denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
General: NAD, AOx3
Lower extremity focused exam: ___ pulses non palpable on the
right, faintly palpable on the left. Superficial ulcerations
noted sub first and fifth metatarsal heads on the left without
surrounding erythema, purulent drainage, or local signs of
infection. Large necrotic ulceration noted to the lateral aspect
of the right foot and right heel with bone exposed. Purulence
and malodor noted. Ulceration tracks proximally and dorsally
along the foot with purulence expressed. fifth digit on the
right is necrotic. Light touch sensation absent bilaterally.
Physical Exam:
Alert and oriented x 3. Cooperative.
VS:BP 146/84 HR 100 RR 18
Resp: Lungs clear
Abd: Soft, non tender
Left: Femoral palp, DP palp ,___ palp
Dry eschar left heel .
Right : Surgical stump incision, clean dry and intact. Soft, no
hematoma or ecchymosis. Slightly edematous. Dry DSD and ACE
wrapped.
Pertinent Results:
Imaging: Right foot radiograph
Findings highly worrisome for acute osteomyelitis in the right
foot involving in plantar calcaneus and the lateral base of the
fifth metatarsal, with extensive subcutaneous gas seen tracking
along the dorsal and lateral foot, from the level of the ankle
to at least the middle phalanx, as well as plantar to the
calcaneus
___ 06:50AM BLOOD WBC-12.6* RBC-3.07* Hgb-8.1* Hct-26.3*
MCV-86 MCH-26.4 MCHC-30.8* RDW-18.2* RDWSD-56.5* Plt ___
___ 06:50AM BLOOD Glucose-184* UreaN-21* Creat-0.7 Na-139
K-4.6 Cl-102 HCO3-23 AnGap-19
___ 06:50AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1
___ 06:54PM BLOOD %HbA1c-11.6* eAG-286*
___ 03:10PM BLOOD calTIBC-159* Ferritn-1854* TRF-122*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have b/l infected ulcerations with gas in the soft tissue and
was admitted to the podiatric surgery service. The patient was
taken to the operating room urgently on ___ for ___
Debridement, 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. ___ was consulted to help
evaluate the pts comorbid conditions. ___ was consulted due
the pts uncontrolled DM and subsequently titrated his insulin
regimen during his stay. Psych was consulted to evaluate any
underlying and unresolved mental health issues. Social work and
OT were also consulted to evaluate the patent.
The patient was then transferred to the vascular surgery service
and he was taken back to the operating room on ___ for a right
guillotine below-the-knee amputation. The procedure was
tolerated well and he had good hemostasis achieved at this BKA
wound, which was left open. He had hemodynamic improvement after
this procedure. He was continued on broad-spectrum antibiotics
(vanc/clinda/zosyn). The clindamycin had been started due to
concern for necrotizing infection and it was thereafter
discontinued 48-hours ___.
He returned to the ___ on ___ for closure of the guillotine
amputation. This was well tolerated. He worked with ___ who
recommended rehab to restore functioning to baseline.
Mr. ___ had not received medical care for many years.
Multiple medical issues have been identified and treated. His
sister ___ is his health care proxy.
Ongoing Issues
-Psychotic-spectrum symptoms
Psych was consulted to determine capacity given his degree of
agitation, paranoia and inattention to personal care on
admission. They found he had capacity to consent for surgery.
Haldol was started.
On follow up postop, this psychotic-spectrum symptoms improved
but were still consistent with schizotypal personality disorder.
THey felt it was reasonable to continue low dose Haldol 2.5 mg
qhs. Persistent tachycardia was thoroughly worked up and was
untimely felt to be related to the Haldol.
-Diabetes
A1c on admission 11.6. ___ diabetes team was consulted who
initiated lantus and sliding scale humalog with excellent
glucose control. Will need teaching/insulin titration.
-Dispo
Per report, he lives at his home in unsanitary/unsafe
conditions. Our social worker
has been involved who contacted the his elder services
caseworker ___: ___ regarding pt admission
and safety concerns.
Caseworker reports pt consented to speak with her since
admission, but that pt had declined both visits and conversation
prior to admission. SW provided information regarding the
extent of pt's home disarray (per communication with pt's
sister) and general information regarding ___ medical status
and plan for d/c to
acute rehab and subsequent SNF (per case management note). In
the event that he does return to his home. A local PCP has
been arranged his ongoing medical needs if he dose return home.
-Gangrene of right lower extremity
A closure BKA was evidentially done on ___. We suggest
continuing for 2 weeks prophylactic oral antibiotics. It is
imperative that the area is protected with DSD and ACE to allow
healing. Gabapentin and Tylenol have been sufficient to
control pain. He does have tissue loss on his contralateral leg
that podiatry will follow closely as there is not evidence of
vascular compromise.
Medications on Admission:
noneThe Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 100 mg PO TID
7. Haloperidol 2.5 mg PO QHS
8. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
10. Senna 8.6 mg PO BID:PRN constipation
11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gangrene Right Lower extremity
Diabetes
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:
Mr. ___,
It was a pleasure taking care of you at ___
___. During your hospitalization, you had surgery to
remove unhealthy tissue on your lower extremity. You tolerated
the procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
LOWER EXTREMITY AMPUTATION
DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility in your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage,
you may leave the incision open to air.
Your staples/sutures will remain in for at least 4 weeks. At
your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD
DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR
STUMP!
IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT
THE WOUND HAS SUFFICIENTLY HEALED.
Followup Instructions:
___
|
10766244-DS-11
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2174-01-25 00:00:00
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2174-01-27 17:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of asthma,
otherwise mostly healthy, who presents after syncopal episode
while at work.
Patient works as a ___ at ___. She was loading books onto a
cart during which time she started to feel weaker than usual. A
few minutes later she sat down in her chair at her desk. She
does not recall the next few minutes. She was told she
complained of feeling lightheaded and unwell and then collapsed
from her chair to the ground. She awoke a few seconds later on
the ground.
She is unable to recall specific symptoms before the episode,
but denies being aware of any chest pain, shortness of breath or
palpitations in the immediate moments surrounding it. She had
significant left ankle pain after the fall and she believes that
her ankle twisted under her as she fell.
She reports palpitations while in church the day prior to
admission. She says she was standing in church when she felt her
heart beating very quickly along with pleuritic pain. She says
she palpated her chest and found that it was tender at the site
of pain so she attributed this to lifting heavy books earlier in
the day. This pain resolved within a few minutes as did the
palpitations.
ROS: Comprehensive 10-point ROS is otherwise negative.
ED course:
- VS: 98.0, 60, 125/94, 18, 100% on RA
- Labs: TnT <0.01, TSH 2.2, otherwise unremarkable
- EKG: NSR, RBBB, compared to prior from ___ the QRS is
longer
- Meds: None
- Imaging: CXR - no acute process, ANKLE - L fibula fracture
Past Medical History:
- ADHD
- Osteopenia
- Asthma
- Dry eyes
Social History:
___
Family History:
Mother: ___ yo, HTN
Father: died at ___ yo from SBO, had CAD, CKD, prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9, BP 121/58, P 63, RR 18, O2 99% on RA
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: soft, non-tender, non-distended. No hepatosplenomegaly
appreciated.
GU: No suprapubic tenderness
Extremities: L ankle swollen, medial aspect very tender to
palpation, range of motion limited by pain
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.0 118/62 67 16
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: soft, BS present
EXT: L leg in walker boot
NEURO: Alert, Oriented, face symmetric
PSYCH: calm, appropriate
Pertinent Results:
Admission Labs:
___ 12:06PM BLOOD WBC-8.2 RBC-4.20 Hgb-13.8 Hct-41.1 MCV-98
MCH-32.9* MCHC-33.6 RDW-12.9 RDWSD-46.8* Plt ___
___ 12:06PM BLOOD Neuts-85.5* Lymphs-8.4* Monos-5.0
Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.04* AbsLymp-0.69*
AbsMono-0.41 AbsEos-0.02* AbsBaso-0.03
___ 12:06PM BLOOD Glucose-99 UreaN-19 Creat-0.8 Na-138
K-5.0 Cl-101 HCO3-21* AnGap-21*
___ 09:48PM BLOOD D-Dimer-1849*
___ 12:06PM BLOOD TSH-2.2
___ 12:06PM BLOOD cTropnT-<0.01
___ 05:47PM BLOOD cTropnT-<0.01
___ 09:48PM BLOOD CK-MB-2 cTropnT-<0.01
Discharge Labs:
___ 09:40AM BLOOD WBC-5.8 RBC-4.34 Hgb-13.7 Hct-41.9 MCV-97
MCH-31.6 MCHC-32.7 RDW-13.1 RDWSD-46.8* Plt ___
___ 09:40AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-140
K-4.2 Cl-103 HCO3-29 AnGap-12
___ 09:40AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.0
ECG - Sinus bradycardia. Right axis deviation. Right
bundle-branch block. Possible right ventricular hypertrophy. No
previous tracing available for comparison.
ECG - Sinus rhythm. Borderline right axis deviation. Right
bundle-branch block. Possible left ventricular hypertrophy.
Compared to the previous tracing of the same date, there is no
significant change.
L Ankle Films - IMPRESSION:
Oblique fracture involving the lateral malleolus likely
representing a Weber B injury without mortise disruption or
significant displacement.
CXR - IMPRESSION:
COPD. No acute cardiopulmonary process.
L Tib/Fib Films - FINDINGS:
There is an obliquely orientated Weber B type fracture of the
left distal fibula extending to the level of the tibiofibular
syndesmosis. Minimal fracture fragment distraction. No
significant change in position with gravity stress view. No new
bony injury.
IMPRESSION: Weber B type fibular fracture.
TTE - The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation.
CTA Chest - IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Limited evaluation of the left subclavian vein due to
artifact. Extensive collateral vessels in the left upper chest
is suspicious for occlusion or severe stenosis of the left
subclavian vein. This can be further evaluated on ultrasound.
3. Mild interlobular septal thickening in the left base may
represent early volume overload.
LUE US - IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
The visualized left subclavian vein demonstrates normal color
flow throughout.
Brief Hospital Course:
___ y/o F with no significant PMHx, who was admitted following
syncopal episode c/b L ankle frx.
# Syncope: She endorses several episodes of palpitations over
the past few weeks; however, she does not recall the events
surrounding this syncopal so is unsure whether she had
experienced palpitations this time. No events on tele here. CTA
(performed ___ elevated D-dimer) was negative for PE. Of note,
she did have significant orthostatic symptoms while working with
___, which improved after 1LNS. While this does argue to
orthostasis as a possible etiology for her presentation, her
syncopal episode as well as prior episodes of
lightheadedness/palpitations occurred while she was sitting,
making this less likely. Given normal TTE and no events on tele
here, pt is medically stable for discharge home. Encouraged pt
to adequately hydrate. Would consider ambulatory heart monitor
to further evaluate for any arrhythmias, given reports of
palpitations over the past few weeks.
# Left Distal Fibular Fracture: Likely ___ fall. Ortho
evaluated. Recommended walker boot with f/u in 1 week. D/c'ed
with walker and home ___.
# Subclavian Stenosis: Suggested by CTA but not seen on
ultrasound.
# Asthma: Restarted home albuterol and Flovent.
TRANSITIONAL ISSUES:
- continue outpatient ambulatory cardiac monitoring, given
reports of palpitations (no events on tele here)
- ortho f/u in 1 week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Restasis 2 gtts Other BID
2. Vitamin D ___ UNIT PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze
5. Docusate Sodium 150 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Primrose Oil (eve prim-linoleic-gamolenic ac) 1,000 mg oral
DAILY
8. Glucos Chond Cplx Advanced (glucosam-chond-hrb 149-hyal ac)
750 mg-100 mg- 125 mg-1.65 mg oral DAILY
9. flaxseed oil 1,000 mg oral DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze
2. Docusate Sodium 150 mg PO QHS
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Multivitamins 1 TAB PO DAILY
5. flaxseed oil 1,000 mg oral DAILY
6. Glucos Chond Cplx Advanced (glucosam-chond-hrb 149-hyal ac)
750 mg-100 mg- 125 mg-1.65 mg oral DAILY
7. Primrose Oil (eve prim-linoleic-gamolenic ac) 1,000 mg oral
DAILY
8. Restasis 2 gtts Other BID
9. Vitamin D ___ UNIT PO DAILY
10. Medical Equipment
Rolling Walker
Dx: Left Fibular Fracture
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
L Fibular 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:
You presented to the hospital after an episode of passing out.
You were placed on a heart monitor and had no concerning
arrhythmias. You had an ultrasound of your heart which was
unremarkable. You had a CAT scan of your chest which did not
show any blood clot. You worked with physical therapy and were
noted to be mildly dehydrated. This improved with IV fluids. It
is important that you continue to hydrate well after you go
home.
You were also found to have a fracture in your left ankle. You
were fitted with a boot for this. You are being discharged home
with a walker and home physical therapy.
Followup Instructions:
___
|
10766251-DS-8
| 10,766,251 | 21,570,032 |
DS
| 8 |
2170-09-19 00:00:00
|
2170-09-19 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zithromax / Keflex
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Ms. ___ is a ___ with internal hemorrhoids and prior episodes
of diverticulitis.
She now presents with abdominal pain and blood in stool with
colitis in descending colon on CT. She has had previously
colitis
three times in the same region. Her colonoscopy appeared grossly
normal, but no biopsies were taken.
She has had lower abdominal pain and BRBPR since evening of
___. She had formed bowel movements but noted that there was
blood covering the stool. Later that evening she had 3x diarrhea
with blood and mucus.
Her bowel movements are not painful. She has not recently had
fevers or chills. She had similar symptoms before when she had
diverticulitis.
In the ED, initial vitals were notable for normotension, no
fever.
Exam notable for:
Rectal: heme + brown stool mixed with bright red blood
Labs notable for:
WBC 12.7, no anemia
CRP 2.0
Normal lactate
Imaging notable for descending colitis as below.
In the ED, she was treated with IV cipro/flagyl.
Gastroenterology
was consulted and recommended admission to medicine with GI
following for further workup.
She also received IV morphine and 1L LR. She had nausea after
the
morphine (no vomiting).
Vitals prior to transfer:
98.7 80 112/64 18 96% RA
Upon arrival to the floor, the patient reports her abdominal
pain
has resolved. She had diarrhea 3x last night but no bowel
movements today (just a little blood and mucus). She feels
nauseous but has not had vomiting. No unintentional weight loss.
She has emphysema and had a cold in ___, s/p steroid taper
(this is completed).
Past Medical History:
Problems (Last Verified - None on file):
BREAST AUGMENTATION
HYPERLIPIDEMIA
HYPERTENSION
LEFT BUNDLE BRANCH BLOCK
OSTEOPENIA
RHINOPLASTY
TONSILLECTOMY
TUBAL LIGATION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CORONARY ARTERY DISEASE
coronary calcifications, negative ETT, aggressive risk factor
modification
EMPHYSEMA
PSORIASIS
ASTHMA
Surgical History (Last Verified - None on file):
BREAST AUGMENTATION
RHINOPLASTY
TONSILLECTOMY
TUBAL LIGATION
Social History:
___
Family History:
Family History (Last Verified - None on file):
Relative Status Age Problem Onset Comments
Other CORONARY ARTERY father
DISEASE
COLON CANCER mother
Mother ___ ___ RECTAL CANCER
Father ___ MYOCARDIAL
INFARCTION
HYPERTENSION
Physical Exam:
Admission exam:
VITALS:
98.0 120 / 67 85 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, 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
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Discharge exam:
Vital signs:
24 HR Data (last updated ___ @ 806)
Temp: 97.9 (Tm 97.9), BP: 134/76 (111-134/63-76), HR: 107
(104-107), RR: 18, O2 sat: 92% (87-94), O2 delivery: RA
(0.5L-1L)
GENERAL: Alert and in no apparent distress, coughing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: regular, borderline tachy
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. trace basilar crackles
GI: Abdomen soft, non-distended, non-tender to palpation. BS+
SKIN: No rashes or ulcerations noted
EXTR: wwp minimal edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
Pertinent data:
WBC 12.7 -> 9.6 -> 7.3 -> ___
hgb 14.5 ----> ___
Plt 170s->140s->170s
CKMB 2, trop <0.01 x2
proBNP 1639
CRP 2.0
Stool cultures, c diff, urine culture, negative
O&P pnd
CXR ___
Pulmonary interstitial edema and small bilateral pleural
effusions.
EKG ___
incomplete LBBB similar to prior except with nonspecific lateral
ST-T changes
Colonoscopy ___
-high residue material throughout
-abnormal segment of mucosa with erythema, loss of vascularity,
friability, and contact bleeding in the descending colon from 30
to 40 cm. Proximal and distal areas appeared normal
-internal hemorrhoids
GI path
PATHOLOGIC DIAGNOSIS:
1. Ascending/transverse colon, biopsy:
Colonic mucosa within normal limits.
2. Descending colon, biopsy:
Colonic mucosa with ischemic pattern of injury. See note.
3 .Sigmoid colon, biopsy:
Colonic mucosa within normal limits.
4. Rectum, biopsy:
Colonic mucosa within normal limits.
Note: Differential diagnoses of this pattern of injury includes
vascular causes of ischemia, certain
infections (e.g. C. difficile, enterohemorrhagic E. coli), or
drug effect. Clinical correlation is
recommended.
Brief Hospital Course:
___ is a ___ year old woman with HTN, CAD, COPD, asthma,
and prior episodes of descending colitis who presented with
abdominal pain and bloody diarrhea, and was found to have
recurrent descending colitis on CT. Course complicated by
dyspnea and hypoxia.
# Descending colitis - suspect ischemic etiology
Patient with recurrent descending colitis, underwent colonoscopy
on ___ that confirmed ~10 cm area of inflammation in proximal
descending colon. Based on endoscopic appearance and biopsy
results colonic ischemia seems most likely, which also fits with
recurrences in same distribution. She received 5 days of
cipro/flagyl. Her pain and bloody diarrhea improved within ___
hours. She had loose stools the day of discharge but no pain or
blood, so this was felt to be less likely recurrence of her
ischemia. Cause of ischemia unclear. however in reviewing
outpatient notes there has been suspicion for white coat HTN.
Her BPs were low normal through most of the early admission, so
her lisinopril was held. She should monitor BPs closely as an
outpatient and discuss with outpatient providers whether or not
to resume treatment.
#Suspected acute diastolic heart failure / hypoxia
No known history of heart failure and had normal echo 3 weeks
ago in ___. However she desatted overnight on ___ and had
wet appearing CXR and elevated BNP, and she felt improved after
20 mg IV Lasix. Suspect that she has some underlying diastolic
dysfunction that led to some overload in setting of IV fluids.
Subsequently her sats were 90-95% on room air while at rest. She
briefly desatted to 87-88% with ambulation on the day of
discharge but quickly recovered. She was offered further
inpatient care to consider another trial of diuresis (although
she appeared euvolemic and her desat was likely multifactorial
including asthma and viral infection), but she preferred
discharge home. It was recommended she have vitals checked in
the next ___ days and ___ very closely with PCP and
cardiology. Inpatient echo felt to be unnecessary since her
troponin was negative, EKG overall unchanged from prior, and
therefore new cardiac event felt to be highly unlikely. She was
not discharged with IV diuretics given her loose stools and
concern for precipitating further colonic ischemia if
over-diuresed.
# Suspected URI
# Asthma
Patient with recent respiratory infection prior to admission.
Endorsed fluctuating
headache and post-nasal drip, which she feels may be sinusitis
related. Also lower respiratory symptoms of cough and dyspnea,
which may be in part viral infection triggering asthma, in
addition to a component of volume overload. Sats as per above.
She did endorse some improvement in symptoms with nebulizer and
with codeine-guaifenesin cough syrup. She was discharged on her
home inhalers and with codeine-guaifenesin cough syrup.
Prednisone was considered but given uncertain etiology this was
deferred for now.
#Tachycardia
HRs ___ early in admission, but up to ___ later in
admission, and slightly higher with ambulation. This occurred
after her nebulizer frequency was increased, so this was a
likely cause, in conjunction with her respiratory process(es).
# CV:
Continued ASA
# HTN:
Holding lisinopril as per above
# HLD:
Continue rosuvastatin
***DISCHARGE PLAN***
Patient continued to have respiratory symptoms (mainly cough),
borderline sats, and mild tachycardia prior discharge, as well
as some loose stools. However she also strongly preferred to
return home, as she was sleeping poorly in the hospital and
generally felt she would be more comfortable at home. I
explained that I thought this plan was acceptable conditional
upon her having very close ___, including vitals check in
the next ___ days, and returning to care with any worsening
symptoms or failure to improve. She expressed an understanding
and preferred discharge home. She was not sufficiently unwell to
warrant an AMA discharge.
===================================
===================================
TRANSITIONAL ___
- given concern for volume overload during admission, suspect
she may have some diastolic dysfunction. could consider repeat
TTE. otherwise would monitor for any evidence of volume overload
moving forward
- should respiratory symptoms fail to improve could consider
prednisone burst for possible asthma flare +/- trial of diuresis
for ?volume overload
- given suspicion for colonic ischemia, her lisinopril was
stopped. she plans to monitor BPs closely at home and discuss
with cardiology and PCP providers in ___
===================================
===================================
>30 minutes in patient care and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN Cough
3. Rosuvastatin Calcium 20 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Ustekinumab Dose is Unknown IV ONCE
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. albuterol sulfate 90 mcg/actuation inhalation QID:PRN wheeze
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Guaifenesin-CODEINE Phosphate 10 mL PO QID
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 10 ml by mouth up to
three times daily as needed Refills:*0
3. Ustekinumab 260 mg IV ONCE Duration: 1 Dose
4. albuterol sulfate 90 mcg/actuation inhalation QID:PRN wheeze
5. Aspirin 81 mg PO DAILY
6. Benzonatate 100 mg PO TID:PRN Cough
7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic colitis
Hypoxia
Suspected congestive heart failure
Suspected upper respiratory infection
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of bloody diarrhea and
abdominal pain. We suspect that this was due to "ischemic
colitis", also called "colonic ischemia", which often results
from not having enough blood flow to the bowel for a period of
time. This can occur if you are dehydrated or if your blood
pressure is too low. For now we recommend stopping your
lisinopril and closely monitoring your blood pressures at home.
You will need to address this with your primary care doctor and
cardiologist.
You also had other symptoms, including cough, shortness of
breath, and nasal congestion during your admission. These seemed
to be in part related to a viral illness, but we were also
concerned that you had a brief period of "congestive heart
failure", which led to some fluid in your lungs. Your symptoms
improved somewhat after a diuretic ("water pill") called Lasix,
which helped remove fluid. We also suspect that your asthma
played a role in these symptoms. Your oxygen levels were at
times on the borderline of the point where we would recommend
additional oxygen therapy. It will be very important to seek
medical care if you have any worsening symptoms and to be seen
in the upcoming days to have your oxygen, blood pressure, and
heart rate checked. For now it is not clear that you need more
Lasix for fluid removal or steroids for your asthma, but should
your symptoms worsen or fail to improve you should discuss with
your doctor.
Followup Instructions:
___
|
10766534-DS-12
| 10,766,534 | 21,547,865 |
DS
| 12 |
2188-04-10 00:00:00
|
2188-04-10 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left hemiparesis & hemiataxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ old man with a history of
hyperlipidemia who presents with left-sided sensory and movement
abnormalities which have largely resolved.
He was in his normal state of health this evening at church when
he had the sudden onset of a funny feeling in his left face,
feeling swollen as if he had been bitten by a bug. Two minutes
later, the sensation abruptly spread to include entire the left
side of his body. He walked home and when he arrived home about
fifteen minutes after onset, he had started to feel dizzy (a
sensation of spinning) and like his tongue felt thick. He called
out to his wife who saw him and noticed that his left face was
drooping. He tried to sit down to rest but his symptoms did not
improve. His wife took him to the hospital. There, he had
difficulty walking because of weakness vs dyscoordination in the
left leg. At this point his symptoms had persisted for about an
hour. They gradually began to resolved to the point that he was
able to walk unassisted to the bathroom. His facial droop
resolved and his weakness improved. By the time he had been
transferred over to ___ his only residual complaint was a
"thick tongue."
Prior to the onset of these symptoms he had had a mild headache
all day which was not associated with photophobia, phonophobia,
nausea or visual aura. He does not have a history of headache or
migraine. He did not have any infectious symptoms prior to these
events. Nothing like these symptoms has ever happened before.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hyperlipidemia (per his wife)
Social History:
___
Family History:
- Father passed away from an MI in her ___.
Physical Exam:
**Unchanged from admission to discharge
.
T 97.6; HR 76; BP 134/81
RR 18; SpO2 95%
General: Well-nourished, jolly man, lying in bed laughing in no
apparent distress.
HEENT: NC/AT, moist mucus membranes.
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Obese, soft, nontender, nondistended. Bowel sounds
present.
Extremities: No lower extremity edema
Skin: No rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. 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. Attentive, able to name ___ backward without
difficulty. Pt. was able to register 3 objects and recall ___
at
5 minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect. Calculations were intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm, both directly and consentually; brisk
bilaterally. VFF to confrontation with finger counting.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions,
and ___ strength noted bilateral in masseter
VII: Slight left facial droop and slightly delayed activation.
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: Upper motor neuron pattern weakness in the 4+ range on
the left side. Normal bulk, tone throughout. Pronation but no
drift on the left. No adventitious movements, such as tremor,
noted. No
asterixis noted.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pin, direction sense, cold
sensation throughout.
No extinction to DSS.
-Coordination: Left-sided dysmetria in upper and lower
extremities. Intention tremor on L FNF, ataxia on HKS. Overshoot
on L finger following, impaired cadence on finger and toe
tapping
on L. Normal on right.
-Gait: Good initiation. Wide-based, cautious. Cannot walk in
tandem. Romberg absent.
Pertinent Results:
==========
LABS
==========
___ 01:16AM BLOOD WBC-6.7 RBC-6.10 Hgb-12.7* Hct-39.8*
MCV-65* MCH-20.8* MCHC-31.9* RDW-18.6* RDWSD-38.7 Plt ___
___ 01:16AM BLOOD Neuts-47.4 ___ Monos-11.3 Eos-1.8
Baso-0.4 Im ___ AbsNeut-3.17 AbsLymp-2.62 AbsMono-0.76
AbsEos-0.12 AbsBaso-0.03
___ 01:16AM BLOOD Plt ___
___ 01:16AM BLOOD ___ PTT-31.4 ___
___ 01:16AM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
___ 06:25AM BLOOD cTropnT-<0.01
___ 01:16AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.9
___ 06:25AM BLOOD Triglyc-145 HDL-34 CHOL/HD-5.8
LDLcalc-134*
___ 06:25AM BLOOD TSH-1.6
___ 06:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:25AM BLOOD %HbA1c-PND
.
==============
IMAGING
==============
- MRI brain
There is a small region of slow diffusion with corresponding
T2/FLAIR signal hyperintensity in the right thalamus. Findings
are compatible with late acute/early subacute infarction.
There is no evidence of hemorrhage, edema, masses, mass effect,
or extra-axial collection. The ventricles and sulci are normal
in caliber and configuration. Major vascular flow voids are
preserved. The orbits are unremarkable. The paranasal sinuses
and mastoid air cells are clear.
IMPRESSION:
Late acute/early subacute right thalamic infarction.
.
- Head CT: There is no evidence of hemorrhage, edema, masses,
mass effect, or
infarction.
- Head CTA: There are no intracranial vascular abnormalities.
There is no
evidence of aneurysm, stenosis or occlusion.
- Neck CTA: The carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses.
.
- CXR: Cardiomediastinal contours are normal. Lungs and pleural
surfaces are clear. Right hemidiaphragm is mildly elevated.
Brief Hospital Course:
Mr. ___ was admitted to the hospital for left hemibody
sensory changes and on examination was found to have a left
ataxic hemiparesis - together implying a likely right
thalamocapsular infarct which is what was found on MRI. CTA
head/neck did not show any acute abnormality. He was
hyperlipidemic (a diagnosis which he likely carried per his wife
but refused to believe). As such, we started ASA 81mg daily and
atorvastatin 40mg daily. He did do well with ___ in hospital and
was cleared for home. We have referred him for ___, OT, and
speech therapy (for a slight dysarthria).
.
Remaining work-up includes
- TTE (to be ordered by PCP ___
- A1c (pending at time of discharge)
.
Transitional issues include:
- Follow-up with Dr. ___ (we will have our
assistant contact the patient with a date and time of an
appointment approximately 3 months from now)
- Re-testing lipids at time of follow up to determine whether
statin dose needs to be adjusted further
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Outpatient Physical Therapy
434.1 Ischemic Stroke
Left hemibody weakness and ataxia
Please evaluate and treat
4. Outpatient Occupational Therapy
434.1 Ischemic Stroke
Left hemibody weakness and ataxia
Please evaluate and treat
5. Outpatient Speech/Swallowing Therapy
434.1 Ischemic Stroke
Slurred speech
Please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
- small vessel stroke, right capsule
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 of left sided clumsiness,
weakness, and sensory complaints caused by a small stroke in the
right side of your brain. We started you on aspirin 81mg daily
and atorvastatin 40mg daily to reduce your risk of another
stroke. Your blood pressures were generally within the normal
range but we would like you to follow up with your primary care
doctor to have your blood pressures checked in the future.
There is a blood test pending (hemoglobin A1c) to be followed up
by your primary care doctor. We would also like you to have an
outpatient echocardiogram (ultrasound of your heart) to make
sure that the same problems that affected your brain (causing
stroke) are not affecting your heart.
You will be contacted with a time and date for a follow-up
appointment with Dr. ___ in stroke neurology in ___ months.
Followup Instructions:
___
|
10766542-DS-9
| 10,766,542 | 21,202,882 |
DS
| 9 |
2161-10-07 00:00:00
|
2161-10-07 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Poison ___ / Poison Oak Extract / Poison Sumac Extract
Attending: ___.
Chief Complaint:
difficulty breathing, left leg pain and swelling
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ old Female with PMH significant for anxiety
disorder, history of recurrent urinary tract infections (on
chronic ___ antibiotics) and ___ nighttime
asthma who presents with left lower extremity pain and swelling
with exertional shortness of breath.
___ notes that she took a flight back from ___ that was
___ in late ___. Two weeks ago she noted gradual
onset of left calf pain that is worsened with ambulation. She
denied any swelling or redness until today in which she noted
mild swelling. She also reports that in the last ___ days she
had the acute onset of shortness of breath with exertion,
improved with resting. The patient reports that exercising
during her cycling class or unloading groceries from her car in
the last few days has made her dyspnea worse. She has no cardiac
or pulmonary disease history. She has no fevers or chills. She
denies cough or URI symptoms. She has no personal history of
clotting disorder or malignancy. She denies hemoptysis. She has
no history of immobilization, recent surgery or venous
thromboembolic disease. She has been taking NSAIDs and applying
warm compresses to manage the pain in her leg.
She does note feeling more fatigued lately and having less
overall energy in the last few weeks.
She had dinner with a friend last evening who is a physician and
she recommended she see her primary care physician - who
ultimately recommended she proceed to the ER.
ED course:
- initial VS 99.4 62 129/77 16 100% RA
- Labs unremarkable, normal WBC, hemoglobin and creatinine, INR
1.0
- LLE US notable for DVT in popliteal
- EKG obtained
- U/A reassuring
- received rivaroxaban 15 mg PO x 1
REVIEW OF SYSTEMS: See HPI for pertinent details. Denies fevers
or chills; (+) nightsweats. No headaches or visual changes. No
chest pain, but (+) difficulty breathing. No notable upper
respiratory symptoms or cough. Denies nausea and emesis or
abdominal pain. No loose stools or diarrhea, constipation or
other changes in bowel habits. No dysuria or hematuria. No new
rashes, lesions or ulcers. (+) left lower extremity swelling,
but no athralgias or joint complaints. No pertinent weight loss
or gain, change in dietary habits.
Past Medical History:
- anxiety disorder
- history of recurrent urinary tract infections (on chronic
___ antibiotics)
- ___ nighttime asthma
Social History:
___
Family History:
The patient denies a history of premature cardiac disease such
as MI, arrhythmia or sudden cardiac death. MGF with CAD and PGF
with DM2. MGM with colon cancer in her ___, mother with lung
cancer (from smoking) in her ___. Father had a DVT in the
setting of arterial stenting (___).
Physical Exam:
ADMISSION EXAM:
================
Vitals: 98.4 101/60 68 16 97% RA
General: patient appears in NAD. Appears stated age. ___
appearing.
HEENT: normocephalic, atraumatic. PERRL. EOMI. Nares clear.
Oropharynx with no notable lesions. Good dentition. Neck supple.
No lymphadenopathy.
___: regular rate and rhythm. No murmurs. S1 and S2. JVP not
elevated while upright.
Respiratory: demonstrates unlabored breathing. Clear to
auscultation bilaterally without adventitious sounds such as
wheezing, rhonchi or rales.
Abdomen: soft, ___ with normoactive bowel
sounds.
Extremities: warm, ___ distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing; left calf medially with
some trace swelling and overlying erythema that is mild; ___
equivocal.
Derm: skin appears intact with no significant rashes or lesions
Neuro: alert and oriented to self, place and time. Normal bulk
and tone. Motor and sensory function are grossly normal. DTRs 2+
throughout. Gait deferred.
DISCHARGE EXAM:
================
Vitals: 98.8 97.8 100/60 56 16 97% RA
General: patient appears in NAD. Appears stated age. ___
appearing.
HEENT: normocephalic, atraumatic. PERRL. EOMI. Nares clear.
Oropharynx with no notable lesions. Good dentition. Neck supple.
No lymphadenopathy.
___: regular rate and rhythm. No murmurs. S1 and S2. JVP not
elevated while upright.
Respiratory: demonstrates unlabored breathing. Clear to
auscultation bilaterally without adventitious sounds such as
wheezing, rhonchi or rales.
Abdomen: soft, ___ with normoactive bowel
sounds.
Extremities: warm, ___ distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing; left calf medially with
some trace swelling and overlying erythema that is mild, now
improved; ___ equivocal.
Derm: skin appears intact with no significant rashes or lesions;
lipoma noted on back
Neuro: alert and oriented to self, place and time. Normal bulk
and tone. Motor and sensory function are grossly normal. DTRs 2+
throughout. Gait deferred.
Pertinent Results:
ADMISSION LABS:
================
___ 10:30PM BLOOD ___
___ Plt ___
___ 10:30PM BLOOD ___
___
___ 10:30PM BLOOD ___ ___
___ 10:30PM BLOOD ___
___
DISCHARGE LABS:
================
___ 07:40AM BLOOD ___
___ Plt ___
___ 07:40AM BLOOD ___ ___
___ 07:40AM BLOOD ___
___
___ 07:40AM BLOOD ___
MICROBIOLOGY:
==============
___ Urine culture - no growth
EKG:
=====
ECG (___): Sinus bradycardia @ 56 bpm. Normal axis, PR
interval shortened. Poor ___ progression across the
precordium. Peaked ___ in leads ___. No ischemic concerns.
IMAGING STUDIES:
=================
___ CTA CHEST W&W/O C&RECON - Bilateral segmental and
subsegmental pulmonary emboli, as described above. There is no
evidence of right heart strain or pulmonary infarction.
Incompletely imaged right hepatic lobe lesions are almost
certainly hemangiomas. Correlation with prior imaging is
recommended. If prior imaging is not available, an ultrasound of
the liver is recommended. Incidentally noted persistent left
superior vena cava, a normal variant.
___ UNILAT LOWER EXT VEINS - Deep venous thrombosis in the
left lower extremity involving the popliteal vein and calf
veins. No deep venous thrombosis in the right lower extremity.
Brief Hospital Course:
___ with PMH significant for anxiety disorder, history of
recurrent urinary tract infections (on chronic ___
antibiotics) and ___ nighttime asthma who presents
with left lower extremity pain and swelling with exertional
shortness of breath found to have likely provoked left lower
extremity DVT and evidence of bilateral pulmonary embolism.
# Pulmonary embolism- Her EKG with poor ___ progression and
exertional dyspnea made pulmonary embolism a serious concern.
CTA indeed demonstrated bilateral pulmonary emboli. No evidence
of right heart strain. She was initially given LMWH with 60 mg
SC Q12 hours and then per patient preference, we agreed to dose
her with rivaroxaban 15 mg PO BID for ___ and transition to
20 mg PO daily for the remainder of ___. BNP flat and
troponin negative which is prognostically favorable. Discharge
ambulatory oxygen saturations were normal.
# Deep venous thrombosis - Recent travel history with period of
immobilization noted, suggesting provoked event. No prior VTE
disease history. Family history mildly concerning given father's
DVT history. She was initially given LMWH with 60 mg SC Q12
hours and the after a discussion with the anticoagulation
pharmacist and the patient, we agreed to dose her with
rivaroxaban 15 mg PO BID for ___ and transition to 20 mg PO
daily for the remainder of ___.
# Liver hemangiomas - Incidental finding on CT chest imaging. No
symptoms. Will obtain outpatient RUQ US to confirm finding.
Study ordered and patient given contact number for radiology.
# Anxiety disorder - Stable. Continued SSRI treatment.
# History of recurrent UTIs - No current symptoms. U/A negative
in ED.
# ___ nighttime asthma - Stable symptoms.
Continued rescue albuterol inhaler.
TRANSITIONAL ISSUES:
- would consider outpatient evaluation for thrombophilic
disorder, has ___ at ___ clinic scheduled
- obtain outpatient RUQ US to confirm finding of liver
hemangiomas on CT chest imaging. Study ordered and patient given
contact number for radiology. Dr. ___
attending) will ___ results.
- discharged with rivaroxaban 15 mg PO BID for ___ and
transition to 20 mg PO daily for the remainder of ___
called her PCP's office and discussed this plan. She received
the prescription for the first ___ here and will need to
have her PCP prescribe the 20 mg PO daily dosing. Her PCP/PA
agreed to ___ this issue (phone conversation noted in
OMR). PCP ___ scheduled.
- encouraged her to wear knee high ___ stockings going forward
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. sertraline 100 mg oral DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY:PRN
___
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. sertraline 100 mg oral DAILY
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY:PRN
___
4. Rivaroxaban 15 mg PO/NG BID
15 mg PO BID dose for ___ and change to 20 mg PO daily
thereafter for at least ___.
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice daily
Disp #*42 Tablet Refills:*0
5. Equipment
___ embolism stockings (knee high). ___: 415.1
Discharge Disposition:
Home
Discharge Diagnosis:
- Bilateral pulmonary embolism
- Left lower extremity deep venous thrombosis
- Exertional hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the Internal Medicine service at ___
___ on ___ 7 regarding management
of your left lower extremity deep venous thrombosis (DVT) and
pulmonary embolism. Your oxygen saturations improved once your
started anticoagulation. ___ received injectable enoxaparin and
on discharge were transitioned to oral rivaroxaban. This
medication needs to be continued at 15 mg by mouth twice daily
for ___, and then 20 mg by mouth daily thereafter. Take the
medication with food. ___ should talk with your primary care
doctor about testing for inherited clotting disorders and
testing for these conditions. Please wear ___ compression
stockings going forward to prevent further clotting.
___ should also have a right upper quadrant ultrasound to
evaluate the small lesions in your liver that were noted on your
chest imaging. These are likely benign hemangiomas or vascular
lesions. The number to schedule the imaging study is listed
below.
Please call your doctor or go to the emergency department if:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* ___ develop new or worsening cough, shortness of breath, or
wheezing.
* ___ are vomiting and cannot keep down fluids, or your
medications.
* If ___ are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit, or have a
bowel movement.
* ___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* ___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* ___ develop any other concerning symptoms.
Followup Instructions:
___
|
10766641-DS-8
| 10,766,641 | 26,953,099 |
DS
| 8 |
2119-09-07 00:00:00
|
2119-09-08 09:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/P assault
Injuries:
bilateral orbital floor fractures
L zygomaticomaxillary complex fx
Communited b/l nasal bone fx
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who complains of ASSAULTED.
Patient was found alert and oriented times one at a ___,
after being assaulted about the face with a full Snapple bottle.
Unknown loss of consciousness. The patient
denies fall or any truncal assault. He is only complaining of
facial pain. He does admit to significant amount of alcohol.
Past Medical History:
Denies
Social History:
___
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAMINATION (___)
Constitutional: Constitutional: Alert and oriented x1,
significantly agitated, boarded and collared
Head/Eyes: Significant facial swelling with multiple abrasions
and lacerations. No clear proptosis. Right pupil ___, left pupil
nonvisualized due to surrounding swelling, active bleeding from
left nares multiple dental problems of unclear acuity, midface
grossly stable
ENT/Neck: C-collar intact
Chest/Resp: NO chest wall tenderness or crepitus, bilateral
breath sounds
Cardiovascular: Regular rate and rhythm
GI/Abdominal: Soft, nontender, nondistended
GU/Flank: No Costovertebral angle tenderness
Musculoskeletal: No deformity
Skin: No abrasions, lacerations, ecchymosis
Neuro: GCS 15, spontaneously moves all extremities to command.
Psych: Normal mood
Pertinent Results:
___ 05:40AM BLOOD WBC-11.6* RBC-4.40* Hgb-12.8* Hct-36.7*
MCV-84 MCH-29.1 MCHC-34.8 RDW-13.2 Plt ___
___ 01:20PM BLOOD WBC-16.2* RBC-4.44* Hgb-13.0* Hct-37.1*
MCV-84 MCH-29.2 MCHC-35.0 RDW-13.3 Plt ___
___ 03:40AM BLOOD WBC-11.2* RBC-5.36 Hgb-15.7 Hct-44.3
MCV-83 MCH-29.2 MCHC-35.3* RDW-13.2 Plt ___
___ 03:40AM BLOOD Glucose-120* UreaN-21* Creat-1.1 Na-143
K-3.7 Cl-103 HCO3-22 AnGap-22*
___ 03:40AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT C-SPINE W/O CONTRAST (___)
1. Slightly motion limited study. No cervical spine fracture
seen. No
subluxation.
2. Dextroconvex curvature at C4-5, chronicity unknown. If acute
ligamentous injury is suspected, then MRI would be more
sensitive for further evaluation.
CT SINUS/MANDIBLE/MAXILLOFACIA (___)
Multiple complex facial bone fractures. Bilateral ___ Fort
fractures, combined type. Left zygomaticomaxillary complex
fracture. Left orbital floor and inferior orbital rim fracture
with herniation of orbital fat and possible left inferior rectus
muscle entrapment. Minimally displaced left lateral and medial
orbital wall fractures. Communited bilateral nasal bone and
nasal septum fractures, with probable comminution of left medial
canthus ligament attachment.
Brief Hospital Course:
The patient is a ___ y/o male who presented to the ED after an
assault. He was admitted to the Acute Care Surgery Service after
sustaining facial fractures. A CT Scan of his sinus/maxillary
revealed " Multiple complex facial bone fractures. Bilateral ___
Fort fractures, combined type. Left zygomaticomaxillary complex
fracture. Left orbital floor and inferior orbital rim fracture
with herniation of orbital fat and possible left inferior rectus
muscle entrapment. Minimally displaced left lateral and medial
orbital wall fractures. Communited bilateral nasal bone and
nasal septum fractures, with probable comminution of left medial
canthus ligament attachment". Due to the nature of his injuries,
plastic surgery was consulted and they recommended outpatient
surgery. The patient was also seen by occupational therapy
during the admission, and they recommended outpatient cognitive
neurology secondary to poor recall. Social work assessed the
patient's support system and he seems to have a good
relationship with his grandparents and states he has many
friends for support. Lastly, Ophthalmology was consulted and did
not have any have need for intervention as the patient's vision
was intact.
The patient's pain was well controlled with PO oxycodone. He was
given instructions to followup at his scheduled appointment in
the Plastics Clinic and to keep sinus precautions upon
discharge.
Medications on Admission:
Denies
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
S/P assault
Injuries:
Bilateral orbital floor fractures
Left zygomaticomaxillary complex fracture
Communited bilateral nasal bone fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you were assaulted; in
which you sustained several facial fractures. During your
hospitalization, you were seen by plastic surgery and the
recommended operating on an outpatient basis. You will be
discharged with pain medications and the necessary outpatient
followup appointments.
SINUS PRECAUTIONS
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved.
Followup Instructions:
___
|
10766795-DS-13
| 10,766,795 | 26,139,956 |
DS
| 13 |
2154-01-03 00:00:00
|
2154-01-03 18:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Penicillins / amoxicillin
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of schizophrenia not currently on medications, carcinoma
of the thyroid s/p removal and subsequent hypothyroidism,
inconsistently adherent to replacement regimen, with recent
admission for hypothyroidism presenting for hematuria and
generalized weakness, found to have pericardial effusion, ___,
uncontrolled hypothyroidism, and pyuria/hematuria.
Of note, was recently admitted (___) for
hypothyroidism,
r scalp cellulitis, SOB (found to have moderate pericardial
effusion and AI), RLE wound, BV, and ___.
Regarding hypothyroidism, she had thyroid carcinoma removed at
___ and was on chronic T4 replacement therapy, although had been
intermittently non-adherent to therapy. Her sx on last admission
included constipation, hypothermia, and myalgias. She was
treated
with IV levothyroxine and discharged on 200mcg PO and her TFTs
improved.
Given SOB, she had TTE that found mild-moderate circumferential
pericardial effusion without tamponade physiology, and
mild-moderate AI. She was planned to get repeat TTE in ___
weeks.
- In the ED, initial vitals were: 98.3 72 112/63 18 100% RA
- Exam was notable for:
cv-muffled
pulm-coarse
RLQ tenderness
R>L lower back tenderness
- Labs were notable for:
CBC: wml, BMP K3.4, BUN 16, Cr 1.9
TSH 165
Lactate 2.2
- Studies were notable for:
1. Moderate low-density pericardial effusion.
2. Normal unenhanced appearance of the bilateral kidneys without
hydroureteronephrosis. No evidence of obstructing stone or
lesion. Normal appendix. No bowel obstruction. No visualized
acute abdominal pathology
U/A: >182 WBCs, 103 RBCs
- The patient was given: IVF, APAP, cipro
On arrival to the floor, patient was somnolent, only awaking to
loud voice and tactile stimulation. She was only able to say
that
she had abdominal pain for the past two days without diarrhea
and
diffuse myalgias. She also has urinary frequency without
dysuria,
change in color, or odor. She denies CP, SOB, fevers, or chills.
She has NOT been taking any of her medications as prescribed.
Past Medical History:
Carcinoma of the thyroid s/p removal
Hypothyroidism
Pericardial effusion
Cocaine use
Bacterial vaginosis
CKD
Scalp cellulitis
Schizophrenia
Social History:
___
Family History:
No FH of hypothyroidism
Physical Exam:
Admission Physical Exam:
========================
GENERAL: Somnolent, but when awake oriented x3. Awakes to loud
voice and tactile stimulation.
HEENT: Pupils constricted, but equal and reactive to light.
NECK: JVP not appreciated above clavicle at 30 degrees.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Soft
pericardial rub.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Abdomen diffusely tender with guarding, no rebound.
EXTREMITIES: Warm with trace edema bilaterally.
NEUROLOGIC: Somnolent, but A&Ox3 when awake. Moving all
extremities, but unable to assess due to patient's ability to
cooperate.
Discharge Physical Exam:
========================
General: Well-appearing female in no acute distress
HEENT: Extra ocular movements intact. Sclera anicteric
CV: RRR
Pulm: CTAB
Abd: Soft, non-distended, non-tender in all quadrants
Back: Tender to touch throughout lower back
Ext: Painful to touch in pretibial area
Pertinent Results:
Admission Labs:
___ 04:52PM BLOOD WBC-8.6 RBC-4.01 Hgb-12.3 Hct-38.6 MCV-96
MCH-30.7 MCHC-31.9* RDW-16.0* RDWSD-56.7* Plt ___
___ 04:52PM BLOOD Glucose-88 UreaN-16 Creat-1.9* Na-143
K-3.4* Cl-104 HCO3-27 AnGap-12
___ 02:35AM BLOOD T4-<0.4* calcTBG-1.23 TUptake-0.81 Free
T4-<0.1*
___ 07:53AM BLOOD T4-0.8* calcTBG-1.22 TUptake-0.82
T4Index-0.7* Free T4-<0.1*
___ 08:45PM BLOOD TSH-165*
Discharge Labs:
___ 10:14AM BLOOD WBC-5.4 RBC-3.74* Hgb-11.5 Hct-35.9
MCV-96 MCH-30.7 MCHC-32.0 RDW-16.6* RDWSD-58.5* Plt ___
___ 07:37AM BLOOD TSH-181*
___ 07:37AM BLOOD T4-3.4* T3-32* Free T4-0.5*
Relevant Imaging:
TTE: There is mild symmetric left ventricular hypertrophy with a
normal cavity size. Overall left ventricular systolic function
is hyperdynamic. The visually estimated left ventricular
ejection fraction is 75%.
There is abnormal interventricular septal motion. The aortic
valve leaflets (3) appear structurally normal.
There is no aortic valve stenosis. There is mild [1+] 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 moderate
[2+] tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate circumferential pericardial
effusion. There are no 2D or Doppler echocardiographic evidence
of tamponade.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
CT Abdomen/Pelvis:
IMPRESSION:
1. Moderate low-density pericardial effusion.
2. Normal unenhanced appearance of the bilateral kidneys without
hydroureteronephrosis. No evidence of obstructing stone or
lesion. Normal
appendix. No bowel obstruction. No visualized acute abdominal
pathology.
Relevant Micro:
__________________________________________________________
___ 10:37 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 10:56 pm
BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:26 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL OF TWO COLONIAL
MORPHOLOGIES.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
___ hx of schizophrenia not currently on medications, carcinoma
of the thyroid s/p removal and subsequent hypothyroidism,
inconsistently adherent to replacement regimen, with recent
admission for hypothyroidism presenting for severe
hypothyroidism and E.coli UTI. Unfortunately, once patient began
to feel better, she no longer wished to remain in the hospital
while her further follow-up was arranged. A follow-up
appointment could not be scheduled prior to her leaving.
ACUTE/ACTIVE ISSUES:
====================
# Hypothyroidism:
Patient with known severe symptomatic post-surgical
hypothyroidism, and recent admission for hypothyroidism from
which patient left AMA. On admission, she reported that she had
not been taking levothyroxine. She did not have bradycardia,
hypothermia, hypotension, hyponatremia, or hypoglycemia,
although she was somewhat somnolent and diffusely TTP. Labs
notable for TSH 165, T4 <0.4, FT4 <0.1. CPK elevated to 1179 on
admission and down trended to 786 on discharge. Endocrine
consulted. Given 200 mcg IV levothyroxine x3 days. Transitioned
to oral 1200 mcg PO levothyroxine on ___, which is the new
weekly dose. Patient may benefit from in-clinic weekly
levothyroxine dosing at discharge. Unfortunately, patient left
prior to a formal plan being established.
[] Patient is being discharged with a plan for 1200mcg of PO
levothyroxine once weekly.
[] Patient can be seen at the ___
for help with medication compliance. Unfortunately, a follow-up
appointment could not be scheduled prior to patient leaving the
hospital.
[] She should have repeat Thyroid studies (TSH, T4, T3) in ___
weeks to continue to monitor her response to therapy.
[] Patient has information for endocrine Fellow clinic ___
___ floor on ___ -- she can come by any ___
in the ___ and walk-in if she needs refills or help administering
her weekly Synthroid dose
# Hematuria/pyuria:
Patient presented with increased urinary frequency without
dysuria or odor. Urine
micro with >182 WBCs and 103 RBCs. Received cipro in ED ___. CT
without evidence of stones. Endocrine concerned patient may not
mount normal inflammatory response to infection in setting of
hypothyroidism. Transitioned to IV CTX ___ due to concern for
pyelo with CVA tenderness, although patient diffusely tender.
UCx with E.coli sensitive to Cipro and CTX. Symptoms improved on
CTX and repeat UCx negative. Transitioned to PO cefpodoxime on
discharge given interaction of Cipro and LT4.
[] She was discharged with 7 days of Cefpodoxime 200mg BID, with
plan to complete a 10 day course of antibiotics.
# Pericardial effusion:
Patient had known small to moderate circumferential pericardial
effusion without e/o clinical or echo tamponade on last
admission. Etiology felt likely due to hypothyroidism, although
it was felt that she could benefit from pericardiocentesis as an
outpatient to rule out malignancy if it fails to resolve. Pulsus
<6 on exam so low likelihood of tamponade physiology. TTE with
stable findings this admission. Repeat chest pain on ___ with
negative cardiac workup (EKG, Trop, CK-MB and pulsus <6).
[] Patient will benefit from a repeat TTE in ___ weeks to
further monitor her pericardial effusion.
# AoCKD: Baseline Cr appears to be ___, presenting at 1.9 but
improved to 1.5 with fluids. CT without e/o hydro, pyelo, or
obstructing stone. On discharge, back to baseline Cr of 1.4.
[] CPK elevated throughout admission. It was still 786 at
discharge. Would recommend repeat labs in ___ weeks to monitor
for resolution.
# Abdominal pain: Patient presented with diffuse abdominal pain
and TTP. CT unrevealing. Lactate mildly elevated to 2.2 although
resolved to WNL. Lipase WNL. Patient complaining of pain
throughout body likely due to hypothyroid state. Appeared stable
at discharge.
# Somnolence: Patient presented with somnolence, likey iso
severe hypothyroidism as similar to prior presentation. MS
improved by discharge.
# Alcohol use disorder: Patient reported that she drinks 1 pint
daily of liquor. She was maintained on diazepam CIWA, but did
not score high enough to require benzos. She declined social
work.
# Back pain: Patient presented c/o lower back pain, non
radiating, felt possible ___ diffuse pain resulting from
hypothyroidism. No bony lesions or fracture on CT. Treated with
APAP
CHRONIC/STABLE ISSUES:
======================
# Schizophrenia: Home risperidone was held in setting of
somnolence.
# Cocaine use disorder: Reported continued active cocaine use,
most recently on ___. No signs of withdrawal.
TRANSITIONAL ISSUES
===================
[] Patient is being discharged with a plan for 1200mcg of PO
levothyroxine once weekly.
[] Patient can be seen at the ___
for help with medication compliance. Unfortunately, a follow-up
appointment could not be scheduled prior to patient leaving the
hospital.
[] She should have repeat Thyroid studies (TSH, T4, T3) in ___
weeks to continue to monitor her response to therapy.
[] Patient has information for endocrine Fellow clinic ___
___ floor on ___ -- she can come by any ___
in the ___ and walk-in if she needs refills or help administering
her weekly Synthroid dose
[] She was discharged with 7 days of Cefpodoxime 200mg BID, with
plan to complete a 10 day course of antibiotics.
[] Patient will benefit from a repeat TTE in ___ weeks to
further monitor her pericardial effusion.
[] CPK elevated throughout admission. It was still 786 at
discharge. Would recommend repeat labs in ___ weeks to monitor
for resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methocarbamol 1000 mg PO TID:PRN back pain
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
3. Levothyroxine Sodium 200 mcg PO DAILY
4. RisperiDONE 1 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Levothyroxine Sodium 1200 mcg PO 1X/WEEK (___)
RX *levothyroxine 300 mcg 4 tablet(s) by mouth once a week Disp
#*16 Tablet Refills:*0
7. Methocarbamol 1000 mg PO TID:PRN back pain
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. RisperiDONE 1 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hypothyroidism
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had a urinary tract infection
and very low thyroid hormone levels.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We treated your urinary tract infection with antibiotics and
gave you thyroid replacement hormone.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. It is especially important to finish your course
of antibiotics (until ___ and take your levothyroxine 1200 mcg
per week (please take this on ___ and weekly thereafter).
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10767156-DS-3
| 10,767,156 | 21,154,323 |
DS
| 3 |
2176-06-02 00:00:00
|
2176-06-03 10:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / ___ Receptor Antagonist
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with presumed nonischemic cardiomyopathy (EF45% in ___,
PVD s/p fem-post tib BPG with perioperative NSTEMI, R BKA, DMII,
HTN, CKD, and HLD who presents with chronic nausea. His nausea
has been going on for >6 months. It primarily occurs when taking
his medications on an empty stomach. It is not dependent on
movement or exertion. He denies heartburn or sour taste. Eating
food typically improves symptoms. He adamantly denies CP, SOB,
or DOE. He has baseline orthopnea that is unchanged over several
months. There is no radiation with these symptoms. He does
occasionally get diaphoretic. He denies palpitations. Denies
emesis, melena, or hematochezia. He does endorse significant
constipation, particularly when taking iron. He notes occasional
cough with clear phlegm in the mornings. He denies syncope and
presyncope. Endorses headache with nitrates. His admits to non
adherence to most of his medications, altering timing for his
nausea. In particular, he does not like his torsemide, causing
him social inconvenience with frequent urination.
ED COURSE
In the ED intial vitals were: 98.8 84 181/94 18 99% RA
EKG:
Labs/studies notable for: Lactate 1.3, TropT 0.14, K 5.8, Cr
3.6, MB 3, ___ ___, Hgb 10.3
Patient was given: Gabapentin 400 mg, Labetalol 1000 mg,
Isosorbide Dinitrate 60 mg ___
On the floor, patient is pleasant and denies symptoms of CP,
SOB, or palpitations. He denies any nausea.
REVIEW OF SYSTEMS: On review of systems, denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, hemoptysis, black stools or red stools. Denies recent
fevers, chills or rigors. 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, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes, +PVD
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PVD s/p fem-post tib BPG, BKA, and left peroneal artery stenting
Perioperative NSTEMI
Cardiomyopathy with systolic dysfunction (EF 45% ___
HTN
HLD
CKD stage IV
Anemia ___ CKD
DMII complicated by peripheral neuropathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Significant
family history of diabetes and PVD
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.8 174/88 95 20 100%RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat neck veins
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pedal edema. No femoral bruits. R BKA
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: trace distal left DP pulse
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.1 150/66 76 19 100%RA, BPs better controlled in 120s with
regular medication administration
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat neck veins
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pedal edema. No femoral bruits. R BKA
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: trace distal left DP pulse
Pertinent Results:
LABS
====
___ 10:30AM BLOOD WBC-4.7 RBC-4.47* Hgb-10.3* Hct-36.0*
MCV-81* MCH-23.0* MCHC-28.6* RDW-18.3* RDWSD-52.6* Plt ___
___ 06:05AM BLOOD WBC-5.0 RBC-4.11* Hgb-9.6* Hct-32.9*
MCV-80* MCH-23.4* MCHC-29.2* RDW-17.9* RDWSD-50.9* Plt ___
___ 10:30AM BLOOD Neuts-63.8 Lymphs-17.7* Monos-17.3*
Eos-0.6* Baso-0.2 Im ___ AbsNeut-2.98 AbsLymp-0.83*
AbsMono-0.81* AbsEos-0.03* AbsBaso-0.01
___ 10:30AM BLOOD ___ PTT-31.6 ___
___ 10:30AM BLOOD Glucose-92 UreaN-56* Creat-3.6* Na-143
K-5.8* Cl-113* HCO3-18* AnGap-18
___ 04:50PM BLOOD Glucose-116* UreaN-57* Creat-3.6* Na-139
K-5.3* Cl-111* HCO3-19* AnGap-14
___ 06:05AM BLOOD Glucose-86 UreaN-56* Creat-3.9* Na-142
K-5.6* Cl-112* HCO3-18* AnGap-18
___ 06:05AM BLOOD ALT-9 AST-13 CK(CPK)-66 AlkPhos-66
TotBili-0.3
___ 10:30AM BLOOD CK-MB-3 ___
___ 10:30AM BLOOD cTropnT-0.14*
___ 04:50PM BLOOD CK-MB-4 cTropnT-0.13*
___ 06:05AM BLOOD CK-MB-4 cTropnT-0.12*
___ 06:05AM BLOOD Albumin-3.4* Calcium-8.6 Phos-4.3 Mg-1.9
___ 10:45AM BLOOD Lactate-1.3
CXR ___
The lungs are relatively hyperinflated but clear without
consolidation,
effusion, or edema. Moderate cardiac enlargement is noted
compatible with
patient's history. No acute osseous abnormalities.
EKG: NSR@90 bpm, LVH, TWI in I, II, III, AVL, V4-V6. J point
elevation in V1, V2
Brief Hospital Course:
___ with cardiomyopathy (___% in ___, extensive PVD s/p
fem-post tib BPG with perioperative NSTEMI, R BKA, DMII, HTN,
CKD, and HLD who presents with chronic nausea and elevated
troponin.
#Nausea: Chronic (>6months), episodic nausea relates directly to
taking medications on an empty stomach. There is no nausea on
exertion or at rest. He has had no emesis nor other GI
complaints outside of constipation. No hematochezia, melena or
diarrhea. His nausea is not associated with chest pain, dyspnea,
or palpitations. His nausea often causes medication
nonadherence.
#Cardiomyopathy with systolic dysfunction: Most recent EF in
___ was 45% Despite ___ in the 36,000 range, no clinical
signs of heart failure. No elevated JVD, no crackles, no lower
extremity edema. ___ likely elevated in setting of HTN and
significant CKD. Continued on Torsemide 30 mg daily. Discharge
weight 88.5kg.
#Troponinemia/ ?ACS: Patient with several cardiac risk factors
(PVD, HTN, HLD, DMII) presented with troponin to 0.14 and vague
story of chest pain. He continues to be unclear of his symptoms
but did note an episode of pressure 1 month ago, nothing more
recent. There were no associated symptoms. Troponinemia remained
flat between 0.12-0.14 and flat MB. Troponins likely related to
HTN and CKD as opposed to ACS. EKG changes likely related to LVH
and hypertension. Presenting EKG NSR@90 bpm, LVH, TWI in I, II,
III, AVL, V4-V6. J point elevation in V1,V2. Continued on ASA81,
Plavix 75, Rosuvastatin 20.
#HTN: Continued home meds: labetalol 1200mg tid, 10mg
amlodipine, torsemide 30 mg, isosorbide dinitrate 60 mg tid
#PVD: continued ASA, Plavix, rosuvastatin
#Hyperkalemia: Appears chronic without EKG changes. Discharge K
was 5.6
#CKD Stage IV: Discharge Creatinine 3.9
#DMII: controlled on diet, most recent A1C ___ 6.3%
#Anemia ___ CKD: To resume home iron. Patient missed iron
infusion as outpatient
#GERD: Continued omeprazole
TRANSITIONAL ISSUES
====================
- Medication Adherence/Nausea: Continue to encourage small
meals/crackers/applesauce to help take meds.
- Cardiomyopathy: Patient should get TTE as an outpatient to
continue asses systolic dysfunction
- History of chest pain: Outpatient nuclear stress testing may
provide more information regarding his chest pain as well as any
defect in myocardial perfusion
- Hyperkalemia: Please check electrolytes at next appointment
- Anemia: Patient missed iron infusion as outpatient; will need
to be rescheduled
- Discharge Creatinine 3.9
- Discharge weight 88.5kg.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 1200 mg PO TID
2. Amlodipine 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. Isosorbide Dinitrate 60 mg PO TID
6. Torsemide 30 mg PO DAILY
7. Rosuvastatin Calcium 20 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Sodium Bicarbonate 650 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. Isosorbide Dinitrate 60 mg PO TID
6. Labetalol 1200 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO QPM
9. Torsemide 30 mg PO DAILY
10. Sodium Bicarbonate 650 mg PO BID
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Nausea
Cardiomyopathy
Hypertension
CKD
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of nausea and concern
for a heart condition. There was no evidence for a heart attack
or heart failure.
What was done?
==============
-Heart attack was ruled out based on EKGs and bloodwork
-Your medications were restarted.
What to do next
================
-Take all medications as directed. This is the best thing to
control many of your symptoms and protect your kidneys.
-Follow up with your PCP. Please talk with him about ways to
make sure you take your medicines. Please tell him what
medicines you are or are not taking.
-You should talk with your doctor about getting an outpatient
stress test to further test heart function.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10767156-DS-4
| 10,767,156 | 23,833,234 |
DS
| 4 |
2176-08-28 00:00:00
|
2176-08-28 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / ___ Receptor Antagonist
Attending: ___
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. ___ is a ___ y/o M followed at ___ w/CKD Stage IV/V
w/chronic hyperkalemia, extensive peripheral vascular disease
s/p
___ tibia bypass graft w/perioperative NSTEMI, right below
the knee amputation, type II diabetes mellitus, hypertension,
hyperlipidemia, presenting to ___ for hyperkalemia to 6.4.
Patient has felt well recently and went to see his PCP ___ ___
at ___. He had routine labs drawn given chronic hyperkalemia
and
was found to have a K of 6.4 and referred in. Per HMED attending
who discussed with ___ nephrologist NP at ___, patient
has
been poorly compliant with diet and also in ___ for dialysis
planning. He has had persistent hyperkalemia for months, and is
able to urinate, presumably his ESRD is from ___ and HTN. His
home situation is difficult since he cares for his sick wife,
and
his daughter provides a majority of his medical assistance at
home but does not have the patient adhere to a renal diet.
Despite multiple nutrition visits, the patient continues to have
difficulties with his potassium and is felt to be refractory to
medical therapy at this time, and likely in need of dialysis. He
was referred in to ___, where his initial vitals were:
98.4 81 156/68 18 100% RA
Labs were significant for:
___
02:07
K:4.9
___
21:58
142 109 64
=============<113
6.4 22 3.9
Ca: 8.4 Mg: 2.2 P: 3.9
7.8 < 11.6/40.4> 130
N:68.9 L:19.1 M:8.6 E:2.6 Bas:0.4 ___: 0.4 Absneut: 5.40
___ Abslymp: 1.49 Absmono: 0.67 Abseos: 0.20 Absbaso: 0.03
In comparison to ___ labs (outpatient):
___: K of 6.4
___: K of 5.7, Cr 4.11
___: K of 5.5, Cr 4.84
___: K of 5.6, Cr 5.78
___: K of 5.7, Cr 3.97
OTHER ___ labs:
___ - 212 on ___
Vitamin D of 52 on ___
BNP of 183
Imaging showed:
EKG: NSR @ 66 bpm, PR 175, QTc 444, stable from prior w/o
significant peaking of T waves.
In the ED, she received:
___ 23:38 IV Insulin Regular 10 units
___ 23:38 IV Dextrose 50% 25 gm
___ 23:49 IV Furosemide 20 mg
___ 00:01 PO/NG Sodium Polystyrene Sulfonate 30 gm
___ 08:41 PO/NG Aspirin 81 mg
___ 08:41 PO/NG Clopidogrel 75 mg
___ 08:41 PO/NG amLODIPine 10 mg
___ 08:41 PO/NG Isosorbide Dinitrate 60 mg
___ 08:53 PO/NG Gabapentin 400 mg
Vitals prior to transfer:
97.6 70 142/50 16 100% RA
Currently, patient feels well w/o complaints.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in
vision or hearing, no changes in balance. No cough, no shortness
of breath, no dyspnea on exertion. No chest pain or
palpitations.
No nausea or vomiting. No diarrhea but no bowel movements since
___. No dysuria or hematuria. No hematochezia, no melena. No
numbness or weakness, no focal deficits.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes, +PVD
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PVD s/p ___ tib BPG, BKA, and left peroneal artery stenting
Perioperative NSTEMI
Cardiomyopathy with systolic dysfunction (EF 45% ___
HTN
HLD
CKD stage IV
Anemia ___ CKD
___ complicated by peripheral neuropathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise ___. Significant
family history of diabetes and PVD
Mother - ___, died from kidney disease
Brothers/Sisters- one sister ___
Physical Exam:
ADMISSION EXAM:
---------------
VS: 97.9 ___ RA
GEN: Alert, sitting up in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple w/mild JVD elevation
PULM: Mild bibasilar crackles.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, ___
EXTREM: LLE w/evidence of prior left extremity bypass graft and
2+ pitting edema to the shin, right below the knee amputation.
NEURO: CN ___ grossly intact, motor function grossly normal
DISCHARGE EXAM:
---------------
VS: 98.1 | 81 (___) | 148/67 (___) | 18 | 100%RA
GEN: Alert, sitting up in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple
PULM: Mild bibasilar crackles.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, ___
EXTREM: LLE w/evidence of prior left extremity bypass graft and
2+ pitting edema to the shin, right below the knee amputation.
NEURO: CN ___ grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
---------------
___ 09:58PM BLOOD ___
___ Plt ___
___ 09:58PM BLOOD ___
___ Im ___
___
___ 09:58PM BLOOD ___
___
___ 09:58PM BLOOD ___
___ 09:58PM BLOOD ___
___ 09:58PM BLOOD ___
___ 07:45AM BLOOD ___
INTERVAL LABS:
--------------
___ 02:07AM BLOOD ___
___ 01:41PM BLOOD ___
___ 09:40PM BLOOD ___
___ 07:45AM BLOOD ___
___ 08:12AM BLOOD ___
___ Plt ___
___ 08:12AM BLOOD ___
___ Im ___
___
___ 08:12AM BLOOD ___ ___
___ 08:12AM BLOOD ___
___
___ 08:12AM BLOOD ___
MICROBIOLOGY:
--------------------
___ ___
PPD PLACEMENT on ___ - left forearm - 0mm induration, 0mm
erythema
IMAGING/STUDIES:
--------------------
___: Vein Mapping (upper extremities):
Patent brachial and radial arteries without significant
calcification. With the exception of the right upper arm
cephalic vein the remaining veins are patent. Please refer to
technologist worksheet for vein diameters.
Discharge Labs:
----------------
___ 02:40AM BLOOD ___
___ Plt ___
___ 02:40AM BLOOD Plt ___
___ 02:40AM BLOOD ___
___
___ 02:40AM BLOOD ___
Brief Hospital Course:
Mr. ___ is a ___ y/o M followed at ___ w/CKD Stage IV/V
w/chronic hyperkalemia, extensive peripheral vascular disease
s/p ___ tibia bypass graft w/perioperative NSTEMI, right
below the knee amputation, type II diabetes mellitus,
hypertension, hyperlipidemia, presenting to ___ for
hyperkalemia to 6.4, currently stable undergoing ___
workup and ongoing monitoring of potassium levels
w/stabilization. Discharge potassium of K =5.
#Acute on Chronic Hyperkalemia:
Likely in context of CKD, poor dietary adherence to renal diet.
No evidence of hemolysis, rhabdomyolysis or other causes of
hyperkalemia. Managed ___ with the following regimen:
- Received 2 doses of IV Lasix and uptitrated home torsemide to
40mg PO daily.
- BID Miralax, docusate, senna to ensure ___ daily stooling;
also received kayexalate x2 and initiated on weekly kayexalate
- Dialysis planning as below
- Strict renal diet w/1g potassium
- Nutritional consultation provided as an inpatient
w/information sheets
#CKD Stage IV/V:
Patient w/progressive CKD, likely multifactorial including from
hypertension and diabetes. Poorly compliant with diet, and per
outpatient nephrology NP will need planning for HD. Patient was
interested in PD but may be a poor candidate given to difficult
home situation. Vitamin D 46, PTH 269, Calcium 8.8. Continued on
Sodium Bicarbonate 1300 mg PO/NG BID and Calcium Carbonate 1000
mg PO/NG TID W/MEALS.
- PPD was read on ___ and is 0mm induration/0mm erythema
#Hypertension: Initially poorly controlled, but now stable on
home medications:
amLODIPine 10 mg PO/NG DAILY
Carvedilol 25 mg PO/NG BID
#Diabetes Mellitus Type II w/neuropathy:
Diet controlled. Stable, patient not on home insulin due to
history of hypoglycemia. Started ISS here in house, A1c 5.4%.
Transitioned from gabapentin 400 mg TID, to renal dosing 200 mg
TID.
#Microcytic Anemia:
Stable, chronic. Patient had iron studies in the past as
recently as ___ ___ with serum iron of 30 (low), TIBC
196 (low), transferrin (140) low. Although consistent with
anemia of chronic disease, the patient does not appear to have
had screening colonoscopy. Would advise outpatient screening
colonscopy.
#sCHF (EF of 45% in ___, acute on chronic) + CAD: Patient
w/evidence of volume overload, no recent TTE. -940cc during
stay. Initially on IV diuresis and then transition to PO
increased dose of torsemide on ___ and again on ___. 2g
sodium diet and 2L fluid restriction.
#PAD: stable. s/p R ___ BPG with perioperative MI (___) and
R BKA (osteomyelitis R foot, ___ and PCI ___ to L tibial
artery. Maintained on home aspirin, clopidogrel, rosuvastatin,
isosorbide dinitrate.
#GERD: Stable. Omeprazole 20 mg PO DAILY.
#Constipation: stable. Maintained on docusate sodium,
polyethylene glycol, senna
#Hyperlipidemia Stable. Continue crestor.
#BPH: Stable. Continue Doxazosin 2 mg PO/NG HS
TRANSITIONAL ISSUES:
--------------------
- ___ with PCP
- ___ with transplant nephrology for dialysis planning (Dr. ___
- ___ with nephrology
- Obtain labs ___ to recheck potassium and
creatinine
- Weekly kayexelate 30g on ___
- Repeat TTE as outpatient for ___
- Outpatient colonoscopy for microcytic anemia
- PPD NEGATIVE on ___ - 0mm induration, 0mm erythema
(documented in OMR)
- See medication changes below
- Patient should be set up with low potassium "meals on wheels"
delivery due to his disability (below the knee amputation)
- Physical therapy as tolerated
- Low potassium teaching and ongoing outpatient nutrition
FULL CODE
CONTACT: Wife ___ Daughter ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 10 mg PO QAM
2. Doxazosin 2 mg PO HS
3. Calcium Carbonate 1000 mg PO TID W/MEALS
4. Rosuvastatin Calcium 20 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Sodium Bicarbonate 1300 mg PO BID
7. Gabapentin 400 mg PO TID
8. Aspirin 81 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Epoetin ___ ___ units SC Q10DAYS anemia
11. Clopidogrel 75 mg PO DAILY
12. Isosorbide Dinitrate 60 mg PO TID
13. Omeprazole 20 mg PO DAILY
14. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate,
dried) 47.5 mg iron oral Q24H
15. Docusate Sodium 100 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
17. LORazepam ___ mg PO DAILY:PRN anxiety
Discharge Medications:
1. Polyethylene Glycol 17 g PO BID
hold for loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*60 Packet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
hold for loose stools
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Sodium Polystyrene Sulfonate 30 gm PO 1X/WEEK (SA)
hyperkalemia
RX *sodium polystyrene sulfonate [Kayexalate] 30g powder(s) by
mouth ___ Disp #*1814.4 Gram Gram Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
6. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth qdaily Disp #*90 Tablet
Refills:*0
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate 1000 mg PO TID W/MEALS
10. Carvedilol 25 mg PO BID
11. Clopidogrel 75 mg PO DAILY
12. Doxazosin 2 mg PO HS
13. Epoetin ___ ___ units SC Q10DAYS anemia
14. Isosorbide Dinitrate 60 mg PO TID
15. Omeprazole 20 mg PO DAILY
16. Rosuvastatin Calcium 20 mg PO QPM
17. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate,
dried) 47.5 mg iron oral Q24H
18. Sodium Bicarbonate 1300 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
20.Outpatient Lab Work
ICD10: E87.5 Hyperkalemia
Please obtain CHEM10 on ___
Please fax results to: ___., ___
Address:___, ___, ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on Chronic Hyperkalemia
CKD Stage IV/V
Hypertension
SECONDARY DIAGNOSIS:
Type 2 DM
Microcytic Anemia
___ (EF of 45% in ___, acute on chronic)
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 Mr. ___,
It was a pleasure taking care of you at ___. You were sent in
by your primary doctor because had a blood potassium level of
6.4. While you were here, we used a combination of medications
called Lasix and Kayexalate to help you eliminate potassium from
your body.
The transplant surgeons also took a look at the blood vessels in
your arms to begin planning for dialysis in the future.
Things to remember:
- low salt diet (2g per day)
- low potassium diet (1g per day)
- limit fluid intake to 64oz per day
- weigh yourself daily and let your primary doctor know if your
weight goes up more than 3 lbs
- please have your blood drawn on ___ for additional tests
and ___ as scheduled with your primary doctor.
Thank you for letting us participate in your care.
-Your ___ team
Followup Instructions:
___
|
10767284-DS-12
| 10,767,284 | 28,161,130 |
DS
| 12 |
2196-06-04 00:00:00
|
2196-06-05 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:
shortness of breath
Major Surgical or Invasive Procedure:
___: Flexible and rigid bronchoscopy with aspiration of
secretions and 12 x 20 mm covered metal stent placement in BI;
EBUS TBNA of #4R and ___: chest port placement
History of Present Illness:
___ w/ PMH of asthma vs bronchiectasis on proAir (never been
intubated) and HTN presenting with ___ weeks of cough with
yellow sputum that transitioned to dry cough, nonradiating chest
pressure, and dyspnea five days ago. She continued to use her
ProAir without improvement and was referred to the ED by her PCP
earlier today for PNA r/o. She notes that she had a similar
episode one year ago and was diagnosed with PNA. She denies
fevers, chills, leg swelling, weight gain, abdominal pain, n/v,
diarrhea or dysuria.
Of note, pt presented to the ED with very similar sxs and was
treated for CAP in ___ as an outpt. In ___, there was an
incidental finding of pulmonary nodules on a CT abd/pel for
nephrolithiasis; these nodules have not been worked up further.
In the ED:
VS: 98.2, HR 99 153/65 20 92% RA
Labs:
11.4 12.5 253
38.9
138 99 13 118 AGap=20
3.7 23 0.8
___: 11.9 PTT: 28.3 INR: ___
FluAPCR: Negative
FluBPCR: Negative
Lactate:2.4
CXR: New right hilar and paramediastinal mass worrisome for
underlying adenopathy or primary mass as well as suspected
subcarinal adenopathy. Chest CT is suggested.
CT chest: Large 8.3 cm right hilar/mediastinal mass likely in
part conglomerate adenopathy and possible primary underlying
mass. Innumerable bilateral pulmonary nodules concerning for
metastases.
EKG: NSR 85 NI NA no STE/D/TWI
Exam notable for:
comfortable, c/o difficulty breathing
LLL crackles
abd soft/nt/nd
BLE no edema
On the floor, she feel smuch better, but still SOB and wheezy.
She endorses a cough for the last few weeks and sputum
production, which had increased, but is now dry. No home O2. No
CP. No f/c. Has been using her albuterol inhaler only once a day
because she didn't know how often she could use it. Says that
all her friends have had a similar illness w/ cough and SOB. No
abd pain/n/v/d. No PND.
Review of systems:
(+) Per HPI
Past Medical History:
ASTHMATIC BRONCHITIS
CUTANEOUS T CELL LYMPHOMA
PEPTIC ULCER DISEASE
POST CONCUSSION SYNDROME
PULMONARY NODULE
STREP THROAT
URINARY TRACT INFECTION
EPISTAXIS
Social History:
___
Family History:
sister and brother both had lung cancer, she is ___ of 11
children, and all 6 of her sisters have died
Physical Exam:
ADMISSION PHYSICAL EXAM
================
VITALS: 97.5 195/ 98 96 20 97 2L
GENERAL: Alert, oriented, no acute distress
HEENT: NCAT, sclerae anicteric, MMM, oropharynx clear, EOMI,
neck supple, JVP right above clavicle when sitting ~60'
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Diffuse wheezing over upper lung fields, crackles at
bases
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema, ankles are large with soft tissue growth (she
says are known lipomas on lateral aspects of ankles bilaterally)
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Pupils equal and reactive, no dysarthria.
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: T 97.8 BP 161/81 HR 92 RR 20 O2 97% on 2L NC
GENERAL: Alert, oriented Caucasian female, awake and smiling.
Slightly less energetic than previous days, speech less
loquacious. Mildly tremulous throughout, in no acute distress.
HEENT: Sclerae anicteric, mucous membranes tacky. Mild erythema
of the soft palate and posterior oropharynx, stable. No oral
ulcers.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
LUNGS: Expiratory wheezing and rhonchi throughout, with
decreased breath sounds at bases bilaterally. Improved compared
to yesterday's exam.
ABDOMEN: NABS. Abdomen is soft, minimally tender in the RLQ
(where Pt states she gets her heparin shots), non-distended,
with no rebound or guarding.
EXTREMITIES: WWP, 2+ pulses, feet with minimal nonpitting edema.
NEURO: Moves all four extremities spontaneously.
Pertinent Results:
ADMISSION LABS:
___ 10:29AM ___ PTT-28.3 ___
___ 10:29AM cTropnT-<0.01
___ 10:29AM estGFR-Using this
___ 10:29AM GLUCOSE-118* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-23 ANION GAP-20
___ 10:52AM LACTATE-2.4*
___ 11:40AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:06PM PLT COUNT-253
___ 12:06PM NEUTS-69.4 ___ MONOS-6.3 EOS-1.1
BASOS-0.5 IM ___ AbsNeut-7.87* AbsLymp-2.48 AbsMono-0.72
AbsEos-0.13 AbsBaso-0.06
___ 12:06PM WBC-11.4* RBC-4.27 HGB-12.5 HCT-38.9 MCV-91
MCH-29.3 MCHC-32.1 RDW-13.4 RDWSD-44.6
SODIUM TREND:
___ 10:29AM BLOOD Glucose-118* UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-99 HCO3-23 AnGap-20
___ 06:15AM BLOOD Glucose-119* UreaN-11 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-25 AnGap-17
___ 04:25AM BLOOD Glucose-112* UreaN-15 Creat-1.2* Na-134
K-3.6 Cl-94* HCO3-25 AnGap-19
___ 03:12PM BLOOD UreaN-15 Creat-1.1 Na-130* K-3.3 Cl-93*
HCO3-23 AnGap-17
___ 04:33AM BLOOD Glucose-107* UreaN-12 Creat-0.9 Na-128*
K-3.3 Cl-88* HCO3-26 AnGap-17
PERTINENT IMAGING:
-___ (___):
IMPRESSION: 1. There is no evidence of acute intracranial
process or hemorrhage
-CT A/P (___):
IMPRESSION:
1. No definite evidence of metastasis in the abdomen or pelvis.
New 8 mm nodule in the right posterior perirenal fat is
nonspecific, may represent metastasis. Recommend attention on
follow-up.
2. Small rounded hypodensity in the left lobe of the liver was
previously diagnosed as a benign hemangioma in ___ and is
similar.
3. Hyperdense fluid adjacent to the anterior wall of the third
portion of the duodenal. This could reflect a duodenal and
periduodenal hematoma. Consider uncinate process pancreatitis
with a hemorrhagic component. Please correlate with pancreatic
enzymes. A duodenal perforation cannot be excluded. There is
no adjacent air.
4. Persistent nonspecific stranding in the right hemipelvis
similar to the study of ___. Findings may be
reactive. Consider sequela of thrombophlebitis. Recommend
attention on follow-up.
5. Numerous small pulmonary nodules better assessed on recent
dedicated CT of the chest.
6. Nonobstructing stone in the right kidney.
7. Diverticulosis without evidence of diverticulitis.
8. Unchanged hyperdense gallbladder sludge without evidence of
cholecystitis.
MRI HEAD (___):
1. No evidence of mass or abnormal enhancement.
2. Diffuse parenchymal volume loss with chronic small vessel
microangiopathy.
3. Unchanged 3 mm tonsillar ectopia similar to prior study from
___.
___
Lymph node, biopsy:
- Metastatic small cell carcinoma
___
INTERPRETATION:
No immunophenotypic evidence of a non-Hodgkin lymphoma is seen
in this specimen. However, an expanded population of CD56(+),
CD45(-), CD38(-), CD3(-) and CD20(-) cells is seen, comprising
11% of total analyzed events. Corresponding biopsy shows
involvement by a neuroendocrine carcinoma (see separate
pathology report ___-___). Thus, the population of CD56(+)
cells is favored to represent carcinoma cells, detected by flow
cytometry. Correlation with clinical, radiologic, and
morphologic (see ___-___) findings is recommended.
Flow cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
Brief Hospital Course:
___ year-old woman w/h/o asthma vs chronic bronchitis, ___
pack-year smoking history (quit ___ years ago), and stable
pulmonary nodules, who presents with ___ weeks of cough
productive of yellow sputum that developed to worsening dyspnea,
dry cough, sinus congestion, and non-radiating chest pressure 5
days prior to admission.
#Extensive small cell lung cancer: CXR revealed right hilar
enlargement and additional opacities in the subcarinal and right
paramediastinal/suprahilar regions. Follow-up CT Chest
demonstrated right paratracheal adenopathy measuring 8.3x5.1 cm
encasing the right mainstem bronchus, bronchus intermedius, and
right pulmonary artery, with mass effect on the RUL pulmonary
artery and possible involvement of the right lateral wall of the
esophagus. In addition, many pulmonary nodules scattered
throughout both lungs were identified, with the largest
measuring 9 mm. Given high suspicion for malignancy, patient
subsequently underwent flexible and rigid bronchoscopy with
aspiration of secretions and placement of covered metal stent
placement in bronchus intermedius. Also underwent EBUS TBNA of
LN. She was found to have extensive small cell lung CA with mets
to LN #4R and #7. Staging MRI brain and CT torso revealed
potential ___ fat metastasis but no other clear evidence
of metastases, including no evidence of mets to brain. She
underwent evaluation by rad-onc and was determined not to be a
candidate for XRT to brain or to the primary lung mass at least
immediately but may undergo XRT after cycles of chemotherapy.
Patient initiated on C1 carboplatin/etoposide (Carboplatin
chosen over cisplatin due to severe h/o Meniere's disease), C1D1
was ___. She tolerated chemo well and received Neulasta on
___. Notably on day 2, uric acid 5.8 from 5.0 (LDH 181) and so
renally dosed allopurinol added due to concern for TLS.
#SIADH: Patient noted to have hyponatremia to 127; felt to be
___ SIADH in setting of lung disease. Patient was placed on
fluid restriction and placed on high protein diet with ensure
TID. Na+ improved and was tolerating po without fluid
restriction by discharge.
___: Baseline Cr 0.9, increased to 1.2 but improved to baseline
prior to discharge. Felt to be prerenal in setting of poor po
intake.
# Men___'s: Patient has a history of vertigo and nausea, which
has previously been treated with meclizine and Ativan. She takes
meclizine at home, and reports frequent hospitalizations for
treatment when her nausea is more severe. No acute intracranial
process on CT head, MRI without obvious metastases. She reports
improvement with Ativan and Zofran.
CHRONIC ISSUES:
#Hypertension: Continued home losartan, diltiazem, and HCTZ
#Depression: continued home fluoxetine 40mg daily
#Peptic ulcer disease: pt was started on omeprazole reportedly
for chronic cough concerning for laryngeal reflux but also
beneficial for PUD. Continued home omeprazole
#Hypothyroidism: ___ wnl; continued home levothyroxine 125 mcg
daily
#Hx of cutaneous T-cell lymphoma: Followed by Dr. ___ ___
___. Treated with PUVA ___ years prior without evidence
of recurrence and without complications.
TRANSITIONAL ISSUES
-Patient will initiate care with ___ oncology after initially
establishing care with ___. She has appointment for this
___
- Patient will require follow up with interventional pulmonary
clinic on ___ ___hest on that date; will see Dr.
___.
- Radiation-onc was consulted for ?candidacy for whole lung
irradiation given lung nodules seen. It was felt that this
should be re-evaluated after ___ cycles of chemo.
- Patient received Neulasta on the day of discharge ___, 24h
after completing chemotherapy
- Patient had chest port placed on ___
- Please ensure medication compliance, as some concern for
Ativan overuse although no issues per ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Meclizine 25 mg PO DAILY
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
7. Naproxen 250 mg PO BID:PRN Pain - Mild
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. FLUoxetine 40 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Levothyroxine Sodium 125 mcg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*7 Tablet Refills:*1
2. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth q8h PRN Disp #*21
Tablet Refills:*0
3. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE
Duration: 1 Dose
RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL deliverable (0.64 mL) 1
injector SQ once Refills:*0
4. Aspirin 81 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO DAILY
6. FLUoxetine 40 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
11. LORazepam 0.5 mg PO DAILY:PRN anxiety
12. Losartan Potassium 100 mg PO DAILY
13. Meclizine 25 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Extensive small cell lung cancer
Secondary:
Syndrome of inappropriate antidiuretic hormone, resolved.
Meniere's disease
Acute renal failure, resolved.
Hypertension
Hypothyroidism
Depression
Peptic ulcer disease
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to cough and shortness of
breath. You were found to have lung cancer, specifically
extensive small cell lung cancer. You were transferred from the
medical service to the oncology service. You were started on a
chemotherapy regimen for the cancer and will follow up with your
oncologist next week (see below for appointments). Please take
all medications as prescribed and please follow up with the
appointments we have arranged. It was a pleasure taking care of
you at ___.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10767527-DS-6
| 10,767,527 | 29,369,637 |
DS
| 6 |
2205-12-07 00:00:00
|
2205-12-07 22:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH asthma, obesity, OSA on CPAP, ADD, who presents with DOE
and chest pain.
Patient reports he was in his USOH until about ___ weeks ago,
when he noticed increasing DOE when exercising (usually biking).
He also noted some pain in his L leg starting slightly after he
noticed the increased DOE, starting in the L popliteal fossa and
over the course of days to weeks spreading into the calf and up
into the posterior thigh, also worse with exertion. DOE got
gradually worse, and over the past few days he had it at rest as
well. He had some associated chest pain with exertion generally
described as band-like and burning across the chest. Had some
discomfort to deep inspiration. Had some nausea/vomiting from
pain today prior to admission. He has had a slight
non-productive cough which tends to be seasonal, and denies
fevers/chills.
He denies any recent travel or immobilization; any change in
medications; any known peripheral vascular disease or
claudication symptoms. He has had some weight loss over the past
month or two, but this has been concurrent with exercising more
after the winter. He denies diarrhea, constipation, black/bloody
stools or any abnormalities in his stools, abdominal pain,
dysuria/hematuria, and has otherwise been in his USOH.
In the ED, initial vitals were: 97.0 153/87 103 19 100/RA
- Exam notable for: rrr, s1/s2, no mgr. ctabl no wheezes, trace
non pitting edema bilaterally
- Labs notable for:
Trp <0.01
D - dimer ___
Chem 7 WNL
BNP 163
CBC WNL
- Imaging was notable for:
- CTA chest:
1. Bilateral pulmonary emboli involving right main, right
segmental, and left segmental pulmonary arteries.
2. Mild enlargement of the main pulmonary artery and equivocal
flattening of the interventricular septum could suggest right
heart strain. Echocardiogram could be obtained for further
evaluation.
3. Peripheral wedge-shaped opacity in the right lower lobe could
represent atelectasis or infarct.
- EKG: NSR, no ischemic changes, no RV strain
- PE/MASCOT was consulted: EKG reviewed, no signs of RV strain
or ischemia. Troponin negative. Evidence of RV strain on CT,
however remains hemodynamically stable. Given stability with
minimal oxygen requirement and lack of symptoms at rest, no
indication for higher level of care or advanced therapy such as
catheter directed TPA.
-OK for floor, either medicine or ___
-no indication for EKOS or TPA
- Patient was given: ASA 325 (risk of ACS), started on heparin
GTT
Vitals prior to transfer:
Upon arrival to the floor, patient reports generally feeling
well, with improved dyspnea with oxygen and no pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Sleep apnea
ADD
obesity
Mild Persistent Asthma - has mildly obstructed PFTs, seen in
past by pulm but not on medications
vasovagal syncope
SURGICAL:
rotator cuff surgery
Social History:
___
Family History:
Uncle with PE in his ___
father age ___ hypoglycemia
mother age ___ h/o uterine cancer
No other significant family history of cancer, hematologic
disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.3 144/81 86 18 92/3L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, adipose but non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: LLE tender to palpation, calf slightly larger than R,
positive ___ sign; otherwise warm, well perfused, 2+ pulses,
no clubbing, cyanosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.0 PO 126 / 85 L Sitting 92 18 95 Ra
Gen: Well appearing obese man, able to finish sentences without
pausing for breath
Neck: No LAD, JVP not elevated, supple
Card: RRR, No MRG
Pulm: Clear to auscultation, no w/r/r
Ab: Non-tender, non-distended, liver edge 1 cm beneath costal
margin, normoactive bowel sounds
Extr: Tightened left calf, trace non-pitting edema, LLE slightly
larger than RLE, bilateral DP pulses appreciated
Neuro: AOx3, Grossly normal motor
Pertinent Results:
ADMISSION LABS:
===============
___ 08:54PM cTropnT-<0.01
___ 02:40PM GLUCOSE-116* UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-18
___ 02:40PM estGFR-Using this
___ 02:40PM cTropnT-<0.01
___ 02:40PM proBNP-163*
___ 02:40PM ___
___ 02:40PM WBC-9.0# RBC-4.44* HGB-14.0 HCT-41.6 MCV-94
MCH-31.5 MCHC-33.7 RDW-12.2 RDWSD-41.7
___ 02:40PM NEUTS-59.8 ___ MONOS-11.2 EOS-3.5
BASOS-0.4 IM ___ AbsNeut-5.35# AbsLymp-2.23 AbsMono-1.00*
AbsEos-0.31 AbsBaso-0.04
___ 02:40PM PLT COUNT-191
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-8.1 RBC-4.56* Hgb-14.5 Hct-43.1
MCV-95 MCH-31.8 MCHC-33.6 RDW-12.0 RDWSD-41.9 Plt ___
___ 06:35AM BLOOD Glucose-95 UreaN-11 Creat-1.0 Na-142
K-4.8 Cl-106 HCO3-21* AnGap-20
IMAGING:
========
+ CTA chest:
1. Bilateral pulmonary emboli involving right main, right
segmental, and left segmental pulmonary arteries.
2. Mild enlargement of the main pulmonary artery and equivocal
flattening of the interventricular septum could suggest right
heart strain. Echocardiogram could be obtained for further
evaluation.
3. Peripheral wedge-shaped opacity in the right lower lobe could
represent atelectasis or infarct.
+ EKG: NSR, normal axis and intervals, no ischemic changes, no
RV strain
+ TTE ___: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF = 70%). 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
arch is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
___ year old man w/ PMH obesity, mild asthma, OSA on CPAP who
presented with dyspnea on exertion and found to have
hemodynamically stable unprovoked PE.
#Unprovoked PE: He presented with dyspnea on exertion, chest
tightness and left leg pain and found to have bilateral
pulmonary emboli involving right main, right segmental, and left
segmental pulmonary arteries. He was hemodynamically stable, but
did have an O2 requirement of ___ on hospital day 1. No clear
inciting factor (no known malignancy, hypercoag, immobilization,
travel), no evidence of right heart strain (trp wnl, BNP normal,
EKG w/ no right heart strain, and TTE w/o right heart strain).
No signs/ symptoms of malignancy (no weight loss, night sweats,
LAD, cough, change in bowel patterns, hematuria). Given uncle
(although in his ___ w/ prior PE and patient's age ___ yo),
hereditary coagulopathy could be possible (although, typically
use guideline of patient ___ yo OR first degree relative ___ yo
w/ PE/DVT). Patient initially managed on heparin but then was
transitioned to apixiban 15 mg BID for 21 days with plan to
switch to 20 mg daily at day 22. Length of need for first
unprovoked PE will be determined by PCP.
#OSA: History of OSA, CPAP at home. CPAP used inpatient.
#ADD: Continue home regimen, Adderall 40 mg PO daily.
TRANSITIONAL ISSUES:
====================
#NEW MEDICATIONS: Xarelto (15 mg BID for 21 days and then 20 mg
daily- length to be determined)
[] xarelto due to start 20 mg daily on ___
[] Please pursue malignancy work-up as outpatient (however, no
signs/sx of malignancy at this time) - would consider
colonoscopy
[] Please consider hypercoag w/u as outpatient (although pt not
___ year old and relative with DVT was an uncle in his ___
[] Please discuss length of need for xarelto in the setting of
first unprovoked PE - recommend minimum of 9 months
[] FYI- seen on CTA was peripheral wedge-shaped opacity in the
right lower lobe could represent atelectasis or infarct.
# CODE: full
# CONTACT: Proxy name: ___, Relationship: wife
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine XR 40 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth twice a day Disp #*1 Dose Pack Refills:*0
2. Amphetamine-Dextroamphetamine XR 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you at ___!
You were in the hospital because you had shortness of breath and
were found to have a blood clot in your lungs. This is also
known as a "pulmonary embolism".
You were started on a blood thinner, called "rivaroxaban" also
known as "Xarelto", to prevent future blood clots. You should
take this medication with food. A side effect of this medicine
is bleeding. Please do not taking any "NSAIDS" such as
ibuprofen, naproxen or aspirin while on this medicine, as the
combination can lead to serious bleeding.
Please follow up with your doctor to determine how long you have
to take "Xarelto" and to try to determine why you had a blood
clot. Your appointment is listed in this paperwork.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
10767569-DS-5
| 10,767,569 | 24,222,102 |
DS
| 5 |
2168-10-19 00:00:00
|
2168-10-20 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Gantrisin
Attending: ___.
Chief Complaint:
Altered mental status, acute kidney injury, hyperkalemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ year old female with chronic kidney disease
(baseline 1.3-1.6), insulin-dependent diabetes, diastolic heart
failure (EF >55%), and dementia who was sent in from her nursing
home after she was noted to have altered mental status with
acute on chronic renal failure (creatinine 3.2, potassium of
5.7). Per the nurse taking care of her the day PTA, she was
having more difficulty eating than usual although she was still
drinking fluids, and she was developed a new cough with nasal
congestion. At baseline the patient is oriented x1-2, is
nonambulatory for the last ___ months, and is incontinent,
although she is able to express herself verbally. She has not
had fevers, abdominal pain, N/V, dysuria, or hematuria.
Of note, her dose of Lasix was recently increased to 40 mg daily
(___). She was started on lisinopril 25 mg daily on ___
but this was discontinued on ___. Outside labs show
potassium 5.7, Cr 3.4, BUN 153, albumin 2.5, WBC 13.7, HCT 30.0.
.
In the ED, initial vitals were: 97.8 65 111/41 16 100% 2L. On
exam, patient was awake, oriented x1, slow to respond, appeared
dry. Labs were remarkable for WBC count of 12.2, HCT of 31.8
(baseline high twenties), creatinine of 3.5, sodium of 131,
potassium of 5.8, phosphorus of 4.9. UA with urine lytes was
obtained. EKG showed sinus w/ peaked T wave. CXR showed
atelectasis with no acute process. Foley catheter placed.
Patient was given calcium gluconate 2gram iv, x1 amp D50, and
regular insulin 8 units iv at 1525 for potassium 5.8 (dysphagia
so not given kayexcelate) for hyperkalemia). Given 500cc normal
saline. Vitals on Transfer: Temp - 97.6 oral, HR - 70, RR - 16,
BP - 135/39, O2 Sat 100% 2lnc.
On the floor the patient was stable but having some difficulty
swallowing water.
Past Medical History:
DM (HbA1C 8.3% ___
Congestive Heart Failure, TTE in ___: EF >55%, mild-to-mod
aortic regurgitation, mild-to-mod mitral regurgitation
Paranoid schizophrenia
Urinary incontinence
Chronic cystitis
Dementia
HTN
Osteoporosis
Chronic renal failure, baseline Cr 1.5 (stage III)
Anemia, has refused colonoscopy in the past.
Hypercholesterolemia
Multiple GI bleeds managed conservatively, last in ___
requiring 3u pRBCs
ORIF left hip fracture ___ complicated by blood loss (Hct
25.9 1u pRBC, 1u FFP)
Social History:
___
Family History:
Per OMR, Unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0 BP: 118/62 P: 67 R: 20 O2: 99% 2L
General: Elderly woman, no acute distress, A&Ox1
HEENT: Sclerae anicteric, proptosis worse on left than right.
Oropharynx very dry with small amount of white material on
tongue; no exudate or erythema.
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Inspiratory crackles at left base, otherwise clear to
auscultation bilaterally. Poor inspiratory effort. No wheezes,
or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2. ___ holosystolic
murmur. No rubs or gallops.
Abdomen: Soft, non-distended. Large ventral hernia present,
tender to palpation, not reducible. Bowel sounds present, no
rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ DP pulses. Trace edema in ___ to
thighs bilaterally. No clubbing, cyanosis.
GU: Foley in place, filled with purulent fluid and frank blood.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 97.6, Tm: 98.6 BP: 134/52 (127-148/50-62) P: 92
(80-100) R: 18 O2: 98% RA
General: Elderly woman, no acute distress, A&Ox1-2
HEENT: Oropharynx very dry with small amount of dried blood on
tongue and hard palate.
Lungs: Bibasilar crackles, but otherwise clear to auscultation
bilaterally. Poor inspiratory effort. No wheezes, or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2. ___ holosystolic
murmur. No rubs or gallops.
Abdomen: Soft, non-distended. Large ventral hernia present,
tender to palpation, not reducible. Bowel sounds present, no
rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ DP pulses. Trace edema in BLE. L
arm with increased swelling.
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-12.2*# RBC-3.79* Hgb-9.9* Hct-31.8*
MCV-84 MCH-26.2* MCHC-31.2 RDW-14.6 Plt ___
___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-10* Monos-5
Eos-0 Baso-0 ___ Myelos-0
___ 03:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 03:00PM BLOOD ___ PTT-26.1 ___
___ 03:00PM BLOOD Glucose-321* UreaN-136* Creat-3.5*#
Na-131* K-5.8* Cl-103 HCO3-16* AnGap-18
___ 03:00PM BLOOD Calcium-8.4 Phos-4.9*# Mg-2.3
___ 05:57PM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-9.7 RBC-3.72* Hgb-9.5* Hct-31.9*
MCV-86 MCH-25.5* MCHC-29.7* RDW-15.2 Plt ___
___ 07:30AM BLOOD Neuts-85.1* Lymphs-12.4* Monos-2.3
Eos-0.2 Baso-0.1
___ 07:30AM BLOOD Glucose-205* UreaN-52* Creat-1.5* Na-143
K-4.5 Cl-113* HCO3-23 AnGap-12
___ 07:30AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9
MICROBIOLOGY:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood Culture, Routine (Pending):
___ Blood Culture, Routine (Pending):
IMAGING
___ ECG: Sinus rhythm. Prominent voltage in leads I and aVL
for left ventricular hypertrophy. Low precordial lead voltage.
Compared to the previous tracing of ___ no diagnostic
interim change.
___ CHEST (PA & LAT): Frontal and lateral views of the chest
demonstrate low lung volumes accentuating cardiomediastinal
silhouette which is likely within normal limits. Minimal
tortuosity is present along the thoracic aorta, with arch
calcifications. There is mild peribronchial cuffing and
interstitial opacities which could represent atypical infection
in the appropriate clinical setting. There is no confluent
consolidation, pneumothorax, or pleural effusion. Small amount
of dependent atelectasis is present in the left base. Diffuse
osteopenia is present, allowing for which no compression
fracture is evident.
___ RENAL U.S.: The left kidney measures 10 cm. The right
kidney measures 9 cm. There is no hydronephrosis, stone, or
mass on the right. The left kidney demonstrates new moderate
hydronephrosis. The ureter is not well seen; however, within the
bladder, there is a 4.6 x 3.1 x 2.3 cm mildly echogenic
nonvascular mass, potentially the cause of obstruction. This
could represent a hematoma or conglomerate debris, versus mass.
A urinary catheter is in place. Also noted is a lateral
interpolar left renal cyst measuring 2.6 x 2.4 cm.
Brief Hospital Course:
___ yo F w/ DM II (on insulin), CKD III (baseline Cr 1.5), ___,
who presents from her nursing home with AMS ___ UTI, ___, and
hyperkalemia.
# AMS secondary to infection - Most likely secondary to UTI.
With treatment of UTI with antibiotic, mental status has
improved. Hyponatremia upon admission was thought to be possibly
contributory but this corrected and pt still not at baseline.
She was treated for her UTI per below.
.
# UTI - Pt w/ urinary tract infection due to E.Coli only
resistant to Ciprofloxacin and Ampicillin. Initially treated
with IV Ciprofloxacin prior to sensitivites returning, but then
was switched to Meropenem on ___. Antibiotics should continue
for a total of 14 days to treat for a complicated UTI given
frank pus that was draining from her foley, new moderate left
hydronephrosis and the 4.6cm mass in the bladder that was
concerning for debris. A heparin-dependent mid-line was placed
in pts left brachial artery for administration of antibiotics.
Her last dose of antibiotics will be ___.
.
# Acute on chronic kidney disease - Baseline Cr 1.5, but
elevated to 3.5 upon admission. FeUrea 19.65% indicating
pre-renal in etiology. Physical exam corroborates this finding
as she appeared clinically very dry. In addition, it was noted
that her lasix had recently increased from 40mg daily to 20mg
daily on ___, which may have contributed to her volume
depletion. This was held during the hospitalization given her
volume depletion and she was discharged on 20mg lasix daily as
it was believed that 40mg daily may be too much for her. Pt's
creatinine improved to baseline with volume repletion. Atenolol
was held during her hospitalization given her ___, but
re-started upon discharge. Renal ultrasound showed new moderate
left hydronephrosis with a 4.6 x 3.1 cm soft tissue mass within
the posterior aspect of the bladder, potentially obstructing.
However, given right kidney was unaffected (no hydronephrosis),
it would be unlikely for it to be affecting the creatinine.
.
# Hyperkalemia - Pt's K was 5.8 upon admission w/ peaked T waves
on EKG, and she was given calcium gluconate, insulin w/ dextrose
given, with repeat K 5.1 in the ED. Etiology likely secondary to
acute kidney injury. She was initiated on lisinopril 2.5mg daily
on ___ but this was discontinued on ___. Potassium
improved as kidney function improved.
.
# Hematuria - Likely due to cysititis, though could be due to
traumatic foley insertion as well. Unclear if 4.6cm mass in
bladder seen on renal ultrasound contributing. Foley
intermittently obstructed by clots, but cleared with irrigation.
Urine was clear and yellow by hospital day 3. Was seen by
Urology in-house, who didn't feel that urgent cystoscopy was
indicated and recommended follow-up as an outpatient in 3 months
for cystoscopy.
.
# Hyponatremia/Hypernatremia - Pt's Na 131 upon admission, which
is below pt's baseline. Unclear in etiology but since pt
appeared clinically dry, it is likely that pt was secreting ADH,
and her Na is lower in concentration because of increased water
absorption. Urine osmolality was consistent with this. Pt's
sodium improved with volume repletion. However, she developed
hypernatremia, likely secondary to normal saline administration
(in the attempt to volume resuscitate). She was then started on
free water, as her free water defecit was calculated around 3L.
Her sodium improved to 143 with free water repletion upon
discharge.
.
# Soft-Tissue Bladder Mass - Renal ultrasound on ___ showed
left kidney
with new moderate hydronephrosis and a 4.6 x 3.1 x 2.3 cm mildly
echogenic
nonvascular mass in the bladder. Urology was consulted and felt
that it was most likely inflammatory debris admixed with blood
clot within the bladder. Per Urology's consult note, she had a
negative cystoscopy as recently as 3 months ago and a negative
urine cytology as well. They recommended follow-up with Dr.
___ in the ___ clinic in 3 months with cystoscopy.
.
# Non-anion gap acidosis - Unclear in etiology though could have
been caused by administration of IVF. Her acidosis was likely
exacerbating (or causing) pts hyperkalemia. Pt was given D5W w/
3 amps bicarb to help correct the acidosis (while repleting
volume), and her acidosis slowly resolved.
.
# Chronic diastolic heart failure - Pt on lasix 40mg daily at
home, which was recently increased from 20mg daily. She did not
receive her dose on the day of admission and her lasix was held
throughout the admission. She did have trace BLE edema and
bibasilar crackles, but appeared volume down. It is likely that
40mg lasix daily is too large of a dose for this patient, and so
she will be discharged on 20mg lasix daily. Upon clinical
re-assessment, this may be re-titrated up as indicated.
.
# DM II - Pt's blood sugars ran high during the admission (even
before administration of D5W). However, when she was given D5W
for free water repletion, her blood sugars ran in the 200-300s
and so her lantus was increased to 22 units BID and her SSI
titrated up slightly. However, she was discharged on her home
lantus of 20mg BID and her home regular insulin sliding scale as
the D5W administration was likely contributing to her high blood
sugars while she was in the hospital.
TRANSITIONAL ISSUES
# Please continue Ertapenem once daily until ___
# Recommend f/u pending blood cultures
# Discharged pt on lasix 20mg daily (decreased from 40mg daily)
though this medication was held during admission given that she
was volume down. Can consider up-titrating as deemed necessary
for fluid overload.
# Would consider uptitration of lantus and/or SSI if blood
sugars continue to run high
# Pt was evaluated by Speech and Swallow in-house, who
recommended Honey-thick liquids, pureed solids, meds crushed in
applesauce, strict 1:1 supervision with all PO intake, NO STRAW
with liquids, TID oral care, and encouraged continued swallow
follow up to assess diet tolerance and consider further diet
advancement.
Medications on Admission:
ALENDRONATE - 70mg tablet: 1 tab PO weekly every ___
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tab by mouth once a
day
CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth every
___ and ___
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth daily
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 20 U sq twice daily (at 6:30am and 4:30pm)
LACTULOSE - 10 gram/15 mL Solution - 15 ml by mouth once a day
prn constipation
OLANZAPINE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime
INSULIN REGULAR HUMAN [HUMULIN R] - SSI
LANTUS 100 units/ml - Inject 20 units subq twice daily at 6:30am
and 4:30pm
Medications - OTC
ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth q4h prn
pain
CALCIUM CARBONATE - 500mg Tablet - 1 Tablet PO daily
VITAMIN D3 - 400 IU Tablet - 2 Tablets PO daily
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
SENNOSIDES [SENNA] - 8.6 mg Tablet - 2 Tablet(s) by mouth twice
daily
DULCOLAX 10MG SUPP - 1 SUPP daily prn constipation if senna
ineffective
FLEET ENEMA - 1 enema per rectum daiy prn constipation if
dulcolax suppository ineffective
?Oxycodone 2.5mg PO q6h prn pain
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Every ___.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three
times weekly, on ___.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous twice a day.
7. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO once
a day as needed for constipation.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain.
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
11. Vitamin D3 400 unit Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day.
12. docusate sodium 50 mg/5 mL Liquid Sig: One (1) Tablet PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Dulcolax 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation: If senna ineffective.
15. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Enema Rectal
once a day as needed for constipation: If dulcolax suppository
ineffective.
16. Regular Insulin Sliding Scale
BS ___ = 0 units sub-q
BS 201-250 = 2 units sub-q
BS 251-300 = 4 units sub-q
BS 301-350 = 6 units sub-q
BS 351-400 = 8 units sub-q
BS > 400 = CALL MD
17. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 11 days. Last dose on ___.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Urinary Tract Infection
Secondary Diagnosis
Acute Kidney Injury
Hyperkalemia
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 Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted because your labs showed worsening
of your kidney function and high potassium levels. You were also
found to have a urinary tract infection.
Your kidney dysfunction was likely caused by dehydration and
obstruction. An ultrasound of your kidney was performed which
showed a small mass in the bladder that was obstructing urine
flow from the left kidney, which could represent debris in the
bladder and may clear. You should call the Urology office at
___
to schedule a follow-up cystoscopy with Dr. ___ in 3 months.
Your high potassium levels were likely caused by your kidney
dysfunction. You were treated with medications to help your body
get rid of the potassium, and your levels were normal upon
discharge.
Your urinary tract infection was treated with antibiotics, which
should continue for another 11 days, until ___.
Please note the following changes to your medications.
Please START taking:
# Ertapenem once daily
Please CHANGE:
# Lasix - take 20mg daily instead of 40mg daily
Please continue taking your other medications as prescribed.
Followup Instructions:
___
|
10768040-DS-12
| 10,768,040 | 22,531,257 |
DS
| 12 |
2143-06-14 00:00:00
|
2143-06-16 16:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with a history of T1DM, ESRD on PD, GERD and
hiatal hernia, and chronic back pain s/p recent fusion who
presents with confusion presumed secondary to an aspiration
event. He has had several recent pneumonias attributed to
aspirations.
Two nights prior to this admission, he had a "coughing fit"
precipitated by severe reflux. The next day, he felt weak,
tired, and slightly confused (eg. unable to list days of week
backwards). When this persisted, his wife brought him to the
hospital.
In the ED, initial VS were T 98.2, HR 75, BP 129/46, RR 12 SpO2
100% on RA. Labs showed leukocytosis of 14.1, HCT of 36.5,
Creatinine of 2.5, glucose of 202. LFTs showed AP of 186
otherwise WNL. UA showed few bacteria and trace protein.
Peritoneal fluid was obtained and was negative for BP. Lactate
was 1.6. CT head was negative except for atropy and mild small
vessel ischemic disease. Portable CXR showed residual scattered
right opacities thought to be associated with chronic
aspiration. Hiatal hernia was also present. Received Zosyn and
Vancomycin prior to admission. VS prior to transfer were T 98.6,
HR 75, BP 129/46, RR 12 satting 100%.
Review of Systems: Patient denies any fevers, chills, headaches,
shortenss of breath, chest pain. No new rashes. No back pain at
his sugical site or new tenderness. No new swelling in his lower
extremities. No abdominal pain or tenderness.
Past Medical History:
-T1DM c/b retinopathy, neuropathy, nephropathy
-ESRD on PD: 7mo on dialysis ___ T1DM, cycler, 4 exchanges per
day, 1800mL x 1.5hrs per dwell
-GERD: Has had for about ___ years. Hiatal hernia diagnosed on
last admission.
-L2-3 lumbar stenosis, buldging disc s/p lumbar fusion ___
-Gout: Last episode ___
-HTN
-HLD
-Hyperparathyroidism
-S/p appendectomy
Social History:
___
Family History:
Mother: ___ at ___ with liver failure
Father: Alive and healthy at ___
Physical Exam:
Admission:
Vitals: Afebrile HR 70 BP 120/50 RR 14 satting 100%
General: NAD. Slow, one word answers.
HEENT: Aniceteric sclera. Pinpoint pupils. No oral lesions or
ulcers Braces present on bottom row of teeth.
Neck: No thyroidmegaly. No elevated JVP.
Heart: ___ pansystolic murmur. No rubs or gallops.
Lungs: Bilateral crackles at the bases otherwise CTABL
throughout.
Abdomen: Soft, nontender abdomen. R side were recent lumbar
surgery is appears well healed and slightly erythematous.
Peritoneal dialysis site on left is CDI with tubing in place and
capped.
Back: Surgical site revelas bilateral erythematous marking
consistent with surgery. No purulence or calor. No tenderness to
palpation in the area. Mild edema at the site of surgery.
Extremities: 2+ Pitting edema to the lower shin bilaterally.
Neurological: AOx3. Slow to respond. Terse, 1 word to short
sentence answers. Pinpoint pupils but reactive. Can do days of
week backwards. Rest of CN exam is normal. Moving in bed without
assitance. Walks with cane (not assessed as requires TLSO for
ambulation)
Discharge:
Vitals: T 98 BP 123/54 HR 65 RR 16 SpO2 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pinpoint pupils, MMM
Neck: Supple, no LAD
Lungs: Mild crackles at bases, otherwise clear bilaterally
CV: Regular rate, irregular rhythm. Normal S1/S2. No
murmurs/rubs/gallops appreciated.
Abdomen: Soft, non-tender, non-distended, bowel sounds present.
Peritoneal dialysis site on left is clean and nonerythematous.
GU: Deferred
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema.
Neuro: Alert and fully oriented. Speech fluent.
Pertinent Results:
Pertinent Labs
___ 04:36PM BLOOD WBC-14.1*# RBC-3.84*# Hgb-11.4*#
Hct-36.5*# MCV-95 MCH-29.6 MCHC-31.2 RDW-17.3* Plt ___
___ 07:05AM BLOOD WBC-9.1 RBC-3.32* Hgb-9.9* Hct-31.2*
MCV-94 MCH-29.7 MCHC-31.6 RDW-17.2* Plt ___
___ 07:00AM BLOOD WBC-8.6 RBC-3.39* Hgb-10.1* Hct-32.2*
MCV-95 MCH-29.6 MCHC-31.2 RDW-17.1* Plt ___
___ 04:36PM BLOOD Glucose-202* UreaN-56* Creat-2.5* Na-134
K-4.3 Cl-94* HCO3-28 AnGap-16
___ 07:00AM BLOOD Glucose-191* UreaN-57* Creat-2.6* Na-136
K-4.3 Cl-96 HCO3-28 AnGap-16
___ 04:36PM BLOOD ALT-25 AST-34 AlkPhos-186* TotBili-0.2
___ 04:36PM BLOOD Albumin-3.4* Calcium-9.8 Phos-2.9 Mg-2.2
___ 07:00AM BLOOD Albumin-2.8* Calcium-8.3* Phos-4.0 Mg-1.9
Imaging
___ CT HEAD W/O CONTRAST: No evidence of hemorrhage or
infarction. Atrophy. Mild small vessel ischemic disease.
___ CHEST (PORTABLE AP): FINAL READ PENDING
Prelim read: Cardiomediastinal silhouette and hilar contours are
unremarkable. Scattered bilateral residual densities are
suggestive of chronic aspiration. There is no pleural effusion
or pneumothorax. A hiatal hernia is observed in the midline. The
osseous structures are grossly unremarkable.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
___ man with DMI, ESRD on PD dialysis, hiatal hernia
with severe GERD and recurrent aspiration who presented with
confusion and leukocytosis.
ACTIVE PROBLEMS
# Leukocytosis
Possibly reactive following aspiration event. Empiric
antibiotics (vanc/zosyn) were started initially, but there were
no localizing symptoms for infection, leukocytosis quickly
resolved, and initial culture results were not suggestive of
infection, so the antibiotics were discontinued.
# Confusion
Although the patient reported having felt confused prior to
presentation (eg. unable to list days of the week backwards), he
was near his baseline upon initial evaluation, and denied
further confusion following this. The confusion is thought to
have been caused by transient hypoxia from aspiration.
# Aspiration
Patient with extensive history of aspiration. CT on prior
admission showed a dilated esophagus which may represent a
mechanical obstruction secondary to hiatal hernia. While
admitted, the head of his bed was kept elevated, he had a
puree/thickened liquid diet, and he had no further aspiration
events. Patient will be seen as an outpatient by Dr. ___
___ assessment of surgical options to prevent future episodes.
CHRONIC ISSUES
# Recent discectomy/fusion: Patient without pain and doing well
with rehab following back surgery.
# ESRD: Received peritoneal dialysis while admitted.
# HLD: Continued Simvastatin 20mg daily.
# DM Type 1: Patient with diabetes complicated by retinopathy,
neuropathy, and nephropathy. Continued on SSI plus standing NPH.
# GERD: Continued home Omeprazole.
TRANSITIONAL ISSUES:
-___ with surgery regarding surgical options of hiatal hernia to
prevent aspiration
Medications on Admission:
1. Allopurinol ___ mg PO twice daily
2. Gentamicin 0.1% Cream 1 Appl TP DAILY
Apply to cream for exit site of peritoneal dialysis
3. Furosemide 40 mg PO twice daily
hold for SBP<100mmhg
4. Omeprazole 20 mg PO BID
5. Metoclopramide 10 mg PO QIDACHS
6. Simvastatin 20 mg PO DAILY
7. Epoetin Alfa 8000 8000 SC 3XWEEK
3x a week
8. Nephrocaps 1 CAP PO DAILY
9. Amoxicillin ___ mg PO PRIOR TO DENTAL WORK
10. TraZODone 25 mg PO HS:PRN insomnia
11. BuPROPion 300 mg PO DAILY
12. Lorazepam 0.5-1 mg PO HS:PRN insomnia
13. Senna 2 TAB PO BID:PRN constipation
14. Docusate Sodium 100 mg PO BID
15. Aspirin 81 mg PO 4X A WEEK
16. NovoLIN N *NF* (NPH insulin human recomb) 100 unit/mL
Subcutaneous qhs
___ U QhS
17. Lantus *NF* (insulin glargine) 12 U Subcutaneous qam
qam
18. Pro-Stat RC *NF* (nut.tx.imp.renal fxn,lac-free) unknown
Oral qday
?19. Losartan 25mg daily [NOTE: some question about whether this
had been d/c'd by an outpatient provider, but could not find any
documentation.]
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO 4X A WEEK
3. BuPROPion 300 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Epoetin Alfa 8000 8000 SC 3XWEEK
6. Furosemide 40 mg PO BID
7. Gentamicin 0.1% Cream 1 Appl TP DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoclopramide 10 mg PO QIDACHS
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 20 mg PO BID
13. Senna 2 TAB PO BID:PRN constipation
14. Simvastatin 20 mg PO DAILY
15. TraZODone 25 mg PO HS:PRN insomnia
16. Amoxicillin ___ mg PO PRIOR TO DENTAL WORK
17. Lantus *NF* (insulin glargine) 12 U SUBCUTANEOUS QAM
18. Lorazepam 0.5-1 mg PO HS:PRN insomnia
19. NovoLIN N *NF* (NPH insulin human recomb) 100 unit/mL
SUBCUTANEOUS QHS
20. Pro-Stat RC *NF* (nut.tx.imp.renal fxn,lac-free) 0 1 ORAL
QDAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Aspiration pneumonitis
2. Confusion/inattention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital at ___ from ___ to ___
with mild confusion, likely due to aspiration. You were started
on antibiotics, but these were stopped because there were no
signs of pneumonia. You recovered quickly.
You are scheduled to follow up with Dr. ___ on ___ to
discuss treatment options to prevent future aspiration events.
However, you may be able to reschedule this appointment sooner.
It was a pleasure caring for you during your admission.
Followup Instructions:
___
|
10768342-DS-16
| 10,768,342 | 20,041,764 |
DS
| 16 |
2132-03-25 00:00:00
|
2132-03-27 05:45:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Caladryl / Caladryl Clear / Tucks / Flagyl / Latex / Potassium
Chloride / polyester / cilantro / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
Small bowel obstruction
Large parastomal herniation
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
___ with complicated surgical/medical history most notable for
rectal cancer s/p LAR, neoadjuvant and adjuvant therapy,
subsequent laparoscopy, end colostomy and VHR with mesh c/b
large parastomal hernia most recently seen by Dr. ___
ongoing management of colitis in neo rectum now presenting with
1 day of abdominal pain and nausea. She reports normal ostomy
function until the day prior to consultation and then no ostomy
output for the past day. She developed distension and nausea
but no vomiting and ultimately presented for evaluation to the
emergency department. An NGT was placed which resulted in 1.5L
of feculent output.
Past Medical History:
End colostomy ___
Colon adenocarcinoma s/p resection (___), ileostomy, and
takedown (___). s/p chemo and XRT
s/p ventral hernia repair w/ mesh (___)
Osteoarthritis
Dyslipidemia
Hypothyroid
Social History:
___
Family History:
Aunt died of colon ca
Physical Exam:
Exam at presentation:
98.1 94 154/71 16 95% RA
AOx3, NGT in place, not in distress
RRR S1S2
Normal unlabored respirations
Abd is obese, incisions well healed. Prominent LLQ parastomal
hernia, soft. Stoma is pink, productive of small amount of
liquid stool. No gas in bag.
Ext WWP
Exam at discharge:
VS: AVSS
GEN: AOx3, NAD
ABD: large parastomal hernia, mildly distended, NT, no rebound
tenderness or guarding, stoma pink
Pertinent Results:
___ 06:25AM BLOOD WBC-4.2 RBC-3.47* Hgb-10.5* Hct-32.3*
MCV-93 MCH-30.4 MCHC-32.7 RDW-13.5 Plt ___
___ 06:51AM BLOOD WBC-6.7# RBC-3.95* Hgb-11.9* Hct-36.2
MCV-92 MCH-30.0 MCHC-32.8 RDW-13.7 Plt ___
___ 03:00AM BLOOD Neuts-89.7* Lymphs-5.6* Monos-4.0 Eos-0.6
Baso-0.1
___ 06:25AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-135
K-3.4 Cl-101 HCO3-24 AnGap-13
___ 06:51AM BLOOD Glucose-136* UreaN-21* Creat-0.6 Na-133
K-4.2 Cl-100 HCO3-25 AnGap-12
___ 10:20PM BLOOD ALT-11 AST-18 AlkPhos-96 TotBili-0.4
Brief Hospital Course:
Mrs. ___ presented to the ED at ___ on ___ for
symptoms of a small bowel obstruction. She was non-operatively
managed with placement of an NGT tube. After a brief and
uneventful stay in the ED, the patient was transferred to the
floor for further management.
Neuro: Her pain was well controlled during this admission.
CV: Her CV status was stable throughout her hospitalization.
Pulm: She was breathing comfortably at room air during this
admission. She did not have any respiratory distress, and her O2
saturation was stable and at goal.
GI: Mrs. ___ was noted to have a large parastomal hernia,
visible on exam and CT scan. She was having abdominal pain,
nausea, and vomiting at the time of admission. Her UGI symptoms
were managed with NPO/IVF and placement of a nasogatric tube.
She tolerated that well, and the NGT helped decompress her
bowel. On ___ she was noted to be passing a small amount os
liquid stool and a small amount of gas from the stoma. In the
afternoon this increased, and the following day she passed
multiple bowel movements from the Colostomy. the NGT was
removed. She began a clear liquid diet and was monitored
closely. She was followed throughout her admission by the wound
ostomy nurses. On ___ she reported feeling nauseated after
prune juice, she felt as though she could continue to attempt
clear liquid and tried watermellon. She was monitored closely
for responce to PO challange. A KUB was obtained which showed
persistent partial SBO. On ___, her upper GI symptoms
improved. She tolerated a regular diet on day of discharge.
ID: There was no issue from an ID standpoint during this
admission.
Heme: There was no issue from a Heme standpoint during this
admission.
On ___, the patient was discharged to home. At discharge, she
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. She will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[X] Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate ___ hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Pantoprazole 20 mg PO Q24H
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 500 mcg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 20 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Large parastomal hernia
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Small Bowel Obstruction (Conservatively Treated)
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10768342-DS-18
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2132-11-27 17:55:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Caladryl / Caladryl Clear / Tucks / Flagyl / Latex / Potassium
Chloride / polyester / cilantro / Statins-Hmg-Coa Reductase
Inhibitors / Benadryl / Pentasa
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of
rectal cancer diagnosed ___ s/p chemo/radiation followed by a
LAR and diverting ileostomy with loop ileostomy reversal in ___
complicated by ventral hernia requiring repair with mesh in ___
who presents with abdominal pain and nausea/vomiting.
She reports a 2 day history of decreased ostomy output. She
reports that the last time she had gas in her bag was this
morning and has had approximately 1 teaspoon of stool over the
past two days. She also reports having increasing abdominal pain
over the past 2 days, as well as abdominal distension, nausea,
and emesis (x6 with little output). An NG tube was placed in the
emergency department with 400cc of light brown output initially.
She reports having some
chills, but no fevers. She denies any changes in her hernia over
the past two days. She does report some weakness preventing her
from standing currently.
In the ED, initial vitals: 97.4 88 158/80 18 95% RA. Labs were
notable for WBC 10.6 (85% PMNs, 12% lymphs), H/H 14.3/43.0, Plt
475, Na 129, Cl 89, HCO3 20, Cr 1.0 (baseline 0.6-0.7), lactate
4.1 -> 4.4, LFTs wnl, UA bland. Imaging was significant for CT
with high-grade small bowel obstruction likely secondary to the
patient's large left-sided peristomal hernia. Per ED resident
bedside ultrasound, patient appeared volume down based on
compressible IVC and lung exam did not show significant fluid.
Surgery was consulted and recommended admission to medicine
given she does not want surgical intervention (unless to save
her life), NPO/IVF, NG tube, and foley for urine output
monitoring. Surgery also attempted a bedside manual reduction of
the hernia. She received a total of 4L NS. She had a total of 3L
out by NGT. Patient was given Vancomycin 1g IV, Dilauid 0.5mg
IV, Zosyn 4.5mg IV, Ativan 0.5mg IV, Zofran 4mg IV. Vitals prior
to transfer were: 98.9 115 100/69 16 96% 3L NC.
As noted in the colorectal surgery note:
She has a history of rectal cancer, treated treated with
neoadjuvant chemo and radiation in ___, followed by a LAR and
diverting ileostomy with subsequent ileostomy takedown. She then
had a large ventral hernia s/p repair and a rectovaginal fistula
requiring an end-colostomy (___), with neorectum and part of
her left colon left in-situ at the time of her colostomy. She
has had diversion colitis intermittently since then, typically
managed with enemas. She has also had a history of obstruction
secondary to a large parastomal hernia. These obstructions have
been treated conservatively in the past and has frequently been
able to self reduce her hernia at home.
The patient has been followed by colorectal surgery, and has
been
involved in multiple discussions regarding possible surgical
intervention to address her diversion colitis and
parastomal hernia. As noted in the prior note, the definitive
treatment would be to resect the remaining colon and neorectum,
along with reconstruction of her abdominal wall and re-siting of
her colostomy. It has previously been thought that given her
age
and medical comorbidities that this would be a very high risk
surgery in this particular patient. Given this, surgical
intervention was not recommended. The patient has also
previously
stated that she does not want to have any surgical intervention
unless she needs surgery to save her life.
Her most recent colonoscopy was on ___, which demonstrated
friability, erythema, and ulcers concerning for colitis. She
has
been treated with hydrocortisone enemas, mesalamine enemas, and
cortifoam through her stoma. She has recently been treated with
po prednisone. She is currently on an 8 week prednisone taper.
GI has been following, and are concerned for possible
inflammatory bowel disease.
She also has a history of bleeding from her stoma and
intermittent rectal bleeding, but has not had any bleeding
recently.
On arrival to the FICU, pt c/o abdominal pain and back pain.
Past Medical History:
End colostomy ___
Colon adenocarcinoma s/p resection (___), ileostomy, and
takedown (___). s/p chemo and XRT
s/p ventral hernia repair w/ mesh (___)
Osteoarthritis
Dyslipidemia
Hypothyroid
Breast cancer
Rectovaginal fistula
factor V Leiden carrier
GERD
HTN
Social History:
___
Family History:
Father with CAD and stroke. Sister with brain cancer. Aunt with
colorectal cancer.
Physical Exam:
ADMISSION:
Vitals: 95.1 100/58 115 33 97% 3L. Pulsus 6mm Hg.
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry
NECK: supple, difficult to appreciate JVP d/t body habitus
LUNGS: crackles right base, decreased breath sounds at bilateral
bases
CV: Tachycardic, difficult to appreciate murmur
ABD: soft, tender to palpation with rebound, nonreducible
ventral hernia in left lower quadrant
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
significant edema
SKIN: no apparent rashes
NEURO: moving all extremities, AAOx3
DISCHARGE:
T 98.1 P 81 BP 143/66 RR 18 Sat 97%RA
GEN: NAD, AAOx3, Pleasant
CV: RRR
PULM: CTAB
ABD: soft, nontender, nondistended, minimal discomfort to palp,
no rebound/guarding, NABS
EXT: no edema
Pertinent Results:
ADMISSION:
___ 12:00AM BLOOD WBC-10.6# RBC-5.13# Hgb-14.3# Hct-43.0#
MCV-84 MCH-28.0 MCHC-33.3 RDW-13.4 Plt ___
___ 12:00AM BLOOD Neuts-85* Bands-1 Lymphs-12* Monos-2
Eos-0 Baso-0 ___ Myelos-0
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD Plt Smr-HIGH Plt ___
___ 12:15PM BLOOD ___ PTT-27.9 ___
___ 12:00AM BLOOD Glucose-185* UreaN-19 Creat-1.0 Na-129*
K-3.7 Cl-89* HCO3-20* AnGap-24*
___ 12:00AM BLOOD ALT-13 AST-15 AlkPhos-76 TotBili-0.4
___ 12:00AM BLOOD Lipase-22
___ 12:00AM BLOOD Albumin-4.3
___ 12:15PM BLOOD Calcium-7.8* Phos-5.9*# Mg-1.7
___ 06:12AM BLOOD Type-ART pO2-70* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
___ 12:12AM BLOOD Lactate-4.1*
___ 06:12AM BLOOD O2 Sat-92
___ 06:12AM BLOOD freeCa-1.01*
IMAGING:
KUB ___
Impression: Multiple air-fluid levels and dilated loops of small
bowel, compatible with early small bowel obstruction given that
air is still noted within the rectum.
CT Abdomen/Pelvis w/ Contrast ___
1. High-grade small bowel obstruction, likely secondary to the
patient's large left-sided peristomal hernia. Trace free
intra-abdominal fluid without evidence of pneumoperitoneum.
2. Postoperative appearance status post lower anterior resection
for rectal cancer, with end colostomy. Note that the location of
the residual left colon and ___ pouch within the left
peristomal hernia is unchanged.
3. Cholelithiasis without evidence of acute cholecystitis.
Brief Hospital Course:
___ w/history of rectal cancer s/p LAR and now with end
colostomy c/b ventral hernia, with SBO likely related to hernia,
complicated by hypotension, rule out septic shock, with acute
kidney injury, hyponatremia. She had spontaneous return of bowel
function and diet was advanced as tolerated.
# SBO: high-grade small bowel obstruction and stomach
protruduing through her parastomal hernia. Patient is not
interested in surgical intervention unless life threatening.
Proceeded with conservative management of SBO including NPO/IVF,
NG tube decompression, foley output monitoring. Her lactate
improved. She was started on ampicillin-sulbactam for empriric
antibiotic coverage on admision and stopped on ___. She
started having stool via her ostomy output on ___. After
ensuring stabilization, she was transferred to the surgery
service where we continued NPO/IVF/NGT. She began to have some
return of bowel function reduced NGT output, a clamp trial
demonstrate minimal residual and the NGT was removed on ___.
Her diet was slowly advanced as tolerated starting on HD#3 and
was tolerating regular diet by HD#5. Abdominal exam was
essentially normal at this point.
# Hypotension: Pt presented initially with significant
hypotension requiring vasoactive support. This was likely a
result of her volume losses and inability to replace these, with
improvement in BP after volume resuscitation with 4L. Other
considerations included potential septic shock from bowel source
(though no e/o perforation at this time), obstructive shock from
pericardial effusion noted on CT chest (but pulsus not
elevated), adrenal insufficiency given pt has been on steroids
for her colitis--however the patient responded well to fluids.
She also required norepinephrine for BP support, but was weaned
early in her hospital course. Her lactate improved with
continued monitoring. She was started on stress dose steroids
with hydrocortisone 100mg q8h x24hr which should be gradually
weaned. Her blood pressure was stable after transfer to the
surgical service.
# Acute kidney injury: Likely related to reduced renal perfusion
from hypovolemia given reduced intake, continuing volume losses,
hemoconcentration resulting in ATN. Improved with fluid
recussitation.
# Hypothyroidism: Home levothyroxine
# GERD: Continued pantoprazole daily.
# HTN: held home lisinopril in setting of hypotension.
At time of discharge, she was afebrile, hemodynamically intact,
tolerating regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO QAM, QPM
2. Acetaminophen 500 mg PO QNOON
3. Aspirin 81 mg PO MON, WEDS, FRI
4. Celecoxib 200 mg oral daily
5. Cyanocobalamin 500 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
8. Levothyroxine Sodium 150 mcg PO ___, MO, ___, WE, TH, FR
9. Levothyroxine Sodium 75 mcg PO QSAT
10. Lisinopril 20 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Calcium Carbonate 500 mg PO DAILY
14. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
15. Vitamin D 400 UNIT PO DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Budesonide Nasal Inhaler 2 sprays Other daily
18. red yeast rice extract (bulk) 600 mg miscellaneous BID
19. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral daily
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO MON, WEDS, FRI
3. Calcium Carbonate 500 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Levothyroxine Sodium 150 mcg PO ___, MO, ___, WE, TH, FR
6. Levothyroxine Sodium 75 mcg PO QSAT
7. Lisinopril 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
10. Vitamin D 400 UNIT PO DAILY
11. Acetaminophen 500 mg PO QAM, QPM
12. Acetaminophen 500 mg PO QNOON
13. Budesonide Nasal Inhaler 2 sprays Other daily
14. Celecoxib 200 mg ORAL DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral daily
17. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
18. Multivitamins 1 TAB PO DAILY
19. red yeast rice extract (bulk) 600 mg miscellaneous BID
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
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 a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
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| 22 |
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|
2135-01-26 03:06:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Caladryl / Caladryl Clear / Tucks / Flagyl / Latex / Potassium
Chloride / polyester / cilantro / Statins-Hmg-Coa Reductase
Inhibitors / Benadryl / Pentasa / prednisone
Attending: ___
___ Complaint:
Nausea/Vomiting/Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per colorectal surgery consult note in the emergency department:
Mrs. ___ is a ___ with h/o rectal CA s/p neoadj chemo/XRT,
LAR/ileostomy, takedown, c/b incisional hernia s/p repair w/
mesh, rectovaginal fistula s/p LOA/end-colostomy c/b parastomal
hernia & ECF, multiple prior SBOs who p/w nausea, vomiting and
decreased ostomy output. Briefly, patient has had numerous SBOs
in the past ___ complicated surgical hx for which she typically
manages symptoms of N/V, abdominal pain and low output and home
until they eventually self-resolve. She reports persistent N/V,
abdominal pain and essentially no ostomy over the past 36 hours
c/w prior SBO episodes. She presents to the ED given persistence
of symptoms. She reports a diagnosis of UTI by her PCP two days
ago for which she was started on Macrobid that she has not been
taking recently as she has been unable to tolerate PO. She
otherwise denies fevers/chills, CP/SOB, overlying skin changes
to
known parastomal hernia.
While in the ED, the patient received PO and IV contrast for CT
A/P and was noted to have active extravasation of contrast from
her R antecubital PIV causing some edema and discomfort - she
was
evaluated by Hand Surgery who ruled out compartment syndrome and
recommended RUE elevation and ice to R AC PRN.
Past Medical History:
DVT/PE ___ on coumadin
End colostomy ___
Colon adenocarcinoma s/p resection (___), ileostomy, and
takedown (___). s/p chemo and XRT
Osteoarthritis
Dyslipidemia
Hypothyroid
Breast cancer
Rectovaginal fistula
factor V Leiden carrier
GERD
HTN
PSH:
Rectal cancer s/p resection and choanal anastomosis with
ileostomy ___ ___
Ileostomy closure ___ ___
Laparoscopic ventral hernia repair with insertion of mesh.
___ ___
Rectovaginal fistula s/p laparoscopy with lysis of adhesions end
colostomy ___ ___
Left wire localized lumpectomy and sentinel lymph node biopsy
___ ___
Rectal pain s/p anal dilatation, transanal excision of polyp
(___)
GI History: She has a history of colitis (Diversion vs IBD).
She has had bleeding from the excluded rectum and a lot of
secretions. She was placed on Rowasa enemas in the past. She
underwent an examination of the excluded colon and the stoma on
___. The excluded colon showed erythema, friability and
exudate in the rectum to the end of the colon at 60 cm. Through
the stoma, there was normal mucosa from 25 cm to the end of the
colon in the cecum, which was at 45 cm and in the terminal
ileum. At 25 cm distally, there were aphthous ulcerations. From
5 cm distally, there was diffuse erythema, congestion and
friability consistent with colitis. There were two inflammatory
polyps seen with a question of a fistula adjacent to one. The
biopsies showed in the excluded colon chronic active colitis.
Through the stoma at 5 cm, there was chronic active colitis and
at 25 cm chronic inactive colitis with normal at the cecum.
These findings raised the question of IBD. She was seen in the
office in ___ and the thought was that she had IBD. She was
started on pentasa which caused diarrhea. She was admitted in
___ with bleeding. CT scan showed thickened residual
right colon leading up to and into the colostomy consistent with
colitis. She was treated with IV steroids and then transitioned
to oral prednisone. She was admitted in ___ with an SBO
which was treated conservatively. She as dischaged on 30 mg of
prednisone and she tapered off by ___.
Social History:
___
Family History:
Father with CAD and stroke. Sister with brain cancer. Aunt with
colorectal cancer.
Physical Exam:
General: tolerating a regular diet, pain controlled, ambulating
VSS
Neuro: A&OX3
Cardio/Pulm: no chest pain or shortness of breath
Abd: obese, well healed prior surgical incisions, soft, non
distended
Ext: WWP
Pertinent Results:
___ 06:44AM BLOOD WBC-4.4 RBC-3.63* Hgb-10.9* Hct-33.7*
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.7 RDWSD-46.7* Plt ___
___ 08:30AM BLOOD WBC-8.1 RBC-4.34 Hgb-13.1 Hct-40.5 MCV-93
MCH-30.2 MCHC-32.3 RDW-14.1 RDWSD-47.8* Plt ___
___ 02:28PM BLOOD WBC-16.2*# RBC-4.52 Hgb-13.7 Hct-41.3
MCV-91 MCH-30.3 MCHC-33.2 RDW-14.3 RDWSD-47.8* Plt ___
___ 02:28PM BLOOD Neuts-87.8* Lymphs-6.0* Monos-5.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-14.22*# AbsLymp-0.98*
AbsMono-0.94* AbsEos-0.00* AbsBaso-0.02
___ 06:44AM BLOOD ___ PTT-36.6* ___
___ 08:30AM BLOOD ___ PTT-39.0* ___
___ 06:44AM BLOOD Glucose-102* UreaN-24* Creat-0.5 Na-132*
K-3.5 Cl-97 HCO3-26 AnGap-13
___ 08:30AM BLOOD Glucose-139* UreaN-32* Creat-0.7 Na-133
K-4.5 Cl-96 HCO3-26 AnGap-16
___ 02:28PM BLOOD Glucose-177* UreaN-33* Creat-1.0 Na-129*
K-9.0* Cl-89* HCO3-22 AnGap-27*
___ 06:44AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.1
___ 08:30AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.3
___ 09:19PM BLOOD Lactate-1.6
___ 03:49PM BLOOD Lactate-3.5* K-4.7
___ 02:36PM BLOOD Lactate-3.7*
Brief Hospital Course:
Mrs. ___ was admitted to the inpatient colorectal surgery
service with a small bowel obstruction. A peripheral IV was
placed in the patient's right antecubital area which infiltrated
while CT contrast dye was administered in radiology. This was
evaluated by hand surgery in the emergency department and the
patients arm was elevated and monitored closely throughout the
admission. A nasogastric tube was placed for decompression. She
was hydrated appropriately. On the afternoon of hospital day one
she reported passing flatus. On the morning of hospital day two
the nasogastric tube was removed and she was advanced to a clear
liquid diet. She tolerated the clear liquids well, but started
having increased abdominal cramping and on hospital day three
was taken back down to sips and IV fluids. The abdominal pain
resolved, and on hospital day four a regular diet was resumed.
Upon discharge, Mrs. ___ was ambulating independently, her
pain was well controlled, her stoma had adequate output, and she
was voiding appropriately.
Medications on Admission:
macrobid (recently started as outpatient for UTI), coumadin
(10mg 5days/week, 12.5mg 2days/week), levothyroxine 150',
lisinopril 20', pantoprazole 20', hydromorphone 2 q4h PRN pain,
celecoxib 200', ASA 81', acetaminophen, tums, budesonide nasal
spray QHS, Vitamin D3, Vitamin B12, Colace, MVI, iron
supplement, glucosamine chondroitin, red yeast rice
Discharge Medications:
1. CeleBREX (celecoxib) 200 mg oral DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H infection
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*7 Tablet Refills:*0
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 20 mg PO Q24H
6. Warfarin 10 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
IV infiltrate of contrast media into right AC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel
obstruction. You were given bowel rest and intravenous fluids
and a nasogastric tube was placed in your stomach to decompress
your bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
If you have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
Followup Instructions:
___
|
10768342-DS-23
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2135-05-19 00:00:00
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2135-05-21 21:28:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Caladryl / Caladryl Clear / Tucks / Flagyl / Latex / Potassium
Chloride / polyester / cilantro / Statins-Hmg-Coa Reductase
Inhibitors / Benadryl / Pentasa / prednisone / ciprofloxacin
Attending: ___
___ Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ w/ complicated abdominal surgical history including LAR
for rectal cancer, lap incisional hernia repair, and LOA w/ end
colostomy for colovaginal fistula now w/ large parastomal hernia
and recurrent SBOs presenting with an SBO. The patient reports
that she has ___ obstructions per year, some of which she treats
at home with bowel rest alone. She was last admitted for an SBO
in ___ and was managed conservatively. She reports that
yesterday she began to develop abdominal distention and
decreased
ostomy output around lunchtime. Throughout the day and
overnight,
her distention became increasingly worse and she began to have
nausea and multiple episodes of vomiting. She also reports
becoming extremely weak and being unable to ambulate and reports
intermittent chills without subjective fever.
Past Medical History:
DVT/PE ___ on coumadin
End colostomy ___
Colon adenocarcinoma s/p resection (___), ileostomy, and
takedown (___). s/p chemo and XRT
Osteoarthritis
Dyslipidemia
Hypothyroid
Breast cancer
Rectovaginal fistula
factor V Leiden carrier
GERD
HTN
PSH:
Rectal cancer s/p resection and choanal anastomosis with
ileostomy ___ ___
Ileostomy closure ___ ___
Laparoscopic ventral hernia repair with insertion of mesh.
___ ___
Rectovaginal fistula s/p laparoscopy with lysis of adhesions end
colostomy ___ ___
Left wire localized lumpectomy and sentinel lymph node biopsy
___ ___
Rectal pain s/p anal dilatation, transanal excision of polyp
(___)
GI History: She has a history of colitis (Diversion vs IBD).
She has had bleeding from the excluded rectum and a lot of
secretions. She was placed on Rowasa enemas in the past. She
underwent an examination of the excluded colon and the stoma on
___. The excluded colon showed erythema, friability and
exudate in the rectum to the end of the colon at 60 cm. Through
the stoma, there was normal mucosa from 25 cm to the end of the
colon in the cecum, which was at 45 cm and in the terminal
ileum. At 25 cm distally, there were aphthous ulcerations. From
5 cm distally, there was diffuse erythema, congestion and
friability consistent with colitis. There were two inflammatory
polyps seen with a question of a fistula adjacent to one. The
biopsies showed in the excluded colon chronic active colitis.
Through the stoma at 5 cm, there was chronic active colitis and
at 25 cm chronic inactive colitis with normal at the cecum.
These findings raised the question of IBD. She was seen in the
office in ___ and the thought was that she had IBD. She was
started on pentasa which caused diarrhea. She was admitted in
___ with bleeding. CT scan showed thickened residual
right colon leading up to and into the colostomy consistent with
colitis. She was treated with IV steroids and then transitioned
to oral prednisone. She was admitted in ___ with an SBO
which was treated conservatively. She as dischaged on 30 mg of
prednisone and she tapered off by ___.
Social History:
___
Family History:
Father with CAD and stroke. Sister with brain cancer. Aunt with
colorectal cancer.
Physical Exam:
Exam at discharge:
VS: WNL
General: NAD
HEENT: NC/AT, EOMI, no scleral icterus, dry mucous membranes
Resp: breathing comfortably without distress
CV: regular rate and regular rhythm
Abd: soft, large parastomal hernia, lower abd mild tender to
palpation, no rebound or guarding, ostomy putting bag full with
stool, pink mucosa
Ext: well-perfused
Pertinent Results:
___ 06:00AM BLOOD WBC-8.1 RBC-3.77* Hgb-11.3 Hct-34.9
MCV-93 MCH-30.0 MCHC-32.4 RDW-13.8 RDWSD-47.1* Plt ___
___ 07:00PM BLOOD WBC-8.3 RBC-3.98 Hgb-12.1 Hct-36.7 MCV-92
MCH-30.4 MCHC-33.0 RDW-13.9 RDWSD-46.9* Plt ___
___ 10:13AM BLOOD WBC-12.7* RBC-4.56 Hgb-13.9 Hct-42.2
MCV-93 MCH-30.5 MCHC-32.9 RDW-13.9 RDWSD-47.5* Plt ___
___ 03:50AM BLOOD WBC-22.7*# RBC-5.31*# Hgb-16.1*#
Hct-49.1*# MCV-93 MCH-30.3 MCHC-32.8 RDW-13.6 RDWSD-46.5* Plt
___
___ 05:12AM BLOOD ___ PTT-39.0* ___
___ 03:50AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-158* UreaN-53* Creat-1.0 Na-145
K-4.2 Cl-101 HCO3-27 AnGap-17
___ 07:00PM BLOOD Glucose-237* UreaN-49* Creat-1.3* Na-141
K-5.6* Cl-99 HCO3-27 AnGap-15
___ 10:13AM BLOOD Glucose-168* UreaN-38* Creat-1.8* Na-141
K-4.9 Cl-94* HCO3-23 AnGap-24*
___ 03:50AM BLOOD Glucose-298* UreaN-30* Creat-1.9*#
Na-134* K-4.6 Cl-83* HCO3-20* AnGap-31*
___ 10:13AM BLOOD ALT-11 AST-19 AlkPhos-80 TotBili-0.3
___ 07:00PM BLOOD Calcium-7.8* Phos-5.2* Mg-2.1
___ 10:13AM BLOOD Albumin-4.3 Calcium-9.1 Phos-6.0* Mg-2.2
___ 03:50AM BLOOD Calcium-11.1* Phos-6.7* Mg-2.5
___ 06:23AM BLOOD Lactate-2.8*
___ 10:21AM BLOOD Lactate-5.2*
___ 06:45AM BLOOD Lactate-4.4*
___ 04:11AM BLOOD Lactate-8.3*
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 6:22 AM
IMPRESSION:
1. Small-bowel obstruction with a transition point at the
proximal jejunum as the bowel exits the inferior edge of the
parastomal hernia. Small bowel distal to the parastomal hernia
remains dilated with gradual tapering to the terminal ileum
likely due to superimposed ileus. No evidence of ischemia. No
free air.
2. Stable left perinephric fluid.
3. Cholelithiasis without cholecystitis.
Brief Hospital Course:
___ was admitted to the inpatient colorectal surgery
service ___ from the emergency with a small bowel
obstruction. The Nasogastric tube was putting out increased
amounts of thick brown/bilious liquid. Her electrolytes were off
however this improved with hydration.
___ stable, ready for dc, tol PO
___ INR 2.5, CLD, foley out, post void, tol clears, good
ostomy OP
___ INR 5.2--> 2 u FFp--> INR 3.0
___ min NGT Op, ostomy OP dark stool, OOB, encourage amb,
maroon op rectum
___ pm C10 hemolyzed, difficult IV access. Nausea-zofran
___ pain, soft abd, full ostomy bag
___ trend labs, fluids
Neuro: Pain was well controlled on tylenol
CV: Vital signs were routinely monitored during the patient's
length of stay.
Pulm: The patient was encouraged to ambulate, sit and get out
of bed as tolerated.
GI: The patient was initially kept NPO with an NGT in place.
After 3 days her ostomy opened up and her NGT stopped putting
out thick feculent material. The patient was later advanced to
and tolerated a regular diet at time of discharge.
GU: Patient had a foley catheter that was removed at time of
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever.
Heme: The patient had vital signs, including heart rate and
blood pressure, monitored throughout the hospital stay. Her INR
was elevated to 5.2 on hospital day 3 despite her warfarin being
held. At the time of dischage her INR had returned to
therapeutic levels and she was instructed to restart her
warfarin on day of discharge with close follow-up with her
___ clinic.
On hospital day 5, the patient was discharged to home. At
discharge,she was tolerating a regular diet, passing flatus,
stooling out of her ostomy, voiding, and ambulating
independently, She will follow-up in the clinic as need be and
will follow up with her PCP and her ___ clinic this week.
This information was communicated to the patient directly prior
to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
CELECOXIB [CELEBREX] - Celebrex ___ mg capsule. 1 Capsule(s) by
mouth once a day - (Prescribed by Other Provider)
HYDROMORPHONE - hydromorphone 2 mg tablet. 1 Tablet(s) by mouth
every four (4) hours as needed for pain
LEVOTHYROXINE [SYNTHROID] - Synthroid ___ mcg tablet. 1
tablet(s) by mouth 150mcg 6xwk; 75mcg 1day/wk No generics -
(Prescribed by Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth
daily - (Prescribed by Other Provider)
PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider;
Dose adjustment - no new Rx)
WARFARIN [COUMADIN] - Coumadin 5 mg tablet. ___ tablet(s) by
mouth once a day or as directed. Currently 10mg 5 days/wk and
12.5mg 2days/wk, awaiting preop instructions from MD -
(Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN [TYLENOL] - Tylenol ___ mg tablet. ___ tablet(s)
by mouth three times a day Taking 5/day - (OTC)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth ___ - (Prescribed by Other Provider)
BUDESONIDE [RHINOCORT ALLERGY] - Rhinocort Allergy 32
mcg/actuation nasal spray. 2 sprays in each nostril at bedtime
usually - (OTC)
CALCIUM CARBONATE [TUMS] - Tums 200 mg calcium (500 mg)
chewable tablet. 1 tablet(s) by mouth once a day as needed -
(OTC)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit tablet. tablet(s) by mouth once a day - (OTC)
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 500
mcg tablet. 1 Tablet(s) by mouth once a day - (Prescribed by
Other Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by mouth once a day - (OTC)
GLUCOSAMINE SUL-CHONDROITN-MSM - Dosage uncertain - (OTC)
IRON,CARBONYL-VITAMIN C - Dosage uncertain - (Prescribed by
Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a
day - (Prescribed by Other Provider)
RED YEAST RICE - red yeast rice 600 mg capsule. 1 capsule(s) by
mouth twice a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
Discharge Medications:
1. Warfarin 7.5-10 mg PO DAILY16 DVT prevention
please take as directed by Outside Provider
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
3. Levothyroxine Sodium 150 mcg IV DAILY
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 20 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for a small bowel obstruction.
___ were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. ___ have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. ___ may return home to finish your recovery.
If ___ have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Have a very happy birthday!
Followup Instructions:
___
|
10768342-DS-24
| 10,768,342 | 21,650,232 |
DS
| 24 |
2136-01-24 00:00:00
|
2136-01-25 11:51:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Caladryl / Caladryl Clear / Tucks / Flagyl / Latex / Potassium
Chloride / polyester / cilantro / Statins-Hmg-Coa Reductase
Inhibitors / Benadryl / Pentasa / prednisone / ciprofloxacin
Attending: ___
___ Complaint:
Recurrent small bowel obstruction
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
___ w/ rectal ca s/p LAR, lap VHR with mesh, and LOA with end
colostomy for colovaginal fistula c/b parastomal hernia presents
with recurrent SBO.
Past Medical History:
DVT/PE ___ on coumadin
End colostomy ___
Colon adenocarcinoma s/p resection (___), ileostomy, and
takedown (___). s/p chemo and XRT
Osteoarthritis
Dyslipidemia
Hypothyroid
Breast cancer
Rectovaginal fistula
factor V Leiden carrier
GERD
HTN
PSH:
Rectal cancer s/p resection and choanal anastomosis with
ileostomy ___ ___
Ileostomy closure ___ ___
Laparoscopic ventral hernia repair with insertion of mesh.
___ ___
Rectovaginal fistula s/p laparoscopy with lysis of adhesions end
colostomy ___ ___
Left wire localized lumpectomy and sentinel lymph node biopsy
___ ___
Rectal pain s/p anal dilatation, transanal excision of polyp
(___)
GI History: She has a history of colitis (Diversion vs IBD).
She has had bleeding from the excluded rectum and a lot of
secretions. She was placed on Rowasa enemas in the past. She
underwent an examination of the excluded colon and the stoma on
___. The excluded colon showed erythema, friability and
exudate in the rectum to the end of the colon at 60 cm. Through
the stoma, there was normal mucosa from 25 cm to the end of the
colon in the cecum, which was at 45 cm and in the terminal
ileum. At 25 cm distally, there were aphthous ulcerations. From
5 cm distally, there was diffuse erythema, congestion and
friability consistent with colitis. There were two inflammatory
polyps seen with a question of a fistula adjacent to one. The
biopsies showed in the excluded colon chronic active colitis.
Through the stoma at 5 cm, there was chronic active colitis and
at 25 cm chronic inactive colitis with normal at the cecum.
These findings raised the question of IBD. She was seen in the
office in ___ and the thought was that she had IBD. She was
started on pentasa which caused diarrhea. She was admitted in
___ with bleeding. CT scan showed thickened residual
right colon leading up to and into the colostomy consistent with
colitis. She was treated with IV steroids and then transitioned
to oral prednisone. She was admitted in ___ with an SBO
which was treated conservatively. She as dischaged on 30 mg of
prednisone and she tapered off by ___.
Social History:
___
Family History:
Father with CAD and stroke. Sister with brain cancer. Aunt with
colorectal cancer.
Physical Exam:
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, mild ttp low abdomen, ND, Colostomy LLQ, parastomal
hernia, ileostomy scar RLQ well healed.
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
WOUND:
[ ] ___ ___________
[ ] ostomy ___________
[ ] surgical drain ___________
[ ] prevena ___________
Pertinent Results:
___ 08:50AM BLOOD WBC-6.7 RBC-3.74* Hgb-10.7* Hct-33.4*
MCV-89 MCH-28.6 MCHC-32.0 RDW-12.9 RDWSD-42.0 Plt ___
___ 01:00PM BLOOD ___
___ 08:50AM BLOOD Plt ___
___ 08:50AM BLOOD Glucose-150* UreaN-51* Creat-1.2*#
Na-133* K-4.1 Cl-99 HCO3-21* AnGap-13
___ 08:50AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8
Brief Hospital Course:
Ms. ___ presented to ___ holding at ___ on ___
with a small bowel obstruction.
Neuro: Pain was well controlled on Tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. Had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was initially kept NPO. The patient was later
advanced to and tolerated a regular diet at time of discharge.
Patient's intake and output were closely monitored.
GU: The patient had a Foley catheter that was removed at time of
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient was closely monitored for signs and symptoms of
infection and fever.
Heme: The patient had blood levels checked daily during their
hospital course to monitor for signs of bleeding. The patient
received subcutaneous heparin and ___ dyne boots were used
during this stay, she was encouraged to get up and ambulate as
early as possible. The patient is being discharged on a
prophylactic dose of Lovenox.
On ___, the patient was discharged to home. At discharge,
she was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. She will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
CELECOXIB [CELEBREX] - Celebrex ___ mg capsule. 1 capsule(s) by
mouth at bedtime - (Prescribed by Other Provider)
CELECOXIB [CELEBREX] - Celebrex ___ mg capsule. 1 Capsule(s) by
mouth once a day - (Prescribed by Other Provider)
HYDROMORPHONE - hydromorphone 2 mg tablet. 1 Tablet(s) by mouth
every four (4) hours as needed for pain
LEVOTHYROXINE [SYNTHROID] - Synthroid ___ mcg tablet. 1
tablet(s)
by mouth once a day No generics - (Prescribed by Other
Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth daily
- (Prescribed by Other Provider)
PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider;
Dose adjustment - no new Rx)
WARFARIN [COUMADIN] - Coumadin 5 mg tablet. ___ tablet(s) by
mouth once a day or as directed. Currently 10mg 1 day/wk and
7.5.5mg 6 days/wk, awaiting preop instructions from MD -
(Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - Tylenol Extra Strength
500 mg tablet. ___ tablet(s) by mouth three times a day Taking
5/day - (OTC)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth ___ - (Prescribed by Other Provider)
BUDESONIDE [RHINOCORT ALLERGY] - Rhinocort Allergy 32
mcg/actuation nasal spray. 2 sprays in each nostril at bedtime
usually - (OTC)
CALCIUM CARBONATE [TUMS] - Tums 200 mg calcium (500 mg) chewable
tablet. 1 tablet(s) by mouth once a day as needed - (OTC)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit tablet. tablet(s) by mouth once a day - (OTC)
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 500
mcg
tablet. 1 Tablet(s) by mouth once a day - (Prescribed by Other
Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth once a day - (OTC)
GLUCOSAMINE SUL-CHONDROITN-MSM - Dosage uncertain - (OTC)
IRON,CARBONYL-VITAMIN C - Dosage uncertain - (Prescribed by
Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a
day - (Prescribed by Other Provider)
PROBIOTICS - probiotics . three times a week - (OTC)
RED YEAST RICE - red yeast rice 600 mg capsule. 1 capsule(s) by
mouth twice a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
Discharge Medications:
1. Acetaminophen 650 mg PO TID Pain
2. Celecoxib 100 mg oral QHS
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY:PRN on this at home
5. Cyanocobalamin 500 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Pantoprazole 20 mg PO Q24H
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 7.5 mg PO DAILY Duration: 1 Dose
10 mg on ___ and 7.5 mg every day for rest of week.
Discharge Disposition:
Home
Discharge Diagnosis:
SBO
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids. Your
obstruction has subsequently resolved after conservative
management. You are tolerating a regular diet, passing gas and
your pain is controlled with pain medications by mouth.
If you have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
Our hope is that you will have a quick return to your life and
usual activities. Thank you for allowing us to participate in
your care!
Followup Instructions:
___
|
10768526-DS-19
| 10,768,526 | 21,362,639 |
DS
| 19 |
2177-07-03 00:00:00
|
2177-07-03 17:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of moderately severe RA (on etanercept), OA, HTN,
peripheral neuropathy and other issues presented to the ED with
a recently diagnosed extensive LLE DVT. The patient had a fall
about 3 weeks ago and noted progressively increasing LLE
swelling since then. He has had mild discomfort but no pain. The
swelling persisted, so he his PCP in the office, and an
ultrasound was obtained which showed an extensive LLE clot
burden. PCP called the patient and advised him to go to the ED
for vascular surgery evaluation given extensive clot burden. He
denies weight loss, decreased appetite, night sweats, CP/SOB,
DOE, or decreased activity tolerance. He has no FHx of bleeding
or clotting disorders, and no recent periods of immobility or
orthopedic surgery. His last colonoscopy was ___ years ago (3
polyps removed), he is ___ year overdo for his repeat
colonoscopy. No changes in bowel habits, blood in stool, or
melena.
In the ED, initial VS were 99.5 71 123/85 18 100% RA. Labs were
unremarkable with the exception of 14.9% monocytes on diff, and
a grossly hemolyzed K 5.6 (3.7 on recheck). Venous dopplers
showed extensive LLE clot burden: "Acute thrombus (partially
occlusive) left common femoral and superficial femoral veins
with Complete occlusion of left popliteal and tibial veins" (per
verbal report, prelim read not available). Vascular surgery was
consulted and recommended no surgical intervention. The patient
was started on a heparin gtt, received acetaminophen, and was
admitted. Vitals prior to transfer were: 98.6 61 151/86 18 100%
RA.
Upon arrival to the floor, patient felt well and had no
complaints.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
-Rheumatoid arthritis on Etanercept
-Osteoarthritis
-HTN
-Peripheral neuropathy
-Insomnia
-Seasonal allergies
-Lumbago
Social History:
___
Family History:
No FHx of bleeding or clotting disorders, no FHx of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 104.2 kg 97.8 139/88 69 18 99% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT no conjunctival pallor or scleral icterus, PERRLA, EOMI,
OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs
PULMONARY: Clear to auscultation bilaterally, without wheezes or
crackles.
ABDOMEN: Slightly distended, normal bowel sounds, soft,
non-tender.
EXTREMITIES: Warm, well-perfused, 1+ pitting edema of LLE to
knee.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, grossly normal
DISCHARGE PHYSICAL EXAM
UNCHANGED
Pertinent Results:
ADMISSION LABS
--------------
___ 07:30PM BLOOD WBC-4.8 RBC-4.56* Hgb-14.0 Hct-41.3
MCV-91 MCH-30.7 MCHC-33.9 RDW-13.0 RDWSD-43.1 Plt ___
___ 07:30PM BLOOD Neuts-52.7 ___ Monos-14.9*
Eos-2.5 Baso-0.6 Im ___ AbsNeut-2.51 AbsLymp-1.39
AbsMono-0.71 AbsEos-0.12 AbsBaso-0.03
___ 07:30PM BLOOD ___ PTT-27.6 ___
___ 07:30PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-136
K-5.6* Cl-100 HCO3-25 AnGap-17
___ 05:49AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.0
___ 11:29PM BLOOD K-3.7
DISCHARGE LABS
--------------
___ 05:49AM BLOOD WBC-4.8 RBC-4.47* Hgb-13.6* Hct-40.9
MCV-92 MCH-30.4 MCHC-33.3 RDW-13.2 RDWSD-43.6 Plt ___
___ 05:49AM BLOOD Neuts-31.4* ___ Monos-16.4*
Eos-5.7 Baso-1.1* Im ___ AbsNeut-1.50* AbsLymp-2.15
AbsMono-0.78 AbsEos-0.27 AbsBaso-0.05
___ 09:11AM BLOOD PTT-129.7*
___ 05:49AM BLOOD Glucose-82 UreaN-13 Creat-0.9 Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
IMAGING
-------
BILATERAL LOWER EXTREMITY ULTRASOUND ___: REPORT NOT FINALIZED
-NONOCCLUSIVE THROMBUS OF THE LEFT COMMON FEMORAL VEIN, FEMORAL
VEIN
-OCCLUSIVE THROMBUS OF THE LEFT POPLITEAL VEIN, POSTERIOR TIBIAL
VEINS
Brief Hospital Course:
___ w/ PMH of moderately severe RA (on etanercept), OA, HTN,
peripheral neuropathy and other issues presented to the ED with
a recently diagnosed extensive LLE DVT.
#LEFT DVT: Appears unprovoked, though patient does have
underlying inflammatory disorder (RA). There are no specific
features of the history to suggest underlying malignancy. The
patient was initially on a heparin drip and was transitioned to
apixaban. He was counseled about bleeding risks and indications
for return to medical attention. He will follow up ___ in
vascular surgery clinic with Dr. ___. He will wear ACE
bandages and elevate his leg at home. Total treatment duration
is as yet undetermined, but at least 3 months are planned
#Rheumatoid arthritis: He is followed by Dr. ___ and is on
etanercept.
#OA: Not currently an active issue. Continued home Tramadol
#Hypertension: Continued home lisinopril 20 mg PO QD and HCTZ 50
mg PO QD
TRANSITIONAL ISSUES:
[]follow up in clinic with Dr. ___ repeat ultrasound
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Hydrochlorothiazide 50 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Lidocaine Jelly 2% 1 Appl TP ASDIR
7. LORazepam ___ mg PO QHS:PRN insomnia
8. TraMADol 50 mg PO BID:PRN pain
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice daily
Disp #*27 Tablet Refills:*0
2. Apixaban 5 mg PO BID Duration: 6 Months
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*90 Tablet Refills:*1
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Hydrochlorothiazide 50 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. LORazepam ___ mg PO QHS:PRN insomnia
8. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
9. Lidocaine Jelly 2% 1 Appl TP ASDIR
10. TraMADol 50 mg PO BID:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Deep vein thrombosis of the left leg
#Rheumatoid arthritis
#Hypertension
#Peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted because of a blood clot in your
left leg. This may be due to your rheumatoid arthritis because
inflammation is a risk factor for blood clots. Alternatively, it
may be due to your recent injury to your leg. We will have you
follow up in clinic with Dr. ___ Vascular ___ in 1
month. You should elevate your leg when you can and use an ACE
bandage to compress the leg from the ankle to the thigh.
The new medication for your blood clot is called "apixaban".
-Take 2 pills twice daily for 7 days, then take 1 pill twice
daily afterward (you will need ___ months of treatment)
This medication raises the risk of bleeding. If you note bloody
or black stools, please call your doctor or go to the ER
immediately.
Followup Instructions:
___
|
10768638-DS-21
| 10,768,638 | 28,665,403 |
DS
| 21 |
2158-01-10 00:00:00
|
2158-01-10 18:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Doxycycline / Latex / pineapple
Attending: ___.
Chief Complaint:
asthma exacerbation, acute
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o asthma who experienced 2 weeks of worsened cough,
dyspnea on exertion, nocturnal dyspnea that peaked at a severe
level impairing her breathing even while sitting still
yesterday. This worsened shortness of breath occurred in the
context of lack of advair refill, tobacco smoke and cat
allergens from her neighbors and spending time packing in her
basement. She could barely breathe at home and her husband
noted that she appeared pale so she presented to the ___ ED.
She experienced some tightness across her chest and a dry cough.
She did not have myalgias, fever or chills.
In the ED she was tachycardic and her room air sat was 93%. She
says she could barely speak and needed to text her history to
the treating providers. She received IV solumedrol, magnesium,
bronchodilators and a dose of prednisone 60mg.
She denies pain currently. 13pt ROS is only notable for night
sweats but is otherwise negative
Past Medical History:
Mild persistent asthma
Migraine
Allergic rhinitis
Depression
Low back pain
Social History:
___
Family History:
asthma in several relatives
Physical ___:
ADMISSION
98.2 102/62 HR 102 in bed, when she walked back from toilet her
pulse was 122, room air sat 92%, then 96% on 2L
aox3 not confused
able to speak full sentences but reporting ___ dyspnea when
sitting in bed and reporting history
facial features and oropharynx symmetric
lips dry
regular tachycardic s1 and s2, soft early systolic murmur in
RUSB c/w flow
no s3 or s4 heard
diffuse exp wheeze also with insp wheeze when she takes deep
breath, no focal crackles
soft abdomen, no palpable hepatomegaly
no peripheral edema
steady gait, all extremity movements are coordinated
calm, fluent speech
no visible rash to face or extremities
no bruising
DISCHARGE
VS: 98.3 127/78 98 16 95%RA
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - mild expiratory wheezing bilaterally, moderate air
movement; no crackles or ronchi
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
CTA Chest - ___ - Significantly limited study secondary
to patient motion/ coughing during the exam. No evidence of
large central pulmonary embolism or aortic abnormality. No
secondary signs of pulmonary embolism such as right heart strain
or ___ hump. No lung parenchymal abnormality identified.
CXR - ___ - Cardiomediastinal silhouette is within normal
limits. There are no focal consolidations, pleural effusion, or
pulmonary edema. There are no pneumothoraces.
ADMISSION
___ 11:35PM BLOOD WBC-14.1*# RBC-5.02 Hgb-15.1 Hct-43.6
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.0 RDWSD-40.5 Plt ___
___ 11:35PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-140
K-3.6 Cl-102 HCO3-25 AnGap-17
DISCHARGE
___ 05:15AM BLOOD WBC-14.8* RBC-4.35 Hgb-12.9 Hct-38.8
MCV-89 MCH-29.7 MCHC-33.2 RDW-13.1 RDWSD-42.7 Plt ___
___ 05:15AM BLOOD Glucose-95 UreaN-18 Creat-0.7 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
Brief Hospital Course:
This is a ___ year old female with past medical history of mild
persistent asthma with known triggers, admitted ___ with
acute asthma exacerbation, on steroids, with slow response, now
satting well on room air, ambulating comfortably with improved
peak flow (to 300) requiring 6 day inpatient stay, now ready for
discharge home to complete an additional 4 days of steroid pulse
(total 10 days).
# Mild Persistent Asthma with Acute Exacerbation / Seasonal
allergies - admitted with tachypnea, cough and significant
wheezing; patient reported recent exposure to environmental
triggers including second hand smoke, cat hair, as well as
unintentional interruption in her advair use; given failure to
initially improve with steroids and trigger for tachypnea, she
underwent at ___ that was a poor quality study but did not show
signs of central pulmonary embolism or infiltrates; she was
continued on PO prednisone, azithromycin, standing nebs with
slow improvement; continued home advair, cetirizine; patient was
discharged with prescription for 4 additional days of prednisone
(total 10 day course), as well as limited course of benzonatate
(reported symptomatic improvement with this).
# GERD - continued home PPI
Transitional issues
- Discharged home
- Patient declined influenza vaccine despite extensive
counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Epinephrine 1:1000 0.5 mg SC ONCE MR1
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Omeprazole 20 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Cetirizine 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*12
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
7. Epinephrine 1:1000 0.5 mg SC ONCE MR1
8. Benzonatate 100 mg PO BID
please do not operate heavy machinery while taking
RX *benzonatate 100 mg 1 capsule(s) by mouth twice a day Disp
#*8 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Mild Persistent Asthma with Acute Exacerbation
# Seasonal Allergies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
for an asthma exacerbation. You were treated with antibiotics
and steroids with slow improvement. You are now ready for
discharge home.
We recommend avoiding triggers for your asthma (cigarette smoke,
cats, dust). We also recommend that you obtain a flu shot to
help prevent future infection.
Followup Instructions:
___
|
10769030-DS-6
| 10,769,030 | 21,539,481 |
DS
| 6 |
2168-08-14 00:00:00
|
2168-08-14 18:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ year old female with history of HTN,
adult acne who presented to the ED with RUQ pain.
THe patient about 2 months ago and earlier this month had been
feeling intermittent sensations of epigastric burning,
nonradiating, thought to be from what she thought was heartburn.
She was taking ranitidine for this. She felt it was heartburn
especially because her parents unfortunately passed away that
time as well and was experiencing a lot of stress.
She saw her PCP, ___ discovered abnormal LFTs and
RUQ US was done on ___ that showed cholelithiasis.
However, yesterday evening she ate a quiche at about 6PM, then
at
8PM she noticed new acute onset of RUQ pain, different in
characteristic from the previously thought heartburn sensation.
She took Pepcid which did not help. She had associated nausea,
but no vomiting. No fever, cough, SOB, diarrhea. Her last bowel
movement was normal yesterday. At time of this interview she
does
not have any pain at rest, but does feel some
She does not have a history of any prior abdominal or major
surgery including C sections.
ED: Found to have lipase ___ and Tbili 1.6, Dbili 1.1, AST
547,
AST 518, ALP 165.
Abdominal US was done showing cholelithiasis without findings of
acute cholecystitis.
Given zosyn, spironolactone, ranitidine, 1L NS
Past Medical History:
- Adult Acne
- HTN
- Cholelithiasis
Social History:
___
Family History:
Sister Living ___ HYPERTENSION
BASAL CELL CARCINOMA
Mother deceased ___ HYPERTENSION
GLAUCOMA
ANOMALOUS PULMONARY
VENOUS RETURN WITH
SHUNTING
VASCULAR DEMENTIA
SUBAORTIC WEBBING
AORTIC VALVULAR DISEASE
Father ___ ___ CORONARY ARTERY
DISEASE
PROSTATE CANCER
NORMAL PRESSURE
HYDROCEPHALUS
Brother Living ___ HYPERTENSION
Brother Living ___ ANAL CANCER
Physical Exam:
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation except
in RUQ with deep palpation there is focal discomfort. BS present
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
AST: 518 --> 1037
ALT: 547 --> 474
Alk Phos: 165 --> 212
Lipase on admission: ___
WBC: 10.5 --> 4.1
Hgb: 14.1 --> 13.6
Brief Hospital Course:
#Suspected passed CBD stone/choledocholithiasis
#Cholelithiasis
#Gallstone pancreatitis
-Elevated lipase suggests inflammation of pancreas likely
related
to a potentially passed gallstone. No ongoing pain now or
evidence of SIRS at time of admission or discharge. Elevated
LFTs most likely from passed stone and without symptoms at this
time will not keep patient here. Discussed that patient should
follow with primary care provider to get her LFTs rechecked this
week to ensure downtrend. If uptrending she should return to the
hospital at htat time. Patient did received 1 dose of Zosyn in
ED, this was held after admission.
___ surgery was consulted while patient inpatient for
possible cholecystectomy, but was not able to get a booking on
the day of discharge. Patient feels well at this time so will
d/c home with close followup from me (___) and Dr. ___
___ timing of surgery in near future.
At time of discharge patient was told she should return if she
has return of symptoms/fevers/chills etc...
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 200 mg PO DAILY
2. Prempro (conj estrog-medroxyprogest ace) 0.3-1.5 mg oral
DAILY
3. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
4. minoxidil 2 % topical DAILY
5. Ranitidine 75 mg PO BID
Discharge Medications:
1. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
2. minoxidil 2 % topical DAILY
3. Prempro (conj estrog-medroxyprogest ace) 0.3-1.5 mg oral
DAILY
4. Ranitidine 75 mg PO BID
5. Spironolactone 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis and cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with gallstone pancreatitis and also
gall stone cholecystitis. Your labs were with very elevated
lipase and LFTs. Due to your not having many symptoms and
imaging without evidence of a blockage at this time, it was
discussed that removal of your gall bladder is the best course
of action at this time.
Followup Instructions:
___
|
10769032-DS-10
| 10,769,032 | 22,531,963 |
DS
| 10 |
2171-10-05 00:00:00
|
2171-10-08 18:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with no known past medical history presents to
___ ED after sustaining a blow to the right jaw during rugby
plan one week ago (last ___. Patient denies loss of
consciousness, head strike, or down time. Patient had some
swelling of jaw which resolved but pain has continued. He has
some right lower lip paresthesia but is otherwise sensate and
neuro-intact. He constituted a liquid and semi-soft diet
initially with improvement of pain but was convinced to come to
___ ED by college friend tonight. Patient has non displaced R
mandibular body fx and L mandibular angle fx seen on CT
sinus/max/mandible and was seen by OMFS with operative plan.
Request for ACS consult for ___ admission.
Patient denies other symptoms. No head aches or evidence of head
injury, no nose bleeds, ear bleeds, or oral bleeds, no injury to
tongue. Patient denies fevers, chills, night sweats. No chest
pain, shortness of breath, trouble breathing or managing
secretions. No change in bowel habits. No dysuria or hematuria.
No abdominal pain. No ___ swelling or MSK pain. Patient is
otherwise healthy.
Past Medical History:
Childhood cardiac murmur w/o treatment or further f/u
Social History:
___
Family History:
NC
Physical Exam:
VS: 97.2 63 140/67 20 100% RA
Gen: AAOx3, affable, white young male, NAD
Neuro: PERRLA, EOMI, CN2-12 intact
HEENT: no maxillary ttp, head atraumatic, no hematympanium,
right
mandibular ttp, minimal malocclusion right jaw, no evidence of
oral trauma or other external injury
CV: RRR no MRG, split S2
Pulm: CTAB No adventitious breath sounds
Abd: Soft nttp no guarding or rebound
Ext: distal pulses, UE and ___ ___ strength, no evidence of
injury
Chest: no sternal or chest wall ttp no evidence of injury
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the Acute Care Surgery Team. The patient was found
to have R mandibular body fx and L mandibular angle fx and was
admitted to the Acute Care Surgery Team for operative treatment
by ___. On HD1 it was determined by ___ that the patient
should follow-up outpatient on ___ 8:30am, ___ ___ outpatient operative intervention.
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
will follow up with ___ 8:30am, ___ ___.
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. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Peridex] 0.12 % Oral Rinse 15mL
twice a day Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
4. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R mandibular body fx and L mandibular angle fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to the hospital for your mandibular fractures.
You will follow up on ___ 8:30am, ___ ___
at:
___
First Floor, ___
Until then please continue a:
-Full Liquid diet
-Keflex ___ qid
-Peridex BID 15ml swish and spit
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.
*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 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:
___
|
10769115-DS-15
| 10,769,115 | 28,192,020 |
DS
| 15 |
2157-05-07 00:00:00
|
2157-05-07 16:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Cardiac cath
History of Present Illness:
___ with history of nonischemic cardiomyopathy, myocardial
bridge across mid LAD, DM, HLD, presenting with chest pain.
Woke up at ___ this AM with severe ___ substernal pressure
associated with nausea and numbness in his right arm. Lasted
about a half hour and then subsided. Since then has had some
residual ___ pain in the area. Took a full dose aspirin at
home. Says he has never had this type of pain before. No change
with position or activity. Has been feeling lightheaded for the
last week. Denies any recent changes in meds, diets, or
lifestyle.
Last Cath was in ___ showing myocardial bridge with 50%
compression of LAD during systole. No other CAD evident. Last
Echo in ___ showed EF 45%, LV systolic dysfunction unchanged
from prior.
In the ED, initial vitals were: 96.8 58 161/94 18 100% RA
- Labs were significant for trop <0.01, ProBNP 135
- The patient was given Nitro SL x 2 for chest pain while in
the ED
Upon arrival to the floor, he states he only has a faint
feeling of pain, and that the nitro helped his pain.
Past Medical History:
IDIOPATHIC DILATED CARDIOMYOPATHY ___
DIABETES TYPE II
HYPERCHOLESTEROLEMIA
CHRONIC RIGHT LOW BACK PAIN
BETA THALASSEMIA TRAIT
HYPERTENSION
Social History:
___
Family History:
Extensive CAD in father, died age ___, siblings (also premature
in father and cousins)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 53 125/53 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: bradycardic, 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
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 ___ 42-65 ___ 98-100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: bradycardic, 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
Pertinent Results:
ADMISSION LABS:
___ 03:00AM BLOOD WBC-8.8 RBC-5.97 Hgb-13.0* Hct-42.0
MCV-70* MCH-21.8* MCHC-31.0* RDW-18.6* RDWSD-42.5 Plt ___
___ 03:00AM BLOOD Neuts-43.4 ___ Monos-12.0 Eos-3.9
Baso-0.9 Im ___ AbsNeut-3.80 AbsLymp-3.43 AbsMono-1.05*
AbsEos-0.34 AbsBaso-0.08
___ 03:00AM BLOOD Glucose-130* UreaN-29* Creat-1.3* Na-139
K-4.3 Cl-101 HCO3-27 AnGap-15
___ 03:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.1
PERTINENT LABS:
___ 03:00AM BLOOD cTropnT-<0.01
___ 10:15AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 06:44AM BLOOD Glucose-125* UreaN-21* Creat-0.8 Na-138
K-4.6 Cl-103 HCO3-25 AnGap-15
STUDIES:
ECG: Sinus bradycardia with LBBB.
CXR: No acute cardiopulmonary process. Stable mild
cardiomegaly.
CARDIAC CATH ___:
Anatomy:
Dominance: RIght
LMCA: Long with mild luminal irregularities
LAD: Minimal luminal irregularities. Diffuse segment of the mid
LAD was intramyocardial with systolic compression/milking; there
is slow flow into distal LAD. The LAD also supplied a branching
diagonal.
LCx: The AV groove CX gave off 2 very high large OM branches
(functioning like a ramus intermedius). The true AV groove CX
had mild plaquing and supplied 3 small short OM branches, a
modest sized OM6, and 2 long LPLs (both with mild plaquing).
Flow in the CX system was slow and pulsatile, consistent with
microvascular dysfunction.
RCA: Somewhat vertical take-off with a mild near-ostial
angulated plaque. The mid RCA had mild plaquing, with slow,
somewhat pulsatile flow consistent with microvascular
dysfunction. The RPDA and RPL1 were long vessels; RPL2 was
shorter, and RPL3 was even shorter still.
Impressions:
1. No angiographically-apparent flow-limiting CAD, although
scattered atherosclerosis and diffuse slow flow consistent with
microvascular dysfcuntion were readily evident.
2. Intramyocardial bridging of the mid LAD with dynamic systolic
compression.
3. Moderate LV diastolic heart failure (most likely acute on
chronic) in the setting of mild LV systolic dysfunction.
Brief Hospital Course:
___ with history of nonischemic cardiomyopathy, myocardial
bridge across mid LAD, DM, HLD, presenting with chest pain.
#Chest pain: Patient with h/o myocardial bridge and long history
of chest pain. IN house this was responsive to nitroglycerin
sublingual. He underwent cardiac cath which showed no
significant CAD. He was started on imdur given possible cardiac
etiology via spasm vs myocardial bridge.
___: On admission Cr 1.3 from baseline around 0.8. Cardiac cath
showed elevated LVEDP and he received IV lasix. Lisinopril held
and not restarted given that he was normotensive on imdur as
above. Cr returned to normal.
#Nonischemic Cardiomyopathy: Lisinopril held for ___ and not
restarted prior to discharge. Carvedilol and ASA continued.
#HLD: Simvastatin continued.
#DM2: Metformin held, continued on sliding scale insulin in
house.
#Anemia: Chronic, from Thalassemia trait. H/H at baseline.
# CODE STATUS: Full
# CONTACT: ___
Relationship: wife
Phone number: ___
# TRANSITIONAL ISSUES:
-Patient started on imdur 30 mg daily given CP responsive to
nitro
-Carvedilol decreased from 12.5 mg bid to 6.25 mg bid; consider
adjusting as tolerated given patient's bradycardia to ___ and
symptoms of dizziness
-Lisinopril held for ___ and not restarted as BPs adequate after
starting imdur; consider restarting if needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Chest pain
Secondary
Acute kidney injury
Nonischemic cardiomyopathy
Hyperlipidemia
Type 2 diabetes
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had chest pain. In
the hospital this improved with nitroglycerin. You had blood
tests that did not show any damage to your heart, and your EKG
was normal. You had a cardiac cath procedure which showed that
one of your coronary arteries dips into the heart muscle, as was
previously known, but no coronary artery disease. Although it is
not clear what caused your chest pain, it is possible that it
was caused by a spasm of a blood vessel. We are starting a
medication called imdur (isosorbide mononitrate) that can help
with this. We have also stopped your lisinopril; please follow
up with Dr. ___ when to restart this.
The dizziness that you had is likely unrelated to your chest
pain. You did have a very slow heart rate, 40-50 beats per
minute, that may explain your dizziness. We decreased your
carvedilol which should allow your heart rate to be higher.
Please follow up with your outpatient cardiologist.
It was a pleasure taking care of you during your stay in the
hospital.
Very best wishes,
Your ___ Team
Followup Instructions:
___
|
10769137-DS-19
| 10,769,137 | 22,740,463 |
DS
| 19 |
2169-07-17 00:00:00
|
2169-07-22 14:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old female who presents with
headache and SAH. 6 weeks prior, she gave birth to her second
child. She has been taking care of her ___ year old and 6 week
old,
so was feeling very tired. She decided to take 40 mg of
Adderall,
which she is not prescribed but occasionally takes 30- 60 mg).
After which, around 7 pm, her heart started racing and she
began
to have a headache. She describes her headache as "finger
slammed
in door" " throbbing" "wanted to break head open like an egg"
lots of pressure". The location is bifrontal to vertex to neck.
She tried ibuprofen 600 mg x1 without relief and Xanax 0.25 mgx
1
for her anxiety. Pain was so terrible, she couldn't open eyes,
so
she went to the ED. Her headache resolved ~11 pm, when was given
morphine and other medications. At ___, a ___
was done and revealed a SAH at parietal vertex, so she was
transferred for neurosurgical eval.
Since transfer, she has had intermittent headache, resolved with
pain medication. Her head mostly feels sore now, and is worse
with sitting up, but not when walking; no nausea/
photophobia/phonophobia. She does not usually have headache.
Past Medical History:
s/p C-Section
Social History:
___
Family History:
Grandfather lung cancer, Uncle leukemia,
Grandmother aortic aneurysm rupture. HTN
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 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. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Unable to
fully
visualize fundus b/l.
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
R 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:
Exam remains non focal without weakness, numbness. Afebrile. No
meningismus. trigger point in the left greater occipital nerve
exit point.
Pertinent Results:
___ 03:15AM WBC-9.4 RBC-4.49 HGB-12.9 HCT-38.9 MCV-87
MCH-28.7 MCHC-33.2 RDW-12.6 RDWSD-39.4
___ 03:15AM PLT COUNT-299
___ 03:15AM NEUTS-80.1* LYMPHS-15.1* MONOS-4.1* EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-7.51* AbsLymp-1.42 AbsMono-0.38
AbsEos-0.00* AbsBaso-0.04
___ 03:15AM ___ PTT-33.8 ___
___ 03:15AM GLUCOSE-108* UREA N-15 CREAT-0.9 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
___ 03:15AM ALT(SGPT)-85* AST(SGOT)-51* ALK PHOS-139* TOT
BILI-0.2
___ 03:15AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
CTA Head/Neck (___):
1. Small amount of right frontal vertex subarachnoid hemorrhage
at the vertex with slight increased vascularity, which is likely
reactive in nature. Trace associated gyral hypodensity.
2. Short-segment right vertebral dissection within the
transverse foramen of C1, with a patent distal right vertebral
artery.
3. No evidence of aneurysm or AV malformation.
4. There is a 3 mm right upper lobe pulmonary nodule. If the
patient has no known risk factors, no further follow-up is
advised by ___ criteria. Otherwise, ___hest followup is recommended.
MRI Head (___):
1. Re-demonstrated is right frontal convexity subarachnoid
hemorrhage with some redistribution into the cerebral aqueduct
and fourth ventricle.
2. No acute intracranial infarct is seen.
CTA Head/Neck (___):
1. Stable small right frontal vertex subarachnoid hemorrhage.
2. Short segment right vertebral artery dissection in the
transverse foramen of C1 with patent distal right vertebral
artery.
3. Probable short segment dissection involving the left
vertebral artery just proximal to the origin of left posterior
inferior cerebellar artery with patent distal artery.
4. No aneurysm or AV malformation.
5. 3 mm right upper lobe pulmonary nodule for which no further
follow-up is advised by the ___ criteria in case
of no known risk factors. If the patient has known risk factors
then ___ year follow-up with chest CT is recommended.
Brief Hospital Course:
Mrs. ___ was admitted to the ___ Stroke service on
___ after presenting at an OSH ED for severe
headache and noted to have a subarachnoid hemorrhage. She was
transferred to ___ for further management. Repeat CTA
Head/Neck demonstrated a small amount of right frontal vertex
subarachnoid hemorrhage at the vertex with slight increased
vascularity, which is likely reactive in nature. There was
trace associated gyral hypodensity. She was also noted to have
a short-segment right vertebral dissection within the transverse
foramen of C1, with a patent distal right vertebral artery.
There was no evidence of aneurysm or AV malformation.
Neurosurgery was consulted and did not recommend surgical
intervention. Basic labs upon admission including CBC, Chem,
Coags, and Utox were unremarkable.
She was admitted to the stroke service for observation and
treatment of headache. Patient was started on Verapamil 40 mg
TID which was subsequently increased to 80 mg TID the following
day due to ongoing headache. Mrs. ___ used Fioricet and
Oxycodone q6h PRN for pain. Her pain was well controlled on
this regimen.
MRI was performed to reevaluate her SAH and assess for any
intracranial pathology associated with her R vertebral
dissections. MRI re-demonstrated right frontal convexity
subarachnoid hemorrhage with some redistribution into the
cerebral aqueduct and fourth ventricle, unchanged from previous
CTA.
Prior to discharge one more image was taken due to ongoing
complaints of L sided neck pain. Initial wet read of the image
showed stable findings as compared to previous images.
Patient's neck pain showed improvement with heat, therefore,
this was felt to be likely musculoskeletal in origin. She was
felt to be stable for discharge home with Fioricet as needed for
HA and Valium as needed for neck pain.
TRANSITIONAL ISSUES:
-CTA Head/Neck was also notable for a 3 mm right upper lobe
pulmonary nodule. It was advised that if the patient has no
known risk factors, no further follow-up is advised by
___ criteria. Otherwise, ___hest
followup is recommended.
Addenedum: At the time this discharge summary was written
(___), final read of CTA Head/Neck from ___ was reviewed
and final read notes: Stable small right frontal vertex
subarachnoid hemorrhage. Short segment right vertebral artery
dissection in the transverse foramen of C1 with patent distal
right vertebral artery and probable short segment dissection
involving the left vertebral artery just proximal to the origin
of left posterior inferior cerebellar artery with patent distal
artery. There was not notable aneurysm or AV malformation. This
new finding was reviewed by myself and the attending physician
who were in agreement with the read. Patient is to be contacted
by attending to determine further evaluation and potential
initiation of ASA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every 6 hours Disp #*30 Capsule Refills:*1
2. Prenatal Vitamins 1 TAB PO DAILY
3. Verapamil SR 240 mg PO Q24H
RX *verapamil 240 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
4. Diazepam 5 mg PO Q8H:PRN neck spasm/pain
RX *diazepam 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Reversible Cerebral Vasoconstrictive Syndrome
Right/Left Vertebral Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the ___ Neurology service for symptoms of
severe headache due to subarachnoid hemorrhage, related to
reversible cerebral vasoconstriction syndrome (___). ___ were
also noted to have an incidental right vertebral dissection
noted on your CT scan, but we do not feel this was related to
your presenting symptoms.
___ were started the following medications:
1. Verapamil - to prevent your headaches
2. Fioricet - to treat the current headache
___ can take Valium 5mg at home if your neck pain continues.
Followup Instructions:
___
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10769306-DS-17
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2182-10-14 10:24:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Patient is a ___ year-old right-handed woman with no
significant past medical history presenting for evaluation of
weakness and numbness. Symptoms started a week ago with
numbness, tingling and hyperesthesia over the dorsal aspect of
her left forearm. This was accompanied by numbness and tingling
in her ___ and ___ finger on the left. A couple days later, she
developed numbness over the entirety of her RLE. She also
noticed around that time that her left leg seemed to be 'jerky'
at night. She has had this before but never to the extent or as
persistently as she does currently. The movement would be
preceded by a sense of needing to move her leg, and she would
feel better after moving her leg. Then, a couple of days ago,
she noticed that her left hand felt weak. She noticed herself
dropping things. She also had onset of weakness in her left leg
around the same time and noticed that her left leg seemed to be
dragging. Around the same time, the abnormal sensation in her
left ___ and ___ fingers transitioned to a burning sensation.
She saw her PCP 3 days ago and had labs done then, including
negative HIV, normal B12 and folate, NR syphilis, A1c 5.1.
Chlamydia and gonorrhea pending. Lyme ab + (2.12, ref range <
1.0) with Western blot pending. She saw a neurologist at ___
today who was concerned for a central process based on
hyperreflexia and an upgoing toe on the left. She was referred
to the BI ED for further evaluation and management.
She has otherwise been well with no headache, no dizziness, no
visual changes, no difficulty speaking or swallowing, no
difficulty urinating or stooling although she has not had a
bowel
movement in a couple of days and would normally stool every day,
no fever, no URI symptoms, no nausea, no vomiting, no diarrhea,
no rash, no joint aches. She did have sharp pains over her
lower
ribs on the right a couple nights ago that resolved by morning,
otherwise no back or other pain. She has not had similar
symptoms in the past.
Review of Systems: Negative except as per HPI.
Past Medical History:
Depression
Anxiety
Social History:
___
Family History:
Dad with Type ___ DM. Maternal aunt with
___. Mom with restless legs.
Physical Exam:
Examination:
Head and face: Normal head shape, no dysmorphic features.
Eyes: No conjunctival injection, pupils equal, round and
reactive
to light.
Ears, nose, mouth and throat: Nasal mucosa not inflamed. Lips,
teeth and gums without lesions. Palate intact, posterior pharynx
without exudate.
Neck: Appeared normal, no meningismus.
Respiratory: Breathing comfortably.
Cardiovascular: Normal rate.
Gastrointestinal: Non-distended.
Musculoskeletal: Back and spine showed no abnormalities, FROM.
Skin: No noted rash or induration.
Neurological exam:
Mental Status: alert and active. Orientation: oriented to
person, place and date. Language: Speech assessment revealed
fluent, articulate speech without paraphasic errors. Follows
commands. She had a normal fund of knowledge. Attention:
Listened carefully to my questions and answered without
requiring
repetition or clarification.
Cranial nerves: Pupils equal, round and reactive. Visual fields
intact to confrontation. Extra-ocular movements intact with
conjugate gaze and good tracking of objects. Facial sensation
and strength normal and symmetric. Palate raised symmetrically
in
the midline. Sternocleidomastoid and trapezius strong
bilaterally. Tongue protruded in the midline with no evidence of
atrophy or fasciculation.
Motor: Normal bulk and tone. No pronation or drift. No
adventitious movements.
D T B WE WF FE FF IP Q H TA G
L ___ ___ 4* 5- 5- 4+ 5- 5-
R ___ ___ ___ ___
* Most prominent in ___ and ___ digits.
Deep tendon reflexes: 2+ but brisker on the left than on the
right, especially at patella. Sustained clonus at left ankle,
none at rigth. Left toe up, right toe down.
Sensory: Intact to light touch, joint position, and vibration.
Decreased temperature over anterior aspect of right lower
extremity. Decreased pin over anterior surface of right lower
extremity and dorsal and plantar surface of right foot.
Coordination: Finger-nose-finger and heel-to-shin movements
normal. No truncal ataxia.
Gait: Mild left leg circumduction. Normal based and able to
perform toe, heel and tandem gait
but movements were not as robust on left as compared to right.
Pertinent Results:
___ 06:20AM BLOOD WBC-11.3* RBC-4.25 Hgb-12.9 Hct-35.4*
MCV-83 MCH-30.3 MCHC-36.4* RDW-13.5 Plt ___
___ 09:52AM BLOOD Neuts-82.5* Lymphs-13.8* Monos-3.3
Eos-0.3 Baso-0.1
___ 06:20AM BLOOD ___ PTT-28.6 ___
___ 06:20AM BLOOD Glucose-100 UreaN-16 Creat-0.6 Na-143
K-4.7 Cl-106 HCO3-30 AnGap-12
___ 11:05AM BLOOD ALT-18 AST-24 AlkPhos-62 TotBili-0.4
___ 06:20AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.4
___ 01:00PM BLOOD Homocys-PND
___ 01:20PM BLOOD TSH-2.1
___ 01:00PM BLOOD 25VitD-17*
___ 01:20PM BLOOD ANCA-NEGATIVE B
___ 01:20PM BLOOD ___ dsDNA-NEGATIVE
___ 01:20PM BLOOD RheuFac-5 CRP-1.3
___ 01:20PM BLOOD C3-112 C4-21
___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Otherwise healthy ___ F presents w subacute bilateral sensory
alteration and left sided weakness. MRI shows enhancing
incomplete transverse myelitis at C6. Visual evoked potentials
negative. MRI brain shows "nonspecific subtle FLAIR
hyperintensity in the right periventricular white matter" -
unclear significance. Treated with IV methylprednisone 1000mg x5
days. Exam on discharge stable.
Also found to have slightly enlarged paratrachial LN on CT
torso. Taken for bx with interventional pulm. Bx results
pending.
LP done. CSF results negative (including bands), though ACE and
NMO Abs remain pending at time of d/c.
Vitamin D deficiency - started on vitamin D 50,000 qWeek x8
weeks, followed by daily dose.
HR to 30's while sleeping- EKG with sinus rhythm, QTc 411.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 100 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. LaMOTrigine 100 mg PO DAILY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) Duration: 8 Weeks
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth ___ Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: transverse myelitis, vitamin D deficiency
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 symptoms of left sided weakness and
bilateral sensory disturbances. We believe that your symptoms
are the result of an inflammatory lesion in your spinal cord -
called transverse myelitis. We are treating this inflammation
with high dose IV steroids and expect you to have complete or
near-complete recovery over the next several weeks.
You will need to have an echocardiogram as an outpatient due to
an unclear finding during an ultrasound of your lymph nodes.
Please coordinate with your PCP.
It was a pleasure taking care of you.
___ Neurology
Dear Ms. ___,
You were admitted for symptoms of left sided weakness and
bilateral sensory disturbances. We believe that your symptoms
are the result of an inflammatory lesion in your spinal cord -
called transverse myelitis. We are treating this inflammation
with high dose IV steroids and expect you to have complete or
near-complete recovery over the next several weeks.
You will need to have an echocardiogram as an outpatient due to
an unclear finding during an ultrasound of your lymph nodes.
Please coordinate with your PCP.
It was a pleasure taking care of you.
___ Neurology
Followup Instructions:
___
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2182-11-11 09:04:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Spinal Lesion on MRI
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman followed by ___ for her recently found enlarging, enhancing left sided
C5-C7 cord lesion. Per her history, her symptoms began on
___, when she noticed acute onset numbness/paresthsias on
the
dorsal medial side of the left forearm. She noted that the
dorsal
forearm was very sensitive to touch at that point, but denied
weakness. She presented to urgent care, where she was diagnosed
with L ulnar neuropathy; however, the next day, she then noticed
that her entire right leg had numbness
and paresthesias.
On ___, she noted that her left leg would feel restless at
nighttime, such that she would have to move it to make it feel
better. On ___, she started noticing that the dorsal surface
of her L ___ and ___ fingers were becoming particularly painful
and the L hand feels weak. She started dropping things, like her
cup and her comb. She also noted that her left leg started
dragging, although no falls occured.
The patient confirmed to Dr. ___ myself that she has had
no prior episodes of diplopia, optic neuritis, dysphagia,
dysarthria, other episodes of previous neurologic symptoms.
Denies bowel/bladder issues. No recent viral infections,
immunizations, URIs, rashes.
Dr. ___ the patient on ___, and given concern
for a L cervical hemicord lesion advised her to present to the
___ ED. She was admitted to ___ from ___. MRI
brain C/T spine (images reviewed) demonstrated a T2
hyperintense,
enhancing lesion within the left-sided aspect of the spinal cord
at C5-6 to C6-7, most likely due to demyelinating disease, and a
nonspecific subtle FLAIR hyperintensity in the right
periventricular white matter. LP performed demonstrated WBC 1,
TP
20, glu 64, LDH 15, OCB neg (1 band). ACE 58 (nl) NMO neg. ___, ESR 2. VEPs were negative. She was diagnosed with vitamin D
deficiency, and
started on vitamin D 50,000 qWeek x8 weeks, followed by daily
dose.
IV methylprednisone 1000mg x5 days helped improve her symptoms;
paratrachial lymph node incidentally seen on imaging underwent
biopsy was negative for malignant cells.
Other labs of note from ___: HIV neg, Lyme Western blot neg,
B12 303, folate 18.5, RPR NR
Follow-up on ___ revealed significant improvement; however,
her numbness had spread up the arm and into the right hand,
which
subsequently stabilized. Per Dr. ___, "She did complain of
some feelings of restlessness in her right leg, so her iron
studies were checked and I did prescribe some PRN pramipexole.
Overall, except for a feeling in her R leg "like I'm sitting on
a
vibrating cell phone", she reports stability of her weakness and
sensory changes since her visit on ___. However, because of the
possibility of neoplasm, and because her
exam had progressed since I first saw her on ___, we
obtained
repeat MRI C-spine on ___, which demonstrated an interval
increase in the intramedullary lesion in C5-C7, now crossing the
midline involving a majority of the cord with sparing of the far
right lateral aspect of the cord, with an increase in
enhancement, and cord expansion.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Depression
- Anxiety
- Iron deficiency anemia
- Asymptomatic bradycardia (hr in ___ noted on last admission
- Paratrachial lymph node incidentally seen on imaging underwent
biopsy was negative for malignant cells
Social History:
___
Family History:
- Mother with ___
- Father with DM2
- ___ and PGF - melanoma
- Grandmother with PD
- Aunt with ___
Physical Exam:
# Admission Exam #
T=99.1F, HR=73, BP=126/70, RR=18, SaO2=98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. 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. Attentive, with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI with extinguishing end gaze nystagmus (few
beats bilaterally). Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5* ___ ___ 5 5 5
R ___ ___ ___ 5 5 5 5 5
* weakness noted in flexor carpi ulnaris ___ compared to flexor
carpi radialis
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 2 2 2 2 1
- Plantar response was flexor on right, extensor majestically on
left.
- Pectoralis Jerk and Crossed Adductors were present on the
left.
-Sensory: Deficits pinprick noted in patchy distribution along
the , cold sensation, vibratory sense, proprioception
throughout.
No extinction to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
# Discharge Exam #
- Unchanged
Pertinent Results:
___ 05:35PM BLOOD WBC-7.8 RBC-4.43 Hgb-13.7 Hct-36.2 MCV-82
MCH-30.8 MCHC-37.7* RDW-13.7 Plt ___
___ 06:15AM BLOOD WBC-6.1 RBC-4.48 Hgb-13.2 Hct-36.9 MCV-82
MCH-29.5 MCHC-35.9* RDW-13.7 Plt ___
___ 06:36AM BLOOD WBC-6.0 RBC-4.59 Hgb-13.5 Hct-38.1 MCV-83
MCH-29.5 MCHC-35.5* RDW-13.7 Plt ___
___ 06:55AM BLOOD WBC-8.3 RBC-4.69 Hgb-13.9 Hct-38.9 MCV-83
MCH-29.6 MCHC-35.7* RDW-13.5 Plt ___
___ 05:35PM BLOOD Neuts-54.7 ___ Monos-6.1 Eos-1.9
Baso-0.3
___ 05:35PM BLOOD ___ PTT-33.2 ___
___ 05:35PM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-33.1 ___
___ 06:15AM BLOOD Plt ___
___ 06:36AM BLOOD ___ PTT-31.8 ___
___ 06:36AM BLOOD Plt ___
___ 06:55AM BLOOD ___ PTT-34.5 ___
___ 05:35PM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-30 AnGap-9
___ 06:15AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
___ 06:36AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 06:55AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-24 AnGap-15
___ 06:15AM BLOOD ALT-17 AST-17 LD(LDH)-234 AlkPhos-58
TotBili-0.3
___ 05:35PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
___ 06:15AM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.9 Mg-2.0
Iron-50
___ 06:15AM BLOOD calTIBC-173* Ferritn-47 TRF-133*
___ 06:36AM BLOOD ANCA-NEGATIVE B
___ 06:36AM BLOOD CRP-1.3
___ 06:15AM BLOOD b2micro-1.8
___ 06:36AM BLOOD b2micro-1.7
___ 06:36AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 06:36AM BLOOD RO & ___
___ 06:36AM BLOOD SM ANTIBODY-Test
___ 06:36AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test
___ 06:36AM BLOOD SED RATE-Test
___ 08:19PM URINE Color-Straw Appear-Clear Sp ___
___ 08:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:19PM URINE UCG-NEGATIVE
___ 07:45PM URINE VoidSpe-PND
___ 07:45PM URINE VoidSpe-PND
___ 07:45PM URINE VoidSpe-PND
___ 02:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2950*
Polys-46 ___ ___ 02:00PM CEREBROSPINAL FLUID (CSF) WBC-2 ___
Polys-49 ___ ___ 02:00PM CEREBROSPINAL FLUID (CSF) TotProt-57*
Glucose-66
___ 02:00PM CEREBROSPINAL FLUID (CSF) BETA 2
MICROGLOBULIN-Test
___ 02:00PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1
CONVERTING ENZYME-Test
___ 02:00PM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND
___ 02:00PM CEREBROSPINAL FLUID (CSF) NEUROMYELITIS OPTICA
(NMO)/AQUAPORIN-4-IGG CELL-BINDING ASSAY, CSF-Test Name
___ ___: ___
CT Abd/Pelvis w/ contrast ___: IMPRESSION: 1. Normal CT of
the abdomen/pelvis. No evidence of malignancy or acute process.
MRI L Spin w/ and w/o contrast ___: IMPRESSION:
1. Mildly decreased T1 marrow signal throughout the lumbar
spine which could be seen in the setting of anemia. A marrow
infiltrative process could also
result in this appearance. Clinical correlation is recommended.
2. No high-grade spinal canal stenosis or neural foraminal
narrowing.
3. No abnormal enhancing lesions on post-contrast images.
4. Mild epidural lipomatosis in the lower lumbar region.
Brief Hospital Course:
___ RHW h/o depression and recent admission for left C5-C6 left
intramedullary lesion s/p IV Steroids presents with increasing
lesion size on repeat MRI. Concerning for possible
intramedulary neoplasm vs demyelinating diease.
# Spinal Cord lEsion
- She was admitted to the neurology service. Prior outside
imaging was uploaded and reviewed. While lesion did appeared
enlarged compared to prior, formal comparison was felt to be
difficult due to differences in technique. She underwent a
repeat serum evaluation for causes of myelopathy including ___,
ANCA, DSDNA, b2 microglobulin, CRP and ESR. These were
unrevealing. She underwent ___ guided LP following failure of
bedside LP with repeat CSF evaluation including, but not limited
to NMO, Sarcoid, CSF flow and cytology. These studies were
pending at the time of discharge
Neuro-oncology was made aware of the case, though not fomrally
consulted and endorsed concern for a possible cord malignancy.
Given recent CT chest evaluating for sarcoid and prior LN
biopsy, further chest CT imaging was deferred. CT abdomen and
pelvis w/o contrast was done to evaluate for malignancy, without
concerning findings. Further L-spine MRI imaging was done to
assess for evidence of malignancy or possible drop mets, but was
notable only for mild signal change within the L-spine itself-
on discussion with the radiology staff, this was felt to likely
represent a normal finding for age, though anemia or
infiltrative process could not be excluded.
She was started on prednisone 60mg Daily, Bactrim SS for PCP
prophylaxis, PPI and Calcium+D. Prednisone treating any
possible underlying demyelinating process. After discussion
with her outpatient neurologist, Dr. ___ will manage her
prednsione and guide further evaluation. Ms. ___ was felt to
be safe for discharge.
===========
- Transitional Issues:
- Outpatient MRI in approximately 4 weeks
- CSF and Serum studies to be followed by outpatient
neurologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pramipexole 0.125 mg PO QHS Resless Leg symptoms
2. LaMOTrigine 200 mg PO QHS Depression
3. Escitalopram Oxalate 20 mg PO DAILY
4. Tretinoin 0.05% Cream 1 Appl TP QHS
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
7. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) injection As
directed by your prescribing physician.
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Ferrous Sulfate 325 mg PO TID
3. LaMOTrigine 200 mg PO QHS Depression
4. Pramipexole 0.125 mg PO QHS Resless Leg symptoms
5. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
6. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) injection As
directed by your prescribing physician.
7. Tretinoin 0.05% Cream 1 Appl TP QHS
8. Outpatient Occupational Therapy
ICD9: 336.9, M62.81
Focus on Hand strengthening, dexterity
Provider: ___, MD ___
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2
10. PredniSONE 60 mg PO Q24H
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*1
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
12. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth QHS PRN Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
C5-C6 Spinal Enhancing Lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___ due to concern that your
previously known C5-C6 Spinal lesion might be growing. While in
the hospital you underwent an evaluation looking for causes of
spinal cord lesions- including malignancy (cancer) and
demyelinating lesions.
At the time of your discharge, the cause of your spinal cord
lesion is not entirely clear. You were started on Prednisone
daily to treat an possible demyelinationg. It is critical that
you take this medication and follow with your Neurologist to
help determine the cause of your symptoms.
While you are on prednisone, you should take the medication
bactrim daily. This is to prevent infections while you are on
steroids. We also started you on pantoprazole to protect your
stomach while you are on steroids. You should continue taking
your vitamin D vitamin as well. If you have trouble sleeping,
you can fill the prescription that we provided for trazadone at
night.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
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10769428-DS-3
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2171-08-12 12:03:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left periprosthetic fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
ORTHOPAEDIC SURGERY CONSULT
NAME: ___
MRN: ___
DATE: ___
Home Phone: ___
CC: Left hip pain
HPI: ___ year old male w/ L Total Hip Replacement s/p fall from a
short ladder when he suddenly tripped and fell landing on his
Left side. He had immediate pain and inability to bear weight.
He
was taken by ambulance to ___ where imaging
reportedly revealed a left periprosthetic femur fracture. He was
transported to ___ for further management.
ROS: No chest pain, shortness of breath, headache, vision
change,
abdominal pain, no weakness outside of H&P
PMH:
Atrial fibrillation s/p porcine valve placement
Hypertension
BPH
Unknown Rheumatologic Condition
PSH:
Left Total Hip Replacement ___ years ago at ___ in
___ by Dr. ___ Total ___ Replacements
Right Total Shoulder Replacement
MED:
Coumadin 2 mg qd for INR goal ___
Terazosin Hydrochloride
Metoprolol Tartrate
Finasteride
Prednisone
ALL: ___ Sulfa
SH:
Activity Level: Community ambulator
Mobility Devices: none
Occupation: ___
Tobacco: none
EtOH: none
PE:
T-98.7 HR-62 BP-125/64 RR-18 SaO2-96% RA
A&O x 3
Calm and comfortable
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
Radial/Median/Ulnar/Axillary ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Fires biceps/triceps/deltoid
LLE skin clean and intact
Tenderness about the left hip. No noticeable deformity,
erythema,
edema, induration or ecchymosis.
Thighs and legs are soft
Pain with passive motion of the hip
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
IMAGING:
AP Pelvis: Left Periprosthetic Hip Fracture.
Left Hip (3 views): *** Intertrochanteric femur fracture.
Left ___ Replacement in good alignment. No fx.
LABS:
CBC: 8>35.6<150
BMP: ___
INR: 1.0
UA: neg
IMPRESSION & RECOMMENDATIONS: ___ year old man w/ Left hip
periprosthetic fracture s/p mechanical fall. This will require
operative fixation.
Admit to Orthopaedic Surgery
NWB LLE
Hold Coumadin
Lovenox for DVT prophylaxis
Contact ___ Department of Medical Records to
elucidate the design of the Left Hip Prosthesis
NPO w/ IVF for OR in am
___________________________
___ MD
___ Combined Orthopaedic ___
Past Medical History:
Atrial fibrillation s/p porcine valve placement
Hypertension
BPH
Unknown Rheumatologic Condition
PSH:
Left Total Hip Replacement ___ years ago at ___ in
___ by Dr. ___ Total ___ Replacements
Right Total Shoulder Replacement
Social History:
___
Family History:
N/C
Physical Exam:
PE:
T-98.7 HR-62 BP-125/64 RR-18 SaO2-96% RA
A&O x 3
Calm and comfortable
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
Radial/Median/Ulnar/Axillary ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Fires biceps/triceps/deltoid
LLE skin clean and intact
Tenderness about the left hip. No noticeable deformity,
erythema,
edema, induration or ecchymosis.
Thighs and legs are soft
Pain with passive motion of the hip
___ Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
___ 06:15PM BLOOD WBC-6.3 RBC-3.38* Hgb-12.3* Hct-33.9*
MCV-101* MCH-36.5* MCHC-36.3* RDW-12.5 Plt ___
___ 07:30AM BLOOD ___ PTT-29.7 ___
___ 07:30AM BLOOD Glucose-139* UreaN-17 Creat-0.9 Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
Brief Hospital Course:
Mr. ___ was admitted to the Orthopedic service on ___
for left periprosthetic femur fracture. He was evaluated and
treated closed without operative intervention.
He had adequate pain management and worked with physical therapy
while in the hospital. He is weight bearing status is LLE TDWB.
Overnight on HD2, he was noted to have emesis x2 which resolved
the next day with increased zofran and a bowel movement, with no
further emesis. KUB unremarkable, abd soft, pt tolerating PO
well. The remainder of his hospital course was uneventful. Mr.
___ is being discharged to rehab in stable condition.
Repeat films as inpatient showed no change in fracture, patient
explains he will obtain follow up images as outpatient and send
to ___ clinic.
Medications on Admission:
HOME MEDICATIONS (As per PCP):
--Proscar 5mg QD
--Terazosin 1mg QHS
--Pantoprazole 40mg QD
--Metoprolol 50mg BID
--Simvastatin 20mg QD
--Dronedarone 400mg BID
--Citalopram 20mg QD
--Prednisone 2.5mg QD
--Coumadin ___ QD
Discharge Medications:
** Patient should have QTC monitored for combination Dronedarone
and Celexa.
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
14. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Target INR ___. Adjust dose daily according to INR.
17. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous BID (2 times a day): Discontinue when INR is > 2.
18. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for Pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Activity:
- Continue to be touch down weight bearing on your left leg
- Obtain follow up Xrays of your left leg and send/fax to the
orthopaedic office with follow up as needed based on xrays.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity: Activity as tolerated
Left lower extremity: Touchdown weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Follow INR, Coumadin dose, Lovenox therapeutic bridge until
INR>2.0
Follow intrinsic factor and heme labs with outpatient PCP.
Follow QTc with PCP, patient on Celexa and citalopram with
possible side effects.
Obtain follow up Xrays in 2weeks left femur and send/fax to
___ office of Dr. ___ review and follow
up planning.
Followup Instructions:
___
|
10770039-DS-18
| 10,770,039 | 26,588,427 |
DS
| 18 |
2166-12-05 00:00:00
|
2166-12-09 14:17:00
|
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 and distension
Major Surgical or Invasive Procedure:
Liver Biopsy (___)- results consistent with Alcoholic Fatty
Liver Disease
History of Present Illness:
Ms ___ is a ___ with no substantial PMHx who presents
with abdominal pain, nausea, anorexia and jaundice. She reports
that her issues with her abdomen and her liver are longstanding,
starting with an admission approximately ___ year prior to
admission at ___. She reports at that time she was
admitted and noted to have both EBV and influenza. She reports
that her hospitalization was complicated by jaundice, hepatitis
and very low blood cell counts. She was discharged from the
hospital, and followed by her PCP for her cytopenias and
transaminitis.
She reports that over the past 6 weeks she has had issues with
abdominal distention and anorexia. She notes that her belly
feels pregnant, though she has been having regular menstrual
cycles. She denies recent fevers. She notes drinking wine
socially, with maximum 8 drinks per week. She notes she has been
using both acetaminophen and ibuprofen regularly since last year
when she was discharged after her ___ admission. She
reports taking up to 4g of APAP in one day, more usually taking
2g (as two divided doses). She denies using other OTC cold
remedies which may also contain Tylenol. She denies IDU, recent
new sexual partners. She denies sick contacts. Her last travel
outside of the ___ area was to ___, ___ in ___.
Past Medical History:
EBV infection c/b cytopenias and transaminitis
Social History:
___
Family History:
Grandmother with ovarian cancer
Sister with breast cancer
No family history of cirrhosis or autoimmune conditions
Physical Exam:
On Admission:
VITALS - 98.7| 119/80 | 102 | 16 | 99% on RA
GENERAL - subtly jaundiced, lying in bed, pleasant and
conversational
HEENT - scleral icterus more pronounced on the medial and
lateral canthi; palatal jaundice. Mucus membrane moist. PERRL.
No nystagmus.
CARDIAC - tachycardic, regular rate and rhythm, normal S1 and S2
LUNGS - clear to auscultation, normal work of breathing
ABDOMEN - notably distended and abdominal veins visible. Soft,
normal percussion, tender to percussion. Mildly tender to
percussion, particularly at the lower R quadrant. Hepatomegaly
on percussion. Normal bowel sounds.
BACK: no ecchymosis
EXTREMITIES - warm and well perfused. No edema appreciated.
SKIN - excoriations all over abdomen, chest, and back.
NEUROLOGIC - no asterixis. Alert and oriented to place, date,
and name.
On Discharge:
VITALS - 98.7| 119/80 | 102 | 16 | 99% on RA
GENERAL - Lying in bed, pleasant and conversational
HEENT - scleral icterus more pronounced on the medial and
lateral canthi; palatal jaundice. Mucus membrane moist. PERRL.
No nystagmus.
CARDIAC - tachycardic, regular rate and rhythm, normal S1 and S2
LUNGS - clear to auscultation, normal work of breathing
ABDOMEN - notably distended and abdominal veins visible. Soft,
normal percussion, tender to percussion. Mildly tender to
percussion, particularly at the lower R quadrant. Hepatomegaly
on percussion. Normal bowel sounds.
BACK: no ecchymosis
EXTREMITIES - warm and well perfused. No edema appreciated.
SKIN - excoriations all over abdomen, chest, and back.
NEUROLOGIC - no asterixis. Alert and oriented to place, date,
and name.
Pertinent Results:
On Admission:
___ 08:20PM BLOOD WBC-8.3 RBC-2.92* Hgb-10.4* Hct-30.1*
MCV-103* MCH-35.6* MCHC-34.6 RDW-14.7 RDWSD-56.2* Plt ___
___ 08:20PM BLOOD Neuts-70.3 Lymphs-15.4* Monos-12.0
Eos-1.0 Baso-0.7 Im ___ AbsNeut-5.81 AbsLymp-1.27
AbsMono-0.99* AbsEos-0.08 AbsBaso-0.06
___ 08:20PM BLOOD ___ PTT-29.2 ___
___ 08:20PM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-129*
K-3.5 Cl-95* HCO3-23 AnGap-15
___ 08:20PM BLOOD ALT-43* AST-173* AlkPhos-154*
TotBili-7.3*
___ 08:20PM BLOOD Albumin-2.7*
___ 04:40AM BLOOD TotProt-6.2* Calcium-7.8* Phos-1.4*
Mg-1.4* Iron-117 Cholest-148
___ 04:40AM BLOOD calTIBC-122* Ferritn-609* TRF-94*
___ 04:40AM BLOOD Triglyc-160* HDL-LESS THAN LDLmeas-100
___ 04:40AM BLOOD IgG-1593 IgA-483* IgM-476*
___ 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
On Discharge:
___ 04:45AM BLOOD WBC-8.1 RBC-2.56* Hgb-9.3* Hct-27.3*
MCV-107* MCH-36.3* MCHC-34.1 RDW-15.8* RDWSD-62.0* Plt ___
___ 04:45AM BLOOD ___ PTT-40.7* ___
___ 04:45AM BLOOD Glucose-71 UreaN-7 Creat-0.6 Na-137 K-4.3
Cl-102 HCO3-20* AnGap-19
___ 04:45AM BLOOD ALT-31 AST-143* AlkPhos-110* TotBili-6.3*
___ 04:45AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8
Imaging:
___ RUQ US w/Doppler:
IMPRESSION:
Cirrhotic morphology of the liver with sequela of portal
hypertension
including variable flow in the portal veins, patent
paraumbilical vein,
splenomegaly, and ascites.
___: Diagnostic/Therapeutic Paracentesis:
IMPRESSION:
Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis. 1.7 L fluid removed
Microbiology:
___ Blood Culture: no growth
___: Peritoneal Fluid Culture:
-Gram stain: POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS
SEEN.
-Fluid Culture: no growth
-Anaerobic culture: no growth
___: Urine Culture: no growth
Pathology:
___ Ascites Cytology:
Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
___ Liver Biopsy:
PATHOLOGIC DIAGNOSIS:
Liver, needle core biopsy:
1. Established cirrhosis (reticulin and trichrome stains
evaluated).
2. Moderate predominantly macrovesicular steatosis with frequent
ballooning degeneration and
frequent intracytoplasmic hyaline.
3. Moderate portal/septal and lobular mixed inflammation
comprised of lymphocytes, neutrophils,
eosinophils and rare plasma cells with few scattered apoptotic
hepatocytes.
4. Patchy lobular neutrophilic aggregates seen.
5. Iron stain shows mild focal iron deposition in hepatocytes.
Note: Overall, the histologic features are compatible with
steatohepatitis due to toxic metabolic injury
and cirrhosis. Definite features of autoimmune hepatitis or
primary biliary disorders are not seen in
this biopsy sample. Clinical correlation is required. Dr. ___.
___ reviewed and concurs, and
discussed the case with Dr. ___ on ___ at 2 pm.
Brief Hospital Course:
Ms ___ is a ___ with no substantial PMHx who presents
with abdominal pain, nausea, decreased appetite, pruritus, and
abdominal distension found to have evidence of new onset
cirrhosis of unknown etiology.
ACTIVE ISSUES:
# Cirrhosis c/b ascites and varices: Patient presents with
acute on chronic history of hepatic dysfunction of unclear
etiology. Abnormal liver studies first presented in ___ with
steatosis, with repeated cycles of symptomatic elevation and
resolution. Imaging confirm liver cirrhosis and abdominal
varices on ___ and she was immediately sent to ___ for
evaluation. Her MELDNa was 21 and ___ discriminant function
= 54 on admission. Paracentesis confirms portal hypertension and
no SBP. Serological testing suggestive of autoimmune process.
Pt's alcoholic liver disease to NAFLD index [ANI] score based
off of MCV, AST/ALT, BMI, and gender, which translates to a
99.9% probability of alcoholic liver disease. Liver biopsy
showed NO sign of autoimmune process and was more consistent
with alcoholic fatty liver disease. Patient was started on
spironolactone, furosemide, ursodiol, cholestyramine,
multivitamin with minerals, folic acid, pyridoxine, and zinc.
Nutritional recommendations include <=2g of sodium daily, high
protein, high calorie diet, and nutritional supplement shakes
TID. EGD, immunosuppression, and HFE testing as an outpatient
(follow up with Dr. ___ in ___
#Hypophosphatemia: On admission, patient had phosphate level of
1.4. She did not endorse any symptoms of hypophosphatemia. In
retrospect, her hypophosphatemia may have been due to alcohol
use, however phosphate levels dipped again as an inpatient. She
was repleted her final phosphate level was 3.0 at discharge.
#Tachycardia: HR consistently in the 100s-110s since admission.
This may be due to pain or could be an early sign of
hypovolemia. However, she has good urine output and mucus
membranes are moist. EKG consistent with supraventricular
tachycardia.
# Constipation: Patient had 2 episode of constipation during
admission. ___ have been exacerbated by oxycodone use. Responded
well to senna, bisacodyl, miralax, and lactulose (lactulose was
given for constipation and not encephalopathy).
#Urinary Retention: Towards the end of her stay, patient
developed urinary hesitancy and retention (post void residual
volume of 400cc). Patient did not have a fever, leukocytosis or
dysuria. Urine analysis showed hazy urine with trace leukocytes,
many bacteria, no nitrites. Urine culture results are still
pending. Since patient is asymptomatic, determined to be
asymptomatic bacteriuria. No antibiotics was initiated.
Key New Medications:
-Cholestyramine 4mg PO BID
-Furosemide 20mg PO QD
-Lactulose 15mg PO QD PRN constipation
-Oxycodone ___ PO Q4H PRN pain
-Pyridoxine 50mg PO QD
-Ramelteon 8mg PO QHS PRN insomnia
-Spironolactone 50mg PO QD
-Ursodiol 300mg TID
Transitional Issues
-f/u with hepatology on ___ (Dr. ___
-Plan for outpatient EGD with hepatology
-Consider further workup as an outpatient for autoimmune
hepatitis
-Counsel alcohol abstinence
-Do not give patient more than 2g acetaminophen each day
-2L fluid restriction
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Cholestyramine 4 gm PO BID
RX *cholestyramine (with sugar) 4 gram 4 grams by mouth twice
daily Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Furosemide 20 mg PO DAILY ascites
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itching
RX *hydrocortisone 0.5 % Apply to affected area three times
daily Refills:*0
7. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS
RX *hydroxyzine HCl 50 mg 1 tab by mouth every 6 hours Disp #*30
Tablet Refills:*0
8. Lactulose 15 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth daily
Refills:*0
9. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
daily Refills:*0
12. Pyridoxine 50 mg PO DAILY
RX *pyridoxine (vitamin B6) 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
13. Ramelteon 8 mg PO QHS:PRN insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bed Disp
#*30 Tablet Refills:*0
14. Sarna Lotion 1 Appl TP QID:PRN itching
15. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice daily Disp
#*120 Tablet Refills:*0
16. Simethicone 40-80 mg PO QID GAS, BLOATING
RX *simethicone 80 mg 80 mg PO every 6 hours Disp #*30 Tablet
Refills:*0
17. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
18. Ursodiol 300 mg PO TID
RX *ursodiol 300 mg 1 capsule(s) by mouth three times daily Disp
#*90 Capsule Refills:*0
19. Zinc Sulfate 220 mg PO DAILY
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Alcoholic Fatty Liver Disease
Secondary Diagnosis
none
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
--Why was I admitted?
You were admitted to the hospital because you had signs and
symptoms of a severe liver disease, cause unknown.
--What was done ?
We tested you for many things that can cause severe liver
disease. We also took a tiny piece of your liver for further
testing. The final diagnosis was "Alcoholic Fatty Liver Disease"
--What should I do going forward?
Please take the medicines that we started during this admission.
Please follow up with your primary care doctor, follow up with
your liver doctor(Dr. ___. Your liver doctor has more
tests and treatments planned for you. Please drink no more than
2 liters of fluid each day.
It was a pleasure taking care of! Best of luck.
-Your ___ Care Team
Followup Instructions:
___
|
10770039-DS-19
| 10,770,039 | 26,878,910 |
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| 19 |
2167-01-03 00:00:00
|
2167-01-06 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, nausea, vomiting and malaise
Major Surgical or Invasive Procedure:
___ Paracentesis (diagnostic and therapeutic, ultrasound
guided)
___ ___ tube placement (fluoroscopically
guided)
History of Present Illness:
Ms ___ is a ___ year old woman with a history of
alcoholic hepatitis and alcoholic cirrhosis complicated by
portal HTN, ascites diagnosed during recent hospitalizion in
___ presenting with worsening abdominal pain, nausea,
vomiting, malaise, myalgias.
Symptoms started on ___ with fatigue, muscle
aches,abdominal discomfort, distension and decreased appetite.
She states that she really hasn't felt better since her last
hospital admission Two nights ago she noted increased frequency
in urination every 30 mins, with no burning, or incontinence.
She has had lower back discomfort. No fevers or chills. She has
been also having dizziness, nausea and vomiting. She vomited 3
times on ___. She had gone to her PCPs office and had UA that
showed increased WBC. Not given antibiotics. She called the
covering doctor for her other symptoms and was given Zofran and
meclizine. Her last paracentesis was this pass ___ at ___
___ and she had 2.9L removed.
She feels like she is still getting worse. No sick contacts. No
recent travel. No flu shot this year. Patient denies fevers,
chills, cough, rhinorrhea, chest pain, shortness of breath.
Patient was admitted from ___ to ___ for alcoholic hepatitis,
jaundice, ascites requiring large volume para. Patient had a DF
of 42 but steroids were not started given risk of infection. As
an outpatient she has had an upper endoscopy that showed
evidence of portal hypertension with three small to medium sized
varicies.
In the ED, initial vitals were: 99.0 106 122/81 20 100% RA
- Exam notable for: jaundice, LUQ ttp, diffuse tenderness on
the abdomen, no peripheral edema, clear lungs.
- Labs notable for:
10.0
7.5 >---< 153
29.7 N:80.0 L:10.5 M:7.6 E:1.1 Bas:0.4 Nrbc: 0.4
136 101 16
-------------- 103
3.7 20 0.9
ALT: 45 AP: 117 Tbili: 5.6 Alb: 2.7
AST: 143 Lip: 142
___: 19.0 INR: 1.7
Lactate:2.0
Serum tox negative
UA Hazy, 4 Urobilinin, small amount of bili, Lg Leuks, Trace
protein, 10 ketones, 25 WBC, few bacteria, Epi 6, 1 hyaline
casts and 6 cast WBC
- Imaging was notable for:
RUQUS
1. Cirrhotic liver, with sequelae of portal hypertension
including
splenomegaly and ascites.
2. Thickening of the gallbladder wall likely secondary to third
spacing from known liver disease.
- Patient was given:
___ 15:08 PO Ibuprofen 400 mg
___ 15:08 PO OxyCODONE (Immediate Release) 5 mg
___ 17:31 PO/NG Spironolactone 100 mg
___ 17:31 PO/NG Furosemide 40 mg
___ 17:31 PO/NG HydrOXYzine 50 mg
___ 17:31 PO/NG Mirtazapine 30 mg
___ 17:31 PO Ursodiol 300 mg
Attempted to do diagnostic para however no pocket available for
safe tap. Patient decided to admit to ET service for further
evaluation.
On arrival to the floor the patient reports symptoms as listed
above. She still feels ill. Not currently having urinary
frequency but she does report lower back pain. No fevers or
chills.
Past Medical History:
EBV infection c/b cytopenias and transaminitis
Alcoholic Fatty Liver Disease complicated the jaundice, ascities
nad portal hypertension -- three small to medium sized varicies
Alcoholic Hepatitis
Social History:
___
Family History:
Maternal Grandmother with ovarian cancer
Aunt with breast cancer
Father with colon cancer
No family history of cirrhosis or autoimmune conditions
Grandfather with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: 98.4 126 / 73 88 18 97 Ra
GENERAL: well appearing woman, non-toxic laying in bed
HEENT: PERRL, no nystagmus, mild scleral icterus, OP clear
without lesions, jaundice under frenulum
NECK: supple, no LAD
CARDIAC: tachycardic, regular, ___ systolic murmur at LSB
LUNGS: CTAB without wheezing
ABDOMEN: mildly distended, soft, ttp in RUQ, no rebound or
guarding. Hepatomegaly noted.
EXTREMITIES: warm well perfused no edema
SKIN: warm no rashes
BACK: Left sided CVA tenderness
DISCHARGE PHYSICAL EXAM:
========================
VITAL SIGNS: 98.0 PO 109 / 64 L Sitting 76 18 ___ Ra
GENERAL: young woman eating breakfast in NAD
HEENT: mild scleral icterus. MMM. tonsillar erythema improved.
No LAD.
CARDIAC: RRR, ___ systolic murmur
LUNGS: non-labored, CTAB
ABDOMEN: soft, mild ttp at RUQ, no rebound or guarding, +BS.
EXTREMITIES: warm, well perfused, no edema
NEURO: normal mental status
Pertinent Results:
___ 12:07PM BLOOD WBC-7.5 RBC-2.94* Hgb-10.0* Hct-29.7*
MCV-101* MCH-34.0* MCHC-33.7 RDW-13.2 RDWSD-49.1* Plt ___
___ 05:16AM BLOOD WBC-6.3 RBC-2.59* Hgb-9.1* Hct-26.3*
MCV-102* MCH-35.1* MCHC-34.6 RDW-13.4 RDWSD-49.7* Plt ___
___ 05:08AM BLOOD WBC-5.7 RBC-2.49* Hgb-8.6* Hct-25.4*
MCV-102* MCH-34.5* MCHC-33.9 RDW-13.3 RDWSD-49.9* Plt ___
___ 05:12AM BLOOD WBC-6.1 RBC-2.56* Hgb-8.8* Hct-26.4*
MCV-103* MCH-34.4* MCHC-33.3 RDW-13.2 RDWSD-49.1* Plt ___
___ 05:46AM BLOOD WBC-6.3 RBC-2.62* Hgb-9.1* Hct-27.0*
MCV-103* MCH-34.7* MCHC-33.7 RDW-13.4 RDWSD-50.5* Plt ___
___ 12:12PM BLOOD ___
___ 05:16AM BLOOD ___ PTT-37.2* ___
___ 05:08AM BLOOD ___ PTT-37.6* ___
___ 05:12AM BLOOD ___ PTT-39.0* ___
___ 05:46AM BLOOD ___ PTT-36.7* ___
___ 12:07PM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-20* AnGap-19
___ 05:16AM BLOOD Glucose-101* UreaN-15 Creat-1.1 Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
___ 05:08AM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-142
K-3.8 Cl-106 HCO3-25 AnGap-15
___ 05:12AM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-106 HCO3-27 AnGap-10
___ 05:46AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-142
K-4.3 Cl-107 HCO3-25 AnGap-14
___ 12:07PM BLOOD ALT-45* AST-143* AlkPhos-117*
TotBili-5.6*
___ 05:16AM BLOOD ALT-35 AST-102* AlkPhos-96 TotBili-4.6*
___ 05:08AM BLOOD ALT-30 AST-87* AlkPhos-85 TotBili-4.0*
___ 05:12AM BLOOD ALT-33 AST-90* AlkPhos-91 TotBili-3.5*
___ 05:46AM BLOOD ALT-32 AST-88* LD(LDH)-172 AlkPhos-96
TotBili-3.1*
___ 12:07PM BLOOD Lipase-142*
___ 12:07PM BLOOD Albumin-2.7*
___ 05:30AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.1 Mg-1.8
___ 05:46AM BLOOD Albumin-2.9* Calcium-9.1 Phos-3.7 Mg-2.1
___ 12:07PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
IMAGING & STUDIES
=========================
___ RUQ US
1. Cirrhotic liver, with sequelae of portal hypertension
including splenomegaly and ascites.
2. Collapsed gallbladder containing sludge. Thickening of the
gallbladder wall likely secondary to third spacing from known
liver disease.
KUB ___:
FINDINGS:
No findings of small bowel obstruct. Mild-to-moderate stool
load.
There is no free intraperitoneal air.Enteric tube appears to
terminate in the stomach. IUD projects over the mid pelvis.
Patient is status post Essure tubal ligation. Faint density
projecting over the right upper quadrant may represent layering
gallstones.
IMPRESSION:
Nonobstructive bowel gas pattern. Mild-to-moderate stool load.
Brief Hospital Course:
___ with recently diagnosed EtOH hepatitis and cirrhosis who
presented with ongoing abdominal pain and nausea. No evidence
for infection, obstruction, or alternate etiology.
# Acute Alcoholic Hepatitis in Alcoholic Cirrhosis
Leading to abdominal pain and nausea. Pt denied any recent ETOH
ingestion. Baseline Childs C, MELD 20. While the patient's
Discriminant Function was quite elevated (35-42), steroids were
held due to initial concern for infection as well as gradual
spontaneous improvement in her symptoms and labs. An enteric
feeding tube was fluoroscopically placed to correct the
patient's severe malnutrition and aid healing. Also had a
therapeutic para of 1.5L with resuming of her home diuretic
therapy. Still with mild abdominal pain with patient previously
given limited amounts of oxycodone that was recommended tapering
as leading to significant constipation that improved with
aggressive bowel regiment. Also given cholestyramine and
ursodiol for pruritus. She was discharged with adequate symptom
control and close follow-up with primary care, hepatology, and
alcohol abstention services.
# Pharyngitis
Likely viral. Centor ___, no fevers or exam findings to suggest
bacterial pharyngitis/sinusitis or lower respiratory infection.
Given anti-histamines for symptom control.
# Malnutrition
Likely due to cirrhosis with high nutritional needs in setting
of alc hep as above. Nutrition consulted with post-pyloric
feeding tube placed. Continued on TFs with ___ at home.
#Sterile pyuria
Urine culture negative, no fevers or leukocytosis, so
discontinued short course of CTX (___) given.
___
Suspect pre-renal given N/V and improvement with albumin. No e/o
HRS.
TRANSITIONAL ISSUES:
==================
- Discharge weight: 55.9 kg (124 lb)
- Discharge labs: DF 40, MELD 17, Hgb 9.1, INR 1.8, Cr 0.8,
Tbili 3.1, ALT/AST ___
- Important medications:
-- Continued furosemide 20/ spironolactone 50
-- Substituted polyethylene glycol for lactulose to improve
abdominal discomfort/distention
-- Added cholestyramine and continued ursodiol for pruritus
- Please continue to counsel patient on alcohol abstention and
encourage her to join AA or a similar program.
- Could consider SBP prophylaxis since meets some criteria:
ascites total protein < 1.5, ___ Score > 9, bilirubin >
3.0.
# CODE: Full (confirmed)
# CONTACT: Father ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Cholestyramine 4 gm PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY ascites
6. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itching
7. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS
8. Lactulose 15 mL PO DAILY:PRN constipation
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Pyridoxine 50 mg PO DAILY
12. Sarna Lotion 1 Appl TP QID:PRN itching
13. Senna 17.2 mg PO BID
14. Simethicone 40-80 mg PO QID GAS, BLOATING
15. Spironolactone 50 mg PO DAILY
16. Ursodiol 300 mg PO TID
17. Zinc Sulfate 220 mg PO DAILY
18. Mirtazapine 7.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
RX *phenol [Chloraseptic Throat Spray] 1.4 % as directed as
directed Disp #*1 Bottle Refills:*0
2. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg ___ tablet(s) by mouth daily as
needed Disp #*60 Tablet Refills:*0
3. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice a day as
needed Disp #*30 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Propranolol 20 mg PO BID
RX *propranolol 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
7. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*90 Tablet Refills:*0
8. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate Duration: 7 Days
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth twice daily as needed
Disp #*14 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO BID:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams
powder(s) by mouth twice daily as needed Refills:*0
10. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily as needed Disp
#*30 Tablet Refills:*0
11. Cholestyramine 4 gm PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Furosemide 20 mg PO DAILY ascites
14. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itching
15. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS
16. Mirtazapine 7.5 mg PO QHS:PRN insomnia
17. Pyridoxine 50 mg PO DAILY
18. Sarna Lotion 1 Appl TP QID:PRN itching
19. Senna 17.2 mg PO BID
20. Simethicone 40-80 mg PO QID GAS, BLOATING
21. Spironolactone 50 mg PO DAILY
22. Ursodiol 300 mg PO TID
23.Tube Feeds
IsoSource 1.5 at 50 ml/hr over 24 hours. ___ cycle as tolerated.
Dispense 1 month supply with 2 refills.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==============================
alcoholic hepatitis
decompensated alcoholic cirrhosis with ascites
SECONDARY DIAGNOSES
================================
severe protein calorie malnutrition
acute renal failure
anemia, thrombocytopenia, and coagulopathy secondary to
cirrhosis
sterile pyuria
viral pharyngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were admitted:
- Nausea and stomach pain
What happened while you were here:
- We determined that the cause of your symptoms is most likely a
condition called alcoholic hepatitis, meaning inflammation and
swelling of the liver from drinking alcohol.
- We determined you were very malnourished and placed a feeding
tube to help your liver and body heal.
- We drained fluid from your stomach to make sure you did not
have an infection and to relieve the pressure.
- We gave you medications to control your pain, remove excess
fluid, and protect your stomach from bleeding.
Instructions for when you leave the hospital:
- Please enroll in a program to help you stay sober. This is the
most important thing you can do to protect yourself from this
dangerous condition, which can be life-threatening.
- Continue to take all of your medications as prescribed. It is
important to take your bowel medications to not become
constipated.
- Follow up with your primary care and liver doctors. ___ see
below for a complete list of follow-up appointments.
- Do not hesitate to call your doctor or return to the hospital
if you have severe pain, vomiting, fever, chills, confusion,
bloody or black stool, or any other symptoms that concern you.
We wish you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10770039-DS-22
| 10,770,039 | 29,572,052 |
DS
| 22 |
2169-01-21 00:00:00
|
2169-01-22 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension, GI Bleed
Major Surgical or Invasive Procedure:
Intubation ___
___ ___
TIPS ___
LP ___
History of Present Illness:
___ w/ PMH of EtOH use disorder c/b cirrhosis, portal HTN
ascites, varices, h/o EtOH hepatitis, presents with hematemesis.
Patient originally lives in ___, and was in ___ and was
visiting father who is hospitalized at ___ when she started to
feel nauseous. Pt reports 3 episodes of bright red blood
vomiting
that began about 6pm with last episode of large volume (>500cc).
She says she ran out of her propranolol 1 week ago. No history
of GI bleed. Described diffuse abdominal pain. Has been taking
ibuprofen 600mg daily x1 week for some back pain. Denies any
fevers chills, chest pain, dyspnea, melena, hematochezia,
worsening abd distention, constipation, diarrhea, swelling in
legs, confusion. She has been compliant with her medications
besides her propranolol. EMS was called and said she was
pale/diaphoretic. Was given fluid bolus. Initial SBP in the ___.
Endorses feeling lightheaded.
Her last endoscopy on ___, showed a small varices
that were without red marking. Was taking 10mg propranolol BID
In the ED,
Initial Vitals: 97.8 120 86/52 16 98% RA
Exam:
LUQ tenderness, epigastric
guaiac neg brown stool
Labs:
7.6
___ 40
-------------<143
5.4 20 1.3
___: 15.8 PTT: 24.8 INR: 1.5
Consults:
Hepatology
-admit to MICU
-transfuse to goal 7
-serial CBC
-albumin 25% for volume support
-octreotide
-ppi
-ceftriaxone
-blood cultures
-NPO
-plan for EGD
In the ED, patient had another episode of hematemesis (~500cc of
dark red blood emesis, not coffee ground).
Patient given 3u PRBC, 3L IVF, IV pantoprazole 40mg, Octreotide
gtt, CTX, ondansetron 4mg IV, lorazepam 1mg IV
VS Prior to Transfer: 129 78/47 22 96% RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
alcoholic hepatitis with cirrhosis (biopsy proven) complicated
the
jaundice, ascities and portal hypertension -- three small to
medium sized varicies
EBV infection c/b cytopenias and transaminitis
Social History:
___
Family History:
-Maternal Grandmother with ovarian cancer
-Aunt with breast cancer
-Father with colon cancer
-Cousin with breast cancer diagnosed at ___ (negative for BRCA,
patient and sister tested negative for BRCA)
-No family history of cirrhosis or autoimmune conditions
-Grandfather with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.6 ___ 100% RA
GEN: laying in bed in NAD
HEENT: PERRL. Nonicteric sclera. Dry MM
NECK: Right EJ IV in place
CV: tachycardic. RRR. No mrg
RESP: Unlabored breathing, speaking in full sentences. CTA b/l
GI: +BS. Soft, nondistended, diffusely tender. No rebound,
guarding
EXT: Warm well perfused. No ___ edema
NEURO: AOx3. Moving all extremities. No focal deficits
PSYCH: euthymic
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1127)
Temp: 98.4 (Tm 99.0), BP: 104/64 (98-106/60-68), HR: 81
(81-100), RR: 17 (___), O2 sat: 96% (95-99), O2 delivery: Ra,
Wt: 142.3 lb/64.55 kg
GENERAL: Alert, interactive, no apparent distress.
HEENT: NC/AT, PERRL, EOMI, No scleral icterus, MMM, OP Clear
NECK: No JVD.
CARDIAC: RRR, no R/M/G.
LUNGS: CTAB, no R/R/W.
ABDOMEN: S/NT/ND.
EXTREMITIES: WWP, no edema.
SKIN: No rash.
NEUROLOGIC: Alert, oriented to person, place, time. Str ___ in
BUE and BLE grossly. No asterixis.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:11PM BLOOD WBC-7.8 RBC-3.04* Hgb-7.6* Hct-26.0*
MCV-86 MCH-25.0* MCHC-29.2* RDW-21.4* RDWSD-65.5* Plt ___
___ 10:11PM BLOOD Neuts-64.7 ___ Monos-11.3 Eos-1.0
Baso-0.4 Im ___ AbsNeut-5.06 AbsLymp-1.73 AbsMono-0.88*
AbsEos-0.08 AbsBaso-0.03
___ 10:11PM BLOOD ___ PTT-24.8* ___
___ 05:50AM BLOOD ___
___ 10:11PM BLOOD ALT-23 AST-45* AlkPhos-59 TotBili-0.8
___ 10:11PM BLOOD Lipase-60
___ 10:11PM BLOOD Albumin-3.3* Calcium-9.8 Phos-3.4 Mg-1.9
___ 05:50AM BLOOD Hapto-<10*
___ 10:01PM BLOOD calTIBC-213* Ferritn-188* TRF-164*
___ 10:11PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:22PM BLOOD Lactate-5.5* Creat-1.3*
___ 10:22PM BLOOD Hgb-8.2* calcHCT-25
RELEVANT LABS:
==============
___ 07:00PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-8* Polys-2
___ Macroph-6
___ 07:00PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-65
LD(LDH)-24
___ 07:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name negative
RELEVANT IMAGING:
=================
___ TIPS
1. Pre-TIPS right atrial pressure of 14 mmHg and portal pressure
measurement of 28 mmHg resulting in portosystemic gradient of 14
mmHg.
2. Portal venogram demonstrating a portosystemic shunt supplied
predominantly by a short gastric vein as well as extensive
esophageal varices from the coronary vein. Additionally, there
was contrast extravasation prior to TIPS
placement likely from an extracapsular portal puncture site.
3. Post TIPS placement portal venogram demonstrated resolution
of the active contrast extravasation.
4. Post TIPS venogram demonstrated persistent flow in the
portosystemic shunt.
5. Post-TIPS right atrial pressure of 9 mmHg and portal pressure
of 15 mmHg
resulting in portosystemic gradient of 6 mmHg.
6. Splenic venogram demonstrating brisk active contrast
extravasation into the stomach with deflation of the ___
tube.
7. Successful embolization and sclerosis of the portosystemic
shunt with
embolization on the both the systemic and portal sides.
8. Successful embolization of the coronary vein.
9. Post TIPS and left gastric embolization and portosystemic
shunt
embolization right atrial pressure of 18 mmHg and portal
pressure of 28 mmHg for a portosystemic gradient of 10 mmHg.
Successful transjugular intrahepatic portosystemic shunt
placement, coronary vein embolization a and portosystemic shunt
embolization/sclerosis.
___ EGD
Paraphrased from OMR
Esophagus 1 grade II varices, ___ tear,
Stomach Pooled fresh blood, gastric varix near fundus
CTA Head/Neck ___
1. No acute fracture, infarction, hemorrhage or edema.
2. Normal CTA head and neck.
3. Diffuse interlobular septal thickening in the setting of
small bilateral
pleural effusions may suggest pulmonary edema.
4. Enlarged main pulmonary artery suggests pulmonary artery
hypertension.
EEG ___
This telemetry captured no pushbutton activations. It showed a
slow background with bursts of generalized slowing, together
indicating a
widespread encephalopathy, similar to that on the previous day's
recording.
Some of the bursts of generalized slowing included blunted sharp
waves, but there were no overtly epileptiform features or
electrographic seizures in the recording.
EEG ___
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
slow and disorganized background throughout, with frequent
bursts of
generalized slowing, all indicative of a continuing
encephalopathy, as on
earlier recordings. Over the course of the recording, however,
background
frequencies increased and the bursts of slowing decreased,
suggesting some
improvement in the encephalopathy. There were no areas of
prominent focal
slowing, but encephalopathies may obscure focal findings. There
were no
definitely epileptiform features in the recording, and no
electrographic
seizures.
EEG ___: PENDING
EEG ___: PENDING
___ MR ___ WITH/WITHOUT CONTRAST
1. Mild degenerative changes cervical spine.
2. Mild paraspinal edema, likely reactive, see above.
___ MR HEAD W & W/O CONTRAST
1. No acute findings, no mass.
2. Findings consistent with chronic liver disease. No acute
changes.
3. Mild cerebral, moderate cerebellar atrophy..
___ RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER
1. Patent TIPS, but with low velocity(<100 cm/sec) internal flow
which is
without prior study for comparison. Additionally, no color flow
seen within the right anterior portal vein which is nonspecific
but could be related to technique or slow flow. Suggest short
interval follow up.
2. Cirrhosis with mild splenomegaly. No ascites. Suspected
liver lesions
previously described on the MR of ___ are not seen on
the current
study.
3. Gallbladder stones and sludge with mild wall thickening.
While the
gallbladder is not distended, acute cholecystitis is not
excluded. HIDA scan should be considered.
4. Small bilateral pleural effusions.
MICROBIOLOGY:
=============
All cultures throughout admission negative including blood,
urine, sputum, CSF
DISCHARGE LABS:
===============
___ 07:08AM BLOOD WBC-6.0 RBC-3.42* Hgb-10.1* Hct-31.6*
MCV-92 MCH-29.5 MCHC-32.0 RDW-18.6* RDWSD-60.6* Plt ___
___ 07:08AM BLOOD ___ PTT-29.5 ___
___ 07:08AM BLOOD Glucose-73 UreaN-15 Creat-0.9 Na-137
K-4.9 Cl-104 HCO3-19* AnGap-14
___ 07:08AM BLOOD ALT-25 AST-37 LD(LDH)-421* AlkPhos-69
TotBili-1.6*
___ 07:08AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.4 Mg-2.2
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
-Follow Up Appointments: Hepatology, ___
-Follow Up Labs: CBC within ___ weeks of discharge to make sure
H/H not downtrending
-Discharge Hgb 10.1
-New Medications: Multivitamins w/ minerals, Pantoprazole 40mg
BID, Rifaximin 550mg BID
-Held Medications: Folic Acid, Furosemide, Hydroxyzine,
Mirtazipine, Spironolactone, Vitamin B
[]Slow flow visualized on post-TIPS ultrasound, will need repeat
study as outpatient
[]Will continue propranolol until outpatient follow up given
slow flow seen on TIPS Ultrasound
MICU COURSE (___)
===========================
___ w/ PMH of EtOH use disorder c/b cirrhosis, portal HTN
ascites, varices, h/o EtOH hepatitis, presented with hematemesis
c/f for brisk variceal bleed. She was intubated out of concern
for airway protection iso massive hematemesis. An urgent EGD was
performed which showed significant extravasation, ___
tears, and significant gastric varices, but no intervenable
lesion. Given her transfusion requirement, ___ was
placed. Despite her impressive blood loss, she never required
pressors. ___ subsequently took the patient for TIPS w/ coiling
and embolization. Her transfusion requirement stabilized and she
remained HDS. Following TIPS, sedation was weaned, however
patient remained obtunded. EEG was c/f epileptiform activity and
AEDs were initiated w/ the guidance of neurology. Her
encephalopathy persisted, attributed to acute HE iso
portosystemic shunting and significant blood digestion. LP was
performed to r/o infection which was negative. EtOH withdrawal
was also considered, but patient's family did not believe she
had been drinking. With initiation of aggressive
lactulose/rifaximin and AED medications, patient's mental status
improved and she was extubated. She remained HDS, without need
of a transfusion for >48hrs s/p TIPS and was called out to the
floor ___. In terms of reason for her presentation, EtOH abuse
was discussed, but patient adamantly denies any EtOH use in ___Y PROBLEM (___)
===================================
#Gastric variceal bleed s/p embolization s/p TIPS
See above for the MICU course. Since arrival to the floor, the
patient did not have any further episodes of hematemesis or
other evidence of GI bleed. H/H was stable.
#Encephalopathy
Upon transfer to floor initial, the patient was still fairly
encephlopathic, with slow speech and poor attention. She
clinically improved significantly in the first 24h. EEG also
showed improvement. Keppra was initially downtitrated then
stopped before discharge per discussion with Neurology, as it
was felt that any seizure activity was provoked in the setting
of the acute illness and potential withdrawal, with continued
improvement in mental status. Continued on lactulose and
rifaximin.
#Fever
Had previously been febrile in the MICU, thought to be secondary
to a ventilator-associated pneumonia, and had been on cefepime
before arrival to the floor without a fever for >48h. Then again
spiked to 101.8F. Infectious studies including blood, urine, CXR
were negative. Ultrasound without evidence of ascites, though
could not rule out cholecystitis. However, patient without
abdominal pain and clinically appeared well, hence did not feel
presentation to be c/w acute cholecystitis. Etiology remained
unclear but patient was clinically improving and completed a
course of antibiotics for HAP on ___ with cefepime as below.
#Ventilator-associated pneumonia
Febrile ___ morning while in MICU. CXR with possible PNA.
Treated initially with vanc/cefepime. Vanc stopped once MRSA
swab came back negative. Finished 7 days of cefepime.
#EtOH Cirrhosis
Known alcoholic cirrhosis (biopsy proven) c/b portal
hypertension with splenomegaly and ascites, now s/p TIPS.
Ultrasound on ___ did not show ascites. Started on lactulose
and rifaximin for encephalopathy. Her diuretics were held
post-TIPS procedure and patient appeared to be maintaining
euvolemia. Urosdiol/hydroxyzine initially held while in MICU,
then restarted. Patient noted to have slow flow on TIPS US and
will need to continue beta-blocker therapy until repeat study.
#CODE STATUS: Full Code
#EMERGENCY CONTACT:
Next of Kin: ___ (Sister)
Phone: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Spironolactone 100 mg PO DAILY
2. Mirtazapine 30 mg PO QHS
3. HydrOXYzine 50 mg PO Q6H
4. Furosemide 40 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Propranolol 10 mg PO BID
7. Ursodiol 300 mg PO TID
8. Lactulose 15 mL PO DAILY:PRN constipation
9. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tab-cap
by mouth once a day Disp #*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. rifAXIMin 550 mg PO BID
4. Lactulose 30 mL PO TID:PRN Titrate to ___ BMs
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Propranolol 10 mg PO BID
7. Ursodiol 300 mg PO TID
8. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do
not restart Mirtazapine until you are told to do so by your
physician
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Hematemesis
#Hepatic Encephalopathy
#Epileptiform discharges
#Ventilator Associated Pneumonia
#EtOH Cirrhosis
SECONDARY DIAGNOSIS:
====================
#Acute Blood Loss Anemia
#Thrombocytopenia
#Coagulopathy
#Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
- You were vomiting blood. This was concerning for bleeding from
your esophagus or stomach. This happened because of your
cirrhosis.
WHAT HAPPENED IN THE HOSPITAL?
- You were initially admitted to the intensive care unit because
you were having a significant amount of bleeding.
- You needed to be intubated to protect you from having blood go
into your lungs.
- The Gastroenterologists performed multiple endoscopies of your
esophagus and stomach but did not find a clear source of
bleeding.
- You continued to bleed from your GI tract, due to your
cirrhosis, which causes a condition called portal hypertension.
To stop the bleeding, the Interventional Radiologists performed
a procedure called a transjugular intrahepatic portosystemic
shunt (TIPS). This ultimately stopped the bleeding.
- You were found to be very confused. This was likely because of
your cirrhosis, as well as possible seizures. You received
lactulose and rifaximin for the cirrhosis, and temporarily
required anti-seizure medications as well. This helped you
become less confused.
- Once you had improved enough, you were transitioned to the
regular medicine floor, where you continued to improve.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed and attend your
doctor's appointments.
- Please take your lactulose and rifaximin. Aim for ___ bowel
movements a day. If you are having fewer than ___ stools a day,
increase the frequency of lactulose. If you are having more than
___ stools a day, decrease the frequency of lactulose.
- Please abstain from drinking alcohol.
We wish you all the best!
Your ___ Care Team
Followup Instructions:
___
|
10770392-DS-7
| 10,770,392 | 23,519,093 |
DS
| 7 |
2133-05-05 00:00:00
|
2133-05-06 21:44:00
|
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:
___ pmhx CAD STEMI ___ s/p DES to ___ @ ___, gout, HFrEF (45
-> 50% on TTE), Grave's s/p RAI on levothyroxine presenting with
chest pain.
Patient reports feeling well since his DES. He was recently
treated for lyme and finished his course of doxycycline a couple
weeks ago. He has had some increasing joint pains and gout
activity for which he was prescribed allopurinol. He has not
taken his colchicine since ___ (was prescribed previously for a
gout flare).
On day of presentation 1500 after a meeting at work he developed
central substernal chest pain at rest. Non-radiating. No
associated symptoms. Felt similar to prior STEMI.
Non-pleuritic. However, it improves with sitting up, worsens
when
laying flat.
He takes Brilinta and aspirin in the morning. Has never missed a
dose. He received 4 baby aspirin by EMS prior to arrival.
The pain has persisted throughout the day. No abdominal pain,
leg
pain, fever, chills, cough.
- In the ED, initial vitals were:
98.9, 77, 115/79, 16, 99% RA
- Exam was notable for:
No marked abnormalities on exam
- Labs were notable for:
Neg trop x2
No leukocytosis
- Studies were notable for:
Clean CXR
- The patient was given:
Nitro SL and morphine without any significant change in symptoms
On arrival to the floor, he gives the above history.
He also endorses longstanding issues with severe GERD.
Past Medical History:
CAD c/b STEMI ___ s/p ___
HFrEF EF 45% recovered to 50%
Gout
Grave's s/p RAI on levothyroxine
Social History:
___
Family History:
Strong fmhx CAD; father
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 0039 Temp: 98.1 PO BP: 132/81 R Sitting HR: 67 RR: 18
O2
sat: 98% O2 delivery: Ra deceased lung ca age ___
GEN: well appearing, comfortable, NAD
HEENT: MMM
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l
GI: S/ND/NT
EXT: WWP, non-edematous
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 923)
Temp: 98.0 (Tm 98.1), BP: 119/72 (117-132/69-81), HR: 68
(67-73), RR: 17 (___), O2 sat: 97% (97-98), O2 delivery: RA,
Wt: 165.12 lb/74.9 kg
Fluid Balance (last updated ___ @ 919)
Last 8 hours Total cumulative -330ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 450ml, Urine Amt 450ml
Last 24 hours Total cumulative -210ml
IN: Total 240ml, PO Amt 240ml
OUT: Total 450ml, Urine Amt 450ml
GENERAL: Lying in bed. Speaking to me in no acute distress.
HEENT: NCAT
NECK: No JVD.
CARDIAC: S1/S2, regular, no obvious murmurs.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
EXTREMITIES: No lower extremity edema. His extremities are warm.
SKIN: Warm. Dry.
Pertinent Results:
ADMISSION LABS
==============
___ 07:10PM BLOOD WBC-9.9 RBC-4.61 Hgb-13.8 Hct-42.4 MCV-92
MCH-29.9 MCHC-32.5 RDW-13.9 RDWSD-47.1* Plt ___
___ 07:10PM BLOOD Glucose-81 UreaN-22* Creat-1.2 Na-141
K-4.2 Cl-101 HCO3-28 AnGap-12
___ 03:35PM BLOOD ALT-66* AST-48*
DISCHARGE LABS
==============
___ 06:49AM BLOOD WBC-8.7 RBC-4.50* Hgb-13.7 Hct-41.6
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.8 RDWSD-46.9* Plt ___
___ 06:49AM BLOOD Glucose-88 UreaN-20 Creat-1.1 Na-140
K-4.2 Cl-101 HCO3-24 AnGap-15
___ 06:49AM BLOOD ALT-71* AST-54* LD(LDH)-212 AlkPhos-75
TotBili-0.9
CARDIAC MARKERS
===============
___ 06:49AM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:44PM BLOOD cTropnT-<0.01
___ 07:10PM BLOOD cTropnT-<0.01
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ pmhx CAD STEMI ___ s/p DES to ___ @ ___, gout, HFrEF (45
-> 50% on TTE), Grave's s/p RAI on levothyroxine presenting with
chest pain. The pain was thought to be atypical for angina and a
TTE only showed a mild wall motion abnormality consistent with
his prior infarction. His pain had resolved by discharge.
====================
ACUTE/ACTIVE ISSUES:
====================
# Chest pain
CAD/ACS vs pericarditis (esp with recurrent gout and recent lyme
infxn though admittedly treated) vs musculoskeletal vs. GI pain.
PR interval only mildly prolonged from baseline, otherwise EKG
not markedly changed. Voltage reasonable. Trops were negative
x3. Acute phase markers not highly elevated. No effusion on TTE.
Overall evaluation not concerning for pericarditis, and it is
likely that is pain is musculoskeletal in nature.
- Trial of maalox
- ___, tricagrelor
# CAD, STEMI s/p ___ ___
We increased his atorvastatin from 40mg to 80mg as an
outpatient. Due to the transaminases we switched the
atorvastatin 80mg to ___ 20mg QD.
- Home ___
- Home ticagrelor
- ___ 20mg QD
# HFrEF EF recovered to 50%
- Home lisinopril
- Home metop
# Transaminitis
Previously thought to be related to statin so dose reduced to
40mg. Notably not a significant improvement on lower dose of
statin. RUQUS negative for hepatic steatosis although the study
was limited.
- hepatitis b serologies show non-immune, non-exposed status
- Switched atorvastatin 80mg to ___ 20mg QD
# Gout
- Uric acid - 8.8
- Home allopurinol
- Initiate colchicine recently prescribed by PCP (but not yet
initiated by patient at home).
# Graves s/p RAI
- TSH 0.08 -> Asx at this time, will f/u as outpt
- home levothyroxine
===================
TRANSITIONAL ISSUES
===================
[ ] Consider repeat TSH as an outpatient as his TSH was found to
be 0.08. He did not endorse symptoms of hyperthyroidism.
[ ] We switched his atorvastatin 40mg to ___ 20mg QD
given the elevation in LFTs; please trend his LFTs on this new
medication as he has a mild transaminitis.
[ ] We started him on colchicine [prescribed as an outpatient]
as he was recently started on allopurinol. Please follow up
regarding sxs related to his gout after tx.
[ ] Found to be non-immune to Hep B, consider vaccination if
indicated.
[ ] Please consider a stress echo as an outpatient
Discharge Weight: 165.12
Discharge Creatinine: 1.1
Discharge Diuretic: None
- New Meds:
Started colchicine 0.6mg [prescribed as outpt]
Started ___ 20mg QD
- Stopped/Held Meds: Stopped atorvastatin 80mg QD
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: Please trend LFTs
- Incidental Findings: Elevated LFTs
- Code Status: Full
- Contact Information: Wife ___ (Home)
Discharge time 25 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. PredniSONE 60 mg PO ONCE:PRN gout flare
3. Allopurinol ___ mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
7. diclofenac sodium 1 % topical TID:PRN arthritis pain
8. TiCAGRELOR 90 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Colchicine 0.6 mg PO DAILY
Discharge Medications:
1. ___ Calcium 20 mg PO QPM
RX ___ 20 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY
5. diclofenac sodium 1 % topical TID:PRN arthritis pain
6. Levothyroxine Sodium 137 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
10. PredniSONE 60 mg PO ONCE:PRN gout flare
11. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Noncardiac 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 caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were admitted to the hospital so we can rule out a primary
cardiac problem for your chest pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
While you were in the hospital we ran many tests including an
EKG showing you heart was in a normal rhythm, a blood test that
demonstrated there was no damage to your heart, and an
echocardiogram that was not significant for structural
abnormalities.
Your liver enzymes were also elevated and it may be related to
your statin use, so we changed your lipid medication from
atorvastatin 80mg to ___ 20mg once a day.
Finally, we started you on colchicine that was prescribed as an
outpatient for your gout.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Carefully review the attached medication list as we may have
made changes to your medications.
Sincerely,
___, MD, PhD
Followup Instructions:
___
|
10770705-DS-7
| 10,770,705 | 22,587,359 |
DS
| 7 |
2129-05-27 00:00:00
|
2129-05-29 21:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
prednisone
Attending: ___
Chief Complaint:
DEHYDRATION AND WEAKNESS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx HTN, CAD, arthritis and inflammatory colitis p/w malaise,
weakness, and worsening dyspnea on exertion for the past 6 days,
+dry cough.
.
Wife noted weakness last evening when she had to support his
body weight when he walked up an incline, which was a profound
change even from his baseline use of crutches due to multiple
b/l hip replacements. No focal muscle pain or weakness, just
overall weakness. No sore throat, no rhinorrhea, no
fever/chills, no sick contacts. Noted no improvement in dyspnea
or cough w/mucinex, tylenol III or benadryl. Sleeps comfortably
with 1 pillow. Does feel very dry and thirsty. No chest pain, no
palpitations. No nausea, vomiting, diarrhea, abdominal pain.
Some dysuria intermittently for ___ days; no hematuria,
frequency or urgency.
.
No prior medical care at ___ so no prior records available for
review; followed by PCP/gastroenterologist ___ at
___ and a cardiologist at ___. Not aware of any history of
heart failure, but he does have history of MI (without chest
pain) leading to PCE w/BMS, for which he continues to take ___
and ___ daily. Pt and wife report that he ambulates at
baseline w/ crutches due to chronic multi-joint arthritis
ongoing for several years. He required numerous joint
replacements, R hip x4 and L hip x3 plus L total knee
replacement. Over the past few years he has been unable to flex
fingers ___ of his left hand. Also notes 40-lb weight loss over
the past ___ years. At baseline he is minimally ambulatory with
crutches.
.
Today in the ED his initial ED VS 98 70 171/92 20 96%. Exam
notable for lack of respiratory distress despite BNP 12K,
troponin 0.03. WBC and Hct wnl. ED CXR showed b/l pleural
effusions, cardiomegaly and pulmovascular congestion concerning
for heart failure exacerbation, cannot exclude PNA. Bedside TTE
in the ED negative for pericardial effusion. Given 325 ___, 750
IV levaquin and admitted for workup of CHF. Transfer VS T 98.9
BP 131/66 HR 78 RR 16 97/RA.
.
Past Medical History:
PMH:
1. CAD s/p MI w/PCI & BMS placement at ___ ___
2. Arthritis, type unknown (AM stiffness), affects neck, hands,
wrists, hips, knees
3. Hip replacement at ___ (R x4, L x3, c/b septic joints
thought ___ bacteremia from oral flora)
4. L total knee replacement ___
5. hypertension
6. hyperlipidemia
7. "colitis" (not UC or Crohn's), diarrhea ___ yrs, on
sulfasalazine
8. atrial fibrillation
9. nephrolithiasis
10. CKD "one kidney doesn't work"
11. Peripheral vascular disease
.
ADDENDUM ___: RECORD REVIEW from ___:
----Most recent LVEF: 32% in ___ 43% in ___ echo
C. CATH x 2:
- ___ BMS to mid-LAD
- ___ DES to mid-LAD stent for 70% instent restenosis; OM1
occluded at ostium with collaterals from LAD, RCA occluded
proximally (known) with collaterals filling
----last stress echo ___ showed no ischemia on EKG; dense
posterobasal scar, incomplete inferolateral scar
----H/O afib/flutter s/p failed cardioversion x 2 ___ and
___. refuses coumadin
----h/o Anemia of chronic disease
----h/o OSA refusing CPAP
----h/o CKD with ___ creatinine 1.3-1.4
--___ hosp at ___ in ___ for hydronephrosis in right
solitary kidney (left is atrophic); tx with abx which finished
on ___
----h/o nephrolithiasis s/p ureteral stent placement and ?
removal ___
Social History:
___
Family History:
No history of cardiac disease, arrhythmia or sudden death.
Physical Exam:
ADMISSION EXAM:
GEN well-appearing thin elderly male lying in bed NAD
HEENT NCAT EOMI PERRL OP clear (numerous fillings) MMM
NECK supple no JVD no LAD
PULM CTAB, no wheeze, dull bases, poor expansion
ABD soft, scaphoid, nontender nondistended +NABS, no sacral
edema
EXT WWP + palpable pulses, minimal non-pitting pedal edema, +
intraosseous extensor muscle wasting both hands
JOINT no joint effusions; +ulnar deviation all digits
NEURO AOX3, CNs intact, strength ___ throughout except unable to
actively flex digits ___ L hand. No focal sensory deficits.
Reflexes/gait not assessed.
DISCHARGE EXAM:
GEN well-appearing thin elderly male lying in bed NAD
NECK supple no JVD no LAD
___ RRR no m/r/g
PULM CTAB, no wheeze; barrel chest, decreased BS at right base
ABD soft, scaphoid, nontender nondistended +NABS, no sacral
edema
EXT WWP + palpable pulses, no edema, atrophy of interosseous
muscles of hands bilaterally, enlarged MP joints and carpal
joints, decreased mobility in right fingers - cannot flex
fingers actively but can do so passively
JOINT no joint effusions; +ulnar deviation all digits
Pertinent Results:
ADMISSION LABS:
___ 01:50PM BLOOD WBC-6.1 RBC-3.92* Hgb-13.0* Hct-39.3*
MCV-100* MCH-33.3* MCHC-33.2 RDW-12.7 Plt ___
___ 01:50PM BLOOD Neuts-61.5 ___ Monos-5.4 Eos-3.7
Baso-0.5
___ 01:50PM BLOOD ___ PTT-37.2* ___
___ 01:50PM BLOOD Glucose-92 UreaN-29* Creat-1.8* Na-142
K-4.9 Cl-111* HCO3-21* AnGap-15
___ 01:50PM BLOOD ALT-24 AST-36 AlkPhos-68 TotBili-0.5
___ 01:50PM BLOOD ___
___ 01:50PM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.6 Mg-2.1
OTHER LABS:
___ 02:04PM BLOOD Lactate-1.5
___ 01:50PM BLOOD RheuFac-10
___ 08:33PM BLOOD ___
___ 01:50PM BLOOD cTropnT-0.03*
___ 09:20PM BLOOD CK-MB-4 cTropnT-0.02*
___ 09:10AM BLOOD CK-MB-3 cTropnT-0.02*
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-6.3 RBC-3.55* Hgb-12.0* Hct-35.7*
MCV-100* MCH-33.7* MCHC-33.5 RDW-12.2 Plt ___
___ 06:20AM BLOOD Glucose-86 UreaN-27* Creat-1.6* Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 06:20AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
IMAGING:
CXR ___: AP and lateral views of the chest. No prior. There
are bibasilar
opacities compatible with small effusions, larger on the right
than on the
left. There is engorgement of the pulmonary vasculature with
indistinct
vascular markings peripherally. The cardiac silhouette is
enlarged. Severe
degenerative changes are partially visualized at the
glenohumeral joints
bilaterally. Osseous and soft tissue structures are otherwise
unremarkable.
CXR ___: 1. Resolved pulmonary edema and vascular congestion
from ___ status post
diuresis. 2. Stable small bilateral pleural effusions on the
right greater than the
left. 3. Stable cardiomegaly.
Brief Hospital Course:
___ w/multiple medical problems p/w ___ days weakness, fatigue
and dry cough; ED labs/CXR consistent with acute on chronic
systolic heart failure with question of underlying rheumatologic
process.
# acute on chronic systolic heart failure: DOE consistent with
CHF exacerbation given BNP 12K, and exam/CXR w/volume overload.
No e/o PNA on CXR and he was afebrile throughout admission so
there was low suspicion for pneumonia as cause of DOE. CXR did
show bilateral pleural effusions, R>L. TTE ___ consistent
with prior echos showing infarct at least as old as ___ LVEF
40%. Trops neg x 3 (stable at 0.03 in setting of CKD). EKG
showed no ischemic changes. Trigger for CHF exacerbation was
thought to be UTI (see below). pt was diuresed with IV lasix and
was weaned off O2 within 24 hours of admission. He reported
feeling much better s/p diuresis and appeared euvolemic at the
time of discharge and was ambulating with ___, who recommended
home with ___. Pt refused home ___ services despite our
recommendation. In house he was continued on ___, and
lisinopril stopped for ___. On the day of discharge, repeat CXR
was obtained due to persistence of decreased breath sounds at
right lung base despite diuresis. CXR showed continued stable
pleural effusions, R>L. Primary team found this concerning,
especially in setting of a chronically ill appearing man with
history of weight loss and possibly undiagnosed rheumatologic
disease. Recommended pt stay for diagnostic tap of pleural
effusion but he refused and insisted on leaving. Explains the
risks of going home, including missed diagnosis of cancer, but
pt chose to leave despite this information. discharged pt on
small dose of maintenance lasix with cards follow up. He agreed
to pursue evaluation of the right pleural effusion as an
outpatient, and this was discussed with his cardiologist at ___.
# rheumatologic disease/gout: Story of AM stiffness which
improves w/use throughout the day, w/minimal relief from
glucosamine chondroitin and tylenol arthritis are suggestive of
an inflammatory joint disease rather than degenerative disease.
Pattern of ulnar deviatiation in all digits and hx numerous
joint replacements is concerning. Additionally, atrophy of
interosseous muscles of hand bilaterally would be unusual for OA
and is more consistent with RA. However, ___, RF, CCP all
negative. Pt had completely lost ability to flex his right
fingers and could only move them passively. He stated the
immobility was due to weakness, not tightness of skin, but his
fingers were somewhat shiny and sausage-like, which could be
suggestive of scleroderma. However, muscle atrophy can occur in
RA and could also cause these sx. Lastly, the night before
discharge pt developed acute gouty flare in left first MTP joint
and was treated with colchicine. He had never had gout before.
Ultimately, the picture for rheumatologic disease was suspicious
enough to warrant recommendation of outpatient rheum follow up,
which has to be set up by PCP at ___, where most of patient's
care takes place.
# Weakness/fatigue: Likely multifactorial etiology including CHF
as discussed above, UTI, and possibly undiagnosed rheumatologic
disease. Pt was treated for UTI and CHF exacerbation and his
symptoms were improved by the time of discharge. He ambulated
well with ___ as above and, though they recommended home with ___,
he refused this.
# UTI: UA positive and pt c/o dysuria so he was treated
empirically with one dose of IV levaquin 750mg in ED and
continued on cipro 500mg po q12h on the floor. Planned for 7 day
course. UCx grew only diphtheroids, so no sensitivities were
ever obtained.
# acute on chronic renal failure: per ___ records his baseline
is 1.3-1.4. Recently admitted to ___ with hydronephrosis of
solitary right functioning kidney with Cr elevated to 1.6 on
admission, down to 1.3 on discharge. Cr fluctuating between
1.7-1.8 here at ___ (1.8 on admission). FeUrea 41% which is
c/w ATN. u/a was bland on admission. improved to 1.6 on day of
discharge. stopped lisinopril. continued lasix due to need for
diuresis in setting of heart failure and continued ___ in
setting of CAD history. continued home PO bicarb. recommended
outpatient follow up.
# HTN: continued carvedilol, stopped lisinopril given ARF as
noted above
# Hx colitis: presumed IBD since pt takes sulfasalazine at home,
but pt/wife deny hx of Crohn's or ulcerative colitis. continued
sulfasalazine.
# CAD: s/p BMS x 1 to LAD in ___ with instent restenosis and
___ 1 to LAD stent in ___ ___E neg x 3 at ___ and
echo findings c/w with prior records from ___ so no evidence of
ACS being cause of fatigue. cont home meds of ___,
carvedilol. held lisinopril in setting of ___. continued crestor
# bradycardia/aflutter: pt in aflutter throughout admission. no
RVR but occasion episodes of bradycardia to ___ overnight.
consulted cards who were unconcerned as bradycardia occurs only
during night when pt sleeping and never during day. cards did
rec DCCV for aflutter but patient can get this with home
cardiologist. He will follow up with his usual cardiologist re:
anticoagulation and DCCV. Offered to provide script for
coumadin or pradaxa to begin anticoag but pt could not decide
which he would prefer so no prescription given and cards f/u
appt made. continued carvedilol
Medications on Admission:
Carvedilol 6.25 BID
Sulfasalazine 1000 mg BID
Aspirin 325 QD
___ 75 QD
Lisinopril 5 QD
Sodium Bicarb 650 mg BID
crestor 5mg daily
MV QD
OTC Tylenol arthritis PRN
OTC Glucosamine chondroitin QD
Discharge Medications:
1. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
9. glucosamine-chondroitin Oral
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 doses: last dose ___.
Disp:*7 Tablet(s)* Refills:*0*
12. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
acute on chronic systolic heart failure
acute on chronic renal failure
urinary tract infection
pleural effusions, R>L
acute gouty arthritis
Secondary Diagnosis:
inflammatory arthritis NOS
colitis NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital because you had shortness of breath
with exertion. You were volume overloaded and found to have an
exacerbation of your heart failure. You were also found to have
a urinary tract infection (UTI). You were given antibiotics to
treat your UTI and a diuretic to reduce the extra fluid on your
body. You had an echocardiogram that did not show any new
cardiac problems. You were, however, found to have fluid in your
thorax (pleural effusion) and were recommended to stay and have
that evaluated, but you declined. You were also recommended home
physical therapy but you refused it. While you were here you
developed gout and were started on colchicine to treat this.
The following changes were made to your medications:
STOPPED lisinopril due to your kidney problems (please ask your
doctor when it is safe to restart this)
STARTED furosemide 20mg daily to prevent reaccumulation of fluid
STARTED ciprofloxacin 500mg twice a day (last dose ___ for
UTI
STARTED colchicine 0.6mg daily for gout
Followup Instructions:
___
|
10771213-DS-15
| 10,771,213 | 25,469,071 |
DS
| 15 |
2173-07-09 00:00:00
|
2173-07-10 14:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE wound
Major Surgical or Invasive Procedure:
I&D ___
punch biopsy ___
History of Present Illness:
Mr. ___ is a ___ with CKD, DM, CHF (unknown EF) who was
recently discharged to rehabilitation after OSH admission now
presenting with ___ pressure ulcer. Reportedly admitted to
___ on ___ with COPD/CHF
exacerbation and was treated with nebulizers, steroids and Lasix
(per notes from ___ pt says he had PNA). Found to have
large ___ wound with tissue edema and hematoma at nursing home,
transferred back to ___ on ___ and underwent
debridement. After transfer to nursing home, he was felt to need
further care for his ___ edema and leg wounds, and transferred to
___ (___). Sent to the ___ ED ___ for concerns
for new LUE swelling as well as increased erythema and pain of
LLE ulcer site. Pt says the swelling and pain in the leg has
gotten worse over the past week, only painful when touched
(___). He does not recall having a PICC in place this past
month. In the ED, vitals stable, heparin gtt started for LUE US
showing L basilic clot, vanc/zosyn started for presumed
superinfection ___ ulcer. ACS consulted and recommended
admission to medicine.
This AM, pt reports being hungry and having loose stools
yesterday, only having pain when LLE site touched but not
otherwise.
Past Medical History:
LLE wound s/p debridement
COPD
HTN
Hyperlipidemia
CHF (EF not mentioned in notes)
Type 2 DM
Stage 3 kidney disease (no documentation of baseline Cr)
Anemia, recent transfusion
Obesity
PVD s/p amputation of L toes
esophageal CA (cared for at ___, doing periodic surveillence,
no treatment yet)
prior hip surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.2, 97.8, 146-150/61-70, 79-92, 96-99% 2L, fs 150
GENERAL - chronically ill-appearing elderly man in NAD,
comfortable, appropriate
HEENT - NC/AT, sclerae anicteric, MMM, OP clear
LUNGS - scattered rhonchi with loud expiratory breath sounds
HEART - regular rhythm, no MRG, nl S1-S2
ABDOMEN - NABS, obese, soft/NT/ND
EXTREMITIES - 2+ BLE edema to knees, 1+ BUE edema in forearms.
LLE posterolateral calf ulceration approximately 8x5cm with
surrounding eschar, surrounded by 2x2 cm fluctuant area with
erythema and tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-7.2 RBC-3.46* Hgb-10.4* Hct-32.4*
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.5 Plt ___
___ 06:50PM BLOOD Glucose-166* UreaN-30* Creat-2.0* Na-138
K-4.9 Cl-95* HCO3-35* AnGap-13
___ 06:50PM BLOOD CK-MB-2 cTropnT-0.04*
___ 09:20AM BLOOD CK-MB-3 cTropnT-0.04*
___ 01:58PM BLOOD Albumin-2.5* Calcium-7.6* Phos-3.9 Mg-1.8
MICRO:
Wound culture ___:
___________
STUDIES:
CXR ___:
Small to moderate bilateral effusions. Please note that basilar
consolidation cannot be completely excluded.
BLE ultrasound ___:
Bilateral calf veins not visualized due to significant
superficial soft tissue edema. No DVT noted in all visualized
veins bilaterally.
LUE ultrasound ___:
Thrombus in the left basilic vein with intermittent patchy flow.
ABI/PVRs ___:
No evidence of peripheral vascular disease in either lower
extremity.
Biopsy of LLE wound ___:
___________
Brief Hospital Course:
___ with HTN, HLD, CHF with unknown EF, COPD, CKD, and LLE wound
s/p recent debridement who presents with worsening erythema of
the LLE wound and new LUE DVT.
# LLE wound: Initially appeared necrotic on admission, and he
was started on vanc/zosyn (soon changed to vanc/cipro/flagyl)
given extensive history of recent hospitalization/rehabilitation
exposure. Despite recent debridement two weeks ago at OSH, a
new area of fluctuance was debrided again by general surgery on
___, which showed no pus, and wound cultures were obtained.
Vascular surgery was consulted and found no indication for
revascularization or angiography as arterial flow seems intact
on exam and noninvasive testing. The violaceous appearance
after debridement made the surgeons concerned for pyoderma
gangrenosum, and dermatology was consulted to obtain a biopsy,
which is highly suggestive of pyoderma gangrenosum. At the time
of discharge the final stains are still pending and will need to
be followed up by the rehabilitation physician. Patient was
started on minocycline. A G6PD level is pending and will need to
be follow up. If this returns normal he will need to be started
on dapsone.
.
# LUE basilic vein thrombosis: OSH records show ___ placed
___, unclear when it was removed. Heparin gtt started on
admission on ___, but he bled actively out of the despite
tight wrapping and eventually required suturing and 2U pRBC
transfusion after Hct dropped from 33 to 25 (asymptomatic,
hemodynamically stable). Heparin gtt was discontinued on ___
when it was clear that the risks of anticoagulation exceeded the
risk. His HCT remained stable for the remainder of his stay.
# Elevated troponin: 0.04 on admission, Likely ___ renal failure
given MB not elevated. ECG was not concerning for ACS. He was
continued on aspirin 325 mg.
# Presumed acute on chronic CHF, unknown EF: There was a concern
for mild volume overload on admission. He was continued on his
home furosemide and beta-blocker, and was given nebulizers as
needed.
# Acute on chronic renal failure: Admission Cr 2.0, baseline
possibly between 1.3-1.5 based on OSH.
# Normocytic anemia: Chronic per notes, unknown baseline, likely
related to CKD.
# type II DM: Glucose control will be important for wound
healing. His finger stinks have remained less than 150 without
insulin support but will need ___ monitored closely during
rehab stay.
****Transitional issues*****
- Follow up final biopsy results- Page On Call Dermatology
resident ___, PAGER ___ On ___ for update.
- Follow up G6PD level as well. If normal will need to start
dapsone per dermatology recs.
- Continue BID dressing changes with adaptec and dry gauze
ocvering. DO NOT DEBRIDE further.
- Patient has pendign conective tissue disease work up: tests
negative or WNL including:
Will need to follow up ___, ANCA, Anti-Phospholipid Antibody,
RPR, SPEP and UPEP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NovoLOG *NF* (insulin aspart) 100 unit/mL Subcutaneous
sliding scale
2. Aspirin EC 325 mg PO DAILY
3. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >
4. Furosemide 20 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. traZODONE 75 mg PO HS
8. DiCYCLOmine 10 mg PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
14. Atorvastatin 10 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Fondaparinux 2.5 mg SC DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin EC 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. DiCYCLOmine 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. traZODONE 75 mg PO HS
11. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
12. Fondaparinux 2.5 mg SC DAILY
13. NovoLOG *NF* (insulin aspart) 100 unit/mL Subcutaneous
sliding scale
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >
16. Minocycline 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
pyoderma gangrenosum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
diagnosed with an inflammatory process in your leg called
pyoderma gangrenosum. This is not an infection. You were also
found to have a clot in your left forearm that you should
continue to treat with warm compresses.
Followup Instructions:
___
|
10771301-DS-7
| 10,771,301 | 28,550,538 |
DS
| 7 |
2165-08-22 00:00:00
|
2165-08-22 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V/D, dehydration.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with head and neck cancer 5d s/p
chemoXRT admitted for N/V/D, severe throat pain, and
dehydration. His symptoms have been steadily worsening over the
week and for ~2 days, he has not been able to eat or drink
anything. PO intake causes chest pain/burning. He also has had
worsening productive cough and sputum production, which he
suctions. He has been confused, talking to people that are not
present; the family states this happens when he becomes
dehydrated. He feels dizzy at times and short of breath. He
also notes occasional shaking chills, but no fever, headache.
There has been blood and coffee grounds in his vomit. He has
been using Aquaphor for the skin breakdown on his neck.
.
ROS: He denies fever, sweats, visual changes, abdominal pain,
back pain, constipation, hematochezia, melena, hematuria, other
urinary symptoms, or paresthesias. All other ROS were negative.
Past Medical History:
Oncologic history: Mr. ___ was undergoing treatment for renal
calculi and at the time of his elective intubation for this
procedure, a right hypopharyngeal mass was discovered. He was
seen by Dr. ___ and in his office was noted to have a right
hypopharyngeal mass encroaching on the arytenoid, as well as
right vocal cord immobility. He underwent a CT scan which was
performed on ___, on which was noted a mass which
appeared to be centered in the right piriform sinus with
possible involvement of the supraglottis and posterior
hypopharyngeal wall and extensive right-sided metastatic
adenopathy. He then went on to undergo a direct laryngoscopy
with biopsy, and esophagoscopy in the OR. The pathology of this
came back invasive squamous cell carcinoma, poorly
differentiated. He also had a GE junction biopsy at that time
that was unremarkable. He started cisplatin on ___ and
finished chemoXRT ___.
.
OTHER PMHx:
1. Hypertension.
2. History of pain in the knees, particularly on the left side.
3. Kidney stones.
4. Prior back trouble.
Social History:
___
Family History:
His father died of some sort of cancer; however, he also had
renal failure needing dialysis.
Physical Exam:
Admission Physical Examination:
VS: T 99.0F, BP 121/87, HR 103, RR 18, O2 sat 99% RA, I/O .
GEN: A&Ox2 (wrong day, date, and year), NAD.
HEENT: Sclerae non-icteric, PEARLA, EOM intact, oropharyngeal
erythema, dry MM, copious secretions.
Neck: Supple, no JVD, no thyromegaly, no cervical LAD.
CV: S1S2, RRR, no MRG.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
BACK: No spine, rib, or iliac tenderness.
ABD: Soft, non-tender, non-distended, no HSM, bowel sounds
present.
EXTR: No edema or calf tenderness.
DERM: Erythema/darkened skin at neck with skin breakdown on the
right side (~4x2cm).
Neuro: Strength ___, no focal deficits.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS:
___ 11:30PM BLOOD WBC-2.2* RBC-3.29* Hgb-9.8* Hct-28.3*
MCV-86 MCH-29.6 MCHC-34.5 RDW-14.8 Plt ___
___ 11:30PM BLOOD Neuts-82.2* Lymphs-7.2* Monos-8.7 Eos-1.5
Baso-0.4
___ 12:22AM BLOOD ___ PTT-25.8 ___
___ 11:30PM BLOOD Glucose-90 UreaN-26* Creat-1.6* Na-141
K-3.4 Cl-95* HCO3-29 AnGap-20
___ 11:30PM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.7 Mg-2.2
___ 11:30PM BLOOD ALT-15 AST-13 AlkPhos-71 TotBili-0.5
___ 11:30PM BLOOD Lipase-16
___ 11:30PM BLOOD cTropnT-<0.01
.
___ CT NECK: IMPRESSION:
1. Stable appearance of hypopharyngeal mass since ___.
Interval
decrease in bilateral cervical adenopathy.
2. No abscess or fluid collection.
ATTENDING NOTE: The hypopharyngeal lesion appears smaller than
prior study.
.
___ CTA CHEST: IMPRESSION: No pulmonary embolism or other
acute process in the chest.
.
___ CXR: IMPRESSION: Lung volumes are slightly low,
exaggerating heart size top normal. Lungs grossly clear. No
pleural abnormalities.
.
DISCHARGE LABS:
Brief Hospital Course:
Assessment/Plan: ___ year old male with head and neck cancer s/p
chemoXRT amitted with nausea, vomiting, diarrhea, throat pain,
and dehydration. He had severe pain and symptom, which
medication regimens were optimized. Increased dose of fentanyl
patch helped to control pain better. Pt reports staying in
___ with friends for ___ weeks before returning to home
in ___ area. Arrangements for patient to see PCP and ___
ONc and Med Onc teams have been made. Coordination of care plans
as an outpatient should need to be well executed for this
patient. At time of discharge, patient symptoms better
controlled, but he can have episodes of pain after
cough/clearing through which can precipitate nausea and
vomiting. He has been instructed to take medications
preventatively and with breakthru pain. Other details below:
# Nausea/vomiting/nutrition: Initially nausea/vomiting
chemo-related, then difficulty swallowing secretions and po
intake poor due to pain. Now tolerating full liquids.
- drinking 4 shakes daily currently
- Diet full liquid with Nepro/Ensure, nutrition service
followed.
- Likely will be able to avoid PEG tube placement
- Frequent suctioning of oral secretions
- Preemptive medication for pain and nausea control.
- Will need guidance for pain med titration, to be done with PCP
and onc teams.
# Head and neck cancer: Completed chemoXRT ___.
- Dr. ___ is primary oncologist. Next appt pending.
# Hx Febrile neutropenia: On 7day course of cipro for Klebsiella
UTI and no fevers recently. Finished on cipro on ___.
- blood cultures no growth.
- WBC count improving since neupogen started on ___. Neupo
given for 2 days only. Though on ___ labs, WBC dropped to 2.8.
Monitor for now. Likely IVF fluid related given ___ ___.
# Pancytopenia: Chemo-induced. Overall, improving.
- Neupogen use as above.
# Throat and chest pain (throat/chest): Due to mucositis and
radiation esophagitis.
- was on morphine PCA, now on Fentanyl 100mcg patch and increase
prn oral morphine solution
- Appreciate palliative care consult
- Magic Mouthwash solution prn
- Nystatin suspension in case of oral/esophageal candidiasis
unseen
- Per case management, will need to call physician closer to
home to set up appropriate outpatient free medication services.
Will have this done with PCP if needed.
# Radiation skin ulceration: Grade 2 skin breakdown. Wound Care
consulted. Aquaphor. Improved.
# Acute on CKD: Resolved with IV fluids.
- Holding HCTZ and ACE-I.
# HTN: Holding HCTZ and ACE-I given dehydration and creatinine
elevation. Currently normotensive.
- ___ not need meds if BP remains normotensive. Will hold off on
these medications for now. Should follow up with PCP for future
need.
# Elevated INR: Improved with vitamin K supplementation
# Anxiety: Improved, standing ativan dc'd. PRN ativan.
# Hematemesis: Resolved.
- lansoprazole dissolving tabs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea
2. Dexamethasone 4 mg PO Q12H
Take for 3 days following chemotherapy.
3. Enalapril Maleate 20 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN Cough
5. Lorazepam ___ mg PO Q4H:PRN Nausea, anxiety, insomnia
6. Guaifenesin 10 mL PO Q6H:PRN Thickened mucus
7. Fentanyl Patch 25 mcg/h TP Q72H
8. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN Pain
9. Ibuprofen 600 mg PO Q8H
10. Metoclopramide 10 mg PO QID:PRN Nausea
11. Hydrochlorothiazide 25 mg PO DAILY
12. Maalox/Diphenhydramine/Lidocaine ___ mL PO Q4H:PRN
Throat/mouth pain
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
2. Aquaphor Ointment 1 Appl TP TID:PRN Rash
RX *white petrolatum [Aquaphor with Natural Healing] 41 % Apply
to skin three times a day Disp #*1 Bottle Refills:*11
3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole 15 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*1
4. Fentanyl Patch 100 mcg/h TP Q72H
RX *fentanyl 75 mcg/hour 1 patch every 72 hrs Disp #*1 Box
Refills:*0
5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety, nausea
RX *lorazepam 0.5 mg ___ tab by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
6. Ondansetron 8 mg PO Q8H:PRN Nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*11
7. Guaifenesin 10 mL PO Q6H:PRN Thickened mucus
RX *guaifenesin 100 mg/5 mL 10 ml by mouth q 6 h Disp #*1 Bottle
Refills:*1
8. Morphine Sulfate (Oral Soln.) ___ mg PO Q1H:PRN pain
RX *morphine 10 mg/5 mL ___ mg by mouth every four (4) hours
Disp #*1 Bottle Refills:*11
9. Nystatin Oral Suspension 5 mL PO TID
RX *nystatin 100,000 unit/mL 5 ml by mouth three times a day
Disp #*1 Bottle Refills:*3
10. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 60 mg/15 mL 15 ml by mouth twice a day Disp
#*1 Bottle Refills:*11
11. Senna 5 ML PO BID
RX *sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day
Disp #*1 Bottle Refills:*5
12. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN throat
pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Nausea/vomiting.
2. Diarrhea.
3. Mucositis (inflammation in mouth/throat).
4. Esophagitis (inflammation in esophagus).
5. Dehydration.
6. Altered mental status (confusion).
7. Head and neck cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for nausea, vomiting,
diarrhea, and dehydration. You had not been able to eat or
drink because of mucositis/esophagitis (inflammation in the
mouth/throat/esophagus) due to radiation therapy but your pain
improved and you were able to start eating again. It is very
important that you continue to take your nutrition shakes after
discharge. You will be given a 1 week supply when you leave, but
you may need to purchase additional cans for future use if
needed.
You were also given IV fluids and pain medication. Your blood
counts were also very low and you were given neupogen to
stimulate your blood counts. You were also treated for a UTI
with ciprofloxacin, which you have completed.
PATIENT INSTRUCTIONS:
1. You have many medications. Be sure you know how to use each
one.
2. For pain, you have been instructed on how to use "breakthru"
medication. Try to use medications before you cough when you
remove mucous, or when you eat. Preventative treatment will
lessen pain.
3. Follow up with your multiple appointments. CALL YOUR PCP or
any of your doctors ___ have questions. Remember to ASK if
you have ANY questions. There are always translators available.
If not, find someone who speaks ___ to help you.
4. For pain medications, these can make you constipated. Be sure
you take bowel regimen medications.
5. Your first appointment with Dr ___ is on ___. See
below.
Followup Instructions:
___
|
10771901-DS-6
| 10,771,901 | 24,977,017 |
DS
| 6 |
2166-06-11 00:00:00
|
2166-06-11 18:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, Fever
Major Surgical or Invasive Procedure:
Lumbar Puncture, ___
History of Present Illness:
Patient is a ___ y/o F with an unremarkable PMH who presents with
fever x1 week and HA/arthralgias x2 days.
Patient reports that she was in her USOH until this past ___
(___), when she developed fever to 100.9. The following day,
she developed severe headache (___), which she describes as a
pressure behind her eyes and associated with photophobia.
Headache persisted all week and did not improve with ibuprofen.
She additionally endorses pressure sensation behind her eyes and
sensitivity to light. She saw her PCP on ___, who recommended
continuing ibuprofen alternating with tylenol for pain. Patient
vomited on ___, so went for an urgent care appointment and
was referred to the ED.
Patient also reports pain/weakness in her legs, particularly in
her knees (left weaker than right). This started 2 days PTA,
and she has never had any sort of joint or muscle problems in
the past. Additionally, she reports that her arms have
occasionally felt "numb" on standing. She does not endorse focal
weakness however and feels that she has diffuse weakness in her
legs currently more secondary to pain in her joints and legs.
Also of note, she complains of trouble sleeping secondary to
aching in her legs particularly her knees and ankles
bilaterally.
Patient reports no recent illness and denies any sore throat,
congestion, rhinorrhea, or rash. With regards to sick contacts,
patient reports that her roommate recently had a sore throat.
She denies any recent travel, insect bites, or rash. She is
otherwise healthy with immunizations up-to-date.
Denies changes in vision, neck stiffness, and confusion. Also
denies diarrhea, SOB, abdominal pain, dysuria.
LP from the ED notable for WBC 61 with 55 lymphocytes,
protein/glucose WNL (___), gram stain negative for
microorganisms. Patient given ceftriaxone and acyclovir for
meningitis and ketorlac, acetaminophen, and oxycodone for pain.
In the ED, initial vitals were: T 98.4, HR 72, BP 113/63, RR
16, O2 98%RA
Vitals prior to transfer were: T 98.5, HR 74, BP 114/75, RR 16,
O2 99% RA
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Urinary Tract Infection
Vaginitis
Egg retrieval Bilateral ___
Social History:
___
Family History:
Father Alive ___
___ Grandfather ___ CAD/PVD - Early
Maternal Grandmother Alive Cancer - ___
Mother Alive ___ - ___ gastric bypass
Paternal Grandfather Alive ___
___ Grandmother Alive CAD/PVD
Sister Alive(2) Healthy
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
========================
Vitals: T 98.3, BP 133/79, HR 71, RR 18, O2 100RA.
General: Alert, oriented, no acute distress but appears slightly
drowsy
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: 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
MSK: ___ knee pain on active > passive motion, also endorses
pain in ankles
Neuro: CNII-XII intact, full strenth ___ in UE (very slight
weakness in L>R though effort dependent and somewhat limited by
pain), ___ ___ weakness, grossly normal sensation, impaired gait
___ leg pain.
PHYSICAL EXAM ON DISCHARGE:
======================
VS: T 97.8, BP 97/44, HR 61, RR 18, O2 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA. No
pain with leftward and rightward gaze.
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
MSK: L knee stiffness, improved. No swelling appreciated.
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities
Pertinent Results:
LABS ON ADMISSION:
==============
___ 05:40AM BLOOD WBC-8.3 RBC-3.99* Hgb-12.7 Hct-36.2
MCV-91 MCH-31.8 MCHC-35.1* RDW-12.6 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
CSF: 61 WBC (55%L, 13%N, 29% M), 1 RBC. TProt 26, Gluc 58 (serum
= 113). ___ neg; Cx neg. (___)
=========================
___ 7:00 pm SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
LYME SEROLOGY (Final ___: NO ANTIBODY TO B. ___
DETECTED BY EIA.
___ 6:49 am CSF;SPINAL FLUID GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Blood Parasite Smear: neg (___)
HSV PCR: neg (___)
Enterovirus PCR: neg (___)
Varicella PCR: neg (___)
HIV viral load negative (___)
PENDING RESULTS:
=============
___ 19:04
BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION Results
Pending
___ 07:00PM BLOOD ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) -PND
Brief Hospital Course:
Patient is a ___ y/o F with an unremarkable PMH who presents with
fever x1 week and HA with ___ arthralgiasx2 days, found to have
CSF notable for 61 WBCs with 55 lymphocytes, concerning for
viral meningitis.
# Meningitis w/arthralgias
The patient presented initially with a week long history of
headache and fevers that worsened in nature the day of
admission. On admission lumbar puncture was obtained which was
notable for: protein/glucose WNL (___), WBC 61 with 55
lymphocytes, supportive of potential viral etiology. The patient
was subsequently started on acyclovir for empiric coverage of
HSV encephalitis. Bacterial meningitis ruled out with negative
gram stain and culture. Infectious work-up ultimately revlealed
negative viral studies in the CSF (negative HSV, VZV,
enteroviral panel). HIV viral load also noted to be negative.
As such acyclovir was discontinued.
Given patient's headache with associated arthralgias and
stiffness in her lower extremeties particularly her knees L > R
there was some concern for lyme and anaplasma as causative
agents of meningitis. Infectious disease consulted and
recommended empiric coverage of these agents with ceftriaxone
and doxycycline. Lyme serologies were negative, however she was
presumptively treated for CNS lyme disease and anaplasma with
high-dose doxycycline (200mg BID) given Lyme Ab in the CSF and
anaplasma serologies were pending at the time of discharge
(anticipate they will result within 10 days) and that it is
plausible that these studies would be negative early in the
course of disease. If CSF Lyme (borrelia studies) or anaplasma
serologies should return positive then patient should be
referred to ___ clinic and continued on doxycyline until that
time.
#Headache
The patient was noted to have an ongoing headache throughout the
course of her hospital stay noted to be exacerbated by standing.
The patient's headache was attributed to ongoing meningitis as
well some degree of post-LP headache given it's worsening with
standing. The patient's headache was initially managed with
Toradol and morphine alternating and the patient was
transitioned to ibuprofen 800 mg Q8 hours and Oxycodone 5 mg Q4
hours PRN pain prior to discharge. The patient was instructed to
call her primary care physician should her headache not worsen
or not improve within the next 5 days.
TRANSITIONAL ISSUES:
=====================
-F/u anaplasma and borrelia CSF studies. If positive please
refer patient immediately to ___ clinic. Also continued patient
on doxycycline 200 mg BID.
-If studies are negative then discontinue doxycyline 200 mg BID
treatment course
Medications on Admission:
None
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H fever or pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth four times a day Disp
#*28 Capsule Refills:*0
3. Doxycycline Hyclate 200 mg PO Q12H Duration: 20 Days
RX *doxycycline hyclate 100 mg 2 tablet(s) by mouth twice a day
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Meningitis (possible Lyme Meningitis)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ with fever, headache, and leg
pain/weakness. We did a lumbar puncture (also called spinal
tap) in the emergency department, which involved taking a sample
of the fluid that surrounds the spinal cord. Based on the cells
that we saw in the fluid, we diagnosed you with meningitis, an
infection and inflammation of the lining of the brain and spinal
cord. We sent off many tests to see what type of bacteria or
virus was causing the meningitis. Most of those tests came back
negative including those for viral causes.
As of this time, it is not entirely clear what caused your
meningitis. One possibility is that the meningitis was caused by
lyme disease (a common tick-borne illness), which is treated
with a medication called doxycycline. We were not able to
confirm this possibility, because the test for lyme meningitis
(which involves looking for antibodies in the fluid surrounding
your brain) will not be available for another 10 days.
Due to the possibility of lyme meningitis, you should take
doxycycline 200mg twice a day until you see your primary care
doctor. By the time that you see your primary care doctor, we
should have results of the lab tests which will either confirm
or rule out lyme meningitis; if the results are negative, you
can stop taking doxycycline. If the results are positive,
continue taking it for a total of 20 days and have your primary
care doctor set you up with an infectious disease specialist.
Your headache should improve within the next 5 days. Take
ibuprofen 800mg three times a day and oxycodone 5mg four times a
day as needed for headache. Seek medical attention sooner than
your scheduled PCP appointment if your headache worsens, does
not improve within 5 days, or if you have a fever or other
concerning symptoms.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10772044-DS-21
| 10,772,044 | 23,541,536 |
DS
| 21 |
2119-07-09 00:00:00
|
2119-07-09 19:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ulna fracture
R radius fracture
Major Surgical or Invasive Procedure:
___: ORIF R ulna
History of Present Illness:
___ RHD s/p fall this AM, slipped on ice, landed on R elbow, no
other injuries, no preceding symptoms; + R elbow pain, unable to
move arm secondary to pain; seen at ___ had films showed
comminuted R ulnar fracture and txf here for further evaluation.
Past Medical History:
___/PSH:
Pre-HTN
Social History:
___
Family History:
N/C
Physical Exam:
PHYSICAL EXAMINATION:
GEN: NAD, A&Ox3
AVSS
RIGHT UPPER EXTREMITY: C/D/I dressing in sling and splint.
EPL/FPL/DIO (index) fire. SILT axillary/radial/median/ulnar
nerve distributions. 2+ radial pulse
Pertinent Results:
ADMISSION LABS:
___ 02:40PM BLOOD WBC-13.6* RBC-6.51* Hgb-13.4* Hct-44.4
MCV-68* MCH-20.6* MCHC-30.2* RDW-17.5* RDWSD-36.9 Plt ___
___ 02:40PM BLOOD Neuts-86.6* Lymphs-7.0* Monos-5.4
Eos-0.1* Baso-0.4 Im ___ AbsNeut-11.79* AbsLymp-0.96*
AbsMono-0.73 AbsEos-0.01* AbsBaso-0.06
___ 02:40PM BLOOD ___ PTT-26.1 ___
___ 02:40PM BLOOD Glucose-102* UreaN-14 Creat-1.2 Na-136
K-5.0 Cl-100 HCO3-25 AnGap-16
IMAGING:
R HUMERUS/ELBOW X-RAY ___:
Comminuted, displaced and angulated fractures to the proximal
right radius and ulna. Intra-articular extension of the radius
fracture. Please see same-day CT report for full details.
CT R UPPER EXTREMITY ___:
Comminuted fractures involving the right radial head, radial
neck, coronoid and olecranon processes of the ulna, and proximal
ulnar diametaphysis with intra-articular extension, as described
above.
R ELBOW X-RAY ___:
Fine bony detail is obscured by an overlying back slab. There
has been prior surgery with open reduction internal fixation of
a comminuted proximal ulnar fracture. The hardware is unchanged
in appearance when compared to the prior study. Alignment of
the fracture is also unchanged compared the prior study. The
fracture of the radial head is less well visualized and there
appears to have been resection of the radial head. Please see
the operative report for further details.
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 R ulna and radius fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a R ulna ORIF, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with OT who determined that discharge to home with OT was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weightbearing in a sling and splint to the right upper
extremity, and will be discharged on Aspirin 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 500 mg 2 tablet(s) by mouth q 8 hours Disp
#*40 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*1
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hours Disp #*60
Tablet Refills:*0
4. Aspirin 325 mg PO BID
RX *aspirin 325 mg 1 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R radial fracture
R ulna fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing to the right upper extremity in splint and
sling. Please keep sling intact and dry until your first follow
up appointment.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg twice a day for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Someone from
our office should call you to schedule this, but if you do not
hear from us within a few days after discharge, please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Right upper extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Wound care:
Site: R arm
Type: Surgical
Dressing: Gauze - dry
Followup Instructions:
___
|
10772100-DS-13
| 10,772,100 | 29,595,808 |
DS
| 13 |
2183-02-25 00:00:00
|
2183-02-28 22:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V, DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with type I DM, frequent syncope with 4 episodes per day
(wears helmet) related to dysautonomia, living related donor
renal transplant in ___ with transplant surgery, presenting to
___ today for syncope, found to be in DKA.
Patient states that he has not been feeling well for ___ days
and has been vomiting "a lot" and "every 20 minutes". Patient
vomiting red-tinged emesis (no hx of cirrhosis or varices).
Patient last vomited ___ hours before initial presentation,
approximately a cupful each time. No melena/hematochezia. Has
had abd pain for a few days last about a week ago before which
stopped a day or two after he started vomiting. Per patient, in
touch with his o/p doctors for ___ of 600 or higher; taking 40U
lantus, 40U Humalog with meals. Took home anti-rejection meds
at ___ and ___ held them down, but feels likely mostly at
home he has been able to keep down most. Sore throat started
after vomiting. Negative head and neck CT scan at OSH. OSH labs:
glucose 946, K=6.1, creat 3.9, GAP29. Patient was given 1L NS at
OSH, started on 0.1u/kg bolus and 0.1u/kg insulin gtt at OSH.
In the emergency department, patient had HTN to 210's SBP
responded well to IV labetolol otherwise blood pressure remained
stable. In the ED, initial vitals: 97.7 85 137/52 18 98% RA.
In the ED patient received:
___ 16:25 IV DRIP Insulin Started 6 UNIT/HR
___ 16:28 IVF 1000 mL NS 4000 mL
___ 16:28 IV Lorazepam 1 mg
___ 17:34 IV DRIP Insulin Rate Changed to 8 UNIT/HR
___ 18:30 PO Potassium Chloride 40 mEq
___ 19:00 IV DRIP Insulin Rate Changed to 7 UNIT/HR
___ 19:57 IV DRIP Insulin Rate Changed to 4 UNIT/HR
___ 20:55 IV Potassium Chloride 40 mEq
___ 21:14 IV DRIP Insulin Rate Changed to 3 UNIT/HR
___ 21:37 IV Labetalol 10 mg
___ 22:06 IV DRIP Insulin Rate Changed to 2 UNIT/HR
___ 23:49 IV DRIP Insulin rate continued at 2 UNIT/HR
Patient was seen and examined by surgical team in the ED, no
acute surgical intervention was required, transplant nephrology
was consulted and agreed with admission to the MICU. On arrival
to the MICU, insulin gtt was continued, IVF was transitioned to
___ for glu <250 and corrected Na > 135.
Past Medical History:
Type I DM
Chronic kidney disease s/p living related donor renal transplant
in ___
Autonomic neuropathy with orthostatic hypotension causing ___
syncopal episodes per day (wears helmet)
Hyperlipidemia
Past Surgical History: repair of right leg fracture
Social History:
___
Family History:
DM, Parkinsons (father), ___ CA (grandmother age ___
Physical Exam:
ON ADMISSION:
=================
Vitals: Wt-, T:97.7, HR: 85, BP: 153/79, RR: 17, 98 (RA)
GENERAL: Alert, oriented, no acute distress. hand tremors
bilaterally (at baseline per patient)
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash appreciated, multiple, well-dressed lacerations
b/l arms which per nurse are not erythematous nor purulent
NEURO: alert and oriented
ON DISCHARGE:
==============
General: Alert, oriented, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
NECK: supple, JVP not elevated, no LAD
CV: Irregular, but not tachycardic, normal S1 + S2, no murmurs,
rubs, gallops.
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, NT, ND, BS+, No HSM, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Abrasions with dried blood on forearms bilaterally, no
surrounding erythema, induration, fluctuance or discharge
Neuro: CNII-XII intact, strength and sensation intact.
Pertinent Results:
LABS ON ADMISSION:
======================
___ 10:21PM ___ PH-7.36
___ 10:21PM GLUCOSE-168* NA+-141 K+-4.1 CL--109* TCO2-25
___ 10:21PM O2 SAT-47
___ 10:00PM GLUCOSE-183* UREA N-54* CREAT-2.6* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-20* ANION GAP-18
___ 07:57PM ___ PH-7.38
___ 07:57PM GLUCOSE-264* NA+-141 K+-4.0 CL--103 TCO2-25
___ 07:57PM O2 SAT-63
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:45PM URINE RBC-3* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:15PM ___ PH-7.34*
___ 04:15PM GLUCOSE-GREATER TH NA+-137 K+-4.3 CL--95*
TCO2-19*
___ 04:15PM O2 SAT-75
___ 04:00PM GLUCOSE-695* UREA N-69* CREAT-3.4*#
SODIUM-137 POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-20* ANION
GAP-32*
___ 04:00PM estGFR-Using this
___ 04:00PM CK-MB-5 cTropnT-0.02*
___ 04:00PM PHOSPHATE-4.1 MAGNESIUM-2.8*
___ 04:00PM WBC-12.6*# RBC-4.55* HGB-9.8* HCT-32.5*
MCV-71* MCH-21.5* MCHC-30.2* RDW-16.6* RDWSD-41.1
___ 04:00PM NEUTS-89.0* LYMPHS-3.9* MONOS-6.4 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-11.25* AbsLymp-0.49* AbsMono-0.81*
AbsEos-0.00* AbsBaso-0.01
___ 04:00PM PLT COUNT-339
PERTINENT LABS:
==================
CHEM 10:
___ 10:00PM Gluc 183* UreaN 54* Cr 2.6* Na 142 K 4.3 Cl-108
HCO3 20
___ 01:13AM Gluc 141* UreaN 54* Cr 2.7* Na 142 K 4.3 Cl-107
HCO3 24
___ 06:09AM Gluc 206* UreaN 45* Cr 2.3* Na-141 K-3.7 Cl-107
HCO3-24
___ 09:47AM Gluc 130* UreaN-41* Cr 2.1* Na-140 K-3.6 Cl-105
HCO3-24
___ 03:18PM Gluc 279* UreaN-34* Cr 1.9* Na-136 K-4.2 Cl-103
HCO3-23
___ 12:45AM Gluc 239* UreaN-30* Cr-1.8* Na-136 K-4.0 Cl-101
HCO3-26
___ 05:55AM Gluc 203* UreaN-26* Cr-1.6* Na-137 K-3.9 Cl-101
HCO3-25
___ 06:20AM Gluc 136* UreaN-19 Cr-1.4* Na-138 K-3.7 Cl-102
HCO3-26
___ 05:55AM BLOOD %HbA1c-11.4* eAG-280*
___ 05:55AM BLOOD T4-4.3*
___ 05:55AM BLOOD TSH-1.6
___ 05:55AM BLOOD TSH-1.6
BLOOD GASES:
___ 04:15PM BLOOD ___ pH-7.34*
___ 07:57PM BLOOD ___ pH-7.38
___ 10:21PM BLOOD ___ pH-7.36
MICRO:
=======
___ 6:09 am BLOOD CULTURE BCx: Pending
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING:
=========
___ Renal US
1. Slightly elevated resistive indices ranging from 0.75 to
0.84, unchanged from ___.
2. No hydronephrosis.
___ CXR AP
The lungs are clear. The hila and pulmonary vasculature are
normal. No pleural abnormalities or pneumothorax. The
cardiomediastinal silhouette is normal. No fractures.
IMPRESSION: No pneumonia or pulmonary edema.
Brief Hospital Course:
============================
SUMMARY
============================
___ yo M with history significant for DM type 1, ESRD ___ ___ s/p
preemptive living related kidney transplant from his sister in
___, and daily episodes of syncope due to dysautonomia who
presents from OSH with DKA. BG was 900 with gap of 29 on first
presentation. Resolved with insulin gtt, IV fluids. Cause of DKA
was likely inadequate insulin administration given HgbA1c 11.4%.
Infection work-up was unremarkable, LFTs, lipase, and troponins
were normal. ___ endocrinologists were consulted who
recommended an adjusted regimen including finger sticks before
every meal as well as bedtime, and sliding scale Humalog to
correct these sugars at each of the finger sticks. His blood
sugars were been better controlled on this regimen. During the
hospitalization, patient had ___ which was treated with fluids
and Cr was back to baseline at discharge. patient had an episode
of syncope, due to his dysautonomia. The autonomic neurologists
were consulted and recommended increasing the dose of midodrine
to be taken during the day at specific times of 8am, 12 pm, 4pm
in addion to his home dose of fludracortisone. They also
recommended lifestyle modifications, and the patient was
educated on these. On ___, patient had a tilt table test. The
results were pending at the time of discharge, but patient was
adamant about going home despite education about the risks of
falling from dysautonomia and going back into DKA without
adequate blood glucose control.
=========================
TRANSITIONAL ISSUES
=========================
- Please repeat thyroid function tests as outpatient
- Initiate work-up for iron deficiency anemia given labs from
___: Fe 20, ferritin 18: should have colonoscopy.
- Follow up tilt table results done on ___ at ___ and
recommendations from autonomic neurologist
- Follow up on recommendations from ___
- Recommended that patient move into assisted living given
frequent episodes of syncope or at least move in with someone to
assist him but he refused. He was set up with ___.
# Communication: HCP is friend ___ ___.
Sister ___ ___. Also has sister ___.
# Code: Full
===============================
ACTIVE ISSUES TREATED
===============================
# Dysautonomia: Long hx of severe dysautonomia with orthostatic
hypotension and supine hypertension, difficult to control, on
midodrine and fludrocortisone at home. OSH records indicate
"extensive work-up" for this, felt to be from diabetes. Records
obtained from ___ and PCP. No mention of tilt table test.
Autonomic neurology consulted who recommended tilt table test
done ___. Also recommended continuing Fludrocortisone Acetate
0.1 mg PO BID, increasing Midodrine 10 mg PO TID (8AM, 12PM, 4PM
when sitting upright) during the day, and lifestyle
modifications including at night, elevating head of bed 30
degrees to prevent supine hypertension and sitting in chair with
feet dangling during the day
# DKA: BG 900 with gap of 29 on first presentation. Now resolved
s/p insulin gtt, IVF. Cause of DKA is likely non-compliance
given HgbA1c 11.4%. Otherwise, initially elevated WBC count that
has now normalized. CXR is normal. Bld, ___ cx negative. LFTs,
lipase normal. Troponins negative. Gap remained closed
throughout the remainder of hospitalization. ___ consulted
for DM management. Blood glucoses better controlled on 20u
Lantus qAM, 3u Humalog prandial, Humalog SS QACHS + bedtime.
# Acute on CKD: Baseline Cr mostly in 1.4-1.6 range, S/p living
donor transplant in ___. ___ likely hypoperfusion/pre-renal
is setting of DKA, now resolved. Cylcosporine levels remained in
appropriate range. Continued mycophenolate and cyclosporine at
home doses as well as Bactrim ppx.
# Anemia: Chronic anemia in ___ 2.2 ?CKD. Also some component
of iron deficiency anemia based on ferritin of 18 in ___. Does
not look to have been treated. Gave PO Iron Sulfate 325mg daily.
# Hematemesis: Originally presented with hematemesis x3-4d of up
to a cup full in the setting of recurrent vomiting ___ DKA.
Likely ___ tear. Treated with pantoprazole 40 mg BID.
Resolved. Hgb remained stable after initial drop. Patient still
with some epigastric pain. Patient may need EGD as outpatient if
pain persists.
# Arrythmia- EKG shows normal rate, but with irregular rhythm,
multiple p wave morphologies. Wandering pacemaker vs PVCs. Pt
asymptomatic.
# Urinary retention: Likely from dysautonomia with contribution
from BPH. Foley catheter placed and home tamsulosin continued.
Foley removed a couple days later with good UOP. Continued home
tamsulosin.
# Cognitive Disorder- Concern for underlying cognitive disorder
given patient's relative apathy about recurrent syncope and
falls at home, not wearing helmet outside on street,
uncontrolled DM1 with HgbA1c 11, weeks of high blood sugars in
500-600s without presenting for medical care, and multiple days
of hematemesis before presenting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fludrocortisone Acetate 0.1 mg PO BID
2. Midodrine 10 mg PO BID
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Mycophenolate Mofetil 500 mg PO TID
5. Vitamin D 1000 UNIT PO DAILY
6. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
7. Glargine 40 Units Breakfast
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Glargine 16 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Midodrine 10 mg PO TID
5. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
6. Fludrocortisone Acetate 0.1 mg PO BID
7. Mycophenolate Mofetil 500 mg PO TID
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Secondary:
Autonomic Dysfunction (Dysautonomia)
Hematemesis
Anemia
Cardiac arrhythmia
Acute on Chronic kidney disease
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, in need of assistance due to
recurrent syncope. Have counciled patient on need for wheel
chair or with helmet given recurrent syncope.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were vomiting blood for
several days. It was realized that this was because your blood
sugar was high and your blood was acidotic, a syndrome called
diabetic ketoacidosis. This can happen when you are not taking
enough insulin to keep your blood sugars in the normal range.
You improved with insulin and intravenous fluids. We consulted
the diabetes specialists at ___, who recommended some changes
to your insulin regimen. We made these adjustments (see
recommendations below), and your blood sugars were improved. The
blood in your vomit before coming to the hospital was likely due
to a tear in the tube to your stomach (esophagus) that can
happen with lots of vomiting. It was treated with an acid
suppressing drug to help it heal (pantoprazole). You should
continue taking this until your primary care doctor tells you to
stop.
While you were in the hospital, you had an episode of fainting,
which you said happens a lot at home due to problems with the
nerves that control your blood pressure (autonomic dysfunction).
The neurologists who specialize in this problem came to see you
and recommended a tilt table test to help clarify the diagnosis.
They did this and the results are pending. As you wanted to
leave the hospital, we arranged an appointment with your primary
care doctor on ___ (see below). You will also follow up
with the autonomic neurologist for recommendations about your
autonomic dysfunction. They will call you with an appointment.
You were found to have low iron and started on iron
supplementation. This may make your stool black and may make you
constipated. We recommend that you have a work up for this with
your PCP including ___ colonoscopy.
We recommended that you move to an assisted living facility or
at least live with someone to assist you given your frequent
episodes of fainting from low blood pressure. We recommend that
you obtain a life alert. We wanted to you stay in the hospital
longer so we could make a safe discharge plan but you insisted
on going home.
We wish you the best!
-Your ___ Care Team
Diabetes Management:
- Please take 20 units of lantus in the morning before breakfast
- Please take 3 units of Humalog with each meal.
- Take a blood sugar measurement before every meal and before
going to bed
- Use a sliding scale Humalog to correct meal-time sugars
Management of Fainting Spells due to Autonomic Nerve Problem:
- Wear a helmet at all times when walking
- Get up from sitting/lying very slowly
- At night, elevate head of bed to 30 degrees
- During the day, try to spend the majority of your time in a
chair with feet dangling
- Take Fludrocortisone Acetate 0.1 mg PO twice a day
- Take Midodrine 10 mg PO three times a day at 8AM, 12PM, 4PM
when sitting upright
- Keep a blood pressure log
- Follow up with the autonomic neurologist for more
recommendations
Followup Instructions:
___
|
10772285-DS-2
| 10,772,285 | 20,569,292 |
DS
| 2 |
2151-08-24 00:00:00
|
2151-08-24 15:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending: ___.
Chief Complaint:
L radius/ulna fracture
Major Surgical or Invasive Procedure:
ORIF of L radius/ulna
History of Present Illness:
___ right-hand dominant gentleman who presents with a
left both-bone
forearm fracture. He was at a concert at the ___
___
at ___ on ___ evening when he was pushed,
tripped and fell on to his left arm. He had immediate pain and
swelling as well as deformity. He was taken to an outside
hospital where he was found to have a both-bone forearm
fracture.
It was deemed too complicated for the institution at the time
and
he was referred to our clinic today for further evaluation and
treatment and surgical fixation. He presented and stated
that his pain has improved with icing and elevation and he
denies
any numbness, tingling or weakness in the left upper extremity.
Past Medical History:
Past medical history is notable for depression and anxiety as
well as hyperlipidemia.
Past surgical histories include a left foot surgery arch implant
complicated by infection, status post I and D and plastics
coverage.
Social History:
___
Family History:
NC
Physical Exam:
Physical Examination:
General: No acute distress, A and O x 3.
Skin: Intact with no evidence of discoloration. No evidence of
an open fracture.
Extremities: Left upper extremity splint in place, clean, dry
and intact. Sensation is intact to median, ulnar and radial
nerve distributions. Fingers are warm and well perfused with
good cap refill. He is able to fire the EPL, FPL and DIO of the
left hand. Limited flexion and extension of the wrist secondary
to pain. No movement of the elbow secondary to pain.
Pertinent Results:
___ 06:36PM GLUCOSE-85 UREA N-16 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-33* ANION GAP-12
___ 06:36PM estGFR-Using this
___ 06:36PM WBC-6.3 RBC-4.45* HGB-14.1 HCT-43.6 MCV-98
MCH-31.7 MCHC-32.3 RDW-12.7 RDWSD-45.6
___ 06:36PM NEUTS-56.5 ___ MONOS-9.5 EOS-4.3
BASOS-0.5 IM ___ AbsNeut-3.56 AbsLymp-1.81 AbsMono-0.60
AbsEos-0.27 AbsBaso-0.03
___ 06:36PM PLT COUNT-204
___ 06:36PM ___ PTT-31.5 ___
Brief Hospital Course:
The patient presented to outpatient clinic and was evaluated by
the orthopedic surgery team. The patient was found to have left
both bone radius/ulna fractures. The patient was reduced and
splinted on the left side and taken to the OR for ORIF. 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
non weightbearing on the left upper extremity, weight bearing as
tolerated on the left lower extremity, and will be discharged on
Aspirin 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:
Simvastatin 40 mg daily, Lexapro 5 mg daily and
hydromorphone 2 mg ___. p.r.n.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*120 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
___ hours Disp #*50 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left radial/ulna fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, independent
Discharge Instructions:
Mr. ___,
- ___ were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weightbearing in the left upper extremity, range of motion
as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 2 weeks
WOUND CARE:
- ___ may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
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