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10080679-DS-12	10,080,679	20,345,216	DS	12	2155-03-01 00:00:00	2155-03-01 12:55:00	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: ___ Laparoscopic appendectomy History of Present Illness: Mr. ___ is an otherwise healthy ___ man who presents with 10h history of abdominal pain. The pain began periumbilically and migrated to the right lower quadrant. He initially had one episode of diarrhea. Has not had any nausea or emesis. Denies fevers or chills. He has not wanted to eat since the pain began. Past Medical History: Past Medical History: seasonal and food allergies Past Surgical History: pilonidal cyst excision Social History: ___ Family History: Non-contributory Physical Exam: On admission: Vitals: 98.1 95 124/61 22 96% 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, very TTP RLQ, +obturator sign, -Rosving sign. No rebound, some voluntary gaurding Ext: No ___ edema, ___ warm and well perfused On discharge: VS 98.3, 80, 120/80, 14, 99% on room air. Pertinent Results: ___ 02:25AM BLOOD WBC-18.0* RBC-5.11 Hgb-15.5 Hct-45.7 MCV-89 MCH-30.2 MCHC-33.8 RDW-12.9 Plt ___ ___ 02:25AM BLOOD Neuts-79.7* Lymphs-13.9* Monos-5.1 Eos-1.0 Baso-0.3 ___ 02:25AM BLOOD Glucose-121* UreaN-14 Creat-0.8 Na-139 K-3.7 Cl-101 HCO3-21* AnGap-21* ___ 02:25AM BLOOD ALT-35 AST-32 AlkPhos-68 TotBili-0.6 ___ 02:25AM BLOOD Lipase-23 ___ 02:25AM BLOOD Albumin-4.9 ___ RUQ U/S (wet read) Findings consistent with acute appendicitis. No drainable fluid collection. Brief Hospital Course: Mr. ___ was admitted on ___ under the Acute Care Surgery service for management of his acute appendicitis. He was taken to the operating room and underwent a laparoscopic appendectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. Mr. ___ was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO intake. His diet was advanced to regular after his procedure, which he tolerated without abdominal pain, nausea, or vomiting. He initially complained of dysuria after his Foley catheter was removed, but had not issues with urination thereafter. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On the morning of ___, Mr. ___ was discharged home with scheduled follow up in ___ clinic. Medications on Admission: None. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #25 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: You were admitted to the hospital with acute appendicitis. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: Please follow up at the appointment in clinic listed below. We also generally recommend that patients follow up with their primary care provider after having surgery. We have scheduled an appointment for you 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 ___ 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" a couple 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 could have a poor appetite for a couple days. 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 dressings 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. Do not drink alcohol or drive while taking narcotic pain medication. 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: ___
10080928-DS-10	10,080,928	22,443,768	DS	10	2203-01-18 00:00:00	2203-01-18 17:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / quetiapine Attending: ___. Chief Complaint: Abdominal pain at site of biliary drain, nausea Major Surgical or Invasive Procedure: -Check and replacment of biliary drain with duct balloon dilatation History of Present Illness: ___ yo male with CAD, LBBB, right Bell's palsy, nephrolithiasis, history of severe PUD necessitating partial gastrectomy with RNY reconstruction, recent hospitalization for cholangitis due to CBD stricture, s/p internal-external biliary drain with concern for post-procedure pancreatitis vs. cholangitis after CBD plasty by ___, was discharged ___ with 1 wk of antibiotics and follow up. Underwent an internal metallic stent placement 1 day PTA. Did well during and post-procedure, but went home and developed significant abdominal pain in the RUQ. Oxycodone provided minimum relief. No fevers/chills. Previous had similar pain with manipulation that resolved over 24hrs. Denies fevers, chills, NS, SOB. Having BMs. No melena or blood. He does report some lower sternal pain that goes towards his stomach. In the ED, initial vitals were: 97.9 62 176/63 24 99% RA. On the floor, he has nausea, abdominal pain, and a headache but is otherwise in NAD. Past Medical History: -anxiety -B12 deficiency -R sided Bell's palsy -cholelithiasis -CORONARY ARTERY DISEASE: hx mi ___, cath no significant coronary disease, ett mibi, EF 61%, ___ neg, perfusion defect related to LBBB -nephrolithiasis -OA R knee -Parkinsonism from seroquel -PUD: s/p partial gastrectomy Social History: ___ Family History: Positive for father having had cancer. Mother had heart disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:97.6 BP:156/87 P:55 R: O2:100RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no teeth. R bell's palsy with atrophy of R muscles of mastication. Neck: supple, Lungs: Crackles in bases b/l, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender with some fluctuance around bile duct drain with some surrounding purulence. Bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: Vitals: T:98.2 ___ P:51-57 R:19 O2:99RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no teeth. R bell's palsy with atrophy of R muscles of mastication. Neck: supple, Lungs: CTA b/l, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender with some fluctuance around bile duct drain.. Bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION: ___ 10:15AM BLOOD WBC-8.1 RBC-4.30* Hgb-12.3* Hct-37.0* MCV-86 MCH-28.5 MCHC-33.2 RDW-14.2 Plt ___ ___ 10:15AM BLOOD Neuts-82.1* Lymphs-13.4* Monos-3.8 Eos-0.2 Baso-0.5 ___ 10:15AM BLOOD ___ PTT-29.4 ___ ___ 10:15AM BLOOD Glucose-126* UreaN-15 Creat-0.7 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-17 ___ 10:15AM BLOOD ALT-9 AST-20 AlkPhos-90 TotBili-0.5 ___ 11:54AM BLOOD ALT-7 AST-19 AlkPhos-81 Amylase-60 TotBili-0.4 ___ 10:15AM BLOOD Lipase-77* ___ 11:54AM BLOOD Lipase-63* ___ 10:15AM BLOOD cTropnT-<0.01 ___ 11:54AM BLOOD Albumin-3.9 ___ 03:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:00PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 03:00PM URINE RBC-5* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE: ___ 06:30AM BLOOD Lipase-19 ___ 06:35AM BLOOD WBC-7.2 RBC-3.91* Hgb-11.0* Hct-33.5* MCV-86 MCH-28.1 MCHC-32.7 RDW-14.3 Plt ___ ___ 06:35AM BLOOD Glucose-73 UreaN-12 Creat-0.7 Na-140 K-3.7 Cl-104 HCO3-27 AnGap-13 ___ 06:35AM BLOOD ALT-11 AST-16 AlkPhos-68 TotBili-0.5 ___ 06:35AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 MICRO: ___: UCx Negative ___: BCx pending STUDIES: ___: Cholangiogram FINDINGS: 1. Persistent high-grade stricture at the level of the distal CBD with moderate dilatation of the proximal CBD. There is minimal contrast flow through the stricture from above, despite several rounds of dilatation. 2. Placement of a 12 mm x 4 cm Luminexx stent through stenotic portion of the distal CBD with subsequent balloon dilatation. Good contrast flow into the duodenum on post-dilatation cholangiogram. 3. Replacement of external drainage anchor drain with tip terminating just proximal to metal stent. 4. Cholelithiasis. IMPRESSION: Persistent high-grade distal CBD stricture despite multiple rounds of aggressive dilatation consistent with failed response. Successful placement of an internal stent through the distal CBD stricture. Patient should return in 1 week for cholangiogram and removal of the anchor drain. ___: CXR IMPRESSION: Patchy nonspecific opacities in the left upper lung with a mild overall volume loss in the left hemithorax. Correlation with procedure findings is suggested regarding the location of the biliary stents. ___: Replacement of biliary drain ReportIMPRESSION: Preliminary Report1. Complete displacement of the anchor drain. Preliminary Report2. Holdup of contrast in the mid portion of the CBD stent. Preliminary Report3. Balloon dilatation of the area of narrowing within the CBD stent Preliminary Report4. Placement of a new ___ de-strung biliary drain through the stent. Brief Hospital Course: ___ yo male with CAD, LBBB, right Bell's palsy, nephrolithiasis, history of severe PUD necessitating partial gastrectomy with RNY reconstruction, recent hospitalization for cholangitis due to CBD stricture, p/w pain at bile drain site one day after manipulation of duct with new stent placement. ACTIVE ISSUES: # ?Post-procedural Pancreatitis/cholangitis: Pt. developed abdominal pain following stent placement. Had nausea, vomiting, and abdominal pain. Previously, had very similar symptoms with manipulation. ___ opened drain in ED. Some purulence coming around drain site. Lipase/LFTs normal. ___ went to ___ for dilatation and replacement of drain. Tolerated very well o/n. Was able to eat upon discharge. Sent home with Metoclopramide prn fo nausea and standing Tylenol, prn Oxycodone. # Normocytic Anemia: Hct dropped from 37 to 31. MCV 85. Possibly in the setting of fluid repletion. No signs of bleeding (bradycardic). Hct increased to 33. # Headaches: Patient with headaches that had been increasing from AM of admission. Felt most likely due to doses of Zofran for his nausea. Improved as this was substituted for Metoclopramide. No CN deficits, or other neuro symptoms. Improved AM ___ CHRONIC ISSUES: # Anxiety: Was changed to Seroquel previously. He was continued on brand name ___ due to reaction to substitute. # CAD: Continue ASA TRANSITIONAL ISSUES: - F/u with ___ to have drain pulled - F/u CXR: Showed atelectasis. Sent home with incentive spirometer but clinically saturating/breathing comfortably - F/u pending BCx's - Pending final read on biliary cath replace Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin ___ mcg PO DAILY 2. Nitroglycerin SL 0.3 mg SL PRN chest pain 3. Quetiapine Fumarate 37.5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin ___ mcg PO DAILY 3. Nitroglycerin SL 0.3 mg SL PRN chest pain 4. Quetiapine Fumarate 37.5 mg PO DAILY BRAND NAME ONLY DUE TO ALLERGY 5. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:0 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 7. Metoclopramide 10 mg PO QID:PRN nausea RX metoclopramide HCl 10 mg 1 tablet by mouth four times a day Disp #120 Tablet Refills:0 8. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp #30 Tablet Refills:0 9. Senna 1 TAB PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary Diagnosis: Post-procedural pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You came to ___ with abdominal pain and nausea due to your biliary drain. We treated you with medications and this improved. The doctors who put the drain in checked in and found it was too far out of your abdomen so they took you back to maneuver it and dialate the bile duct. Afterwards, your pain was well controlled and you were able to tolerate eating food. You should follow up with your doctors. Followup Instructions: ___
10080928-DS-8	10,080,928	25,710,110	DS	8	2202-09-18 00:00:00	2202-09-18 13:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / quetiapine Attending: ___. Chief Complaint: Abdominal pain, fevers. Major Surgical or Invasive Procedure: ___ ERCP ___ 1. Percutaneous transhepatic biliary drainage via right lobe access. 2. Crossing of distal CBD stenosis 3. Brush and forcep biopsies of the distal CBD. ___ 1. Cholangiogram. 2. Brushings and forceps biopsy. 3. Balloon dilation at the ampulla up to 10 mm. 4. Exchange of the 8 ___ drain for a 10 ___ internal-external biliary drain. History of Present Illness: Mr. ___ is a ___ year old male presenting from a rehabilitation facility after a right TKA on ___. He was transferred to ___ for evaluation of his abdominal pain and a reported fever > 100. He states that he has been having intermittent abdominal pain located in his RUQ for the past 2 months. He also reports some right shoulder pain as well. He denies any association with food. The pain usually resolved on its own and is "crampy" in nature. He did have a temperature of > 100 today at rehab. He also endorses recent bouts of nausea but no emesis. He is tolerating a diet with normal bowel function. He denies jaundice, diarreha, and melena. He does have a known history of gallstones but denies any similar attacks in the past. EMS found him to be "hypotensive" but no BP is recorded. His BP here was noted to be 84/48 which is responsive to IVF resuscitation. Of note he did well postoperatively after his right TKA. He was discharged to rehab with a Hct of 24. Past Medical History: PMH: Osteoarthritis right knee, h/o peptic ulcers, known gallstones, CAD with ? MI ___ years ago, anxiety PSH: Gastric resection for perforated peptic ulcer ___ years ago at ___, ventral incisional hernia repair x 2 (most recent one ___ years ago at ___ Social History: ___ Family History: Positive for father having had cancer. Mother had heart disease. Physical Exam: On admission: PE: 97.9, 60, 84/48, 18, 100% on room air Gen: no distress, alert and oriented x 3 HEENT: PERLA, EOMI, anicteric Chest: RRR, lungs clear bilaterally Abd: soft, nontender, nondistended, well healed midline incision with no obvious hernia appreciated Rectal: Ext: warm, well perfused, no edema On discharge: VS 99.6, 65, 107/65, 16, 96% on room air Pertinent Results: ___ 11:00PM BLOOD WBC-13.2# RBC-2.64 Hgb-7.9* Hct-24.2* MCV-92# MCH-29.9 MCHC-32.7 RDW-15.6* Plt ___ ___ 06:20AM BLOOD WBC-10.2 RBC-2.66* Hgb-7.7* Hct-23.9* MCV-90 MCH-29.1 MCHC-32.4 RDW-16.0* Plt ___ ___ 02:23AM BLOOD WBC-10.5 RBC-2.84* Hgb-8.6* Hct-25.3* MCV-89 MCH-30.3 MCHC-34.0 RDW-16.2* Plt ___ ___ 05:53AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.7* Hct-26.8* MCV-90 MCH-28.9 MCHC-32.3 RDW-15.8* Plt ___ ___ 08:50AM BLOOD WBC-12.7* RBC-3.41* Hgb-9.9* Hct-30.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.7* Plt ___ ___ 06:04AM BLOOD WBC-11.1* RBC-3.11* Hgb-9.1* Hct-28.0* MCV-90 MCH-29.1 MCHC-32.3 RDW-16.0* Plt ___ ___ 05:32AM BLOOD WBC-7.7 RBC-2.98* Hgb-8.6* Hct-26.8* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.8* Plt ___ ___ 07:35AM BLOOD WBC-6.7 RBC-3.43* Hgb-9.8* Hct-31.0* MCV-90 MCH-28.5 MCHC-31.6 RDW-15.6* Plt ___ ___ 09:15AM BLOOD WBC-6.9 RBC-3.57* Hgb-10.2* Hct-31.9* MCV-89 MCH-28.6 MCHC-32.0 RDW-15.5 Plt ___ ___ 11:00PM BLOOD Neuts-94.0* Lymphs-3.8* Monos-2.0 Eos-0 Baso-0.1 ___ 11:00PM BLOOD Plt ___ ___ 11:21PM BLOOD ___ PTT-30.0 ___ ___ 09:15AM BLOOD ___ PTT-31.0 ___ ___ 09:15AM BLOOD Plt ___ ___ 02:23AM BLOOD ___ ___ 11:00PM BLOOD Glucose-103* UreaN-27* Creat-0.9 Na-142 K-4.2 Cl-104 HCO3-27 AnGap-15 ___ 09:15AM BLOOD Glucose-104* UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-101 HCO3-26 AnGap-15 ___ 11:00PM BLOOD ALT-159* AST-279* AlkPhos-470* TotBili-1.5 ___ 06:20AM BLOOD ALT-119* AST-170* CK(CPK)-51 AlkPhos-360* TotBili-1.1 ___ 11:03AM BLOOD ALT-115* AST-136* AlkPhos-319* TotBili-1.1 DirBili-0.6* IndBili-0.5 ___ 02:23AM BLOOD ALT-90* AST-88* AlkPhos-289* TotBili-0.9 ___ 05:13AM BLOOD ALT-77* AST-114* LD(___)-373* AlkPhos-752* TotBili-0.9 ___ 06:04AM BLOOD ALT-58* AST-62* AlkPhos-581* TotBili-0.8 ___ 05:32AM BLOOD ALT-49* AST-44* AlkPhos-503* TotBili-0.8 ___ 05:16AM BLOOD ALT-40 AST-35 AlkPhos-445* TotBili-0.8 ___ 06:55AM BLOOD ALT-32 AST-27 AlkPhos-404* TotBili-0.8 ___ 07:35AM BLOOD ALT-28 AST-30 LD(LDH)-400* AlkPhos-383* TotBili-0.8 ___ 05:27AM BLOOD ALT-23 AST-23 AlkPhos-339* TotBili-0.7 ___ 09:15AM BLOOD ALT-25 AST-26 CK(CPK)-13* AlkPhos-361* TotBili-0.8 ___ 11:00PM BLOOD Lipase-34 ___ 06:04AM BLOOD Lipase-574* ___ 05:32AM BLOOD Lipase-121* ___ 05:16AM BLOOD Lipase-73* ___ 06:55AM BLOOD Lipase-104* ___ 11:00PM BLOOD proBNP-958* ___ 11:00PM BLOOD cTropnT-<0.01 ___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 09:15AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:00PM BLOOD Albumin-3.4* ___ 06:20AM BLOOD Albumin-2.8* Calcium-7.1* Phos-3.1 Mg-1.8 ___ 09:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 ___ 01:30PM BLOOD CEA-2.5 IMAGING: ___ ECG Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of ___ ventricular ectopy is no longer recorded. Otherwise, no diagnostic interim change. ___ CTA abdomen and pelvis Distended gallbladder with cholelithiasis and a significantly dilated common bile duct and pancreatic duct. There is no definite pericholecystic fluid or gallbladder wall thickening. Moderate intrahepatic biliary duct dilatation. 2. No evidence of pulmonary embolism. 3. Stable pulmonary nodules. 4. Right lower lobe consolidation may represent aspiration. ___ Liver/gallbladder U/S Very distended gallbladder filled with sludge and stones and a very dilated common bile duct. This may represent acute cholecystitis. ___ Common bile duct, distal, forceps biopsy: 1. Fragments of benign biliary mucosa. 2. Multiple levels have been examined. ___ Common bile duct (distal), brushing: ATYPICAL. Hypocellular specimen with rare groups of atypical glandular cells. ___ Biliary Drain Placement Uncomplicated right lobe percutaneous transhepatic biliary drain as above with biopsies and ___ internal-external drain placement. As above the findings suggest ampullary stricture versus sphincter of Oddi dysfunction; pathology will be pending. Of note, the cystic duct appeared patent. ___ile duct brushing results pending Brief Hospital Course: Mr. ___ was admitted to the inpatient ward under the Acute Care Surgery service for further evaluation of his abdominal pain and fevers. On presentation he had mild leukocytosis and a mildly elevated Tbili of 1.5. He underwent a RUQ US and CT scan which revealed cholelithiasis, dilated CBD up to 15mm, with mild intrahepatic ductal dilatation. There was no evidence of pericholecystic fluid or wall thickening. He was initiated on Unasyn and then cipro/flagyl. An ERCP was attempted, but could not access his ampulla due to his reconstructed anatomy. Instead a PTBD was placed, during which cholangiography demonstrated stenosis of his distal CBD, and brushings were performed. A clamping trial of the PTBD was attempted, but the insertion site began to leak biliary fluid. On further evaluation, it was found that the PTBD drain became clogged, which required him to return to Interventional Radiology for placement of a larger drain. During the same procedure, the patient underwent a balloon dilation of his ampulla. Brushings and biopsy specimens were obtained as well. At the time of this writing, the patient's alk phos was stable at 361. His lipase continues to downtrend, now at a level of 104. Prior to this admission, Mr. ___ recently underwent a right knee replacement on ___. From an orthopedic standpoint, the patient has progressed well. Physical therapy was consulted and has worked with the patient multiple times while an inpatient. His staples have been removed and the wound is healing well. His is weight bearing as tolerated to the right lower extremity. On the evening prior to discharge, Mr. ___ stated he had chest pain. His ECG had no acute findings. Troponin levels were normal. Blood cultures were also drawn (results pending). He has had no further instances of chest pain since that time. His hematocrit level is stable at 31 (max low of 23.9 on admission). At the time of discharge, Mr. ___ is hemodynamically stable and afebrile. He did complain of some gum soreness, so his cardiac diet was changed to one with soft consistencies. Viscous lidocaine has been ordered PRN for short-term pain relief. He should be further evaluated if he continued to have pain when wearing his dentures. His pain has been managed well with narcotic and non-narcotic analgesics. His last dose of ciprofloxacin and metronidazole will be tomorrow, ___. He has no leukocytosis. He has received pantoprazole for GI prophylaxis and subcutaneous heparin for DVT prophylaxis. Mr. ___ is now being discharged to a rehabilitation facility. He is in no acute distress and is expected to recover well. His right lower quadrant drain remains in place. An appointment has been made with Dr. ___ of ___ service for follow-up within one week. He should also follow up with orthopedics regarding his prior knee replacement surgery. Lastly, the patient will need to follow up with Interventional Radiology for a likely dilation of his ampulla. Medications on Admission: Aspirin 81mg daily, seroquel 37.5mg qam Discharge Medications: 1. Bisacodyl 10 mg PR HS:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Lidocaine Viscous 2% 20 mL PO TID:PRN mouth/gum pain Duration: 2 Days 4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q24H 6. Quetiapine Fumarate 37.5 mg PO QAM 7. Senna 1 TAB PO BID:PRN constipation 8. Ciprofloxacin HCl 500 mg PO Q12H 9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 10. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Cholangitis Distal common bile duct stricture 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 ___ on ___ after you were experiencing abdominal pain and fevers while at a rehabilitation facility. On further evaluation, a CT scan showed a dilated common bile duct and pancreatic duct. On ___, you had an ERCP to further evaluate your ducts. At that time, the procedure could not be completed because your anatomy was difficult due to your prior Roux-en-Y surgery. You were then transferred back to the inpatient ward for further recovery and management. On ___, you were taken to the radiology department where a drain was placed into your right liver lobe. You tolerated the procedure well. As you began to improve, an attempt was made to cap off the drain to see how you tolerate it. However, bile began leaking from around the insertion site. It was then uncapped so the drainage could flow freely. On further exam in radiology, the tube was found to be clogged. On ___, you returned to the radiology for a cholangiogram, dilation of your ampulla and replacement of your biliary drain to a larger one. Due to your recent knee replacement, you were seen by Orthopedics and physical therapy. Your knee staples have been removed. Physical therapy has worked with you during your stay. You will continue to receive physical therapy at the ___ facility. You have now recovered well from the above procedures and are ready to be discharged to a rehabilitation facility for continued recovery. o Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. o Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. DRAIN CARE: o Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). o If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. o Wash the area gently with warm, soapy water. o Keep the insertion site clean and dry otherwise. o Avoid swimming, baths, hot tubs; do not submerge yourself in water. o Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10080961-DS-6	10,080,961	26,875,005	DS	6	2140-03-28 00:00:00	2140-04-01 12:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___ Chief Complaint: anemia Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ yo female with a PMH significant for ESRD secondary to Polycsystic Kidney disease s/p living donor unrelated kidney transplant on ___ complicated by renal artery thrombosis s/p bovine patch angioplasty who presented to ___ with cough, fever and significant anemia. Patient is on dialysis 3 times a week following complications from renal biopsy, although produces urine, but without solute clearance. On Neupogen as outpatient but gradual decline of Hct, Hgb 5.5 at ___. Pt denies bleeding in her stool, urine and has no abdominal pain or headache. Negative guaiac exam, negative hemoloysis, and iron studies consistent with ACD. Of note, patient reportedly w low-grade fever and dry cough over the last one week. CXR at ___ left basilar atelectasis versus developing infiltrate. Short-term follow-up suggested. Pt given cefepime empirically for HCAP coverage. No documentation of vancomycin. Past Medical History: - End-stage renal disease with associated hyperparathyroidism and anemia s/p LURT ___ - Polycystic Kidney Disease - Hypertension - Hyperlipidemia Social History: ___ Family History: - Father had ___ s/p renal transplant x2 - Mother with diabetes Physical Exam: ADMISSION EXAM: Vitals: VS: 98.8 Tmax99.4 136/95 102 18 100RA General: Alert, oriented, no acute distress , very pleasant young lady HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD Chest: Tunneled catheter noted in right chest, non-tender. CV: Tachycardic rate and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: subtle R basilar crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding . Renal allograft is in LLQ, nontender with a well-healed incision. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: VS: 98.2 99 147/98 (127-155/84-104) 88 (88-102) 18 99-100% RA General: Alert, oriented, no acute distress , very pleasant young lady HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD Chest: Tunneled catheter noted in right chest, non-tender. CV: Tachycardic rate and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: subtle R basilar crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding . Renal allograft is in LLQ, nontender with a well-healed incision. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABORTAORY STUDIES: ============================== ___ 11:10PM WBC-4.2 RBC-1.85* HGB-5.7* HCT-17.5* MCV-95 MCH-30.8 MCHC-32.6 RDW-17.1* RDWSD-5802* ___ 11:10PM NEUTS-84* BANDS-1 LYMPHS-7* MONOS-5 EOS-3 BASOS-0 ___ MYELOS-0 AbsNeut-3.57 AbsLymp-0.29* AbsMono-0.21 AbsEos-0.13 AbsBaso-0.00* ___ 11:10PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-OCCASIONAL ___ 11:10PM ___ PTT-39.4* ___ ___ 11:10PM HAPTOGLOB-320* ___ 11:10PM GLUCOSE-99 UREA N-16 CREAT-4.5* SODIUM-129* POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-26 ANION GAP-17 ___ 11:10PM LD(LDH)-401* TOT BILI-0.4 ___ 11:10PM CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.8 ___ 02:40AM RET AUT-2.1* ABS RET-0.04 DISCHARGE LABORATORY STUDIES: =============================== ___ 02:40AM WBC-4.1 RBC-1.93* HGB-6.1* HCT-18.3* MCV-95 MCH-31.6 MCHC-33.3 RDW-16.9* RDWSD-58.0* ___ 02:40AM NEUTS-87* BANDS-0 LYMPHS-7* MONOS-3* EOS-2 BASOS-1 ___ MYELOS-0 AbsNeut-3.57 AbsLymp-0.29* AbsMono-0.12* AbsEos-0.08 AbsBaso-0.04 ___ 02:40AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ___ 09:25AM ___ PTT-39.8* ___ ___ 09:25AM WBC-5.1 RBC-2.62# HGB-8.2# HCT-24.3# MCV-93 MCH-31.3 MCHC-33.7 RDW-16.9 RDWSD-55.8* ___ 09:25AM ALBUMIN-2.9* CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-1.8 ___ 09:25AM tacroFK-7.9 ___ 09:25AM ALT(SGPT)-7 AST(SGOT)-12 ALK PHOS-73 ___ 09:25AM GLUCOSE-82 UREA N-19 CREAT-5.3* SODIUM-130* POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-22 ANION GAP-20 ___ 04:22PM URINE RBC-9* WBC-38* BACTERIA-FEW YEAST-NONE EPI-3 TRANS EPI-<1 ___ 04:22PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD ___ 04:22PM URINE COLOR-Straw APPEAR-Clear SP ___ IMAGING: ================================= CXR: As compared to the previous radiograph, the appearance of the cardiac silhouette and of the right lung is unchanged. On the left, there is minimal elevation of the hemidiaphragm and a small platelike atelectasis at the left lung bases. No evidence of pneumonia. Brief Hospital Course: This is a ___ yo female with a PMH significant for ESRD ___ ___ s/p LURT <90d, c/b RA thrombosis s/p bovine patch angioplasty who presented to ___ with cough and significant anemia. #Anemia: she has previously been reluctant to get transfusions, but on admission was more agreeable given her fatigue. Admission hgb 5.7, improved to 8.8 after receiving 3 units PRBCs total (1 unit at ___ and 2 units at ___. She had no transfusion reactions noted during the admission. She had no evidence of bleeding, guaiac negative stool, hemoylsis labs negative, and remained hemodynamically stable during admission. Labs consistent with anemia of chronic inflammatory disease. #Low grade fevers: she presented with low grade fevers, dry cough, and intermittent diarrhea so infectious workup sent. Urinalysis consistent with known chronic pyuria but urine culture negative. CXR negative. Cdif and fecal culture negative (except viral culture still pending). Blood cultures are still pending but have shown no growth to date. On discharge, patient reported that her diarrhea had improved. Patient advised to call immediately if diarrhea returns or she has infectious symptoms like fevers or chills. #ESRD s/p LURT now on dialysis: Received HD on ___. # Immunosuppression. She was continued on her home tacrolimus 7 mg twice daily and mycophenolate 1 g twice daily. Her target tacro trough is ___. Taco level increased from 7.9 to 13.5 on discharge on her stable home dose of 7 mg q12h. We did not change her dose on discharge; however, she should have Tacro level drawn on ___. #Supratherapeutic INR: admission INR 4.3 so Warfarin held and increased to 5.1 on discharge, likely in setting of getting Cefepime at OSH. She was discharged with a plan for INR to be drawn on ___ with Warfarin adjusted accordingly. Transitional Issues Consider weekly CBC to assess H&H and tranfuse for Hgb <7 Will Need INR drawn on ___ with Warfarin adjusted accordingly. Taco level increased from 7.9 to 13.5 on discharge on her stable home dose of 7 mg q12h. We did not change her dose on discharge; however, she should have Tacro level drawn on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. Famotidine 20 mg PO DAILY 3. Mycophenolate Mofetil 1000 mg PO BID 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. ValACYclovir 500 mg PO Q24H 6. Warfarin 3 mg PO DAILY 7. sevelamer CARBONATE 800 mg PO TID W/MEALS 8. Multivitamins 1 TAB PO DAILY 9. Simvastatin 10 mg PO QPM 10. Tacrolimus 7 mg PO Q12H 11. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) Discharge Medications: 1. Famotidine 20 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Mycophenolate Mofetil 1000 mg PO BID 4. sevelamer CARBONATE 800 mg PO TID W/MEALS 5. Simvastatin 10 mg PO QPM 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Tacrolimus 7 mg PO Q12H 8. ValACYclovir 500 mg PO Q24H 9. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 10. Carvedilol 25 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for your worsening anemia. Your received 1 unit of blood at ___ and 1 unit at ___, with improvement of your anemia. You also had an elevated INR, so we held your Warfarin. We decreased your dose from 3mg daily to 2.5mg daily. It is important for you to follow-up on your INR and Warfarin dosing as it is 5.1 on discharge, likely from an interaction with an antibiotic at the outside hospital. Thus, do not restart your warfarin until you have your level checked; it should be drawn in HD on ___. It was a pleasure taking care of you. Sincerely, Your ___ renal team. Followup Instructions: ___
10081375-DS-6	10,081,375	26,017,796	DS	6	2179-07-10 00:00:00	2179-07-10 15:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: coffee ground emesis, melena, RUQ pain Major Surgical or Invasive Procedure: Endoscopy ___ Diagnostic paracentesis ___ and ___ History of Present Illness: ============================================================ MEDICINE ADMISSION NOTE Date of admission: ___ ============================================================ PRIMARY CARE PHYSICIAN: ___ MD CHIEF COMPLAINT: GI Bleeding HISTORY OF PRESENT ILLNESS: This is a ___ male with h/o EtOH cirrhosis presenting with abdominal pain, vomiting, and melena. He reports developing the RUQ abdominal pain after an episode of black-appearing vomiting 3d prior to presentation. He also noted that his stools appeared black at this time. He has continued to have melena and non-bloody non-bilious emesis, with 5 episodes of emesis 1 day prior to presentation. This has been associated with subjective fevers/chills, lightheadedness, and dark urine. He endorses increasingly productive cough (has chronic cough at baseline) and new exertional SOB. He denies any headache, syncope, CP, jaundice, pruritus, diarrhea, dysuria, hematuria, ___ edema. Of note, over the past few weeks, he has noted progressively increasing abdominal girth and occasional light-colored stools. He was seen at ___ ___ today, where VS were notable for T 102.4, otherwise stable. A CT abd/pelvis was performed, which showed cirrhosis, portal hypertension, splenomegaly, and periesphageal, perigastric, and perisplenic varices, as well as possible main portal vein and SMV thrombosis. The patient rec'd 3L IVF, morphine, reglan, Benadryl, zosyn and tylenol; and was subsequently transferred to ___ for further evaluation. In the ED, initial vitals: T 97.6 HR 83 BP 122/67 RR 16 SpO2 96% RA - Exam notable for: Minimal diffuse tenderness, diffuse wheeze, distended abdomen with fluid wave. - Labs notable for: H/h 11.3/33.5 Plt 35 INR 1.6 Na 132 Glu 200 Lactate 2.2 AST/ALT 51/31 ALP 134 Tbili 3.6 Alb 2.9 - Imaging notable for: CT A/p: RUQUS: Cirrhotic liver, splenomegaly, small ascites, patent PV w partial thrombus in main PV and SMV, R pleural effusion. CXR: Small R pleural effusion, RLL infiltrate - Paracentesis performed w return of 20cc straw-colored fluid - Hepatology was consulted who recommended: Admit to floor ___ under Dr. ___, NPO for EGD tomorrow. Zosyn for SBP ppx and tx of PNA. Pan culture. - Pt given: Zosyn, Pantoprazole, Octreotide, Morphine, Zofran - Vitals prior to transfer: HR 82 BP 102/55 RR 18 SpO2 94% RA On the floor, he notes improvement in his abdominal pain after receiving morphine. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: PAST MEDICAL HISTORY: Cirrhosis (h/o of variceal bleeding s/p banding; ascites tapped multiple times in ___ Dieulafoy lesion (s/p endoscopic therapy ___ years ago) Colonic polyps (on colonoscopy ___ years ago) LLE compound fracture ___ motorcycle accident Lyme Babesiosis Social History: ___ Family History: FAMILY HISTORY: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: GENERAL: AOx3, attentive, NAD HEENT: Normocephalic, atraumatic. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. No gynecomastia. LUNGS: Diffuse inspiratory and expiratory wheezing. No ronchi or rales. No increased work of breathing. No dullness to percussion. ABDOMEN: Distended, not tense, + fluid wave. Tender to deep palpation in RUQ. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No palmar erythema or spider angiomata. NEUROLOGIC: No asterixis. DISCHARGE PHYSICAL EXAM: ___ 0747 Temp: 98.1 PO BP: 91/56 HR: 75 RR: 20 O2 sat: 93% O2 delivery: ra GENERAL: AOx3, attentive, NAD, no asterixis HEENT: Normocephalic, atraumatic. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. No gynecomastia. LUNGS: Small crackles at left lung base. ABDOMEN: Distended, not tense, + fluid wave. Dull to percussion. Non tender. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No palmar erythema or spider angiomata. NEUROLOGIC: No asterixis. Pertinent Results: ADMISSION LABS: ___ 02:02PM BLOOD WBC-5.5 RBC-3.61* Hgb-11.3* Hct-33.5* MCV-93 MCH-31.3 MCHC-33.7 RDW-16.0* RDWSD-54.6* Plt Ct-35* ___ 02:02PM BLOOD Neuts-73.1* Lymphs-13.3* Monos-11.3 Eos-1.5 Baso-0.4 Im ___ AbsNeut-4.01 AbsLymp-0.73* AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02 ___ 02:02PM BLOOD ___ PTT-31.3 ___ ___ 02:02PM BLOOD Glucose-200* UreaN-11 Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-22 AnGap-13 ___ 02:02PM BLOOD ALT-31 AST-54* AlkPhos-134* TotBili-3.6* ___ 06:10AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.4* Mg-1.5* DISCHARGE LABS: ___ 08:21AM BLOOD WBC-2.4* RBC-3.60* Hgb-11.5* Hct-34.0* MCV-94 MCH-31.9 MCHC-33.8 RDW-16.5* RDWSD-55.6* Plt Ct-40* ___ 08:21AM BLOOD ___ ___ 08:21AM BLOOD Glucose-153* UreaN-7 Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-23 AnGap-13 ___ 08:21AM BLOOD ALT-24 AST-45* AlkPhos-122 TotBili-2.4* ___ 08:21AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 PERITONEAL FLUID LABS: ___ 16:17 TNC 727* RBC 1591* POLYS 5* ___ 14:45 TNC 2546* RBC 1669* POLYS 90* CT A/P: 1. Limited by a poor contrast bolus and poor opacification of the portal venous system. Within these limitations, there is nonocclusive thrombosis in the main portal vein and also the superior mesenteric vein. In addition, there are eccentric linear calcifications adjacent to these areas of nonocclusive thrombosis which may suggest a chronic component. Correlation with any available prior imaging is recommended. 2. There is wall thickening of the ascending colon which is nonspecific and could be secondary to inflammation or portal colopathy. 3. Wall thickening of the fourth portion of the duodenum which could be secondary to inflammation. 4. Cirrhotic morphology liver with moderate volume ascites, varices, and splenomegaly. 1. Cirrhotic liver with splenomegaly and small amount of ascites. 2. The main portal vein is patent with normal hepatopetal flow. Region of eccentric partial thrombus seen within the proximal main portal vein and portion of the SMV was better seen by same-day CT scan. 3. Right pleural effusion. Brief Hospital Course: Mr. ___ is a ___ male with h/o EtOH cirrhosis presenting with fever, abdominal pain, melena, coffee ground emesis, found to have SBP, partial portal vein thrombus, and portal hypertensive gastropathy with esophageal varices. # Cirrhosis c/b GI Bleed and SBP: Melena and coffee ground emesis on admission found to have esophageal varices and portal hypertensive gastropathy on EGD with friable gastric mucosa, no active variceal bleed. Febrile to 102.4 at OSH, HDS after 4L IVF. Paracentesis performed in ED, results c/w SBP. MELD 21 on day of admission. Patient was treated with ceftriaxone IV ×5 days and albumin per SBP protocol. Patient was treated with octreotide ×3 days and twice daily PPI. He was not given any lactulose due to history of excessive diarrhea with lactulose and no further encephalopathy. Discharged on ciprofloxacin 500 mg daily for ppx. Also restarted on reduced dose diuretics at 20 mg furosemide and 50 mg spironolactone. Also discharged on home 40 mg nadolol daily. #PORTAL VEIN THROMBOSIS: RUQUS region of eccentric partial thrombus seen within the proximal main portal vein and portion of the SMV, with patent main portal vein and normal hepatopetal flow. CT at OSH showed partial thrombus. In setting of bleed, holding anticoagulation. Will need anticoagulation as outpatient and close monitoring in a couple weeks when acute bleed is resolved. # Cough, SOB: Patient denies cough, SOB this AM compared to on admission. Flu negative. Patient appears well and will narrow to Ceftriaxone. Unclear if patient truly had pneumonia. After first day of admission patient did not have any further symptoms of cough or shortness of breath, denies diagnosis of pneumonia seems unlikely. #Leukopenia #Thrombocytopenia: Per records patient has platelets of 50 in ___. Attributed to liver disease. Platelets stable in the ___ here. CHRONIC ISSUES: =============== # Chronic Pain - Continued oxycodone 15mg BID PRN # Anxiety: - Continued home Ativan 2mg QAM and 1 mg QHS # Tobacco use - Smoking cessation education - Nicotine patch TRANSITIONAL ISSUES: - He needs follow-up with his PCP and GI doctor. - Needs EGD and banding as outpatient in ___ weeks. - Will need liver ___ outpatient f/u and eval for transplant. - Needs to discuss anticoagulation as outpatient for portal vein thrombosis. - Needs twice daily PPI due to acute GI bleeding. - Discharged on 20 mg Furosemide, 50 mg Spironolactone, 40 mg Nadolol daily. Please uptitrate diuretics as needed based on exam. Please repeat Chem7 at next clinic visit. - Please do thrombophilia work up at next PCP or GI doctor visit. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 40 mg PO DAILY 2. Spironolactone 100 mg PO DAILY 3. Nadolol 40 mg PO DAILY 4. LORazepam 1 mg PO TID 5. OxyCODONE (Immediate Release) 15 mg PO BID:PRN Pain - Severe 6. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO DAILY RX ciprofloxacin HCl 500 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. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Spironolactone 50 mg PO DAILY RX spironolactone 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. LORazepam 1 mg PO TID 6. Nadolol 40 mg PO DAILY 7. OxyCODONE (Immediate Release) 15 mg PO BID:PRN Pain - Severe Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Spontaneous bacterial peritonitis Alcoholic cirrhosis Upper GI bleed Portal hypertensive gastropathy Esophageal varices Portal vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It has been a pleasure taking care of you at ___. Why was I here? - You were admitted due to clots in the blood vessels in your liver, and infection in the fluid in your belly. -You were also vomiting up dark blood. What was done for me here? -You had an endoscopy, which showed that you have new varices in your esophagus. It also showed that you have portal hypertensive gastropathy, and that is where the bleeding was felt to be coming from. -You were treated for an infection of the fluid in your belly called SBP. You were given IV antibiotics for 5 days. -You are not started on anticoagulation because of your risk of bleeding. What should I do want to go home? - Used to take your medications as prescribed. - You should follow up with your gastroenterologist and with the ___ at ___. - You need a repeat endoscopy for your new varices. Sincerely, Your ___ team Followup Instructions: ___
10081525-DS-15	10,081,525	28,566,281	DS	15	2148-02-04 00:00:00	2148-02-04 14:35:00	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 fall down stairs Injuries: Left ___ posterior rib fractures Splenic injury (type V) Major Surgical or Invasive Procedure: ___ Exploratory laparotomy, splenectomy History of Present Illness: This patient is a ___ year old male who complains of TRAUMA STAT. The patient is status post fall down 5 steps. This was a mechanical fall. This occurred at 8 ___. There was no loss of consciousness. He does have a left hand abrasion. Care negative head and neck CT at the outside hospital. By torso CT he has a splenic laceration. He's had episodes blood pressure to 68 systolic. He is receiving packed red blood cell transfusion. On chest x-ray and CT has left hemothorax with left rib fractures. Past Medical History: Bilateral knee surgeries, carpal tunnel syndrome BUE Social History: ___ Family History: Non contributory Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ HR: 120 BP: 93 systolic Resp: 100% Normal Constitutional: Comfortable Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, left upper quadrant tenderness but no rebound Extr/Back: No cyanosis, clubbing or edema the back is nontender Skin: No rash Neuro: Speech fluent Pertinent Results: ___ 08:50AM BLOOD WBC-12.6* RBC-3.19* Hgb-9.7* Hct-29.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-13.7 Plt ___ ___ 08:50AM BLOOD WBC-12.6* RBC-3.19* Hgb-9.7* Hct-29.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-13.7 Plt ___ ___ 05:24AM BLOOD WBC-12.6* RBC-3.31* Hgb-10.3* Hct-30.6* MCV-93 MCH-31.0 MCHC-33.5 RDW-14.1 Plt ___ ___ 12:00AM BLOOD WBC-16.0* RBC-3.33* Hgb-9.6* Hct-30.8* MCV-93 MCH-28.9 MCHC-31.3 RDW-13.6 Plt ___ ___ 08:50AM BLOOD Plt ___ ___ 05:24AM BLOOD ___ PTT-31.4 ___ ___ 12:00AM BLOOD ___ ___ 08:50AM BLOOD Glucose-137* UreaN-23* Creat-0.8 Na-138 K-4.1 Cl-107 HCO3-25 AnGap-10 ___ 05:24AM BLOOD Glucose-131* UreaN-25* Creat-0.9 Na-139 K-4.3 Cl-108 HCO3-25 AnGap-10 ___ 02:16AM BLOOD Glucose-168* UreaN-24* Creat-0.9 Na-141 K-4.8 Cl-115* HCO3-20* AnGap-11 ___ 04:23PM BLOOD CK(CPK)-761* ___ 09:30AM BLOOD CK(CPK)-720* ___ 12:05AM BLOOD cTropnT-0.01 ___ 04:23PM BLOOD CK-MB-17* MB Indx-2.2 ___ 02:16AM BLOOD cTropnT-0.13* ___ 08:50AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.1 ___: chest x-ray: FINDINGS: The lungs are low in volume, but clear. Cardiomediastinal contours are unremarkable with normal heart size. Displaced fracture of the one of the left lower ribs is noted without definite pneumothorax or pleural effusion on this supine film. Note, the right costophrenic angle is excluded, but the patient was ___ transferred to the operating room, so repeat images were not obtained ___ ekg: Baseline artifact. Sinus tachycardia. Leftward axis. T wave abnormalities. No previous tracing available for comparison. ___: Chest x-ray: IMPRESSION: 1. The NG tube terminates in the fundus of the stomach. 2. Lung volumes are low and bibasilar atelectasis is mild. Brief Hospital Course: The patient was admitted to the hospital after a fall. In emergency room, found to have a + FAST. Upon admission, he was made NPO, given intravenous fluids, and underwent radiographic imaging. Chest x-ray imaging showed left displaced posterior rib fracture, but no evidence of pneumothorax. By torso cat scan, he was found to have a splenic laceration. He was reported to have isolated episodes of hypotension and he received a unit of packed red blood cells. He was transferred to the Trauma ICU for close monitoring. On HD # 2 he was taken to the operating room where he underwent an exploratory laparotomy and splenectomy. The operative course was notable for a 2 liter blood loss in the abdominal cavity. The abdomen was packed in all 4 quadrants. Once the hemorrhage was controlled, the packs were systematically removed. A ___ tube was placed for bowel decompression. The patient was extubated after the procedure and transferred back to the intensive care unit for ongoing monitoring. During this time, he was reported to have ST changes on his EKG and troponins were cycled, initially at .13 but subsequently trended down to .01. He was transferred to the surgical floor once hemodynamically stable in the ICU. His vital signs continued to be closely monitored along with serial hematocrits have been monitored with a current hematocrit of 26. The ___ tube was removed on POD 3 once bowel function returned and his diet was slowly advanced. He was noted with intermittent drops in his oxygen saturations associated with thick green sputum and productive cough. CXR was done showing bibasilar atelectasis worse on the left and unchanged on the right and a new small left pleural effusion. CTA of the chest was also done to assess for pulmonary emboli and this was ruled out. The CTA also showed chronic obstructive airway disease. Given his exam and greenish sputum production he was started on ___ugmentin. Incentive spirometry was encouraged in addition to scheduled nebulizers, chest ___ and cough and deep breathing. His oxygen was weaned and his room air saturations were 90-92% without any symptoms of dyspnea. A follow up CXR on day of discharge showed overall improvement as well. Upon further discussion with patient it was discovered that he had a long tobacco use history consisting of 4 packs/day. He was discharged home in stable condition on ___ with an appointment to follow up with his ___ clinic and was also instructed to follow up with his PCP for pneumonia and obstructive airway disease. He will have visiting nursing services who will remove his staples in about 1 week. Medications on Admission: Claritin ASA 81 daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID RX metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 3. Docusate Sodium 100 mg PO BID 4. Acetaminophen 1000 mg PO Q8H 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days RX amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #8 Tablet Refills:0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #80 Tablet Refills:0 7. Senna 1 TAB PO BID:PRN constipation 8. TraMADOL (Ultram) 50 mg PO QID RX tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #180 Tablet Refills:1 9. Tucks Hemorrhoidal Oint 1% ___AILY hemorrhoids 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing RX albuterol sulfate 90 mcg 2 puffs every 6 hours Disp #1 Inhaler Refills:2 11. Ipratropium Bromide Neb 1 NEB IH Q6H RX ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 puff every 6 hours Disp #1 Inhaler Refills:2 Discharge Disposition: Home With Service Facility: ___ ___: s/p Fall Injuries: Left posterior rib fractures Grade V splenic injury Secondary diagnosis: Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you had fallen down some stairs. You were found to have a splenic laceration and left sided rib fractures. You were taken to the operating room where you had your spleen removed. You were monitored in the intensive care unit. Your vital signs have been stable and you are slowly recovering from your fall. You are preparing for discharge home with the following instructions: Followup Instructions: ___
10081573-DS-10	10,081,573	25,935,442	DS	10	2130-01-13 00:00:00	2130-01-13 12:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / Penicillins Attending: ___. Chief Complaint: trauma: left acetabular and R ___ rib fxs Major Surgical or Invasive Procedure: ___ ORIF transverse acetrabular fracture with posteiro wall comminution and dislcoated/subluxed hip History of Present Illness: This patient is a ___ year old female who complains of hip pain. This patient has diabetes and takes insulin. She was driving her car. She felt as if her blood sugar was getting low and before she could give herself some glucose, she crashed her car into a pole. She was belted. When the paramedics arrived, her fingerstick sugar was 50 and they gave her an amp of D50. They took her to outside hospital where her trouble workup disclosed multiple right-sided rib fractures as well as a left acetabular fracture. She was transferred here for trauma evaluation. Past Medical History: PMH: Type II diabetes managed with lantus (24 units at bedtime) and humalog (sliding scale); hyperlipidemia; hypercholesterolemia; asthma (last ED visit for asthma exacerbation ___ yr ago); seasonal allergies; depression; chronic low back pain w/radiculopathy into left thigh. PSH: Tonsilectomy as a child; hysterectomy (due to leiomyomas/uterine bleeding); spinal fusion C4-7 (due to disk herniation and radiculopathy) in ___. Social History: ___ Family History: non contributory Physical Exam: Afebrile, vital signs stable General: NAD HEENT: MMM, on scleral icterus Neuro: A&Ox3 Cardiac: RRR Pulmonary: CTAB Abdomen: Soft, NT/ND Extremities: surgery site c/d/i, no erythema or purulence. extremities warm and well perfused Pertinent Results: ___ CT Torso: IMPRESSION: 1. No evidence of acute intrathoracic or intra-abdominal injury. 2. Displaced right second through fourth rib fractures. 3. Comminuted left acetabular fracture involving the base of the ileum and the posterior column with associated posterior and superior subluxation of the left femoral head. 4. Collar of hazy mesentery / retroperitoneal fat and small lymph nodes surrounding the infrarenal abdominal aorta. Correlate with inflammatory markers on a nonurgent basis, as vasculitis could have a similar appearance. ___ Head CT: No acute intracranial process. Brief Hospital Course: The patient was admitted to the acute care surgery service on ___ after a MVC. She was found to have R ___ displaced rib fxs and comminuted l acetabular fx. She went to the operating room on ___, and a open reduction, internal fixation, transverse posterior wall acetabular fracture with columnar plating and posterior wall reconstruction using allograft for support of marginal impaction was performed by the orthopedic surgery service. The operation went well without complication (refer to operative note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor. The ___ Diabetes service was consulted regarding the management of her diabetic medications, their recommendations were followed. The patient was evaluated by physical therapy, who recommended that she be discharged to a rehab facility. At the time of discharge, the patient was tolerating a regular diet, ambulating with assitance, voiding independently, and able to verbalize understanding with the discharge plan/instructions. Medications on Admission: Aspirin 81 mg PO daily GABApentin 300 mg PO QID Insulin glargine (Lantus) 24 units at bedtime Insulin lispro (humalog) - with meals, sliding scale Lisinopril 2.5 mg PO daily Simvastatin 40 mg PO QHS Simbicort OTC allegra OTC flonase Welbutrin Calcium Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Gabapentin 300 mg PO QID 4. Lisinopril 2.5 mg PO DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 6. Senna 1 TAB PO BID constipation 7. Simvastatin 40 mg PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q6H RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 9. Docusate Sodium 100 mg PO BID 10. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Ipratropium Bromide Neb 1 NEB IH Q8H SOB Discharge Disposition: Extended Care Discharge Diagnosis: S/P trauma Injuries: Comminuted Left acetabular fracture Right ___ displaced rib fractures 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 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 driving or operating heavy machinery while taking pain medications. Please follow-up with your PCP or an endocrinologist immediately following your discharge from the rehab facility so that your insulin regimen can be appropriately modified. Followup Instructions: ___
10081869-DS-18	10,081,869	24,176,922	DS	18	2188-06-13 00:00:00	2188-06-13 12:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Demerol Attending: ___. Chief Complaint: Recurrent Spontaneous Pneumothorax Major Surgical or Invasive Procedure: Right chest pigtail placement by interventional pulmonology ___ History of Present Illness: ___ F transferred from ___ for pneumothorax management. Patient has hx of 2 spontaneous R pneumothoraces (___) with prior chest tube and R bleb resection and pleurodesis. She p/w exertional dyspnea and pain in R lateral thorax pain since ___. She denies dyspnea at rest. No recent trauma. She was moving furniture on ___ and thinks this may have caused her symptoms. Her symptoms have been stable for 5 days. CXR at ___ showed large R pneumothorax. Transferred to ___ for thoracic surg eval. Past Medical History: POBHx: G1P0 PGYNHx: Infertility, unknown. ___ IVF. Denies HSV although medical chart states positive HSV PMH: None PSH: Wisdom teeth Social History: ___ Family History: Denies knowledge of pulmonary disease or enzyme abnormalities in family. Otherwise noncontributory. Physical Exam: Vitals: T 98.4 HR 80 BP 101/51 RR 18 SAT 90RA General Appearance: NAD, resting comfortably HEENT: MMM, O/P clear, sclera anicteric Neck: trachea midline, no stridor, supple Lymphatics: no cervical or supraclavicular lymphadenopathy, no thyromegaly Chest: Clear, some diffuse bibasilar crackles which are very faint. Excursion is symmetric Cardiovascular: reg rate, nl S1/S2, no MRG Abdomen: soft, NT/ND, NABS, no HSM Extremities: no CCE Neurological: A&O x3 Skin: No rash, skin eruptions, or erythema Pertinent Results: ___ 05:48AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9 ___ 05:26AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9 ___ 12:52AM BLOOD Glucose-119* UreaN-15 Creat-0.9 Na-139 K-3.7 Cl-104 HCO3-26 AnGap-13 ___ 05:48AM BLOOD Glucose-137* UreaN-13 Creat-0.8 Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 ___ 05:26AM BLOOD Glucose-86 UreaN-10 Creat-0.8 Na-140 K-3.7 Cl-106 HCO3-27 AnGap-11 ___ 12:52AM BLOOD Plt ___ ___ 05:48AM BLOOD ___ PTT-29.0 ___ ___ 05:48AM BLOOD Plt ___ ___ 05:26AM BLOOD Plt ___ ___ 12:52AM BLOOD Neuts-82.7* Lymphs-10.7* Monos-5.4 Eos-0.6* Baso-0.2 Im ___ AbsNeut-6.88* AbsLymp-0.89* AbsMono-0.45 AbsEos-0.05 AbsBaso-0.02 ___ 12:52AM BLOOD WBC-8.3 RBC-3.97# Hgb-11.5# Hct-34.1# MCV-86 MCH-29.0 MCHC-33.7 RDW-11.7 RDWSD-35.9 Plt ___ ___ 05:48AM BLOOD WBC-7.8 RBC-3.99 Hgb-11.5 Hct-34.5 MCV-87 MCH-28.8 MCHC-33.3 RDW-11.7 RDWSD-37.1 Plt ___ ___ 05:26AM BLOOD WBC-6.7 RBC-3.55* Hgb-10.2* Hct-31.4* MCV-89 MCH-28.7 MCHC-32.5 RDW-11.9 RDWSD-38.8 Plt ___ ___ 06:09AM BLOOD WBC-9.3 RBC-3.63* Hgb-10.5* Hct-32.4* MCV-89 MCH-28.9 MCHC-32.4 RDW-11.9 RDWSD-37.9 Plt ___ ___ 06:09AM BLOOD Plt ___ ___ 06:09AM BLOOD Glucose-115* UreaN-14 Creat-0.9 Na-138 K-3.9 Cl-101 HCO3-31 AnGap-10 ___ 06:09AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.8 CXR PA LAT ___ with chest pigtail clamped overnight FINDINGS: There is similar sized right pneumothorax with apical component with increasing pleural effusion compared to the exam performed 12 hours earlier. Right basal atelectasis is less conspicuous on this exam. There is a small left pleural effusion. The pigtail catheter appears to be in similar position. Heart size is within normal limits. Mediastinal and hilar contours are unremarkable. IMPRESSION: Similar size right pneumothorax and slightly increased right pleural effusion. Unchanged small left pleural effusion. Brief Hospital Course: Mrs. ___ is a ___ F transferred from ___ for atraumatic pneumothorax management 5 days following presentation to ___. Patient has hx of 2 spontaneous R pneumothoraces (___) with prior chest tube and R bleb resection and pleurodesis. On this occasion she presented 1 day following moving some heavy furniture at home following which she experienced acute right chest pain and worsening SOB. She was admitted to the Thoracic Surgery Service on ___. Also on ___ she underwent Right pigtail chest tube placement by IP without issue. Serial CXR subsequently showed gradual reinflation of the right lung, and the chest tube was kept to suction until ___, at which time TALC was administered over a 6 hour period and then the chest tube was flushed and placed back to suction. Subsequent CXR showed appropriate lung reinflation. On ___ the chest tube was clamped with subsequent CXR remaining stable. The pigtail chest tube was removed ___ by the Interventional Pulmonology service and the patient did very well. She reported near complete resolution of her pain with removal of the chest tube. She had resumed normal diet, ambulation, activity, and restroom use. She was ultimately discharged home on ___ with scheduled follow up and CXR as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours Disp #60 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #45 Capsule Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours Disp #45 Tablet Refills:0 5. Senna 8.6 mg PO BID:PRN constipation RX sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth twice daily Disp #45 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Recurrent spontaneous pneumothorax (right) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___: You were admitted to ___ for recurrent right spontaneous pneumothorax, for which a right chest tube was placed to suction. Following this you experienced adequate reexpansion of your right lung and resolution of your symptoms. Following this the chest tube was removed and you were able to tolerate normal diet, ambulation, activity, and your home medication regimen without issue. Adequate pain control was obtained with oral medications. You were discharged home to continue your recovery. You should continue your normal home diet, medication regimen, and activities. In terms of your daily activities, take it easy initially. Do not over-exert yourself or engage in heavy exercise. You should walk daily and continue to use your inspiratory spirometer at home several times per hour while awake. You may be given oral pain medications including narcotic medications. Do not drive or operate heavy machinery while taking these medications. You should seek emergent medical attention if you experience the following: fevers/chills, worsening chest pain, difficulty breathing, sudden shortness of breath or pain with deep breaths, redness/pus at your wound site. Wound site care: Keep the wound site covered for 48 hours following removal of the chest tube. Following this you may clean by allowing warm soapy water to run over the wound site. Rinse and pat dry. You may cover with dry gauze and paper tape. Followup Instructions: ___
10081891-DS-9	10,081,891	27,752,151	DS	9	2128-01-23 00:00:00	2128-01-23 21:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / Dicloxacillin Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo man with a history of DM, HTN, chronic pain due to prostate malignancy, anemia and heart failure who presents from rehab after a fall. Patient was found this morning by the ___ ___ staff lying face down in his bathroom. Per the HeRe records a ear phone cord was wrapped around one of his legs. The patient reports that he fell backwards and landed on his back, but is not able to elaborate much further though denies any loss of consciouness. Any further history of event is lost as the patient was alone at the time and does not clearly answer questions about the fall. Vitals at Rehab prior to transfer were 97.3, 74, 20, 150/68, 96RA and was complaining of head and neck pain. . In ED 97.6, 80, 164/60, 28, 96% on 3L NC he was complaining of pain everywhere. A CT head and spine were performed and demonstrated chronic degenerative changes, but no evidence of fracture or hemorrhage. A CXR was aslo performed and showed trace bilateral effusions. Patient was noted to have new acute rise in creatinine and a K of 6.5, he was given kayexcelate and Insulin with decrase in K to 5.9. . On arrival to the medical floor he was complaining of pain "everywhere" but unchanged from his chronic pain. He was very distressed saying he "was going to die" and oriented to person only. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: Past Medical History -___ score 9 adenocarcinoma of the prostate treated with radiation and hormone therapy -insulin-dependent diabetes mellitus -peptic ulcer disease, -asthma, -hypertension -renal disease . PAST SURGICAL HISTORY: Neck fusion, tonsillectomy, appendectomy,peptic ulcer surgery, hernia repair and radiation external beam for prostate cancer. Social History: ___ Family History: Coronary artery disease, hypertension, lung cancer, and breast cancer Physical Exam: On admission: VS 97.4, 158/70, 96, 20, 95% on 2L NC GEN Alert, oriented to person, thinks he is at ___, knows year but not month or day of the week. HEENT MM dry, EOMI sclera anicteric, OP clear, scrape on the bridge of the nose NECK supple, no JVD, no LAD, no cervical sign tenderness or pain with motion. PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT mildly distented normoactive bowel sounds, no r/g EXT 2+ edema to the knees bilaterally reported as chronic NEURO CNs2-12 intact, 5+ strength in upper and lower extremities, down going toes, no hyperrflexia, SKIN no ulcers or lesions At discharge: VS: 97.9, 160/78, 80, 20, 95% 2L GEN Alert, oriented to person and BID, knows year but not month or day of the week. HEENT MM dry NECK no JVD, no LAD PULM Diminished BS on R, crackles bilateral to mid thorax CV RRR normal S1/S2, no mrg ABD somewhat tense, diffusely tender, mildly distented normoactive bowel sounds, no r/g EXT 2+ edema to the knees bilaterally reported as chronic Pertinent Results: ___ 11:30AM BLOOD WBC-8.3# RBC-3.30* Hgb-9.4* Hct-30.8* MCV-93 MCH-28.4 MCHC-30.4* RDW-16.5* Plt ___ ___ 11:30AM BLOOD Neuts-85.5* Lymphs-8.0* Monos-4.9 Eos-1.2 Baso-0.4 ___ 11:30AM BLOOD Glucose-204* UreaN-107* Creat-2.7* Na-141 K-6.6* Cl-113* HCO3-15* AnGap-20 ___ 07:10PM BLOOD CK(CPK)-138 ___ 07:15AM BLOOD ALT-21 AST-23 AlkPhos-51 TotBili-0.1 ___ 07:15AM BLOOD Lipase-24 ___ 11:30AM BLOOD cTropnT-0.14* proBNP-645 ___ 02:35PM BLOOD cTropnT-0.13* ___ 07:10PM BLOOD cTropnT-0.13* ___ 07:15AM BLOOD cTropnT-0.13* ___ 02:35PM BLOOD Calcium-8.8 Phos-6.4* Mg-2.4 ___ 03:23PM BLOOD D-Dimer-1179* ___ 06:52AM BLOOD %HbA1c-5.6 eAG-114 ___ 10:34AM BLOOD Type-ART Temp-36.8 Rates-/40 O2 Flow-3 pO2-88 pCO2-52* pH-7.25* calTCO2-24 Base XS--4 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL ___ ___ 05:44PM BLOOD Type-ART Temp-36.8 O2 Flow-3 pO2-72* pCO2-51* pH-7.28* calTCO2-25 Base XS--2 Intubat-NOT INTUBA Vent-SPONTANEOU ___ 11:18AM BLOOD Lactate-0.6 ___ 10:34AM BLOOD Lactate-0.4* MICRO Urine Culture: No growth Studies: CT FINDINGS: There is no acute fracture or traumatic malalignment. Persistent 5mm of anterolisthesis of C3 on C4 which appears chronic given bridging osteophytes and is unchnagedd from prior. Patient is status post C2 through C6 bilateral laminectomies, also similar to prior. The C2-C3 through C5-C6 facet joints are fused on the left and the C2-C3 and C3-C4 on the right. There is severe multilevel degenerative joint disease most prominent at the craniocervical junction that is unchanged compared to the prior CT C-spine, as previously documented. There is no lymphadenopathy. The imaged portion of the thyroid is normal. There are left greater than right pleural effusions in the visualized portions of the lung apices. IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Unchanged severe multilevel degenerative changes. 3. Bilateral left greater than right pleural effusions. CT Head FINDINGS: There is no acute hemorrhage, edema, mass effect, or acute territorial infarction. Prominent ventricles and sulci likely indicate age-related involutional changes. The basal cisterns are patent and there is preservation of gray-white differentiation. No fracture. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. IMPERSSION: No acute intracranial process. CXR: IMPRESSION: Bilateral small pleural effusions, greater on the left than right. No other acute intrathoracic process. ECHO: The left atrium is normal in size. 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal study. Mild symmetric left ventricular hypertrophy with normal cavity size and preserved global biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Indeterminate pulmonary artery systolic pressure. ___ U/S IMPRESSION: No lower extremity DVT with limited evaluation of the calf veins. VQ Scan IMPRESSION: Matched ventilation/perfusion/chest radiograph abnormalites at the right lower lung field consistent with an indeterminate likelihood ratio for acute pulmonary embolism. ___ 08:00AM BLOOD WBC-8.2 RBC-3.47* Hgb-9.8* Hct-32.1* MCV-92 MCH-28.2 MCHC-30.5* RDW-16.6* Plt ___ ___ 12:40AM BLOOD Na-146* K-4.5 Cl-112* Brief Hospital Course: #FALL: Mechanical in origin, possibly worsened by hypoglycemia- see below. Patient ruled out for MI, had no arrhythmia, relatively normal Echo. #Acute on Chronic Renal Injury: Patient has diabetic related chronic kidney disease with an apparent baseline creatinine of 2.0. He was 2.7 on admission with improvement to 1.9 with diuresis. He made 4L extra urine output over two days on 20IV lasix daily. Nephrology consult was generated, which recommend nephrology followup. Enalapril was stopped and amlodipine was started. He was started on low K diet and sevelemar. # Diastolic CHF: He was overloaded on exam with leg edema, pleural effusions on CXR, renal function improved with lasix. Echo showed EF 60% and good LV function, so likely diastolic due to HTN and DM. He will likely benefit from lasix therapy, but this was stopped at discharge due to hypernatremia. #HYPERKALEMIA: no EKG changes and improvement with kayexcelate/insulin in the ED. He was ruled out for rhabdo. This is likely due to his diabetic kidney disease. #HYPOXIA: new O2 requirement since arrival to the hospital lung exam and imaging do not suggest fluid overload, but pleural effusions are present. He developed signs of aspiration with pH 7.2 and tachypnea. He had elevated D-dimer, but neg ___ ultrasound and inconclusive VQ scan. Speech and swallow recs were implemented - thin liquids, 1:1 feeding. #DM2: He had two episodes of BS ___, and home 70/30 was reduced to 18 units qam and 10 nits qPM. A1C was 5.8, which is likely too aggressive for ___. #Hypertension: Enalapril was stopped given ___, he was started on amlodipine, hydralazine continued at 100 TID. TRANSITIONAL ISSUES: - Patient may benefit from lasix diuresis- Patient is aspiration risk - Patient had low blood sugars and A1C of 5.8, requiring ongoing trending of blood sugars at rehab and possible continued liberalizing of insulin - He will need outpatient followup with nephrology - Patient will require 2L oxygen via nasal cannulae MEDICATION CHANGES - Insulin 70/30 decreased to 18qam 10qpm - sevelemar started - amlodipine 5mg started - enalapril stopped - albuterol and ipratropium started - docusate and senna started Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE (Immediate Release) 5 mg PO HS pain 2. Calcium Carbonate 1250 mg PO QPM 3. 70/30 22 Units Breakfast 70/30 12 Units Dinner 4. Pravastatin 80 mg PO DAILY 5. Tamsulosin 0.4 mg PO HS 6. HydrALAzine 100 mg PO TID 7. Enalapril Maleate 20 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Cyanocobalamin 100 mcg PO DAILY 10. Vitamin D 50,000 UNIT PO Q21D 11. darbepoetin alfa in polysorbat NF 40 mcg/mL Injection Q14D 12. Acetaminophen 650 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Calcium Carbonate 1250 mg PO QPM 3. Cyanocobalamin 100 mcg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. HydrALAzine 100 mg PO TID 6. OxycoDONE (Immediate Release) 5 mg PO HS pain 7. Pravastatin 80 mg PO DAILY 8. Tamsulosin 0.4 mg PO HS 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. darbepoetin alfa in polysorbat NF 40 mcg/mL Injection Q14D 11. Vitamin D 50,000 UNIT PO Q21D 12. Amlodipine 5 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Senna 1 TAB PO BID:PRN constipation 15. 70/30 18 Units Breakfast 70/30 10 Units Dinner 16. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN dyspnea 17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H dyspnea Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Chronic kidney disease stage III-IV Diastolic congestive heart failure Diabetes 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: Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted after falling at your rehab facility. It was determined that you did not suffer any serious injury from this fall, but it is possible that your blood sugar level has been too low on occasion, which could increase your likelihood of falling. You had several episodes of low blood sugar while you were here. Your insulin regimen has been changed so that future low blood sugar levels will be less likely. You will follow up with your doctors at rehab to further adjust your insulin. While you were here, you were found to have some electrolyte abnormalities caused by your ongoing kidney disease, as well as your heart disease. Your Enalapril was stopped because it may be worsening these abnormalities, and you were started on Amlodipine. Finally, your had some trouble breathing, which was likely caused by inhaling some food contents while eating. Xray and CT imaging of your chest did not show any concerning new abnormalities. You were seen by our speech and swallow therapists: We recommended that you have supervision at all times, to prevent you from inhaling your food. You were given a medication to help your kidney and heart function by promoting you to urinate off some extra fluid. Your electrolytes were monitored while you were here and adjusted accordingly. You will follow up with a kidney doctor to help further regulate your body's electrolytes. Finally, your breathing was monitored and you were found to oxygenate your blood adequately. Pelase followup with your doctors, see below. Followup Instructions: ___
10082014-DS-19	10,082,014	22,293,901	DS	19	2185-07-06 00:00:00	2185-07-07 13:50:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Lorazepam Attending: ___. Chief Complaint: Right femoral neck fracture Major Surgical or Invasive Procedure: Right hip hemiarthroplasty (___) History of Present Illness: Ms. ___ is a pleasant ___ year old female with a history of dementia, anxiety, hypertension, and hypercholesterolemia who presents today after sustianing a ground level mechanical fall. She is accompanied by her son who provides most of the history documented in this note. Per her some, patient was up and standing behind a closed door. Her son, who was working outside had decided to come in and opened the door without realizing that his mother was standing behind the door, and in the process knocked her over. Patient reports she fell onto her right side. She does report hitting her head. She denies any loss of consciousness. Immediately after the fall, her son noted that Ms. ___ was unable to get up and stand or bear and weight through the right lower extremity. EMS was called and the patient was brought into the ___ emergency department for further evaluation and management. Preliminary plain film radiographs of the right hip were obtained and revealed a femoral neck fracture. Orthopaedic surgery was consulted for further assistance with evaluation and management. Patient currently complains of moderate to severe right hip pain which is worsened with any motion. She also makes note of right knee pain and left lower extremity thigh and lower leg pain. She denies any injury to her upper extremities. She denies any numbness or paresthesias of her bilateral lower extremities. Past Medical History: - aortic insuficiency - cerebral anyeurism s/p coiling ___ years ago - HTN - HLD - h/o GERD - systolic dysfunction EF ___ - R hip fracture ___ Social History: ___ Family History: NC Physical Exam: Exam on admission: In general, the patient is an elderly female, resting comfortably on the ED stretcher in no apparent distress. Vitals: AVSS, please see ED flowsheet. Right lower extremity: Skin intact There is tenderness to paplation at the lateral aspect of the right hip and right groin. There is equisite pain with log roll of the right lower extremity. Additionally patient reports some diffuse tenderness over the distal femur. Thigh and lower leg compartments are soft and easily compressible Full, painless AROM/PROM of the right ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions. No numbness or paresthesias. ___ pulses, foot warm and well-perfused Left lower extremity: Skin intact Some tenderness to palpation over the distal lateral aspect of the left thigh and left distal lower leg. No frank crepitus or gross malalignment. Thigh and lower leg compartments are warm and soft; easily compressible. Full, painless AROM/PROM of hip and ankle. There is limited ROM of the left knee which is at the patient's baseline. ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Exam on discharge: VS: 97%; 155/73; 106; 18; 99RA GENERAL: calm, NAD HEENT: NC/AT, sclerae anicteric, MMM LUNGS: unable to sit patient up but clear anteriorly and in posterolateral aspects of lungs. No wheeze, ronchi. HEART: tacycardic. Nml S1, S2 No MRG ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox2-3 but significant improvement Pertinent Results: ADMISSION LABS: ___ 04:35AM BLOOD WBC-7.1 RBC-3.21* Hgb-9.3* Hct-29.6* MCV-92 MCH-28.8 MCHC-31.2 RDW-14.7 Plt ___ ___ 07:05PM BLOOD Neuts-79.9* Lymphs-11.8* Monos-6.6 Eos-1.4 Baso-0.3 ___ 04:35AM BLOOD Plt ___ ___ 07:05PM BLOOD ___ PTT-26.0 ___ ___ 04:35AM BLOOD Glucose-206* UreaN-30* Creat-1.1 Na-139 K-4.5 Cl-102 HCO3-28 AnGap-14 ___ 04:35AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.8 ___ 09:18PM BLOOD K-4.6 DISCHARGE LABS: ___ 05:55AM BLOOD WBC-8.8 RBC-3.10* Hgb-8.9* Hct-28.4* MCV-92 MCH-28.6 MCHC-31.3 RDW-15.1 Plt ___ ___ 05:55AM BLOOD Glucose-85 UreaN-23* Creat-0.7 Na-142 K-3.6 Cl-105 HCO3-28 AnGap-13 ___ 05:55AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0 MICRO: Blood Culture, urine culture no growth at discarhge STUDIES/IMAGING: Hip XR: Acute right femoral neck fracture, mid cervical level. CXR ___: Large hiatus hernia is significantly more distended today than on ___. There is new opacification at the right lung base which could be an acute aspiration pneumonia. Upper lungs are clear. Heart size is hard to assess, probably top- normal. A small right pleural effusion is new. There is no pneumothorax. Brief Hospital Course: ___ with hx of dementia and HTN who presented following a fall found to have a R hip fracture. Hospital course complicated by delirium and pneumonia. ACTIVE ISSUES THIS ADMISSION: SURGICAL COURSE: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hemiarthroplasty, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. MEDICAL COURSE: DELIRIUM: The patient was transferred to the medicine service for management of delirium. Her derlirium was felt to be related to the narcotics she received, her post-operative state and her pre-existing dementia as well as pneumonia. The patient also has a long history of delirium during hospitalizations. Interventions were minimized. Narcotics were stopped and the patient's pain was controlled with IV tylenol. The patients delirium resovled and she returned to her baseline mental status. Of note, the patients home donepenzil and Seroquel were discontinued in an attempt to minimize polypharmacy and the indications for the seroquel were not clear to the patient or the patient's son. PNA: The patient developed a RLL likely aspiration PNA this admission. She was started on IV Ampicillin/Sulbactam which was switched to Amoxicillin/Clav at time of discharge. She will complete a 8 day course (last day ___ CHRONIC ISSUES: #HTN - continued home lisinopril this admission. #HLD - continue simvastatin this admission. TRANSITIONAL ISSUES: # PNA: patient will need to complete 8 day course of antibiotics for PNA. Last date ___. She will be discharged on augmentin. If she develops worsening diarrhea, can consider switching antibiotics at rehab. # DEMENTIA: patient currently lives alone but would benefit from a ocupational therapy evaluation at rehab for cognitive evaluation and home safety evaluation. # ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks from ___ # 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. # ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated in the right leg - Anterolateral hip precautions in the right leg Medications on Admission: 1. Donepezil 5 mg PO HS 2. Lisinopril 10 mg PO DAILY 3. QUEtiapine Fumarate 200 mg PO QHS 4. Simvastatin 40 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Simvastatin 40 mg PO DAILY 3. Acetaminophen 650 mg PO TID 4. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days Start: ___, First Dose: Next Routine Administration Time 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days Last day ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Right femoral neck fracture - Pneumonia - Toxic-Metabolic Encephalopathy Secondary Diagnosis: - Hypertension - Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospitalization. You were admitted for a hip fracture which was repaired by the orthopedic surgeons. You also developed delirium. You were managed by the medicine service for your delirium and this resolved. Finally, you also developed a pneumonia this admission that may be due to aspiration. You were started on antibiotics. You will complete a course of augmentin after discharge. Sincerely, Your ___ Team Followup Instructions: ___
10082014-DS-20	10,082,014	20,221,705	DS	20	2185-08-15 00:00:00	2185-08-15 14:04:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Lorazepam Attending: ___. Chief Complaint: lethargy Major Surgical or Invasive Procedure: endotracheal intubation, mechanical ventilation History of Present Illness: ___ yof with a history dementia, anxiety, hypertension, hypercholesterolemia, CHF (EF ___, cerebral anurysm s/p coiled, hip fracture s/p right hemiarthroplasty (___), lethargic for the past few days, has been refusing ___. She was altered today and presented to ___. She was intubated at ___ for a head CT which was negative. Found to have UTI, with likely urosepsis. A foley and CVL placed at ___, 2g cefepime was given at 1600 - due to previous CNS coiling ICU at ___ requested patient to be transferred to ___ ___. She got 2L NS ___ our ___, had 1L of NS at ___, still have on off pressure requirement. Per ___ record of ___ course: there from SNF with confusion and lethargy. While ___ their ___, decompensated, dropped 02 sats and mental status deteriorated required intubation. Urine is very cloudy. Concern for urosepsis - recieved vanc and cefepime 2g IV. Briefly on levophed. Arrives sedated on fent 200mcg/hr and versed 1mg/hr. Opened eyes and moved both arms - bolused as ordered with 25mcg fent and 1mg versed. Versed gtt increased to 3mg/hr as ordered. R CVL line ___ place. ___ ___, initial vitals were: Vital Signs: Temperature 34.5 °C (94.1 °F).Pulse 74.Respiratory Rate 14.Blood Pressure 115/50.O2 Saturation 100 on Invasive Mode:CMV FiO2:50% PEEP:5 RR:14 Vt:400 7.5 ett 23@lip. Per review of records: She was admitted and underwent right hemiarthroplasty on ___, surgically uncomplicated. However, her hospital course was complicated by delirium related to the narcotics, post-operative state and pre-existing dementia as well as pneumonia (RLL likely aspiration PNA, started on IV Ampicillin/Sulbactam switched to Amoxicillin/Clav at time of discharge (last day ___. The patient also has a long history of delirium during hospitalizations. Patient's pain was controlled with IV tylenol. Of note, the patients home donepenzil and Seroquel were discontinued ___ an attempt to minimize polypharmacy and the indications for the seroquel were not clear to the patient or the patient's son. Review of systems: unable, intubated and sedated Past Medical History: - aortic insuficiency - cerebral anyeurism s/p coiling ___ years ago - HTN - HLD - h/o GERD - systolic dysfunction EF ___ - R hip fracture ___ Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM GENERAL: Intubated, making no movements, breathing comfortably HEENT: Sclera anicteric, PERRL, ET tube ___ place LUNGS: Clear to auscultation anteriorly CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-distended, bowel sounds present EXT: Cold, 2+ pulses, no cyanosis or edema NEURO: Withdraws to painful stimuli DISCHARGE PHYSICAL EXAM Vitals: Tm 98.1 149/83 89 18 99 RA General: NAD, AAOx2 HEENT: NCAT, PERRL, EOMI, MMM CV: RRR, nl S1, S2, no m/g/r Lungs: CTAB Abdomen: Soft, ND, NT, no HSM, no g/r/r Ext: Pulses 2+ dp bilaterally, 1+ edema around feet up legs, bilaterally. Neuro: cn2-12 grossly intact, moving all extremities. AAOx2 per above. Skin: wwp Pertinent Results: ADMISSION LABS: ___ 06:45PM BLOOD WBC-9.1 RBC-2.70* Hgb-7.7* Hct-25.4* MCV-94 MCH-28.4 MCHC-30.2* RDW-17.6* Plt ___ ___ 02:00AM BLOOD Neuts-74.3* ___ Monos-3.2 Eos-4.1* Baso-0.1 ___ 06:45PM BLOOD Plt ___ ___ 06:45PM BLOOD ___ PTT-27.5 ___ ___ 06:45PM BLOOD UreaN-32* Creat-1.2* ___ 02:00AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.5* ___ 10:41PM BLOOD Type-ART Temp-37.1 pO2-150* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 Intubat-INTUBATED ___ 06:57PM BLOOD Glucose-81 Lactate-1.0 Na-141 K-4.1 Cl-107 calHCO3-28 ___ 10:41PM BLOOD freeCa-1.00* ___ 06:45PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 06:45PM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 06:45PM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 ___ 06:45PM URINE Hours-RANDOM ___ 06:45PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG PERTINENT LABS: ___ 02:00AM BLOOD WBC-8.5 RBC-2.31* Hgb-6.8* Hct-22.1* MCV-96 MCH-29.3 MCHC-30.6* RDW-18.2* Plt ___ ___ 01:47PM BLOOD WBC-13.8# RBC-3.16# Hgb-8.9# Hct-28.5# MCV-90 MCH-28.2 MCHC-31.4 RDW-18.2* Plt ___ ___ 04:01AM BLOOD WBC-12.7* RBC-2.95* Hgb-8.4* Hct-26.2* MCV-89 MCH-28.5 MCHC-32.1 RDW-18.8* Plt ___ ___ 05:20AM BLOOD WBC-10.4 RBC-3.02* Hgb-8.6* Hct-26.8* MCV-89 MCH-28.4 MCHC-31.9 RDW-19.1* Plt ___ ___ 05:10PM BLOOD WBC-9.9 RBC-3.19* Hgb-8.9* Hct-27.8* MCV-87 MCH-28.0 MCHC-32.2 RDW-18.7* Plt ___ ___ 07:40AM BLOOD WBC-10.7 RBC-3.27* Hgb-9.2* Hct-28.5* MCV-87 MCH-28.1 MCHC-32.1 RDW-19.0* Plt ___ ___ 06:45PM BLOOD ___ 04:01AM BLOOD Ret Aut-0.6* ___ 06:45PM BLOOD ___ PTT-27.5 ___ ___ 02:00AM BLOOD Plt ___ ___ 02:00AM BLOOD ___ PTT-38.4* ___ ___ 01:47PM BLOOD Plt ___ ___ 04:01AM BLOOD ___ PTT-46.5* ___ ___ 02:00AM BLOOD Glucose-63* UreaN-27* Creat-0.8 Na-143 K-3.7 Cl-114* HCO3-23 AnGap-10 ___ 01:47PM BLOOD Glucose-102* UreaN-29* Creat-0.8 Na-142 K-4.4 Cl-113* HCO3-22 AnGap-11 ___ 04:01AM BLOOD Glucose-83 UreaN-28* Creat-0.7 Na-143 K-4.1 Cl-112* HCO3-23 AnGap-12 ___ 06:00PM BLOOD Glucose-74 UreaN-25* Creat-0.6 Na-140 K-3.9 Cl-107 HCO3-23 AnGap-14 ___ 05:20AM BLOOD Glucose-68* UreaN-22* Creat-0.6 Na-141 K-3.4 Cl-106 HCO3-23 AnGap-15 ___ 07:40AM BLOOD Glucose-88 UreaN-16 Creat-0.6 Na-141 K-3.6 Cl-109* HCO3-18* AnGap-18 ___ 07:40AM BLOOD Glucose-112* UreaN-15 Creat-0.5 Na-141 K-3.5 Cl-107 HCO3-27 AnGap-11 ___ 07:10AM BLOOD Glucose-86 UreaN-15 Creat-0.5 Na-144 K-2.6* Cl-107 HCO3-29 AnGap-11 ___ 05:19PM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-146* K-3.7 Cl-109* HCO3-26 AnGap-15 ___ 06:00PM BLOOD ALT-21 AST-26 AlkPhos-124* TotBili-0.4 ___ 06:45PM BLOOD Lipase-28 ___ 01:47PM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0 ___ 04:01AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.9 ___ 06:00PM BLOOD Albumin-2.3* ___ 05:20AM BLOOD Calcium-7.5* Phos-2.4* Mg-1.6 ___ 07:40AM BLOOD Albumin-2.1* Calcium-7.8* Phos-2.3* Mg-2.1 ___ 07:40AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.9 ___ 06:05AM BLOOD Vanco-21.3* ___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:41PM BLOOD Type-ART Temp-37.1 pO2-150* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 Intubat-INTUBATED ___ 02:13AM BLOOD Type-ART Temp-36.0 Rates-18/ Tidal V-400 PEEP-5 FiO2-40 pO2-121* pCO2-30* pH-7.47* calTCO2-22 Base XS-0 Intubat-INTUBATED ___ 02:28AM BLOOD Type-MIX ___ 01:57PM BLOOD Type-ART Temp-37.5 Tidal V-400 PEEP-5 FiO2-30 pO2-49* pCO2-46* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED ___ 02:13AM BLOOD freeCa-1.15 ___ 01:57PM BLOOD freeCa-1.18 DISCHARGE LABS ___ 06:19AM BLOOD WBC-10.2 RBC-3.21* Hgb-8.9* Hct-28.6* MCV-89 MCH-27.7 MCHC-31.1 RDW-20.3* Plt ___ ___ 06:19AM BLOOD Glucose-88 UreaN-16 Creat-0.5 Na-145 K-3.9 Cl-108 HCO3-28 AnGap-13 ___ 06:19AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 STUDIES/IMAGING: Head CT at ___ ___: This exam is partially limited due to metal artifact, however no evolving infarct, hemorrhage or fractures identified. 2. There is soft tissue density within the left external auditory canal, most likely cerumen, however clinical correlation is advised. CXR ___: Right IJ central venous catheter and endotracheal tube positioned appropriately. CXR ___: Lung volumes have improved, although there is still mild atelectasis at the left lung base. Pleural effusions are minimal if any, and there is no pneumothorax. Upper lungs are clear. Heart size is normal. ET tube and right internal jugular line are ___ standard placements. EKG ___: Sinus tachycardia. Premature atrial contraction. Low voltage ___ the limb leads. Compared to the previous tracing of ___ heart rate is higher CXR ___: 1. New small bilateral pleural effusions since ___. 2. Expected post-extubation bibasilar atelectasis. Cardiac Echo ___ No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Preserved global biventricular systolic function. Increased left ventricular filling pressure. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Compared to the previous study of ___ (images unavailable for review), moderate LV global hypokinesis is no longer appreciated. A small pericardial effusion is no longer seen. A left to right interatrial septal defect is not seen, but may be secondary to suboptimal image quality on the current study rather than a physiological change. CXR ___: New right PIC line tip projects at a level 65 mm below the aortic knob and would need to be withdrawn 2 cm to reposition it ___ the low SVC, if required. Small bilateral pleural effusions which developed between ___ and ___ are unchanged. Cardiomegaly has decreased since ___. Upper lungs are clear. Moderate left lower lobe atelectasis is presumed. Micro: ___ 5:26 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. ___ 1:06 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS, CHAINS, AND CLUSTERS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. ___ 7:50 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:30 pm BLOOD CULTURE #2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:45 pm URINE Site: NOT SPECIFIED TRAUMA. **FINAL REPORT ___ URINE CULTURE (Final ___: THIS IS A CORRECTED REPORT 1037, ___. Reported to and read back by ___ ___ ___ @ 1040, ___. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. RESISTANT TO CEFEPIME (MIC: > 32 MCG/ML). CEFEPIME PERFORMED BY MICROSCAN. PREVIOUSLY REPORTED AS (___). SENSITIVE TO CEFEPIME (MIC: 4 MCG/ML). KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ESCHERICHIA COLI \| KLEBSIELLA OXYTOCA \| \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R 8 S CEFAZOLIN------------- =>64 R 8 R CEFEPIME-------------- R <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S Brief Hospital Course: ___ with hx of dementia and HTN, recently had a fall with R hip fracture s/p right hemiarthroplasty d/c'd to rehab ___ ___, found to be lethargic, was intubated ___ ___ transferred to ___ ___, admitted to MICU for urosepsis. Sepsis/shock resolved with antibiotics, patient later extubated and transferred to the floor for further antibiotics and management of delirium. Active Issues: # Sepsis: Patient presented with AMS at OSH and was transferred for respiratory decompensation while intubated. Started on Vanc/Cefepime for postive UA. Was initially hypotensive and was placed on levophed. She had already been bolused with 3+L at OSH before transfer. She was given an additional ___ while ___ the ___ and ___ the ICU. Her levophed was quickly weaned as tolerated over her first day ___ the ICU. After her pressures stabilized, she was diuresed with IV lasix due to her LOS volume status of +8L. Vanc later d/c'd and cefepime continued. Cultures and sensitivites of urine showed e coli and klebsiella. Initial e coli sensitivity showed sensitivity to cefepime, however repeat testing showed resistance. Cefepime later changed to zosyn ___. Access lost ___ with ___ placed ___ and plan for total 7 day course of zosyn starting ___ to be completed ___. # Delirium: 1 week history of lethargy and a generalized decline since hip fracture. Initially intubated for mental status ___ order to obtain CT Head at OSH, extubated ___ without problem. Likely precipitant was urosepsis. Upon extubation, she remained delerious on top of her baseline dementia. She was started on haldol 1mg BID to help during this acute process. After transition to the floor and delirium precautions enacted, delirium gradually cleared and haldol was discontinued. Patient cleared by speech and swallow eval for PO intake, and resumed home meds with further improvement. By time of discharge patient at baseline mental status AAOx2. # Fluid overload: Patient +8L coming from ICU, initially received IV lasix for diuresis but later autodiuresed well without medication. Pt received further IV fluids during stay ___ poor PO which were later discontinued as PO improved, but by ___ patient with persistent ___ edema with small effusions seen on CXR. Given 10 mg IV lasix with some improvement ___ exam by day of discharge. Pt not dyspneic and satting well on room air. Not on standing diuretic at home. Last ECHO ___. Echo obtained prior to discharge for further eval of edema showed an EF 65%. ___ need further diuresis/titration of medications as an outpatient. Please monitor volume status and consider starting lasix if patient develops pulmonary edema or worsening lower extremity edema # Healthcare associated pneumonia: Per report, intubated for airway protection, but also question of transient hypoxemia ___ the outside ___. Sputum gram stain with GNRs and GPC which was concerning for HCAP, having been ___ the hospital recently for hip replacement. She was already on vanc and cefepime for urosepsis so she was ___ effect being treated for this issue. She was extubated without issue and did not have an oxygen requirement after extubation. Exam/imaging less concerning for PNA and vanc eventually d/c'd. Patient maintained sats on room air throughout remainder of stay. # Acute renal failure: cr 1.2 on admit. likely pre-renal, improved with fluid resuscitation with cr stable throughout remainder of stay # Anemia: chronic since hip replacement. Transfused 1 unit pRBC ___ with counts stable at current baseline throughout remainder of stay. High ferritin with low retic count consistent with anemia of chronic disease. #HTN - home lisinopril initially held, restarted prior to discharge and increased dose to 20 mg daily for hypertension #Skin breakdown/candidal infection on sacrum/coccyx- seen ___ with wound care consulted. Likely ___ loose stools which gradually resolved, c. diff negative. Recs as follows were observed and should be continued upon discharge pending resolution: 1. Follow pressure redistribution guidelines. Turn patient q 2 hours off back. 2. Cleanse perineum/perianal tissue with foam cleanser. Apply Critic aid clear antifungal skin barrier ointment daily. ___ reapply after each ___ cleansing. 3. Place Xeroform dressing perianal area to add protection to skin. 4. Place Soft sorb dressing over perianal and perineum area to wick urine and stool. 5. If FI continues consider FIP (fecal incontinence pouch) refer to policy application technique of a FIP # ___. I have left copy ___ front of patients chart. Transitional Issues: - home lisinopril increased to 20 mg daily - continue zosyn IV 4.5 g q8h through ___ - pls monitor volume status and consider starting furosemide if she develops signs/sx of pulmonary edema or lower extremity edema - f/u cbc, further work-up/treatment of anemia as needed - pls monitor electrolytes closely given hypokalemia during admission - patient found to have scattered tissue erosion from moisture contact on coccyx/sacrum with candidal rash- wound care consulted with recs provided per above -pls monitor electrolytes closely given hypokalemia during admission Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. Acetaminophen 650 mg PO Q8H:PRN pain 4. Multivitamins 1 TAB PO DAILY 5. Duloxetine 20 mg PO DAILY 6. TraZODone 25 mg PO BID:PRN anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Duloxetine 20 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 40 mg PO QPM 5. TraZODone 25 mg PO BID:PRN anxiety 6. Piperacillin-Tazobactam 4.5 g IV Q8H 7. Lisinopril 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses: Urosepsis with shock Muli-drug resistant e. coli infection ___ urine Delirium Secondary Diagnoses: Dementia Hypoalbuminemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay at ___. You were admitted for altered mental status and septic shock caused by a urinary tract infection that spread into your blood stream. You were initially treated ___ the ICU for low blood pressure and airway management, requiring intubation. Your blood pressure improved and your breathing was stable after removal of the breathing tube. You did require a blood transfusion on the ___ for low blood counts, and your blood counts remained stable throughout the remainder of your stay. You were transferred to the general medicine floor where your antibiotics were continued and your mental status gradually improved to your baseline before you came ___ to the hospital. We did a repeat ultrasound of your heart that showed great improvement ___ your heart's ability to function. We have changed your antibiotics and placed a PICC line as the bacteria growing ___ your urine was found to be highly resistant to previous antibiotics. You will require a total 7 day course of these new antibiotics to be completed at rehab. Wishing you well, Your ___ Medicine Team Followup Instructions: ___
10082014-DS-21	10,082,014	26,270,834	DS	21	2185-09-04 00:00:00	2185-09-04 10:32:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Lorazepam Attending: ___. Chief Complaint: Hypotension Altered Mental Status Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy on ___ by Dr. ___ ___ and Dr. ___ History of Present Illness: Primary Care Physician: ___ Chief Complaint: Hypotension, AMS Reason for MICU transfer: Hypotension, GIB, intubation History of Present Illness: Ms. ___ is an ___ woman with a history of dementia, anxiety, hypertension, hypercholesterolemia, CHF (EF ___, cerebral anurysm s/p coiling, hip fracture s/p right hemiarthroplasty (___), and recent hospitalization (___) for septic shock/urinary source requiring intubation, completing course of pip-tazo on ___. She represents with hypotension, GIB, and seizure necessitating intubation for airway protection. Patient had been at ___, where she was noted to be hypotensive. She was transferred to ___, where dark, tarry stools were noted. Initial HCT 16. An IO was placed and she received 2 uncrossed units of pRBC for hypotension to SBP 60's. Given AMS, head CT was done that was reportedly negative. Patient was reportedly hypothermic with K 2.7. She received Vancomycin. Patient was prepared for transfer to ___. However, upon loading into ambulance, patient had a GTC seizure. She received 1 dose of ativan and was intubated prior to transfer. In the ___ ED, initial vitals were not posted. Patient was noted to have ongoing melanotic stool with some bright red blood mixed in. A cordis catheter was placed. NG lavage was attempted but unsuccessful due to NG/OG coiling on 10+ attempts. Labs were notable for INR 1.4, Mg 1.3, K 2.9, Cr 1.0, trop-T 0.03. Lactate was elevated at 4.0. WBC 8.9 (N 83.6, L 13.1), H/H 8.2/23.4, plt 120. GI was consulted and plans EGD in the ICU. Patient's BP remained low (SBP 60-80), and she received 2 additional units pRBC and volume prior to transfer. Antibiotics were broadened to include Zosyn (received Vanc dose at OSH ED). Of note, during patient's recent admission she was treated for septic shock from urinary source. There was also some concern for HCAP, though this was felt to be less likely. Urine grew resistent E. Coli and Klebsiella. BCx's here then were negative. She completed course of pip-tazo on ___. Upon arrival to the MICU patient was still intubated and stable with BP 101/59, HR 70 and 100% Intubated Past Medical History: - aortic insuficiency - cerebral anyeurism s/p coiling ___ years ago - HTN - HLD - h/o GERD - systolic dysfunction EF ___ - R hip fracture ___ Social History: ___ Family History: Noncontributory Physical Exam: Vitals- Temp: BP 101/59 HR 74 100% Intubated General: Intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, no murmurs/rubs/gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Labs: Reviewed in OMR DISCHARGE EXAM BPS 110S/70S 70S 2l R PICC SITE CLEAN MILD EDEMA WITH PITTING AT FLANKS NO FOCAL CRACKLES UNLESS POSITIONED ON SIDE TO LISTEN WHERE THE DEPENDENT RIGHT BASE HAS INSP CRACKLES NO FOLEY CONFUSED BUT CAN MAINTAIN CONVERSATION Pertinent Results: Admission Labs: ___ 12:20PM BLOOD WBC-8.9 RBC-2.64* Hgb-8.2* Hct-23.4* MCV-89 MCH-31.2 MCHC-35.2* RDW-18.3* Plt ___ ___ 11:38AM BLOOD ___ PTT-44.0* ___ ___ 11:38AM BLOOD Glucose-193* UreaN-23* Creat-1.0 Na-143 K-2.9* Cl-102 HCO3-28 AnGap-16 ___ 11:38AM BLOOD ALT-34 AST-92* AlkPhos-56 TotBili-0.8 ___ 11:38AM BLOOD cTropnT-0.03* ___ 11:38AM BLOOD Albumin-1.7* Calcium-7.0* Phos-3.5 Mg-1.3* ___ 09:25PM BLOOD freeCa-0.92* EGD Report: Traumatic ulcers (likely from previous OG tube placement) were seen in the oropharynx Hypertonic lower esophageal sphincter Medium hiatal hernia Ulcers in the stomach body and antrum Ulcer in the posterior wall of the duodenal bulb Ulcer in the duodenal sweep (thermal therapy, injection) Ulcers in the duodenal bulb, first part of the duodenum and second part of the duodenum An OG tube was placed into the stomach under endoscopic visualization. Otherwise normal EGD to third part of the duodenum ___ 05:45AM BLOOD WBC-6.5 RBC-2.97* Hgb-9.2* Hct-27.0* MCV-91 MCH-31.0 MCHC-34.0 RDW-17.2* Plt ___ ___ 06:45AM BLOOD UreaN-15 Creat-0.7 Na-140 K-3.4 Cl-103 ___ 05:45AM BLOOD Plt ___ ___ 06:20PM BLOOD Mg-1.4* ___ 11:38AM BLOOD ALT-34 AST-92* AlkPhos-56 TotBili-0.8 ___ 11:38AM BLOOD cTropnT-0.03* Brief Hospital Course: ___ with PMH of dementia, anxiety, hypertension, hypercholesterolemia, CHF (EF ___, cerebral anurysm s/p coiling, hip fracture s/p right hemiarthroplasty (___), recent hospitalization (___) for septic shock/urinary source requiring intubation, completing course of Zosyn on ___, now p/w hypotension, GI bleed and seizure. 1. Acute GI Bleed: Multiple gastric and duodenal ulcers see on endoscopy, cauterized. No further evidence of active bleeding, no further transfusions required. PPI drip transitioned to BID and subsequently to PO when patient able to swallow pills. Recommended patient avoid all NSAIDs and repeat EGD in ___ weeks. SHe received a fifth RBC transfusion on ___ and had one episode of maroon stool on the floor but her hematocrit stayed the same at 27. 2. Generalized Seizure: ?Due to hypotension, hypothermia, and hypokalemia. No further seizures this admission; not placed on anti-epileptics. 3. Hypernatremia: Likely due to inability to access and safely drink free water. Improved with D5W. Cleared for nectar thickened liquids and regular diet with SLP. 4. Chronic diastolic CHF: Patient not on Lasix as an outpatient; required low doses of Lasix in the FICU and on the floor in the setting of resuscitation and transfusions on admission. She was continued on her home lisinopril and statin. Given ongoing hypervolemia on the floor she received additional IV lasix beginning on ___. 5. Dementia; acute delirium: Acute worsening of mental status likely ___ acute illness, electrolyte abnormalitis, intubation, ICU stay, and recent prolonged illness. Home psychiatric medications were slowly re-started and Seroquel was uptitrated; she was reportedly on as much as 200mg qHS in the past as an outpatient, and was started at 25mg in the ICU. Of note, Duloxetine was not on her medication list from her facility, but was prescribed at discharge on ___. Duloxetine was continued here. TRANSITIONAL ISSUES []REMOVE PICC WHEN NO LONGER NEEDED []CONTINUE IV LASIX TO HELP REDUCE EDEMA, REPLETE WITH KCL AS NEEDED (ORDERED DAILY FOR NOW) []CAN TRANSITION TO PO LASIX, BUT MAY NOT NEED THIS CHRONICALLY []MAKE SURE SHE IS ON PPI AND NO FURTHER GI BLEEDING []ARRANGE REPEAT EGD IN ___ WEEKS []CAN SUBSTITUTE MEDS THAT CAN'T BE CRUSHED IF SHE FAILS TO RELIABLY TAKE THEM IF NOT IN APPLE SAUCE; IE METOPROLOL XL. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: GI Bleed encephalopathy acute blood loss anemia edema 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: You were admitted to the hospital with GI bleeding and a seizure. You were briefly intubated and cared for in the intensive care unit. You received multiple blood transfusions and underwent an EGD which showed multiple ulcers. Your bleeding resolved. Your hospital course was complicated by increased confusion and anxiety, and your home anxiety medications were adjusted. Followup Instructions: ___
10082090-DS-11	10,082,090	27,631,162	DS	11	2189-10-28 00:00:00	2189-10-28 17:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / morphine / ferrous gluconate Attending: ___. Chief Complaint: rt forearm pain at area of IV infiltration Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o with reported hx IBD (Crohn's) who reports recent hospitalization at ___ for IBD 'flare' - she reports rx with solumedrol, antiemetics, ivf, pain control, and left ama over a week ago as she wanted to go home and was dissatisfied with care (did not specify further). She states that her IV appeared to be 'infiltrating' while there (painful, fluid swelling, but no redness) during infusions. She then, all of last week had progressive swelling of the distal volar rt forearm ant IV site with pain and erythema, and ultimately, last WED (5 dd ago) feels that she lost sensation in the hand (really an ulnar distribution described) followed by loss of strength in the hand three days ago (last ___. She presented back to ___, was ordered for CTX IV, and sent here for 'vascular' evaluation. In our ED, AF, VSS, labs sig for marked anemia, hypokalemia. Seen by Hand/Plastic surgery ___ ___ - who I discussed with this evening) - who felt that findings on Soft tissues of ? cellulitis and site of IV infiltration very unlikely to explain neurologic findings. He recommended CT (done, with contrast, c/w cellulitis only), and pt. was given pain meds, antiemetics, IV vancomycin and admitted. Past Medical History: Crohn's disease - not on treatment Iron deficiency Anemia Social History: ___ Family History: Denies Physical Exam: AF and VSS Indpendently ambulating - observed NAD Alert, oriented, fully, PERRL, EOMI Str intact throughout, but rt hand weak, cannot grip fully, visible intrinsic mm wasting. Hand is warm, palpable pulses, good capillary refill throughout. Rt volar distal fa with marked induration/warmth, cellulitis, sl fluctuance at very center (peaking) and crustging/dry blistering relating to erythema. No drainage. Very ttp (exquisitely), but only where erythyematous. No compartment tension, soft throughout rest of forearm, full rom of elbow, supination/pronation, but cannot flex/extend wrist due to pain. no necrosis, no crepitation RRR CTA throughout Soft, nt, nd, bs present, no HSM No edema, no rash other than above Pertinent Results: ___ 05:30AM BLOOD WBC-7.3 RBC-3.47* Hgb-7.3* Hct-24.7* MCV-71* MCH-21.0* MCHC-29.6* RDW-18.1* RDWSD-45.9 Plt ___ ___ 06:45AM BLOOD WBC-6.4 RBC-3.74* Hgb-7.8* Hct-26.5* MCV-71* MCH-20.9* MCHC-29.4* RDW-18.0* RDWSD-45.7 Plt ___ ___ 05:38AM BLOOD WBC-7.5 RBC-3.79* Hgb-7.9* Hct-27.1* MCV-72* MCH-20.8* MCHC-29.2* RDW-18.2* RDWSD-46.7* Plt ___ ___ 11:10AM BLOOD WBC-6.6 RBC-3.66* Hgb-7.6* Hct-26.2* MCV-72* MCH-20.8* MCHC-29.0* RDW-18.1* RDWSD-47.1* Plt ___ ___ 07:25AM BLOOD WBC-6.7 RBC-4.00 Hgb-8.4* Hct-28.7* MCV-72* MCH-21.0* MCHC-29.3* RDW-18.1* RDWSD-46.8* Plt ___ ___ 01:26PM BLOOD WBC-8.3 RBC-4.07 Hgb-8.6* Hct-29.4* MCV-72* MCH-21.1* MCHC-29.3* RDW-18.2* RDWSD-47.5* Plt ___ ___ 06:12AM BLOOD WBC-7.5 RBC-3.87* Hgb-8.1* Hct-27.4* MCV-71* MCH-20.9* MCHC-29.6* RDW-18.0* RDWSD-45.5 Plt ___ ___ 06:45AM BLOOD ___ PTT-30.3 ___ ___ 05:30AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-138 K-3.8 Cl-103 HCO3-29 AnGap-10 ___ 11:47PM BLOOD Glucose-78 UreaN-7 Creat-0.7 Na-141 K-3.2* Cl-104 HCO3-25 AnGap-15 ___ 01:26PM BLOOD ALT-6 AST-19 LD(LDH)-269* CK(CPK)-83 AlkPhos-65 TotBili-0.1 ___ 06:12AM BLOOD CK(CPK)-65 ___ 11:47PM BLOOD ALT-19 AST-16 AlkPhos-56 TotBili-0.2 ___ 11:47PM BLOOD Lipase-54 ___ 05:30AM BLOOD Phos-4.8* Mg-1.8 ___ 11:47PM BLOOD Albumin-3.5 Iron-10* ___ 11:47PM BLOOD calTIBC-290 Ferritn-9.6* TRF-223 ___ 11:53PM BLOOD Lactate-1.1 . EKG ___: Clinical indication for EKG: R10. 84 - Generalized abdominal pain Sinus bradycardia with baseline artifact. Non-specific anteroseptal ST-T wave changes. No previous tracing available for comparison. . CT arm: IMPRESSION: Skin thickening and soft tissue edema along the ulnar aspect of the distal forearm compatible with cellulitis, without fluid collection or soft tissue gas. . MRI arm: IMPRESSION: Edema and enhancement of the subcutaneous tissues along the volar aspect of the distal forearm is suggestive of cellulitis. Enhancement several of the flexor muscles is also seen --this is non-specific, the differential diagnosis includes intravasated fluid and myositis. Small amounts of flexor tenosynovitis are of the ___ and ___ flexor digitorum superficialis and flexor carpi ulnaris tendons are demonstrated on the post-contrast images Although the median and ulnar nerves and swells are grossly unremarkable, the ulnar nerve is surrounded by areas of soft tissue edema which could account for the described neuropathy. The median nerve also abuts an area of soft tissue edema. The radial nerve lies remote from the areas of soft tissue edema. Consultation with a hand specialist is recommended. RECOMMENDATION(S): Given the presence of muscle edema, tenosynovitis, and soft tissue edema surrounding the ulnar and abutting the median nerves, consultation with a hand specialist is recommended. . KUB ___: IMPRESSION: No radiopaque metallic objects are seen. . CXR: IMPRESSION: Tip of left PICC terminates in the lower superior vena cava. Heart size is normal, and lungs and pleural surfaces are clear. . KUB: ___ IMPRESSION: No ileus or obstruction. Brief Hospital Course: ___ y.o woman with h.o Crohn's disease who presented with L.arm pain consistent with cellulitis. 1. Cellulitis - presumably this is due due to IV infiltration at OSH. MRI obtained suggestive of small, nondrainable abscess with associated myositis. The patient was evaluated by the hand surgery specialists who did not recommend any surgical intervention but did recommend PO antibiotics and hand follow up within 1 week of discharge. Hand exam continued to improve on antibiotic regimen. IV vanc and cefazolin was continued for 7 days, and then transitioned to clindamycin to continue through ___. The patient seemed to exhibit high opioids tolerance and requirements during admission for her hand pain. She requested IV formulations at times. She was discharged with a limited supply of dilaudid and instructed to taper this medication to off within a few day. She was advised to try Tylenol first for pain. She was urged that follow up is very important with a hand specialist. Pt is uncertain as to her disposition when leaving the hospital and is unsure of how long she will remain in ___ and when she will be returning to ___. Therefore, she was told that should her stay up here be prolonged she will need to f/u in hand clinic here. Importance was stressed with patient. . 2. Inflammatory bowel disease - Per patient, had mild-moderate inflammation on colonoscopy in past. Electrolytes WNL. Pt stated that she was on asacol 800mg TID prior to her admission to ___. Therefore, resumed this medication. Pt also told of the importance to follow up with a GI provider. Again, as above, she is uncertain as to whether she will be staying in the area vs. returning to ___. She was given the number to ___ clinic and advised to follow up soon. KUB x2 without any evidence of obstruction or ileus. Pt reported nausea, vomiting, and diarrhea at times but stated that she did not feel she was having a flare and that symptoms were improving. . 3. Severe, likely iron-deficient anemia. Allergic to IV iron per report ___ be secondary to IBD. 4.Dispo=f/u may be problematic. Pt stated her plan was to return home to ___ soon but she did not know when. Expressed importance of GI, PCP and hand surgery f/u. Provided numbers to BI hand and GI clinics should pt remain in the area. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Clindamycin 300 mg PO Q6H RX clindamycin HCl 150 mg 2 capsule(s) by mouth every 6 hours Disp #96 Capsule Refills:0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #30 Tablet Refills:0 3. Mesalamine ___ 800 mg PO TID RX mesalamine [Delzicol] 400 mg 2 capsule(s) by mouth three times a day Disp #180 Capsule Refills:0 4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN severe pain please taper this medication down daily with the goal to taper off. Take only as directed RX hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp #20 Tablet Refills:0 5. Docusate Sodium 100 mg PO BID if needed for constipation while taking pain medication. Can purchase over the counter 6. Acetaminophen ___ mg PO Q6H:PRN pain take first. Max daily dose 4grms. Take as directed. You may purchase over the counter Discharge Disposition: Home Discharge Diagnosis: Cellulitis Myositis Crohns disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were admitted for cellulitis of the hand and infection in the underlying muscle. To treat this, we started IV antibiotics which you continued for 7 days. We then started you on oral antibiotics (clindamycin), which you should continue for an additional 2 weeks (see prescriptions). It is very important that you follow up with a hand surgeon within 1 week of discharge. Please see the number below to arrange for follow up should you be staying in the ___ area. Also, you had some nausea and vomiting during admission. Your xray was unrevealing. However, it will be very important that you establish care with and arrange for gastroenterology follow up to ensure appropriate care for your Crohn's disease. Please see the number to the ___ clinic below if you will remain in the ___ area for some time. These follow up appointments are very important. You were given a small supply of pain medication to take upon discharge. The goal is to taper this medication down daily to stop taking this medication. Please take only as directed. Please try Tylenol first as directed and take this with the pain medication. Do not drive when taking this medication. Take with a stool softener that you can purchase over the counter if needed for constipation. This medication can become addicted so be sure only to take sparingly and as needed. Followup Instructions: ___
10082090-DS-13	10,082,090	21,995,625	DS	13	2189-11-09 00:00:00	2189-11-09 20:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / morphine / ferrous gluconate / Zofran (as hydrochloride) Attending: ___. Chief Complaint: abd pain, hand pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH Crohn's disease, esophageal erosions, presenting with abdominal pain. Patient was recently discharged on ___ after recently being admitted for R forearm cellulitis from an infiltrated IV - she was treated with IV vanco/cefazolin and discharged on PO antibiotics however has been unable to tolerate PO and represented to the hospital. Pt was again admitted from ___ for cellulitis which was improving. Pt developed abdominal pain a few days ago during her admission which did not remind her of prior crohn's pain. She had an unrevealing KUB. She was seen at least 2x by nursing manipulating IV pump re: medication rate for opiates. Today she states unable to tolerate PO meds including oral dilaudid and clindamycin at home. She now for ongoing RLQ pain. No fevers/chills, diarrhea, CP, dyspnea, dysuria, additional complaints. In the ED, initial vital signs were: 99.0 135 97/47 16 96% RA -Labs significant for Lactate:1.7, platelets 683, Cr 1.1 -Pt was given: ___ 20:11 IV HYDROmorphone (Dilaudid) .5 mg ___ 20:11 IV Ondansetron 4 mg ___ 20:11 IV DiphenhydrAMINE 25 mg ___ 21:02 IVF 1000 mL NS 1000 mL ___ 23:08 IV Ondansetron 4 mg ___ 23:08 IV DiphenhydrAMINE 50 mg ___ 23:35 PO/NG HYDROmorphone (Dilaudid) 2 mg ___ 03:22 IV Lorazepam 1 mg ___ 03:22 IV Clindamycin 600 mg -Physical exam significant for: pelvic --> R adnexal tenderness, no CMT -Pelvis U/S: Normal pelvic ultrasound. -VS prior to transfer to the floor: 88 ___ 100% RA Past Medical History: # Crohn's disease - not on treatment currently, has been off for ___ years, was previously on Asacol, no biologics # Iron deficiency Anemia Social History: ___ Family History: no history of Crohn's disease Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS - 98.5 116/88 88 16 95%/RA GENERAL - pleasant, well-appearing, in mild discomfort HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal to hyperactive bowel sounds, soft, diffusely tender (worse in RUQ), non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - healing area of cellulitis on medial aspect of R wrist, with erythema but no warmth, significant TTP, eschar present NEUROLOGIC - A&Ox3, face symmetric, impaired sensation in ulnar distribution of right hand PSYCHIATRIC - listen & responds to questions appropriately, pleasant \ DISCHARGE PHYSICAL EXAM ======================= VITALS: 98.3 84-104 93-100/52-60 16 99%RA GENERAL - well-appearing, NAD HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, TTP in RLQ with voluntary guarding although distractable, no guarding or rebound tenderness, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - healing area of cellulitis on medial aspect of R wrist, with slight erythema but no warmth, mild TTP NEUROLOGIC - A&Ox3, face symmetric, impaired sensation in ulnar distribution of right hand and ___ strength of ___ digits. Pertinent Results: ADMISSION LABS ============== ___ 07:45PM BLOOD WBC-9.9 RBC-5.03 Hgb-10.3* Hct-34.9 MCV-69* MCH-20.5* MCHC-29.5* RDW-19.7* RDWSD-45.7 Plt ___ ___ 07:45PM BLOOD Neuts-70.2 Lymphs-17.1* Monos-5.4 Eos-6.2 Baso-0.6 Im ___ AbsNeut-6.94# AbsLymp-1.69 AbsMono-0.53 AbsEos-0.61 AbsBaso-0.06 ___ 07:45PM BLOOD Glucose-87 UreaN-6 Creat-1.1 Na-140 K-4.5 Cl-101 HCO3-26 AnGap-18 ___ 07:45PM BLOOD ALT-11 AST-29 AlkPhos-66 TotBili-0.2 ___ 07:45PM BLOOD CRP-2.5 ___ 08:09PM BLOOD Lactate-1.7 ___ 06:15AM BLOOD SED RATE-PND DISCHARGE AND PERTINENT LABS ============================ ___ 06:15AM BLOOD WBC-10.1* RBC-3.78* Hgb-7.8* Hct-26.6* MCV-70* MCH-20.6* MCHC-29.3* RDW-19.1* RDWSD-46.8* Plt ___ ___ 06:15AM BLOOD ___ PTT-27.6 ___ ___ 06:15AM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-136 K-4.0 Cl-102 HCO3-24 AnGap-14 ___ 06:15AM BLOOD Calcium-8.9 Phos-5.4* Mg-2.0 MICROBIOLOGY ============ ___ 7:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING ======= ___ Transvaginal Ultrasound FINDINGS: The uterus is anteverted and measures 4.3 x 2.8 x 6.7 cm. The endometrium is homogenous and measures 5 mm. The ovaries are normal. There is no free fluid. Due to acute, localized pain symptoms, spectral and color Doppler of the ovaries was performed. There was normal arterial and venous flow demonstrated within the ovaries. IMPRESSION: Normal pelvic ultrasound. Brief Hospital Course: ___ with PMH significant for inflammatory bowel disease, and recent admission for left arm cellulitis treated with clindamycin, complicated by abdominal pain with inability to tolerate PO now re-presenting for right hand pain and RLQ pain. Please see discharge summary dated ___ for additional details. #RLQ pain: During recent admission, pt noted to be tender to palpation with voluntary guarding although distractable and ambulated easily around unit. KUB unremarkable during last admission. Last hospitalization abdominal CT showed rectosigmoid colitis with biopsy results consistent with chronic colitis without granulomas or dysplasia. Extent of inflammatory bowel disease did not explain extent of pain. Recent CT abd/pelvis, flex sig, KUB, and pelvic u/s without clear etiology for her pain. Most likely cause of symptoms is narcotic bowel syndrome from administration of narcotics. Will need outpatient GI follow up. # Persistent nausea/emesis: Unclear etiology, most likely due to decreased motility in setting of opioids. Pt declined CT head on day of discharge to evaluate for central etiology for persistent nausea, as she is concerned about radiation exposure. In the absence of IV access alternative routes of antiemetics were considered. There was no indication for continued IV access. # Anemia: Ferritin 9.6, Fe 10, reflecting severe ___. Pt previously had IV iron infusion and developed fevers and SOB, which was confirmed in records from ___. On this basis, she declined IV iron repletion, and was unable to tolerate PO iron due to emesis as described above. She will need iron supplementation and further w/u for iron deficiency anemia as outpatient. # R wrist cellulitis: Improved with clindamycin, has completed 14 day course on ___ with intermittent interruption due to n/v. Per last admission evaluation by hand surgery patient needs an EMG in ___ weeks. #Thrombocytosis: likely in setting of iron deficiency anemia. Platelets in 600s on admission, close to recent baseline. # IV access: Difficult access, required EJ during prior hospitalization. When PIV lost during this hospitalization pt requested that EJ be replaced; given absence of indication for IV access as above, EJ was not replaced. TRANSITIONAL ISSUES =================== [] patient has profound iron deficiency anemia and needs therapy as an outpatient [] follow up patient's right arm pain and weakness. Completed clindamycin 14 day course on ___ while in hospital [] needs an EMG in ___ weeks Medications on Admission: 1. Pantoprazole 40 mg PO Q24H 2. Clindamycin 300 mg PO Q6H 3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. DiphenhydrAMINE 25 mg PO Q8H:PRN nausea w/ zofran 6. Acetaminophen ___ mg PO Q6H:PRN pain Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain 3. Ondansetron 4 mg PO Q8H:PRN nausea 4. DiphenhydrAMINE 25 mg PO Q8H:PRN nausea w/ zofran 5. Acetaminophen ___ mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Abdominal Pain Nausea SECONDARY DIAGNOSES ==================== Right arm cellulitis and pain Inflammatory bowel disease Iron deficiency anemia Thrombocytosis 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 while you were at the ___ ___. You were admitted to us after you developed worsening abdominal pain. You were evaluated with a pelvic ultrasound that was normal. We tried to control your pain with oral medications and IV Zofran for nausea. However, you lost IV access. We felt that we could try to control your nausea with alternative medications. In addition, we proposed to obtain a head CT to look for alternative causes of nausea. We feel like some of the nausea is possibly from the dilaudid which is a known side effect. We wish you a speedy recovery and safe travels back home to your family. Sincerely, Your ___ Care Team Followup Instructions: ___
10082163-DS-20	10,082,163	21,587,377	DS	20	2126-12-02 00:00:00	2126-12-04 00:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keppra / ciprofloxacin Attending: ___. Chief Complaint: Drainage from groin Major Surgical or Invasive Procedure: ___ ___ Drain placement History of Present Illness: ___ w/ CD, ___ transferred from OSH for pus draining from R inguinal region. Today she presented to ___ w/ pus draining from her R inguinal region. She has been experiencing R groin, R lateral hip, and R low back pain for a month since a fall. Her PCP had diagnosed her with bursitis, but upon going to the bathroom on ___ she found that she could not control the groin discharge, which was yellow/green. She went to ___ ED for evaluation. She was HDS, labs significant for wbc 25. CT scan of abdomen and pelvis shows a "4.1 cm long segmental terminal ileal wall thickening identified with bowel wall defect resulting in leakage of oral contrast posteriorly into the right ilipsoas compartment and into the right superficial inguinal region. Inflammatory changes are seen in the subcutaneous tissues of the right inguinal region surrounding the collection of oral contrast." She was given IV antibiotics, Ceftriaxone (allergic to cipro) and flagyl and she was transferred here for consult from colorectal surgery. In the ED: Vitals: T 97.6 HR 66 BP 139/68 RR 16 96% RA Exam: Very large right groin abscess with surrounding cellulitis Abdominal pain surrounding the abscess Labs: wbc 14.3, hgb 9.2, INR 1.2, Cr 0.9, lactate 1.4. Consults: Surgery recommended admission to medicine w/ GI consult. GI recommended antibiotics and IVF. edications: 1 L NS, flagyl 500 mg IV Vitals upon transfer: T 97.8, HR 69, BP 140/56 RR 18, 98% room air She has had Crohn's disease since ___, but has not had flares or been on medication for years. She denies abdominal pain, but has R groin pain ___. She has had some nonbloody diarrhea the past few days, but no weight loss. Denies N/V/F/C. She denies h/o MI, CVA, blood clots. REVIEW OF SYSTEMS: General: no weight loss, fevers, sweats. Eyes: no vision changes. ENT: no odynophagia, dysphagia, neck stiffness. Cardiac: no chest pain, palpitations, orthopnea. Resp: no shortness of breath or cough. GI: no nausea, vomiting,. GU: no dysuria, frequency, urgency. Neuro: no unilateral weakness, numbness, headache. MSK: no myalgia or arthralgia. Heme: no bleeding or easy bruising. Lymph: no swollen lymph nodes. Integumentary: per HPI Psych: no mood changes Past Medical History: Crohn's Hypertension Seizure disorder (started in ___, no seizures for years) Social History: ___ Family History: No family history of IBD Physical Exam: =================== EXAM ON ADMISSION =================== Vitals: 97.6 170 / 68 72 18 96 Ra General: Alert, oriented, no acute distress and lying comfortably HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, or rhonchi CV: RRR, S1/S2, no m/r/g Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding, no organomegaly. Has purulent draining, mildly TTP and erythematous R inguinal fold region. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: ___ intact, no focal deficits Skin: No rash or lesion ================== EXAM ON DISCHARGE ================== Vitals: 97.5 PO 143/66 HR 65 RR 18 97% RA IN 800 mL OUT 600 mL no BM ___ drain 20 mL General: Alert, oriented, no acute distress and lying comfortably HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, or rhonchi CV: RRR, S1/S2, no m/r/g Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding, no organomegaly. Has purulent draining ___ drain in place draining purulent material , mildly TTP and erythematous R inguinal fold region. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: ___ intact, no focal deficits Skin: No rash or lesion Pertinent Results: ==================== LABS ON ADMISSION ==================== ___ 05:45AM BLOOD ___ ___ Plt ___ ___ 05:45AM BLOOD ___ ___ Im ___ ___ ___ 05:45AM BLOOD ___ ___ ___ 05:45AM BLOOD ___ ___ ___ 05:45AM BLOOD ___ TotBili-<0.2 ___ 05:45AM BLOOD ___ ___ 06:37AM BLOOD ___ ==================== MICRO ==================== Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:00 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 11:15 am BLOOD CULTURE Blood Culture, Routine (Pending): ==================== PERTINENT LABS ==================== ___ 05:45AM BLOOD ___ ___ 04:20AM BLOOD ___ =================== DISCHARGE LABS =================== ___ 04:20AM BLOOD ___ ___ Plt ___ ___ 04:30AM BLOOD ___ ___ Im ___ ___ ___ 04:20AM BLOOD ___ ___ ___ 04:20AM BLOOD ___ ___ 04:20AM BLOOD ___ TotBili-<0.2 ===================== IMAGING ===================== ___ CT Guided Drain Placement Using intermittent CT fluoroscopic guidance, an ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 20 cc of dark, opaque fluid was aspirated. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. 1. Fistula tract communicating between the cecal pole/terminal ileum, right iliacus muscle, right inguinal subcutaneous tissues and right lower quadrant skin surface. 2. 3.2 x 10.1 cm gas and fluid containing collection within the subcutaneous tissues of the right inguinal region, which was targeted for catheter placement. Brief Hospital Course: ___ w/ CD, ___ transferred from OSH w/ concern for enterocutaneous fistula. #Enterocutaneous fistula: Patient with a history of Crohn's disease diagnosed in ___, reportedly free from flares for serveral years and off treatment. Presented to OSH with purulence draining from groin. Patient was hemodynamically stable with SBP 160's HR ___, afebrile with a leukocytosis 14K with neutrophil predominance on admission. CT at OSH w/ PO contrast leaking into right superficial inguinal region c/w entercutaneous fistula. Upon arrival to ___ ED she received 1L IVF, 500 mg IV flagyl. Colorectal surgery was consulted and recommended admission to ? surgery service however was admitted to medicine, made NPO and treated with CTX (D1 9.17), Flagyl (D1 9.17) and continuous IVF at 125 mL/hr while NPO. She underwent drainage to the superficial subcutaneous fluid collection on ___ with ___ mL of purulent drainage per day. She was transitioned from CTX 1g to ___ mg BID Augmentin on discharge (9.22) to complete a 6wk course with flagyl (9.19) to complete a six week course. Diet was advanced after drain removal with no issue. She will follow up with Dr. ___ in GI clinic in 4 wks with repeat CT abd/pelvis with contrast ordered at discharge. She was discharged with ___ services for drain teaching and instructions for ___ to ___ interventional radiology if output < 10 cc for 48hrs for drain removal. #HTN: Upon admission, antihypertensives were held for c/f sepsis then restarted after source control. She was restarted on home lisinopril 20 mg with SBP 150/70 at discharge. She was instructed to restart amlodipine 7.5 mg qd on 9.23 day after discharge. She was continued home dose metoprolol 25 mg daily. #Seizure disorder:Has not had seizures for years. Continued home oxcarbazepine 150 mg BID #CODE: Full code #COMMUNICATION: ___ (husband): ___ (brother) ___ ==================== TRANSITIONAL ISSUES ==================== - F/u with GI at ___ - F/u with PCP - ___ to ___ Interventional Radiology when drain output LESS THAN 10cc/ml for 2 days in a row, please have the ___ Interventional Radiology at ___ at ___ and page ___ - NEW MEDICATIONS Augmentin ___ mg BID 6 wks (D1 ___) Flagyl 500 mg Q8hr 6 wks (D1 ___) - FOLLOW UP PCP, GI CT abdominal/pelvis in ___ wks; pt discharged with order to schedule scan on day of appointment with GI doctor Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OXcarbazepine 150 mg PO BID 2. Lisinopril 20 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. amLODIPine 7.5 mg PO DAILY 5. Lidocaine 5% Patch 1 PTCH TD QAM Discharge Medications: 1. ___ Acid ___ mg PO Q12H may cause diarrhea. take with food for six weeks. RX ___ clavulanate 875 ___ mg 1 tablet(s) by mouth once in the morning and once in the evening Disp #84 Tablet Refills:0 2. MetroNIDAZOLE 500 mg PO Q8H do not drink EtOH RX metronidazole 500 mg 1 tablet(s) by mouth every eight hours Disp #126 Tablet Refills:*0 3. amLODIPine 7.5 mg PO DAILY Take this medication tomorrow morning. ___ MD if feeling lightheaded 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY Take this medication tomorrow morning ___ 7. OXcarbazepine 150 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Enterocutaneous fistula Crohn's disease Intrabominal infection Hypertension Seizure disorder 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 ___ with an intrabdominal infection. A CT scan was performed that showed an a collection of fluid likely related to infection in your abdomen. You were seen by the colorectal surgeons who said there was no need to operate. You were seen by the Gastroenterology department who said to continue antibiotics and they will treat the chron's disease once the infection is controlled. A drain was placed to drain the infection by the interventional radiologists. NEW MEDICATIONS: - Augmentin 875 mg BID to treat abdominal infection. Take with food. may cause diarrhea. You should take this medication for six weeks or until a doctor tells you to stop taking this medication - Metronidazole 500 mg three times daily. Take with food. Do not drink alcohol when taking this medication. You should take this medication for six weeks or until a doctor tells you to stop taking this medication WHO TO ___: - If you have questions about your abdominal drain, ___ interventional radiology at ___ and page ___ - If you have diarrhea, blood in stool, worsening abdominal pain, fevers, chills, vomiting first ___ your GI doctor at ___ or go to emergency department CARING FOR YOUR DRAIN: ___ Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. -You may shower; wash the area gently with warm, soapy water. -Keep the insertion site clean and dry otherwise. -Avoid swimming, baths, hot tubs; do not submerge yourself in water. - If you develop worsening abdominal pain, fevers or chills please ___ Interventional Radiology at ___ at ___ and page ___. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the ___ Interventional Radiology at ___ at ___ and page ___. This is the Radiology fellow on ___ who can assist you. It was a pleasure caring for you Followup Instructions: ___
10082163-DS-21	10,082,163	26,875,625	DS	21	2127-03-15 00:00:00	2127-03-15 16:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keppra / ciprofloxacin / metronidazole Attending: ___. Chief Complaint: abscess Major Surgical or Invasive Procedure: ABSCESS DRAINAGE History of Present Illness: Ms. ___ is a ___ with Crohn's disease (diagnosed in ___ being managed solely with budesonide in the past but no longer taking) complicated by EC fistula and right groin abscess which recurred within two weeks of drain removal, now presenting with abscess requiring drainage. She presents from ___ for right hip abscess and abdominal pain. She noted approximately 1 week of slowly progressing erythema spreading around her right groin with only slight abdominal pain. She also noted increased purulence. Patient has a history of abscesses drained in past. Recent Crohn's history is as below: - Diagnosed ___ when she had abdominal pain, has not had any recurrence since then (managed solely on budesonide which was actually stopped for years, briefly restarted this year). At baseline has never had constipation, diarrhea, or blood in stools. Colonoscopy ___ years ago showing no abnormality, patient has declined future colonoscopies. - Hospitalized from ___ for fistula (presenting symptoms included erythema as well as purulence); CT scan showed fistula tract from cecal pole/terminal ileus, right iliacus muscle, right inguinal subcutaneous tissues and RLQ skin surface as well as a 3.2 x 10.1cm collection within right inguinal region, for which a catheter was placed - Patient was discharged with antibiotics (6 weeks augmentin/flagyl) - Drain output decreased but a follow-up CT scan on ___ showed persistent fluid collection- Cultures (from ___ grew multisensitive ENTEROBACTER CLOACAE COMPLEX. - She had drain repositioned with good output from drain and was continued on her antibiotics - Repeat Ct scan ___ showing resolution of fluid collections but with persistence of fistula tract - Seen by GI on ___, drain was removed, recommended planning Humira treatment. At that visit, she had TB/Hep B checked (Negative for TB-Quantiferon and Negative for hep B infection or immunization), Zoster vaccination. She was recommended bone density study and regular dermatology appointments. - She is currently not on any treatment including the budesonide She currently denies any pain and is afebrile. She denies any chills or rapid spread. WBC was elevated at OSH and was given ceftriaxone and flagyl prior to admission. In the ED, initial vitals: T 98.4 HR 66 BP 130/70 RR 18 O2 Sat 97% RA - Exam notable for: Abdomen soft, non-tender, no signs of distension. Skin warm and dry. Abscess to right hip/groin area actively draining, yellow drainage @ this time. Appx 4cm. Redness around site. - Labs notable for: CHEM 7: Unremarkable. Cr 0.6 CBC: WBC elevated at 11.2 (neutrophilic predominance 84.6%), normocytic anemia Hgb 9.9, Hct 30.7, MCV 88, Plt 287 Coags: ___ 12.7, PTT 22.6, INR 1.2. Blood cultures are pending - Imaging notable for: CT C/A/P at OSH: 1. Terminal ileitis 2. Extensive stranding with associated 4.9 cm fluid collection present within the right groin compatible with abscess and cellulitis. Stranding and foci of gas are noted present tracking throughout the iliopsoas muscle into the iliac is muscle body compatible with pelvic spread of an infectious process. 3. Renal and hepatic cysts 4. Stable left adrenal mass - Colorectal surgery was consulted who recommended admission for IV abx, ___ to evaluate percutaneous drainage, and GI evaluation to plan for Humira therapy once source control is achieved. - Vitals prior to transfer: T 97.5 HR 96 BP 136/58 RR 14 O2 Sat 99% RA On the floor, she is feeling well without any pain. She had a last BM this AM which was normal. Other than erythema on right hip abscess (which is covered with dressing), she notes no other complaints. She does mention that she got the zoster vaccine in ___ but then got shingles from ___ (rash on back when she was traveling in ___ followed by significant postherpetic neuralgia and pain requiring lidocaine patches. Even though her GI doctor recommended another zoster shot, she is hesitant to try this given her prior vaccination. Past Medical History: Crohn's Hypertension Seizure disorder (started in ___, no seizures for years) Social History: ___ Family History: No family history of IBD Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 0726 Temp: 98.2 PO BP: 156/74 HR: 67 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: NAD, lying comfortably in bed EYES: sclera anicteric ENT: OP clear, MMM CV: RRR, no m/r/g RESP: CTAB GI: There is a fistula noted in the RLQ/R groin, draining purulent fluid. The opening of the fistula is approx. 1 cm in size. There is erythema surrounding the fistula site. The prior fistula on the LLQ appears well healed. The rest of her abdomen was nontender. GU: deferred MSK: no pitting edema SKIN: no rashes noted NEURO: A&Ox3 DISCHARGE PHYSICAL EXAM: ======================== VITALS: reviewed in OMR GENERAL: NAD, lying comfortably in bed EYES: sclera anicteric ENT: OP clear, MMM CV: RRR, no m/r/g RESP: CTAB GI: There is a fistula noted in the RLQ/R groin, draining purulent fluid. The opening of the fistula is approx. 1 cm in size. There is minimal erythema surrounding the fistula site. The prior fistula on the LLQ appears well healed. The rest of her abdomen nontender. GU: deferred MSK: no pitting edema SKIN: no rashes noted NEURO: A&Ox3 Pertinent Results: ADMISSION LABS: ___ 06:30AM BLOOD WBC-7.6 RBC-3.29* Hgb-9.4* Hct-28.8* MCV-88 MCH-28.6 MCHC-32.6 RDW-13.4 RDWSD-43.1 Plt ___ ___ 03:41PM BLOOD Neuts-84.6* Lymphs-6.8* Monos-6.5 Eos-1.0 Baso-0.2 Im ___ AbsNeut-9.44# AbsLymp-0.76 AbsMono-0.72 AbsEos-0.11 AbsBaso-0.02 ___ 03:41PM BLOOD ___ PTT-22.6* ___ ___ 06:30AM BLOOD Glucose-88 UreaN-18 Creat-0.6 Na-142 K-4.0 Cl-99 HCO3-29 AnGap-14 ___ 03:51PM BLOOD Lactate-0.9 PERTINENT/DISCHARGE LABS: none MICRO: blood cultures NGTD IMAGING REPORTS: ================ US R GROIN ABSCESS ___: Transverse and sagittal images were obtained of the superficial tissues of the right groin. There is an irregular hypoechoic collection spanning approximately 10.0 cm transverse and 4.5 cm sagittal, with a significant hyperechoic component consistent with air seen on prior CT. IMPRESSION: Collection of fluid and air in the right groin spans approximately 10.0 x 4.5 cm. US R GROIN ABSCESS ___ The patient presented for potential drain placement into a subcutaneous fluid collection in the right groin, which is secondary to a known enterocutaneous fistula. Preprocedure ultrasound images demonstrated a thin fluid collection containing echogenic gas, which appears to have decreased in thickness compared to prior CT of the abdomen/pelvis from ___. The patient has an actively draining wound in the skin lateral to the site of the collection. The amount of fluid was felt to be insufficient for drainage at this time. Actively draining enterocutaneous fistula. Subcutaneous fluid collection in the right groin has decreased in thickness, insufficient for drainage at this time. Brief Hospital Course: This is a ___ year old female with past medical history of hypertension, seizure disorder, Crohn's disease recently complicated by enterocutaneous fistula and R groin abscess requiring drainage and prolonged course of antibiotics, admitted with recurrent abscess, unable to be drained due to insufficient fluid, improving on antibiotics, seen by GI and planned for outpatient imaging and follow-up, able to be discharged home. # Crohn's Disease complicated by R groin Enterocutaneous Fistula and R groin abscess Patient with recent history of infected enterocutaneous fistula requiring prolonged antibiotic course who presented with pain and erythema at right hip. CT scan showed a fluid collection present within the right groin compatible with abscess, with associated cellulitis. Colorectal surgery was consulted who recommended drainage of abscesss by ___. She had a repeat ultrasound performed by ___ which showed fluid collection decreased in size, so much so that it was not amenable to drainage. Per discussion with consulting services, plan was ton continue antibiotic therapy, until her GI follow-up. Of note, given recent metronidazole course and new peripheral neuropathy symptoms, patient was transitioned from flagyl to clindamycin this admission. Patient aware of warning signs that should prompt her to seek additional care (relating to worsening of skin findings / pain or failure to improve). Per GI consult, the patient will follow-up in ___ clinic on ___ for consideration of humira pending resolution of her abdominal abscess. Patient will have a CT abdominal scan to determine resolution of the abscess in ___ weeks. # HTN: BP well controlled on this admission, on lisinopril, amlodipine and metoprolol. TRANSITIONAL ISSUES: -------------------- [] Repeat CT abdomen/pelvis prior to GI appointment on ___ to ensure abscess has resolved on antibiotics [] Continue clindamycin and augmentin until GI follow-up and repeat imaging [] Discontinued flagyl given concern for flagyl-induced peripheral neuropathy CONTACT: ___ ___ > 30 minutes spent on this discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. OXcarbazepine 300 mg PO QHS Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #80 Tablet Refills:0 2. Clindamycin 300 mg PO Q6H RX clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #150 Capsule Refills:0 3. amLODIPine 5 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. OXcarbazepine 300 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Crohn's Disease complicated by R groin Enterocutaneous Fistula and abscess # Peripheral neuropathy # Hypertension # Epilepsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you during your hospital stay, You were admitted to the hospital because: - You were having redness and pain in your right groin, and the emergency department saw another abscess What happened to you while you were in the hospital: - You were started on antibiotics for the abscess - You had your abscess drained by our radiologists - You were seen by our colorectal surgeons What should you do when you leave the hospital: - Continue taking all of your antibiotics as listed - Please follow up with your gastroenterologist to decide on future treatments for your Crohn's disease - Please follow up with your primary care doctor ___ wish you the best, Your ___ Care Team Followup Instructions: ___
10082640-DS-12	10,082,640	22,930,426	DS	12	2179-09-03 00:00:00	2179-09-03 21:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back pain and anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ year old female with a history of beta thalassemia intermedia who initially presented to ___ ___ this morning ___ increasing right flank pain and was found to have multiple calculi in the right terminal ureter and UV junction with moderate hydrouteronephrosis. On that same CT she was also noted to have marked splenomegaly, and bilateral paravertebral soft tissue lesions in the midthoracic spine of unclear etiology. She receives her hematologic care at ___ and was consequently transferred from ___ to ___. In the ___, she was seen by urology who recommended starting Flomax and IVFs for her renal stones. She was also seen to have severe anemia, as was seen in ___, with Hb of 3.9. LDH was 250 with tbili of 1.4 and haptoglobin < 5. She was admitted to the floor for further evaluation. On review of systems, she endorses intermittent hematuria over the past two days with bright red blood, but only on a couple of occasions. Otherwise, her urination has been normal. No other bleeding in stool, or bruising. No weight loss, fevers, chills. No chest pain, dyspnea, abdominal pain, or vomiting. 12 pt ROS otherwise negative. She once had a similar episode of low HCT requiring blood transfusions ___ years ago, but she has not needed any in the past several years. She sees Dr. ___ management of her beta-thalassemia and receives therapy for iron overload. She has been evaluated for cirrhosis secondary to iron overload and has been negative for this per recent fibroscan. Past Medical History: Beta thalassemia intermedia Iron overload Social History: ___ Family History: per OMR, no hx of hematological disease or malignancy Physical Exam: ADMISSION VS: 98, 112/40, 74, 18, 97% RA Gen: Caucasian female, somewhat yellow in appearance, in NAD HEENT: Anicteric Cardiac: Loud, mid-systolic murmur, most prominent in aortic area Pulm: clear bilaterally Abd: soft NT ND + BS Ext: warm and well perfused, small bruise overlying right ankle DISCHARGE VS: 98.1 104/42 72 16 98%RA Gen: sitting up in bed, comfortable Eyes - EOMI, +icterus, +pallor ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender, normoactive bowel sounds; markedly enlarged and palpable spleen Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION ___ 11:59AM BLOOD WBC-2.3* RBC-UNABLE TO Hgb-3.9# Hct-14.0# MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-51* ___ 11:59AM BLOOD Neuts-78* Bands-0 Lymphs-16* Monos-3* Eos-2 Baso-0 ___ Myelos-1* NRBC-10* AbsNeut-1.79 AbsLymp-0.37* AbsMono-0.07* AbsEos-0.05 AbsBaso-0.00* ___ 11:59AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-3+ Macrocy-NORMAL Microcy-3+ Polychr-1+ Ovalocy-3+ Schisto-1+ Stipple-1+ Tear Dr-3+ Bite-1+ Ellipto-2+ ___ 11:59AM BLOOD Glucose-89 UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-107 HCO3-21* AnGap-14 ___ 11:59AM BLOOD LD(LDH)-262* TotBili-1.4 DirBili-0.5* IndBili-0.9 DISCHARGE ___ 06:00AM BLOOD WBC-2.1* RBC-UNABLE TO Hgb-5.3* Hct-19.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-44* ___ 06:00AM BLOOD Glucose-82 UreaN-20 Creat-0.7 Na-142 K-3.9 Cl-112* HCO3-21* AnGap-13 Abdominal Ultrasound ___ 1. Massive splenomegaly with the spleen measuring 25 cm. 2. Normal appearance of the liver. 3. Right pleural effusion. 4. Right nonobstructing nephrolithiasis Brief Hospital Course: This is a ___ year old female with past medical history of beta-thalassemia intermedia who initially presented ___ with symptomatic ureterolithiasis, but incidentally also found to have severe anemia with a Hgb 3.9, s/p transfusion 2 units pRBCs, workup notable for poor hematopoiesis thought to represent resolving bone marrow suppression from recent viral infection, seen by hematology and cleared for discharge home with close outpatient follow-up. # Acute Anemia / Aplastic Crisis - Hgb 3.9 on admission (baseline ~6), without signs of active bleeding. Workup was notable for signs of stable chronic hemolysis with poor erythropoiesis with persistently low retic counts. Patient was seen by hematology who felt she had chronic splenomegaly due to extramedullary hematopoiesis, were not concerned about worsening sequestration, and suspect recent aplastic crisis due to viral infection. Patient was transfused 2 units and then felt to be medically ready for discharge with close outpatient hematology follow-up. Discharge Hgb 5.3. Continued Exjade, increased folate to 5mg daily per hematology # Nephrolithiasis - noted on admission imaging to have "multiple calculi in the right terminal ureter and UV junction with moderate hydrouteronephrosis". She was started on a trial of Flomax and recommended for outpatient urology follow-up to see she would be able to pass the stones with medical management. Provided with ___ urology contact information at discharge Transitional Issues - Parvovirus serology and SPEP pending at discharge, to be followed up by discharging hospitalist - Patient discharged home - Provided instructions regarding hematology and urology following; per hematology, they will contact patient at home to set up close follow-up Medications on Admission: The Preadmission Medication list is accurate and complete. 1. deferasirox 750 mg oral DAILY 2. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. deferasirox 750 mg oral DAILY 2. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #14 Capsule Refills:0 3. FoLIC Acid 5 mg PO DAILY RX folic acid 1 mg 5 tablet(s) by mouth once a day Disp #70 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: - Beta-thalassemia intermedia - Acute Anemia due to viral infection - Nephrolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___, It was a pleasure taking care of you. You were admitted with low blood counts. You were seen by hematology experts, who thought your blood counts were low because of a recent viral infection. They recommended increasing your folic acid to 5mg daily. You were treated with a blood transfusion, and your blood counts improved. It will be important for you to see your hematologist Dr. ___. His office will be in touch within ___ days regarding setting up a follow-up visit. If you do not hear from them, please call ___. You were also found to have kidney stone and were started on a new medication ("Flomax"). Please schedule an appointment with a urologist within ___ weeks by calling ___. Please see your primary care doctor within the next 2 weeks. Followup Instructions: ___
10082662-DS-10	10,082,662	22,060,359	DS	10	2146-07-27 00:00:00	2146-07-30 11:39:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___. Chief Complaint: PE Major Surgical or Invasive Procedure: None. History of Present Illness: ___ is a ___ year old woman with metastatic melanoma who is admitted from the ED after routine staging CT incidentally noted new right sided PE. Patient has been feeling generally well, but in retrospect has had increasing SOB with exertion over the last few weeks. Also with URTI several weeks ago and chronic LLE swelling. She was seen in ___ clinic on day of admission for routine staging scans. CT showed substantial right sided PE. She was referred to the ED. In the ED, initial VS were T 99.8, HR 67, BP 137/65, RR 16, O2 98%RA. Labs notable for Na 139, K 4.5, HCO3 26, Cr 1.8, ALT 20, AST 26, ALP 202, TBili 0.3, Alb 3.4, WBC 4.6, HCT 33.9, PLT 183 Trop negative x1. INR 1.0. Head CT showed no evidence of intracranial hemorrhage or acute process and ___ showed left leg DVT. She was given 60mg SC lovenox. VS prior to admission were HR 65, BP 128/62, RR 16, O2 100%RA. On arrival to the floor, patient had no c/o. denied c/p and denied SOB. admits to subtle doe on going up hills, which started roughly 4 wks ago, and has not stopped her from exerting herself. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: Ms. ___ is a ___ female with widely metastatic melanoma (BRAF V600B or V600K). She experienced disease progression while on ipilimumab/bevacizumab (___), near complete response on RAF+MEK inhibition, received one dose of pembrolizumab which was complicated by ___ and ___, with current treatment of dabrafebib/trametinib. On her CT scan on ___, some unclear endobronchial and bronchcentric nodular lesions were appreciated. Repeat CT chest on ___ showed an increase in the size of her pulmonary lesions, but commented that they had some atypical features for metastatic lesions. She underwent bronchoscopy with and FNA of a subcarinal lymph node with showed the presence of aspergillus, but did not have clear evidence of angioinvasion. On ___, she visited the ___ clinic to discuss the finding of pulmonary aspergillosis. She reported that she did not have any cough or dyspnea, fatigue, or fevers. Azole therapy is contraindicated with BRAF/MEC inhibitors (dabrafebib/trametinib), with remaining options of IV antifungals (lifelong therapy), use of voriconazole or isavuconazole with very close monitoring, or "watch and wait" approach to determine if infection clears as she is immunocompetent. -___ F/u CT scan showed findings consistent consistent with a partially treated infection. The result was discussed with the ID team and the decision was made to continue watchful waiting. -___: CT of the chest showed improving infiltrates. The remainder of her CT TORSO showed stable disease -___: CT TORSO shows stable to decreased disease with some resolution of her pulmonary infiltrates -___: CT TORSO shows stable disease -___: CT TORSO shows stable disease -___: CT Torso increase in size of bilateral hilar nodes and new 0.5 cm right upper lobe nodule. Left fissural nodules have also increased in size in the interim, now measuring up to 0.6-cm. Possibly related to aspergillus diagnosis that she carries. OTHER PAST MEDICAL HISTORY: - Dental implants - S/p tonsilectomy - HLD - Osteoporosis - CKD, stage IV Social History: ___ Family History: She is adopted and unsure of any family history. Her children are healthy without cancer. Physical Exam: ADMISSION EXAM: VS: 98.0 PO 155 / 72 71 18 97 RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes DISCHARGE EXAM: Vital Signs: 97.8PO 134 / 67 59 18 97 Ra GEN: Alert, NAD HEENT: NC/AT, MMM NECK: No JVD noted CV: RRR, no m/r/g PULM: Breathing comfortably, lungs CTA GI: S/NT/ND, BS present EXT: mild LLE edema, no calf tenderness NEURO: ___ PSYCH: Calm, appropriate Pertinent Results: ADMISSION LABS: ___ 12:10PM BLOOD WBC-4.6 RBC-4.02 Hgb-11.0* Hct-33.9* MCV-84 MCH-27.4 MCHC-32.4 RDW-15.0 RDWSD-46.0 Plt ___ ___ 12:10PM BLOOD Neuts-71.4* Lymphs-12.3* Monos-12.3 Eos-2.9 Baso-0.4 Im ___ AbsNeut-3.26 AbsLymp-0.56* AbsMono-0.56 AbsEos-0.13 AbsBaso-0.02 ___ 05:32PM BLOOD ___ PTT-29.0 ___ ___ 12:10PM BLOOD UreaN-39* Creat-1.8* Na-139 K-4.5 Cl-101 HCO3-26 AnGap-12 DISCHARGE LABS: ___ 06:40AM BLOOD WBC-3.7* RBC-3.60* Hgb-9.9* Hct-31.7* MCV-88 MCH-27.5 MCHC-31.2* RDW-15.0 RDWSD-48.9* Plt ___ ___ 06:40AM BLOOD Glucose-91 UreaN-30* Creat-1.5* Na-143 K-4.6 Cl-106 HCO3-26 AnGap-11 ___ 06:40AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.4 OTHER PERTINENT LABS: ___ 12:10PM BLOOD proBNP-241 ___ 05:32PM BLOOD CK-MB-4 cTropnT-<0.01 ___ 06:04AM BLOOD cTropnT-<0.01 proBNP-349 ___ 02:35AM BLOOD LMWH-0.54 ___ 10:40AM BLOOD LMWH-0.71 IMAGING: CT A/P - IMPRESSION: 1. Stable hepatic and splenic lesions. No new lesions. 2. Stable retroperitoneal and mesenteric lymphadenopathy. No new or enlarging lymphadenopathy in the abdomen or the pelvis. 3. Stable 1.0 cm cystic lesion in the pancreatic head, likely a side branch IPMN. Attention on follow is recommended. 4. Persistent, nonspecific mild thickening along the anterior wall of the gallbladder. CT CHEST - IMPRESSION: New substantial right lower lobe pulmonary emboli. No infarction. Borderline heart failure, improved. Improving central adenopathy. No evidence of active intrathoracic malignancy or infection. Single, indeterminate 4 mm pulmonary nodule. Mild pathologic compression fracture lower thoracic spine unchanged since at least ___. CT HEAD - IMPRESSION: No acute intracranial process. No evidence of intracranial hemorrhage. No evidence of metastatic lesions, however note that MRI is a more sensitive modality for evaluation of masses. B ___ - IMPRESSION: Deep venous thrombosis in the leftlower extremity veins. Brief Hospital Course: ___ y/o F with PMHx of metastatic melanoma, pulmonary aspergillosis, CKD IV, HLD, who was referred to the ED after routine staging CT showed PE. Imaging also notable for LLE DVT. She was started on Lovenox, with doses adjusted to get levels in therapeutic range. # DVT/PE: Pt was only minimally symptomatic (endorsed several months of mild progressive DOE). No evidence of right heart strain on lab work (BNP and Tn not elevated); however, ECG did show TWI in III. She was started on Lovenox at once daily dosing given renal function. However, renal function subsequently improved on HD2, and dosing was increased to BID per discussion with pharmacy. Levels were followed and were therapeutic at the time of discharge. Would continue to monitor renal function in the outpatient setting and consider rechecking LMWH levels if Cr increases. # CKD STAGE IV: Cr appears to generally range 1.5 to 1.8 over the past year in OMR. Cr was 1.8 on presentation but has improved to 1.5 at the time of discharge. # CHRONIC DIASTOLIC HEART FAILURE: No evidence of volume overload on exam. Continued home metoprolol and Lasix. # METASTATIC MELANOMA: Home Dabrafebib/Trametinib held while patient in house and restarted at discharge. # ANEMIA: H/H below recent baseline, but no clear evidence of bleeding. ?possibly related to recent chemotherapy. Remained stable throughout hospital course. TRANSITIONAL ISSUES - Pt will need to remain on Lovenox indefinitely given concurrent malignancy diagnosis. - Would continue to trend Cr in the outpatient setting and consider rechecking LMWH levels if there were a change in renal function. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO BID 4. Metoprolol Succinate XL 50 mg PO DAILY 5. dabrafenib 150 mg oral BID 6. trametinib 2 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 60 mg SC twice a day Disp #60 Syringe Refills:*0 2. Acetaminophen ___ mg PO Q6H:PRN pain 3. Aspirin 81 mg PO DAILY 4. dabrafenib 150 mg oral BID 5. Furosemide 20 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. trametinib 2 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: DVT PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented to the hospital after routine staging scans showed a blood clot in your lungs. Follow up ultrasound imaging also showed a blood clot in your left leg (likely the source of the blood clot in your lung). You were started on Lovenox, and your dose was adjusted based off of your Lovenox levels. You are now being discharged home. It is very important that you follow up with your doctors as ___. Followup Instructions: ___
10082662-DS-11	10,082,662	28,631,269	DS	11	2148-07-24 00:00:00	2148-07-24 15:42:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___ Chief Complaint: Hip pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a pleasant ___ years old Female who presents to ___ ED for the further evaluation s/p mechanical fall and now c/o L hip pain. Pt states she was in her usual state of health until approx. one month ago when she experienced a mechanical fall. She recalls it was near the ___ ___ while walking up the steps to an office building. No prodromal sxs reported including any dizziness, lightheadedness, blurred vision, or palpitations. Denies any head trauma or LOC at the time. Since the fall she has been experiencing gradual worsening pain involving the L hip, which is the location of the fall. She states it has been difficult to bear weight and ambulate given the pain. She went to see her PCP who proceeded to order a CT, given her oncological history and was found to have a nondisplaced acetabular fracture. Of note, at baseline pt utilizes a walker for assistance. She was seen in ___ clinic and referred to the ED for further medical care. No recent fevers, chest pain, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, or known exposure to sick contacts. In the ED, initial vitals: 99.2 114 123/76 20 96% RA REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: -___: Dysplastic nevus syndrome -___: referred to ___ w/ history of dysplatic nevus removal in ___ presents in referral for consideration of clinical trial enrollment for treatment of newly diagnosed stage IVb melanoma metastatic to axilla, lung, liver and spleen (BRAF V600B or V600K). Was on clinical trial ___ ___ --> caused swelling), pembrolizumab x1 (c/b nephritis). -___: Started on BRAF and MEK inhibition with Dabrafenib-Trametinib. -___: she visited the ___ clinic to discuss the finding of pulmonary aspergillosis, no cough, dyspnea, fatigue, or fevers. Azole therapy is contraindicated with BRAF/MEK inhibitors (dabrafebib/trametinib), with remaining options of IV antifungals (lifelong therapy), use of voriconazole or isavuconazole with very close monitoring, or "watch and wait" approach to determine if infection clears as she is immunocompetent. -___ CT scan showed partially treated infection. ID team rec'd continue watchful waiting -___: CT showed improving infiltrates, otherwise stable -___: CT showed improving infiltrates, otherwise stable -___: CT TORSO shows stable disease -___: CT TORSO shows stable disease -___: CT Torso increase of bilateral hilar nodes and new 0.5 cm right upper lobe nodule. Left fissural nodules have also increased in size in the interim, now measuring up to 0.6-cm. Possibly related to known Pulmonary Aspergillosis. -___: Blood work concerning for rising LDH from 420 to 2173 and worsening anemia concerning for disease progression. -She has most recently been on BRAF/MEK inhibition with dabrafenib/trametinib. PAST MEDICAL HISTORY: L arm fx Metastatic melanoma, as above, known bone mets to R femur L Humerus lesion HTN Pulmonary Aspergillosis CKD Social History: ___ Family History: Patient adopted, family history unclear. Physical Exam: VITAL SIGNS ___ 1105 Temp: 98.6 PO BP: 101/67 HR: 121 RR: 18 O2 sat: 96% O2 delivery: RA General: NAD, comfortable and pleasant Neuro: AOx3, no focal deficits, no asterixis HEENT: no scleral icterus or conjunctival injection, MMM CV: no JVD, RRR, no MRG Resp: effort normal, CTAB Abdomen: non-tender, no rebound tenderness, no organomegaly Extremities: warm, trace ___ edema; L hip: mild tenderness to palpation; sensation intact Skin: no wounds ACCESS: PIV Pertinent Results: ___ 06:20AM BLOOD WBC-5.6 RBC-3.35* Hgb-9.0* Hct-29.6* MCV-88 MCH-26.9 MCHC-30.4* RDW-16.3* RDWSD-53.3* Plt ___ ___ 06:20AM BLOOD Neuts-82.8* Lymphs-4.3* Monos-7.6 Eos-0.4* Baso-0.4 Im ___ AbsNeut-4.60 AbsLymp-0.24* AbsMono-0.42 AbsEos-0.02* AbsBaso-0.02 ___ 07:00PM BLOOD ___ PTT-30.8 ___ ___ 06:20AM BLOOD Glucose-105* UreaN-21* Creat-1.2* Na-138 K-4.3 Cl-106 HCO3-21* AnGap-11 ___ 06:20AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9 ___ 07:02PM BLOOD Lactate-1.6 ___ 08:23AM BLOOD TSH-6.5* ___ 08:23AM BLOOD Free T4-1.0 STUDIES: CT A/P w/ contrast ___ IMPRESSION: 1. Interval growth of a now 1.6 cm hypodense lesion within the right hepatic lobe, previously 0.3 cm, with new, scattered subcentimeter hepatic hypodensities, concerning for worsening metastatic disease. 2. New, bilateral adrenal nodules, measuring up to 0.8 cm, also concerning for new sites of metastasis. 3. No substantial change in multiple splenic hypodensities, reflecting treated metastases. 4. New, nondisplaced left superior acetabular fracture. 5. New, interval compression deformity of the T12 vertebral body, with retropulsion of the posterior aspect of the vertebral body and resultant moderate vertebral canal narrowing. 6. Please refer to the separate report of the chest CT performed on the same day for intrathoracic characterization CT Chest w/ contrast ___ IMPRESSION: Multiple bilateral lung nodules ranging from 2-6 mm, some are new, some are enlarged and others are stable, concerning for metastatic disease. New T12 vertebral body fracture with fragment retropulsion into the spinal canal. Stable T9 compression fracture with increased density suspicious for metastatic disease. Moderately worsened pulmonary edema. Xray Hip b/l ___ IMPRESSION: 1. No plain film radiographic evidence of acute fracture. However, there is a vertically oriented minimally displaced fracture of the superior acetabulum that is seen on the CT of the pelvis from ___. 2. Mild degenerative joint disease in the bilateral hips and sacroiliac joints. Brief Hospital Course: Ms. ___ is a ___ who presents to ___ ED for eval s/p mechanical fall and now c/o L hip pain. # Nondisplaced left acetabular fracture # T12 compression defmority: She was evaluated by orthopedics and spine service. No acute operative intervention planned. Per spine team, can have activity as tolerated including ___. TLSO is not necessary for spine stabilization (but could consider if needed for comfort). She was cleared for discharge with home ___. - Follow-up in Spine Clinic in 6 weeks if no symptom improvement - Continue oxycodone PRN pain # Stage IV Metastatic Melanoma, BRAF V600 mutant: Most recently on Dabrafenib/Trametinib. She has imaging evidence of progression including liver and adrenal metastases. Dabrafenib/Trametinib were held pending planned wash-out period for clinical trial. Patient was seen by primary oncologist Dr. ___ her admission. # History of PE: Continue apixaban 2.5mg BID # Tachycardia: Mild tachycardia to 100s-120 likely secondary to holding metoprolol. She was asymptomatic from this during her hospitalization. # History of hypertension, diastolic heart failure: Home metroprolol was held on admission and will be resumed after discharge. She was advised to resume furosemide day after discharge if tolerating PO well. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. dabrafenib 75 mg oral BID 2. Furosemide 20 mg PO BID 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. trametinib 2 mg oral DAILY Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:*0 2. Apixaban 2.5 mg PO BID 3. Furosemide 20 mg PO BID 4. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Acetabular fracture # T12 compression deformity SECONDARY DIAGNOSES: Metastatic melanoma History of pulmonary embolism 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 being part of your care at ___. You were admitted after a recent fall and found to have a fracture in your left hip as well as a compression fracture of the spine (T12). You were evaluated by orthopedics, spine surgery and radiation oncology. It was determined that surgery is not currently needed for your injuries. You were evaluated by physical therapy as well prior to discharge and were cleared for going home with home physical therapy. It was a pleasure being part of your care. Sincerely, Your ___ team Followup Instructions: ___
10082701-DS-16	10,082,701	20,717,652	DS	16	2110-03-23 00:00:00	2110-03-23 19:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left distal humerus fracture, left proximal humerus fracture Major Surgical or Invasive Procedure: left distal humerus open reduction internal fixation History of Present Illness: ___ female with no significant past medical history presents with left arm pain. Patient was in the ___ 2 nights ago when she fell getting out of the bathtub. Positive head strike questionable LOC. Was unable to get up due to left-sided rib pain and arm pain. She went to the emergency room found to have multiple fractures in her left arm was placed in a cast and sent home because they said they could not do surgery there and would have to go to the ___. She has had continued pain over this time but no shortness of breath fevers chills lightheadedness nausea or vomiting neck pain. She remembers the entire event. She has not been taking anything for pain Past Medical History: none Social History: ___ Family History: nc Physical Exam: Exam: Vitals: AVSS General: Well-appearing female in no acute distress. Resting comfortably in her sling MSK: LUE: Mild edema in the left hand. Soft, non-tender shoulder, arm and forearm. Fires EPL/FPL/DIO. SILT axillary/radial/median/ulnar nerve distributions. 2+ radial pulse, WWP. dressing c/d/i Brief Hospital Course: Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left distal humerus fracture and left proximal humerus fracture was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for an open reduction internal fixation of the left distal humerus, 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. 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 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. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #100 Tablet Refills:1 2. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #28 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID hold for loose stools RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain dont drink, operate heavy machinery, or drive while taking RX oxycodone 5 mg ___ tablet(s) by mouth every four hours as needed Disp #60 Tablet Refills:0 5. Senna 8.6 mg PO BID hold for loose stools RX sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: left distal humerus fracture, left proximal humerus 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: - nonweightbearing on the left upper extremity, range of motion as tolerated in elbow, wrist, shoulder and fingers; sling for comfort as needed 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 daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Leave soft dressing on Followup Instructions: ___
10082986-DS-8	10,082,986	26,111,347	DS	8	2189-06-22 00:00:00	2189-06-23 11:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: increased frequency of urination Major Surgical or Invasive Procedure: ___ - ___ line placement History of Present Illness: ___ yr old female with hx HTN, DM and bladder suspension surgery who presented to PCP ___ ___ with urinary urgency, frequency and incomplete emptying which she started 1 month ago. Also describes 'ball' like sensation in bladdder to. Urine culture revealed MDR Klebsiella that was not susceptible to oral antibiotics (nitrofurantoin intermediate) and so she was referred to the ED on ___ where she was afebrile without signs of sepsis on admission and she was started on cefepime. She states that these symptoms have been coming and going for years. She currently has frequency and feels like she doesn't completely empty her bladder when she goes. She went to her PCP for evaluation on the ___ and was found to have a multi-drug resistant klebsiella. She has had symptoms for about a month this time around. She denies any fever, chills, back pain. Past Medical History: HTN GERD T2DM, A1c 6.8% ___ osteoarthritis Bladder suspension (___) R. Total knee arthroplasty (___) Gyn hx: 6 vaginal deliveries Social History: ___ Family History: mother with colon cancer. other family members with hypertension Physical Exam: admission: Vitals- 98.0 159/80 84 18 100% RA General- comfortable in NAD HEENT- sclera anicteric, MMM Neck- supple Lungs- CTAB CV- RRR. normal s1/s2. no murmurs Abdomen- soft. +BS. NT/ND GU-no foley. no suprapubic or CVA tenderness Ext-no edema Neuro- A&Oxperson, hospital. did not know date. EOMI. tongue midline. moving all extremities. discharge: VS - 97.8 135/61 75 18 98% RA BG 114-219 General- comfortable in NAD HEENT- sclera anicteric, MMM Neck- supple Lungs- CTAB CV- RRR. normal s1/s2. no murmurs Abdomen- soft. +BS. NT/ND GU-no foley. no suprapubic or CVA tenderness Ext-no edema Neuro- A&Ox3. EOMI. CNII-XII grossly intact, gait normal Pertinent Results: ADMISSION: ___ 07:25PM BLOOD WBC-9.6 RBC-5.11 Hgb-14.2 Hct-43.8 MCV-86 MCH-27.8 MCHC-32.4 RDW-13.2 Plt ___ ___ 07:25PM BLOOD Neuts-59.6 ___ Monos-3.6 Eos-2.7 Baso-1.5 ___ 06:00AM BLOOD ___ PTT-30.4 ___ ___ 07:25PM BLOOD Glucose-159* UreaN-18 Creat-1.0 Na-141 K-4.2 Cl-102 HCO3-31 AnGap-12 ___ 06:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7 MICROBIOLOGY: ___ 11:51 am URINE ___. URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. CEFEPIME sensitivity testing confirmed by ___. FOSFOMYCIN FOR SENSITIVITIES PER ID ___, R. ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R ___ 8:18 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Brief Hospital Course: ___ yo F w/ PMHx type 2 DM and HTN referred to ED w/ multi-drug resistant klebsiella after experiencing urinary frequency and dysuria ACUTE ISSUES: # Complicated urinary tract infection - Presented to her primary care doctor with frequency and dysuria. Urine culture revealed a multi-drug resistent Klebsiella. Infectious disease was consulted for management. Per ID recommendations, she will complete a ten day course of cefepime. She should have a follow-up urine culture to ensure clearance. She is being treated for a complicated UTI given her history of diabetes and past gyn surgery. She should be considered for oral suppressive therapy. She will complete a ten day course of antibiotics on ___. CHRONIC ISSUES: # HTN - continued home medications # type 2 Diabetes - Blood glucose was controlled with insulin sliding scale. She was re-started on metformin at discharge. # GERD - continued omeprazole TRANSITIONAL ISSUES: repeat urine culture after completion of antibiotics to ensure clearance of klebsiella * consider oral suppressive therapy if she has recurrent UTIs * consider urogynecology evaluation given past history of urogyn surgeries Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Alendronate Sodium 70 mg PO QMON 4. Lisinopril 40 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 9. Loratadine 10 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atenolol 100 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. CefePIME 2 g IV Q24H RX cefepime [Maxipime] 2 gram 2 gm IV daily Disp #7 Unit Refills:0 8. Alendronate Sodium 70 mg PO QMON 9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush RX sodium chloride 0.9 % [BD PosiFlush Normal Saline] 0.9 % ___ mL PICC PICC flush Disp #20 Syringe Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: 1. urinary tract infection, complicated SECONDARY: 2. hypertension 3. diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You came into the hospital at the advice of your primary care doctor because of the bacteria that you had in your urine. The bacteria in your urine requires antibiotics through your vein. You will be on the antibiotic called cefepime for a total of ten days. Your last day of antibiotics will be ___. At this time, you will see your primary care doctor to ensure the infection has cleared. Thank you for choosing ___. Followup Instructions: ___
10083375-DS-16	10,083,375	20,979,796	DS	16	2199-05-03 00:00:00	2199-05-03 16:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hematuria Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ yo M with CKD ___ PCKD who presents with 2 days of painless hematuria. The patient reports that he had a similar episode one month ago which lasted for 2 days and resolve spontaneously. He did not seek medical attention at that time as urine was a light pink. 2 days ago he again noticed painless hematuria - but this time urine was bright red. The patient additionally reports that he has felt more tired than usual for the past 2 days. He has not noticed the passage of any clots. He feels that today urine looks a little less concentrated red than yesterday. He has no fever, chills, chest pain, shortness of breath no abdominal pain, nausea, vomiting, bowel changes, dysuria or runary frequency. He is not suffering from urinary retention. He does not take any anticoagulation. Reports that he will likely be starting dialysis in the future and is on the renal transplant list. Does have h/o renal stones, but all of those were accompanied by pain. Vitals in the ED: 98.4 78 136/82 16 100% RA Labs notable for: hematuria, bacturia and leukocytosis, H/H 8.7/25.8 (baseline H/H 10.1/29.9), Cr 5.6 (baseline 4.7-5.1), and HC03 19. PVR 13 ml. Uro c/s'd in the ED, said patient will need cystoscopy, but not emergently and recommended either bringing patient in for Hct checks or d/cing home. ED decided to err on this side of caution and admit, of course. Vitals prior to transfer: 98.5 85 150/82 16 100% RA On the floor, he continues to deny pain. Review of Systems: (+) per HPI Past Medical History: - polycystic kidney disease - polycystic liver disease - HTN - HLD - ?COPD with hyperinflated lungs on the last chest x-ray a couple of years ago - osteoporosis - nephrolithiasis Social History: ___ Family History: Both of his parents died of stroke in their ___. He has a brother and son with polycystic kidney disease. Physical Exam: Admission Vitals - 97.7 154/93 75 18 100% RA GENERAL: NAD HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: no CVA tenderness EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII intact SKIN: warm and well perfused, errythematous papular rash over shins Discharge Vitals - 98.2 98.2 124/86(124-154) 76 16 100RA Is/Os o/850 wt 58.1kg GENERAL: NAD HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: no CVA tenderness EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII intact SKIN: warm and well perfused, errythematous papular rash over shins Pertinent Results: Admission Labs ___ 07:15PM BLOOD WBC-5.5 RBC-2.82* Hgb-8.7* Hct-25.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-15.0 Plt ___ ___ 07:15PM BLOOD Neuts-46.9* Lymphs-15.3* Monos-8.8 Eos-28.9* Baso-0.1 ___ 07:15PM BLOOD Glucose-93 UreaN-91* Creat-5.6* Na-139 K-4.8 Cl-106 HCO3-19* AnGap-19 ___ 07:15PM BLOOD Albumin-3.7 ___ 07:12PM URINE Color-RED Appear-Hazy Sp ___ ___ 07:12PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 07:12PM URINE RBC->182* WBC-59* Bacteri-MANY Yeast-NONE Epi-0 Discharge Labs ___ 07:55AM BLOOD WBC-5.8 RBC-2.80* Hgb-8.8* Hct-25.5* MCV-91 MCH-31.6 MCHC-34.7 RDW-14.8 Plt ___ ___ 07:55AM BLOOD Glucose-95 UreaN-85* Creat-6.0* Na-139 K-4.6 Cl-105 HCO3-21* AnGap-18 ___ 07:55AM BLOOD Calcium-7.2* Phos-6.0* Mg-1.8 MICRO Urine Culture ___: NO GROWTH IMAGING ___ non-contrast CT Abd & Pelvis IMPRESSION: 1. No evidence of a retroperitoneal bleed. 2. Re demonstrated are innumerable kidney and hepatic simple/hemorrhagic cysts, compatible with patient's polycystic kidney disease. No signs of portal hypertension suggestive of varices, splenomegaly, or ascites. ___ Renal U/S IMPRESSION: 1. Innumerable bilateral renal cysts in keeping with known polycystic kidney disease, grossly stable from the previous examination. 2. No obvious mass to explain patient's hematuria, although evaluation with ultrasound is limited and MRI could be performed as a more definitive examination. Brief Hospital Course: Mr ___ is a ___ yo M with CKD ___ PCKD who presents with 2 days of painless hematuria and worsened anemia. # Painless hematuria/anemia: ___ yo M with CKD ___ PCKD, on renal transplant list who presents with 2 days of painless hematuria and Hgb of 8.7 from 10.1(3 months ago). Source of bleeding most likely thought to be from known innumerable hemorrhagic cysts. Renal U/S and non-con CT notable for priorly noted cysts. However, there is still concern for bladder malignancy. Urine cytology sent and pending on discharge. UTI on ddx but UCx was negative. Pt seen by urology during hosptialization and will follow up as an outpatient with a plan for cystoscopy. Hematuria significantly improved during hospitalization with stable H/H. No hemodynamic instability. No urinary retention or other urinary c/o. Discharged with urology f/u. # ESRD ___ PCKD: on transplant list. Only slight decrease in GFR from 13 to 10 during hospitalization. - continued home calcitrol, cacium acetate, furosemide and sodium bicarb # HTN: - continued home amlodpine ==================================== TRANSITIONAL ISSUES ==================================== [ ] Will f/u with urologist, Dr. ___, for further work-up of hematuria [ ] Needs f/u of urine cytology sent as inpatient Contact: ___ Relationship: WIFE Phone: ___ CODE: FULL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sodium Bicarbonate 1300 mg PO DAILY 2. HydrOXYzine 25 mg PO QHS:PRN insomnia 3. Amlodipine 2.5 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Calcium Acetate 667 mg PO TID W/MEALS 6. Calcitriol 0.25 mcg PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Furosemide 40 mg PO DAILY 5. HydrOXYzine 25 mg PO QHS:PRN insomnia 6. Sodium Bicarbonate 1300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Hematuria likely from ruptured hemorrhagic cyst Secondary: Polycystic Kidney disease Chronic Kindey 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 caring for you at ___. You were admitted due to blood in your urine and anemia (low red blood cell count). You were seen and evaluated by the urology team (bladder doctors). The bleeding was most likely caused by rupture of blood collections in your kidney which you have had before. However, there are also other possible causes (including bladder cancer) and you will need to have futher tests done by a urologist(bladder doctor) as an outpatient. During hospitalization, your blood counts were stable and the bleeding in your urine improved significantly. Please make sure to follow up with the scheduled urology appointment so you could continue your care. Please contact your providers if you develop fever, have difficulity urinating, lightheadedness, dizziness or have increased blood in your urine. Sincerely, Your ___ Team Followup Instructions: ___
10084077-DS-8	10,084,077	28,745,424	DS	8	2162-12-11 00:00:00	2162-12-14 11:02:00	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: ___ ___ embolization of splenic artery ___ ___ embolization of splenic artery History of Present Illness: ___ presents after undergoing screening colonoscopy on ___. She noted pain immediately after the procedure that has since become severe and unbearable. It initially was in the LLQ but is now tracking up to the LUQ. +Nausea, no vomiting. No f/c/ns. +small amount of flatus. She went to the ___ ER which showed a perisplenic hematoma. She currently says her pain is improved. Past Medical History: PMH: b/l retinal hemorrhages, HTN, Rosacea, HSV PSH: hysterectomy ___, laminectomy ___ Social History: ___ Family History: N/C Physical Exam: Physical Exam upon admission: Vitals: 88 126/53 15 95% Gen: NAD CV: RRR Resp: CTA Abd: S, TTP LLQ, mildly TTP LUQ Ext: no c/c/e Discharge: VSS General: Alert, oriented, no acute distress, lying in bed HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Elevation of the L hemidiaphragm with egophony CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild TTP in upper qauds, non-distended, + bowel sounds, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 12:40PM BLOOD WBC-9.1 RBC-3.42# Hgb-10.6# Hct-31.7# MCV-93 MCH-30.9 MCHC-33.5 RDW-15.6 Plt ___ ___ 07:20PM BLOOD WBC-9.3 RBC-2.57* Hgb-8.0* Hct-24.1* MCV-94 MCH-31.3 MCHC-33.3 RDW-15.0 Plt ___ ___ 12:40PM BLOOD WBC-10.7 RBC-2.86* Hgb-8.9* Hct-26.7* MCV-93 MCH-31.2 MCHC-33.5 RDW-14.2 Plt ___ ___ 06:20AM BLOOD WBC-9.9 RBC-3.14* Hgb-9.8* Hct-29.8* MCV-95 MCH-31.1 MCHC-32.7 RDW-14.0 Plt ___ ___ 11:31PM BLOOD Hct-30.7* ___ 05:35PM BLOOD Hct-30.2* ___ 05:05PM BLOOD Hct-28.3* ___ 01:55PM BLOOD Hct-32.5* ___ 05:20AM BLOOD WBC-7.1 RBC-3.67* Hgb-11.7* Hct-35.1* MCV-96 MCH-31.8 MCHC-33.3 RDW-13.6 Plt ___ ___ 05:20AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-133 K-4.5 Cl-102 HCO3-23 AnGap-13 ___ 05:39AM BLOOD Lactate-1.0 ___ 06:18AM BLOOD WBC-7.9 RBC-3.20* Hgb-9.8* Hct-29.5* MCV-92 MCH-30.6 MCHC-33.1 RDW-15.3 Plt ___ ___ 12:50PM BLOOD WBC-9.8 RBC-3.25* Hgb-10.1* Hct-30.1* MCV-93 MCH-31.2 MCHC-33.7 RDW-15.7* Plt ___ ___ 12:50PM BLOOD Glucose-100 UreaN-9 Creat-0.5 Na-140 K-4.3 Cl-104 HCO3-29 AnGap-11 ___ 08:45PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:50PM BLOOD CK-MB-2 cTropnT-<0.01 Imaging: ___ EMBO: IMPRESSION: Successful proximal splenic artery coil embolization in the setting of large splenic hematoma and hemodynamic instability. ___ CT abd/pelvis with cont IMPRESSION: 1. Increasing size of the perisplenic hematoma and marked interval increase in the left upper quadrant, pericolic gutter and pelvic hemoperitoneum consistent with continued bleeding likely from the perisplenic hematoma. No active extravasation or overt source of bleeding is seen. The patient is status post coiling of the splenic artery with collateral flow through the short gastric arteries. 2. Possible 3.3 cm left lobe hepatic laceration, though not definitively characterized on single-phase contrast-enhanced examination. Increased perihepatic high density fluid is consistent with blood; however, given the large amount of high-density fluid through the peritoneum, this is likely to be tracking into the perihepatic space from the spleen as well. ___: IMPRESSION: 1. Questionable liver laceration on previous CTs with no angiographic evidence of active extravasation, yet prophylactic Gelfoam embolization of the left hepatic artery. 2. No evidence of active extravasation involving the spleen with residual perfusion of the organ via collaterals. Given questionable residual supply by one splenic artery branch, previous splenic artery embolization was reinforced by additional coil embolization. Brief Hospital Course: ___ Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of splenic laceration. Pt initial received 2 units of blood on ___ before ___. On ___ the patient underwent Proximal splenic artery coil embolization,which went well without complication (reader referred to the ___ Operative Note for details). Pt received another additional 3 units of blood on ___. On ___, the patient underwent Selective common and left hepatic angiography, Gelfoam embolization of left particle artery and Selective conventional and rotational angiography of splenic artery with further coil embolization which went well without complication (reader referred to the RADS Operative Note for details)due to concern for further bleeding. After the ___ ___ procedure HCT were monitored and did not drop. ___ pain eventually was controlled over the next several days and on discharge on ___ pain was controlled with PO medication. Neuro: The patient received dilaudid with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. 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 received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: MVI, Valtrex ___, Venlafaxine 37.5', irbesartan Discharge Medications: 1. Omeprazole 40 mg PO DAILY 2. irbesartan NF 75 mg Oral Daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 3. Fexofenadine 60 mg PO BID 4. Fluticasone Propionate NASAL 2 SPRY NU BID 5. Claritin NF 10 mg Oral daily 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth q4 hrs Disp #30 Tablet Refills:0 7. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Splenic hematoma, 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 bleeding in your belly. You had 2 coils placed to stop the bleeing and blood transfusion. You sustained an injury to your liver/spleen. You should go to the nearest Emergency department if you suddenly feel dizzy or lightheaded, as if you are going to pass out. These are signs that you may be having internal bleeding from your liver/spleen injury. Your liver/spleen injury will heal in time. It is important that you do not participate in any contact sports or any other activity for the next 6 weeks that may cause injury to your abdominal region. Avoid aspirin producs, NSAID's such as Advil, Motrin, Ibuprofen, Naprosyn, or Coumadin for at least ___ weeks unless otherwise directed as these can cause bleeding internally. Followup Instructions: ___
10084262-DS-5	10,084,262	26,913,631	DS	5	2179-06-03 00:00:00	2179-06-03 20:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ PMHx of HTN and pre-diabetes presents as a transfer from ___ for evaluation of hyponatremia. Per wife, 1 month ago, patient was switched from metoprolol to HCTZ/lisinopril due to a BP of 210/105. Patient was otherwise asymptomatic with this BP. After starting the new med, patient became very nauseous, then developed dizziness, balance issues, and altered gait. Approx 1.5 wks ago, wife reports the patient started slurring his words, had word finding difficulty, and developed personality changes. Patient endorses word slurring. Per wife, patient became very animated, saying inappropriate things, and "not himself." Yesterday at work, patient reportedly was asked to fill out some paperwork and forgot how to use a pen. Patient denies any focal neurologic exams. Denies diplopia, dysphagia, numbness/tingling, weakness, or facial droop. Patient continued to take HCTZ/lisinopril until yesterday ___, first missed dose). Patient was also recently told he was pre-diabetic and cut down on his drinking from ___ beers a day to 3/day. Patient's last drink was night of ___ (2 hard lemonades). Patient had a decreased appetite due to nausea, but was still eating adequately. She reports that he usually ate an ___ muffin for breakfast, ham sandwich for lunch, and full dinner she cooked each night. Also of note, patient had a chest CT on ___ at ___ to follow-up pulmonary nodules on CXR that was negative. Due to personality changes, wife brought Mr. ___ to his ___ office yesterday where he had his blood drawn. Due to critically low Na, PCP called patient to have him go to the ED. The patient and his wife's cell phones were turned off, so PCP sent police to his house at ~1AM to tell patient he had to go to the hospital for his low sodium. He then presented to ___, where his sodium was noted to be 114 (2:43 AM, serum Na). His neurologic examination was positive for some mild confusion but non focal. They got labs there which were notable for Na 114, Cl 76, Glucose 109, K 4.1, CO2 25, Cr 0.9, Ca 9.6. Serum ___ 246. Urine ___ (not obtained). He was given 1 L NS and was subsequently transferred to ___. In the ED, patient had a non focal neuro exam and ataxic gait but mild slurred speech. His Na was 118. Renal was consulted and thought etiology of his hyponatremia is likely due to diuretic use compounded by increased intake of hypotonic fluids along with lower solute intake. In ED initial VS: 97.7, 70, 128/82, 17, 97% RA Labs significant for: - CBC: WBC 10.8 - Chem7: Na 118, Bicarb 21, BUN 9, Cr 0.8, AG 19 - UA: unremarkable - ___ 186 - ___ Na 37 - ___ cx pending Patient was given: None Imaging notable for: None Consults: Renal On arrival to the MICU, patient was stable and denied any headaches, chest pain, sore throat, cough, fevers, chills, nausea, vomiting, diarrhea, dysuria, hematuria. He is an avid beer drinker, consuming approximately 8 bottles of beer per day, however he cut down drinking about 1 week ago. Last drink was night prior to admission (___), which he states he drank ___ ___ Hard Lemonades. Past Medical History: HTN Prediabetes Cholecystectomy ___ years ago) Abdominal hernia repair (in his teens) Social History: ___ Family History: Maternal grandfather with MI in ___. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, many fillings LUNGS: Breathing comfortably on room air, in no respiratory distress. Bilateral inspiratory and expiratory wheezes diffusely CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: warm and dry, no rashes NEURO: A&Ox3, speech fluent, No obvious facial asymmetry. Can state the days of the week backwards, moving all extremities to command. CN II-XII intact, with exception of known reduced hearing in left ear. Some end gaze nystagmus. No asterixis. DISCHARGE 24 HR Data (last updated ___ @ 640) Temp: 98.2 (Tm 98.3), BP: 151/90 (136-175/77-91), HR: 62 (62-80), RR: 18, O2 sat: 99% (99-100), O2 delivery: Ra, Wt: 155.42 lb/70.5 kg GENERAL: NAD, lying comfortably in bed, alert and interactive HEENT: NC/AT, EOMI, PERRLA, sclera anicteric, MMM HEART: RRR, S1/S2, no murmurs, gallops, or rubs. No JVP. LUNGS: Breathing comfortably on room air, CTAB, no wheezes, crackles, or rhonchi ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: No cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact, moving all four extremities with purpose, no dysmetria, no flap or asterixis. AAOx3 SKIN: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ============= ___ 06:40AM BLOOD WBC-10.84* RBC-4.67 Hgb-UNABLE TO Hct-42.6 MCV-91.2 MCH-UNABLE TO MCHC-UNABLE TO RDW-11.7 RDWSD-38.5 Plt ___ ___ 06:40AM BLOOD Neuts-53.7 ___ Monos-5.9 Eos-3.5 Baso-0.7 Im ___ AbsNeut-6.04 AbsLymp-4.03* AbsMono-0.67 AbsEos-0.40 AbsBaso-0.08 ___ 06:40AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-118* K-6.7* Cl-78* HCO3-21* AnGap-19* ___ 06:40AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.5* ___ 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 02:21PM BLOOD Osmolal-251* PERTINENT/DISCHARGE LABS: ====================== ___ 02:21PM BLOOD Glucose-118* UreaN-8 Creat-0.7 Na-119* K-3.9 Cl-80* HCO3-25 AnGap-14 ___ 12:08AM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-121* K-4.5 Cl-84* HCO3-26 AnGap-11 ___ 08:52AM BLOOD Glucose-151* UreaN-7 Creat-0.7 Na-122* K-4.3 Cl-85* HCO3-22 AnGap-15 ___ 03:40PM BLOOD Glucose-173* UreaN-9 Creat-0.6 Na-125* K-4.3 Cl-86* HCO3-27 AnGap-12 ___ 11:15PM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-126* K-4.4 Cl-89* HCO3-26 AnGap-11 ___ 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 03:59AM BLOOD Cortsol-14.2 ___ 09:45AM URINE Osmolal-186 ___ 10:19PM URINE Osmolal-392 ___ 12:17PM URINE Osmolal-294 ___ 09:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 05:11AM BLOOD WBC-12.4* RBC-3.78* Hgb-12.8* Hct-35.7* MCV-94 MCH-33.9* MCHC-35.9 RDW-11.7 RDWSD-40.4 Plt ___ ___ 05:11AM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-133* K-5.2* Cl-97 HCO3-24 AnGap-12 ___ 05:11AM BLOOD Calcium-9.7 Phos-5.3* Mg-1.7 ___ 06:36AM URINE Hours-RANDOM Creat-114 Na-127 K-33 ___ 06:36AM URINE Osmolal-585 IMAGING REPORTS: =============== CXR PICC PLACEMENT ___: FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unremarkable. There is no definite focal consolidation, pleural effusion, or pneumothorax. A right-sided PICC terminates at the cavoatrial junction. IMPRESSION: Right-sided PICC terminates at the cavoatrial junction. MICROBIOLOGY: ============ NONE PERTINENT Brief Hospital Course: ___ w/ PMHx of HTN and pre-diabetes presented as a transfer from ___ on ___ for evaluation of Hyponatremia. # Euovolemic Hypotonic Hyponatremia Presented with progressive personality changes, ataxia, and slurred speech over one month. Na at ___ on ___ was 114, Serum ___ from ___ 246 (low) with urine ___ 186, and he was given 1 L normal saline. Most likely HCTZ plus element of beer potomania as initial cause. On day of admission to MICU, patient was fluid restricted to 1L within 24 hours with strict monitoring of I/O's with improvement in sodium. On floor urine ___ rose inappropriately as compared to serum ___ and Na, consistent with SIADH (unknown etiology, reportedly had normal chest CT at ___ recently making lung malignancy less likely). Started on salt tabs ___ with continuous fluid restriction. Fluid restriction liberalized and discharged with sodium tabs 1g TID and 1.5-2L fluid restriction. Additional labs were obtained to workup other possible causes of his Hyponatremia, including TSH, B12, and RPR, all of which were unremarkable. # AMS # Slurred speech # Ataxia Most likely all due to hyponatremia. Thiamine was administered given patient's history of alcohol use and his mental status was monitored closely. His RPR returned negative. In the MICU and floor, the patient was consistently A&Ox3 with no focal neurological deficits. # ETOH use disorder Patient has extensive history of ETOH use, drinking up to 10 beers/night until about 3 weeks ago when patient cut down to ___ beers/night. Patient's last drink was the night of ___ drinks). No overt signs of withdrawal were appreciated. He was also given Thiamine, Folate, and Multivitamin. # HTN Discontinued HCTZ iso hyponatremia. Patient's BPs elevated, so started on amlodipine 5mg. # Pre-diabetes Patient reports his PCP told him he was pre-diabetic. He is not on any anti-hyperglycemic medications at home. Cut down on drinking in light of this. Glucose was monitored and he did not require insulin during admission. # Tobacco use disorder Patient reports a 45 pack year smoking history. He was given nicotine patches and lozenges for cravings. # Acute hearing loss Patient reports that ___ days prior to admission he developed hearing in left ear reduced. Also described viral URI symptoms a few days prior to this. On evaluation with otoscope, patient had scant amount of fluid behind left tympanic membrane. Decision was made to not give steroids at this time. TRANSITIONAL ISSUES: ================= [ ] Discharge Serum Na: 133 [ ] Please repeat serum ___ and urine ___ to monitor hyponatremia and SIADH on ___, if Na stable and urine ___ not significantly elevated above serum, can discontinue salt tabs and monitor sodium off salt tabs. [ ] Consider further work up for other causes of SIADH (malignancy work up etc.) [ ] Consider ENT referral if L sided hearing impairment is not improved [ ] Patient pre-contemplative re: alcohol abuse. Please readdress cessation with patient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide ___ mg oral DAILY 2. Omeprazole 20 mg PO BID 3. ibuprofen 400 mg oral QHS:PRN 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 2. Nicotine Patch 21 mg TD DAILY 3. Sodium Chloride 1 gm PO TID RX sodium chloride 1 gram 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 4. ibuprofen 400 mg oral QHS:PRN 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7.Outpatient Lab Work Chem-10 ICD-10: E87.1 Name: ___. MD Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Primary ====== Severe symptomatic hyponatremia SIADH Secondary ======== HTN Alcohol use disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you at ___. WHY WERE YOU HERE? You were admitted to the hospital because you were confused and your sodium levels were very low. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - While you were in the hospital you were treated for your low sodium levels and the levels were monitored closely every day - We stopped your medication, hydrochlorothiazide, because we think it may have caused your low sodium levels - We gave you salt tablets and restricted your fluid intake to help improve your potassium levels - We started you on a new blood pressure medicine called amlodipine WHAT SHOULD YOU DO WHEN YOU GET HOME? 1) Please follow up at your outpatient appointments. 2) Please take your medications as prescribed. 3) Please continue to take your salt tabs and limit your fluid intake to 1.2-2 liters per day. 3) Do NOT take hydrochlorothiazide. We wish you the best! Your ___ Care Team Followup Instructions: ___
10084454-DS-3	10,084,454	28,036,597	DS	3	2147-06-14 00:00:00	2147-06-14 11:29:00	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: Right hip hemiarthroplasty History of Present Illness: Ms. ___ is an ___ year old female with a history of previously undiagnosed emphysema (no pulmonary function tests on record) who was transferred from an outside hospital after a right femoral neck fracture status post mechanical fall. She was outside on ___ walking her dogs when she missed a brick step, falling to her right side. She was able to ambulate afterwards into her home, where she called the ambulance. She did not hit her head, denies loss of consiousness, and has full recollection of the event. She denies headaches/visual changes. She was taken to an outside hospital, found to have right hip fracture and an increasing oxygen requirement. She got 2mg IV dilaudid and was transferred to ___ for further care. In the ___ Department, her initial vital signs were 98 80 172/105 18 87% RA. She was put on 4L NC, with saturations improving to 92%. She was then placed on facemask with Fi02 50%, satting at 96%. She was given Zofran once for nausea. The ED ordered a CT thorax, which was negative for PE but did demonstrate severe emphysema as well as a large hiatal hernia. Ortho was consulted. She underwent right hip arthroplasty on ___ without complication under general anesthesia. She had 200 mL EBL, received 800 mL LR with 200 mL urine output (net positive 400 mL). She was intubated and extubated without difficulties. In the ___ period, she received ancef x 2 doses. In the PACU, she had persistent requirement of facemask and nasal cannula for adequate oxygenation. At one point, she was weaned to 4 L NC with pOx ___ but upon falling asleep was requiring facemask and nasal cannula in high ___. She was given duoneb x 1 with minimal imiprovement. ROS otherwise positive for intermittent GERD and occasional urinary frequency at night. Ms. ___ has "lung problems" at baseline, as per her PCP. She has an extensive smoking history, but quit ___ years ago. As per patient, she has never required oxygen and has never been diagnosed with COPD. She does become 'fatigued' with exertion however. Denies chronic cough. Denies wheezing. Denies paroxysmal nocturnal dyspena or orthopnea. She was transferred to the floor on ___ after her oxygen saturations improved. Past Medical History: - Hiatal hernia: has known about this for quite some time, s/p EGD last month to evaluate. Patient has intermittent GERD, was offered surgery by GI but refused. - emphysema: no formal PFTs on record - denies other medical history Social History: ___ Family History: father - diabetes, mother - healthy brother - died of MI in his ___ Physical Exam: Admission Physical Exam 98 80 172/105 18 87% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, 2+ systolic murmur heard best left sternal border Lungs: poor air entry throughout, no rales/rhonchi/wheezing appreciated Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: hip exam deferred due to pain Neuro: CNII-XII intact, upper and lower extremity strength testing deferred. Discharge Physical Exam: VS - 98.1 146/92 90 20 92% 3L General: Alert, oriented, no acute distress Neck: JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs Lungs: good air movement Abdomen: soft, non-distended, no tenderness to palpation Ext: No clubbing, cyanosis or edema MSK: Right hip with no erythema or drainage around incision line. Some ecchymoses. Pertinent Results: Admission labs: ___ 02:30AM BLOOD WBC-13.4* RBC-5.04 Hgb-14.6 Hct-44.8 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.3 Plt ___ ___ 02:30AM BLOOD Neuts-90.0* Lymphs-6.4* Monos-2.4 Eos-0.3 Baso-0.8 ___ 02:30AM BLOOD ___ PTT-26.7 ___ ___ 02:30AM BLOOD Glucose-182* UreaN-13 Creat-0.6 Na-137 K-3.8 Cl-102 HCO3-20* AnGap-19 ___ 02:30AM BLOOD ALT-24 AST-29 AlkPhos-112* TotBili-0.5 ___ 02:30AM BLOOD Albumin-4.7 Calcium-9.0 Phos-3.2 Mg-1.7 ___ 02:30AM BLOOD %HbA1c-5.7 eAG-117 ___ 10:29PM BLOOD Type-ART pO2-58* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 Discharge Labs: ___ 07:45AM BLOOD WBC-8.8 RBC-3.40* Hgb-10.0* Hct-30.2* MCV-89 MCH-29.5 MCHC-33.2 RDW-13.9 Plt ___ ___ 07:45AM BLOOD ___ PTT-25.0 ___ ___ 07:45AM BLOOD Glucose-121* UreaN-7 Creat-0.6 Na-135 K-4.3 Cl-99 HCO3-28 AnGap-12 ___ 07:45AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.7 ___ 08:54AM BLOOD Type-ART pO2-62* pCO2-32* pH-7.51* calTCO2-26 Base XS-2 IMAGING: CXR ___: No acute cardiothoracic process. Large hiatal hernia containing at least stomach. CT Chest ___- INDICATION: ___ with hypoxia after fall (hip fracture). TECHNIQUE: CT angiography of the chest was obtained with arterial phase imaging. Axial, coronal, sagittal and oblique reformats were acquired. COMPARISON: None. FINDINGS: CTA OF THE CHEST: There is no pneumomediastinum, mediastinal hemorrhage, pericardial or large pleural effusion. There is no pulmonary embolism. There are moderate-to-severe atherosclerotic calcifications of the thoracic aorta and the coronary arteries. Moderate-to-severe centrilobular emphysema is seen most pronounced in the upper lobes. There is a right azygos lobe (incidental finding). There is a large Bochdalek hernia containing fat, stomach (upside down stomach), and colon (with diverticula) without evidence of bowel obstruction or gastric strangulation. This large hernia causes streak-like atelectasis of the right lower lobe. The partially visualized abdomen demonstrates a left liver lobe cystic lesion, likely a simple cyst or hemangioma. BONES: There is moderate to severe osteopenia. There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. Large hiatal hernia containing fat, stomach (upside down stomach), and colon (with diverticula) - no obstruction or acute findings. 2. No pulmonary embolism. 3. Severe atherosclerotic disease of the thoracic aorta and coronary arteries. 4. Severe centrilobular emphysema. 5. Left liver lobe cystic lesion, likely cyst or hemangioma. 6. Moderate to severe osteoporosis. ___ Hip XRay: INDICATION: ___ after fall. FINDINGS: There is a fracture of the right femoral neck fracture with varus angulation. No fracture of the pelvic bones, femur, proximal tibia of fibula. There are mild degenerative changes of the right knee joint with joint space narrowing. Atherosclerotic calcification are seen at the superifical femoral and popliteal arteries. IMPRESSION: Right femoral neck fracture with varus angulation. Brief Hospital Course: Ms. ___ is an ___ year old female with a history of previously undiagnosed emphysema (no pulmonary function tests on record), transferred from an outside hospital after a right femoral neck fracture status post mechanical fall, who had an uncomplicated right hip hemiarthroplasty on ___, with post-operative course complicated by hypoxemia. ACTIVE ISSUES: #Right femoral neck fracture- Patient transferred from OSH to ___ for right hip hemiarthroplasty. No complications during the surgery, EBL 200 cc. She was monitored in the MICU afterwards due to hypoxemia (below). No evidence of vascular compromise or compartment syndrome while in house. Her pain was controlled with oxycodone ___ mg PRN as well as acetaminophen. Per ortho recs patient will stay on lovenox 40 qhs x 2 weeks. Physical therapy was also consulted who advised WBAT with assist to pivot. She will continue ___ at rehab. #Hypoxemia- The differential for Ms. ___ hypoxia was likely multifactorial. She has a large hiatal hernia, splinting from pain, as well as underlying emphysema. She was monitored in the ICU on ___ after her procedure on ___ and had improvement in her SpO2. CTA chest demonstrated no evidence of pulmonary embolism or fat embolism. She never required any noninvasive or invasive respiratory support and had no evidence of hypercarbia on an ABG. She was rapidly weaned to 2L NC and transferred to the floor on ___. While on the floor her oxygen saturation was weaned to 92-94% on 2L. She was given albuterol/ipratropium nebulizers and incentive spirometry. ABG prior to discharge showed improved oxygenation, as well as no evidence of carbon dioxide retention. #TRANSITIONAL ISSUES: -Patient should have outpatient PFTs and ECHO to eval for pulmonary hypertension as an outpatient. -Monitor respiratory status, and continue nebulizer treatments as needed. -Patient to follow up with Dr. ___ orthopedic care at his ___ office. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS Duration: 2 Weeks 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain hold for sedation, RR < 10 RX oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #30 Tablet Refills:*0 7. Senna 1 TAB PO BID:PRN Constipation 8. Bisacodyl ___AILY:PRN constipation 9. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Right Femoral Neck Fracture Hypoxemia Secondary diagnoses: Emphysema Hiatal Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Dear Ms. ___, You were admitted for a fracture of your bone and for trouble breathing. While you were in the hospital you had surgery to correct your bone fracture. You were in the ICU briefly due to your breathing difficulties, but they improved with extra oxygen. We would recommend you follow up with your primary care physician to address your breathing difficulties. Please note, the following changes have been made to your medications: - START oxycodone as needed for pain control - START acetaminophen for pain control - START ipratropium and albuterol inhalers to help your breathing Followup Instructions: ___
10085111-DS-18	10,085,111	24,078,130	DS	18	2126-03-05 00:00:00	2126-03-05 14:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Appendicitis Major Surgical or Invasive Procedure: ___ Laparascopic Appendectomy History of Present Illness: ___ with one day of lower abdominal pain that started after having a bowel movement at 5pm. Felt a lower abdominal pressure that radiated into the groin which has not gone away since. Mild nausea, no vomiting. Another bowel movement this evening. Feels pressure with voiding as if he has to push to expel urine, although has urinated multiple times since 5pm. Never had pain like this before, does not radiate to one side or the other. No fevers, no sweats, no chills. No prior surgeries. Past Medical History: ___: premature born at 32 weeks, found to have crytorchidism at birth, testes had descended into the scrotum as a toddler per patient and his mother, no issues since PS: none Social History: ___ Family History: Non contributory Physical Exam: Physical Exam upon admission: Exam: 97.6, 72, 120/64, 16, 99RA no acute distress, obese young male clear to auscultation bilaterally regular rate and rhythm abdomen soft nondistended mildly to moderately tender in suprapubic region down into right groin, obese abdomen, no obvious palpable testicle in right inguinal canal, no testicles present in scrotum rectal no gross blood, hemoccult negative, no masses Physical Exam upon discharge: VS: 97.5, 80, 110/68, 95/RA Gen: Sleeping in bed, NAD Heent: EOMI, MMM Cardiac: Normal S1, S2. RRR Pulm: Lungs CTAB Abdomen: Obese, soft/nontender/nondistended lap sites C/D/I. Ext: + pedal pulses Neuro: AAOx4 Pertinent Results: ___ 07:46PM BLOOD WBC-16.1* RBC-5.92 Hgb-16.3 Hct-49.0 MCV-83 MCH-27.5 MCHC-33.2 RDW-13.0 Plt ___ ___ 07:46PM BLOOD Neuts-77.3* Lymphs-16.6* Monos-4.5 Eos-1.2 Baso-0.4 ___ 03:50AM BLOOD ___ ___ 07:46PM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-143 K-3.6 Cl-105 HCO3-28 AnGap-14 ___ 07:46PM BLOOD ALT-42* AST-49* AlkPhos-75 TotBili-0.3 ___ 07:46PM BLOOD Albumin-5.1 ___BD & PELVIS WITH CO IMPRESSION: 1. Acute uncomplicated appendicitis. 2. Bilateral undescended testicles. Brief Hospital Course: Mr. ___ was admitted on ___ under the acute care surgery service for management of his acute appendicitis. He was taken to the operating room and underwent a laparoscopic appendectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of ___ to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. The patient was initally ordered for oxycodone, however it was transitioned to PO Dilaudid for better pain control. He was admitted to and cared for by the acute care surgery service. On ___, he was discharged home with scheduled follow up in ___ clinic. He was also instructed to followup with a pediatric urologist regarding the incidental finding of bilateral cryptoorchidism. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #30 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: You were admitted to the hospital with acute appendicitis. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: Please follow up at the appointment in clinic listed below. We also generally recommend that patients follow up with their primary care provider after having surgery. We have scheduled an appointment for you 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 ___ 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" a couple 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 could have a poor appetite for a couple days. 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 dressings 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. Do not drink alcohol or drive while taking narcotic pain medication. 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 We recommend that you also followup with pediatric urology regarding the incidental finding of bilateral cryptoorchidism on CT Scan, which essentially means that your testes have not descended. Followup Instructions: ___
10085725-DS-12	10,085,725	26,264,561	DS	12	2172-06-13 00:00:00	2172-06-16 14:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Right sided recurrent malignant pleural effusion Major Surgical or Invasive Procedure: Pleurex placement ___ History of Present Illness: ___ with PMH notable for metastatic lung cancer cycle 4 of Keytruda (care at ___ and known recurrent left sided pleural effusion s/p ~4X thoracentses in the past 3 months who presented to ___ today with dyspnea worsened with exertion for 6 days and Chest CXR/CT with worsening left sided pleural effusions. She was transferred to ___ ED for evaluation for placement of a pleurex catheter by interventional pulmonary. Patient denied fevers, chills, nausea, vomiting, diarrhea, or abdominal pain. In the ED, initial vitals were: - Exam notable for: T 98.1, HR 75, BP 108/75, RR 18, O2sat 97% RA - Labs notable for: Na+ 129 (at baseline), BUN 11, Cr 0.7, Osm 272 WBC 8.2, hgb 9.7 (at baseline), plt 277 INR 1.1 PTT 30.5 - Imaging: CT Moderate sized partly loculated left pleural effusion has increased in size compared to ___ and results in severe left lung atelectasis. Mild mediastinal and left hilar adenopathy has increased. Right lung nodules are stable. Severe emphysema is noted - In the ED, Ketorolac 15 mg was given. -IP was consulted for pleurex vs thoracentesis. Upon arrival to the floor, patient reports she feels short of breath but otherwise feels well. Past Medical History: Type II DM- Managed with diet Hx of MI ___ yrs ago medical managed on meto/ASA/losartan Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: =========================== VITAL SIGNS T 98.0, BP 96/57, HR 80, RR 21, O2sat 98% GENERAL A&O3X well appearing HEENT - MMM, oropharynx clear, PEERL NECK - supple, JVD not elevated CARDIAC - RRR no mrg normal S1/S2 LUNGS - decreased lung sounds on left compared to right; wheezes throughout ABDOMEN - soft NT ND, normoactive bowel sounds EXTREMITIES - No perpherial edema, warm, well perfused, 2+ pulses NEUROLOGIC - CNII-VII intact, no focal neurologic deficits SKIN - warm, dry, intact DISCHARGE PHYSICAL EXAM: =========================== VS - T 97.7, BP 119/72, P 81, RR 18, O2sat 93% on RA General: alert and awake, in mild distress due to pain HEENT: MMM, EOMI Neck: no JVD, no LAD CV: rrr, no m/r/g Lungs: diminished breath sounds at left lung base Abdomen: soft, nontender, nondistended GU: deferred Ext: warm and well perfused, pulses, no edema Neuro: grossly normal Pertinent Results: ADMISSION LABS: ================== ___ 09:02PM BLOOD WBC-8.2 RBC-3.22* Hgb-9.7* Hct-29.7* MCV-92 MCH-30.1 MCHC-32.7 RDW-13.3 RDWSD-45.0 Plt ___ ___ 09:02PM BLOOD Neuts-63.9 Lymphs-18.5* Monos-11.6 Eos-5.1 Baso-0.7 Im ___ AbsNeut-5.21 AbsLymp-1.51 AbsMono-0.95* AbsEos-0.42 AbsBaso-0.06 ___ 09:02PM BLOOD ___ PTT-30.5 ___ ___ 09:02PM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-129* K-4.2 Cl-94* HCO3-21* AnGap-18 ___ 06:05AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1 ___ 09:02PM BLOOD Osmolal-272* ___ 09:22PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:22PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 09:22PM URINE RBC-3* WBC-7* Bacteri-FEW Yeast-NONE Epi-7 TransE-<1 ___ 09:22PM URINE Hours-RANDOM Creat-61 Na-61 ___ 09:22PM URINE Osmolal-442 OTHER RELEVANT LABS: ========================= URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION ___ 06:05AM BLOOD WBC-6.6 RBC-3.10* Hgb-9.4* Hct-28.7* MCV-93 MCH-30.3 MCHC-32.8 RDW-13.2 RDWSD-44.6 Plt ___ ___ 06:10AM BLOOD WBC-7.7 RBC-3.03* Hgb-9.3* Hct-28.0* MCV-92 MCH-30.7 MCHC-33.2 RDW-13.2 RDWSD-44.4 Plt ___ ___ 06:05AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-127* K-4.3 Cl-92* HCO3-24 AnGap-15 ___ 06:05AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-127* K-4.3 Cl-92* HCO3-24 AnGap-15 ___ 06:10AM BLOOD Glucose-93 UreaN-13 Creat-0.9 Na-133 K-4.6 Cl-95* HCO3-20* AnGap-23* ___ 06:10AM BLOOD Calcium-8.8 Phos-5.5* Mg-2.0 DISCHARGE LABS: ====================== ___ 05:48AM BLOOD WBC-9.2 RBC-3.15* Hgb-9.6* Hct-29.2* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.2 RDWSD-44.5 Plt ___ ___ 05:48AM BLOOD Glucose-71 UreaN-11 Creat-0.8 Na-128* K-4.4 Cl-91* HCO3-21* AnGap-20 ___ 05:48AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.8 CXR (___): Possible tiny left apical pneumothorax. Mildly decreased left pleural effusion. Improved left basilar consolidation, likely atelectasis. CXR (___): Minimally improved left pleural effusion. Brief Hospital Course: ___ yo female with a history of metastatic NSCLC complicated by recurrent left sided effusions with quick reaccumulation after the last thoracentesis on ___ . # Hypoxemia # Left sided pleural effusion # Emphysema Chronic, locaulated left sided likely malignant pleural effusion in the setting of lung cancer with emphysematous changes on CT. Given that she has required 1 thoracentesis per month and presented with a very quick reaccumulation, IP placed pleurex on ___. Patient initially required ___ NC and was eventually weaned to RA, with O2sats > 92%. Patient was given duonebs and Tylenol/tramadol for pain control. # Hyponatremia: chronic (baseline per ___ records 129), likely due to SIADH secondary to metastatic lung carcinoma. Urine lytes suggestive of SIADH given UOsm 442 and UNa 61. Na at discharge 128. Transitional issues: ========================= - Pleurex placed on ___ by IP - Amlodipine stopped on admission and NOT restarted on discharge for soft/low blood pressures. Can consider restarting if needed in the outpatient setting. - Follow-up with PCP and oncology after discharge Pleurex Catheter instructions: 1. Please drain Pleurx three times weekly. Keep a log of amount & color, have the patient bring it with herto her appointment. 2. Do not drain more than 1000 ml per drainage. 3. Stop draining for pain, chest tightness, or cough. 4. Do not manipulate catheter in any way. 5. Keep a daily log of Drainage amount and color. 6. You may shower with an occlusive dressing 7. If the drainage is less than 50cc for three consecutive drainages please call the office for further instructions. 8. Please call office with any questions or concerns at ___. Pleurex catheter sutures to be removed when seen in clinic ___ days post PleurX placement. Medications on Admission: 1. Losartan Potassium 50 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Metoprolol Succinate XL 50 mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. FoLIC Acid 1 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Magnesium Oxide 400 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Left sided pleural effusion Hyponatremia Secondary: Anemia Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___, You were admitted because you had some fluid in your lungs that was causing your shortness of breath. The lung doctors placed ___ ___ called a pleurex to help remove the fluid from your lungs. You should follow-up with your PCP and oncologist after you leave the hospital. It was a pleasure taking care of you, Sincerely, Your ___ Team Followup Instructions: ___
10086022-DS-17	10,086,022	24,567,350	DS	17	2159-11-20 00:00:00	2159-11-20 13:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Ultram / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Nitrofurantoin / mirtazapine / Cipro / levofloxacin / Macrobid / fentanyl Attending: ___. Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of chronic fatigue, CHB (s/p PPM), AS (s/p tissue valve replacement), HTN who presents for fevers with large coccygeal ulcer. Per her family, she has recently had a series of falls and was placed on flexeril back spasms after these. The family states that she has been slurring her speech, but has otherwise been at her baseline. She had been feeling fatigued and having diffuse myalgias, worse on her back, but no other symptoms. The ___ where she resides discovered an extensive coccygeal ulcer (on the day of presentation) and sent her in for further evaluation. In the ED: Initial Vitals: T 100.4F HR 56 BP 93/36 RR 18 92% RA Exam: "Elderly female who is lethargic and appears unwell. Extensive, full thickness coccygeal ulcer with surrounding erythema. Foul smelling." Labs: WBC 11.3 80.4% Neutrophils Hgb 8 Plts 334 Cr 1.3 BUN 42 Na 129 CRP 282.6 Lactate 1.3 Flu negative Imaging: CXR: "Limited evaluation of the lung apices due to patient positioning and overlying structures. Streaky retrocardiac opacity could reflect atelectasis. Otherwise, no definite focal consolidation to suggest pneumonia." CT torso: 1. Large soft tissue defect overlying the distal sacrum and coccyx, which extends down the gluteal cleft and may involve the anorectal region. The defect extends to within 0.9 cm of bone. No definite underlying bony destruction is demonstrated, however it is difficult to exclude osteomyelitis secondary to the extensive degenerative changes. An MRI would be more sensitive. No focal fluid collections. No subcutaneous emphysema. 2. Dense opacity in the right lower lobe could represent aspiration versus pneumonia. 3. Cardiomegaly with a dilated ascending aorta to 4.3 cm. There is possible dilatation of the main pulmonary artery, as well as fullness of the central vessels and mild pulmonary edema. Heavy atherosclerotic calcifications are noted above as well as a atrial valve replacement and prior CABG. 4. Compression for deformity of the T7 vertebral body appears worsened from the prior study. 5. Small focus of air within the urinary bladder. Recommend correlation with prior catheterization. If none recently, recommend correlation with urinalysis. 6. Diffuse degenerative changes throughout the visualized spine as above. 7. Diverticulosis, no secondary signs of diverticulitis Interventions: 1 L LR, 1 L NS Cefepime 2 g IV Vancomycin 1000 mg IV Ketorolac IV Acetaminophen Norepinephrine VS Prior to Transfer: HR 93 BP 91/39 RR 18 O2 93% RA Upon arrival to the ICU, she is feeling better than this morning, she's just very tired. She has noted pain in her back, but she thinks it's from her recent falls. She denies fevers at home, shortness of breath, cough (although she describes being careful with eating because she chokes even with water), dysuria, abdominal pain, diarrhea. Past Medical History: Aortic stenosis s/p valve replacement CHB s/p PPM Hypertension Hearing loss Social History: ___ Family History: -brother: DM -father: "heart disease", died at ___; also, colon CA -mother: PVD Physical ___: ADMISSION PHYSICAL EXAM ======================== VS: T 98, BP 150/56, HR 82, RR 17, O2 sat 96% GEN: In NAD, hard of hearing HEENT: PERRL, EOMI, dry mucous membranes NECK: No JVD at 30* CV: RRR, soft systolic murmur at the base, no gallops/rubs RESP: Bibasilar crackles, otherwise clear to auscultation ABD: Soft, non tender, non distended EXT: Warm, well perfused, no ___ edema SKIN: No visible rashes, 4x4 stage IV sacral decubitus ulcer extending to perianal area NEURO: A&Ox3, motor and sensation grossly intact DISCHARGE PHYSICAL EXAM ======================= VS: T 98, BP 124/73, HR 90, O2 sat 95% GEN: In NAD, hard of hearing CV: RRR, soft systolic murmur at the base RESP: No increased WOB ABD: Soft, non tender, non distended EXT: Warm, well perfused, no ___ edema NEURO: A&Ox3, motor and sensation grossly intact Skin: exam of sacral wound deferred d/t dressing, patient comfort Pertinent Results: ADMISSION LABS: =============== ___ 04:17PM BLOOD WBC-11.3* RBC-2.74* Hgb-8.0* Hct-25.7* MCV-94 MCH-29.2 MCHC-31.1* RDW-12.8 RDWSD-43.8 Plt ___ ___ 04:17PM BLOOD ___ PTT-23.2* ___ ___ 04:17PM BLOOD Glucose-133* UreaN-42* Creat-1.3* Na-129* K-4.7 Cl-95* HCO3-20* AnGap-14 ___ 04:17PM BLOOD ALT-7 AST-17 AlkPhos-71 TotBili-0.6 ___ 04:17PM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.1 Mg-1.9 ___ 04:17PM BLOOD CRP-282.6 ___ 04:28PM BLOOD Lactate-1.3 ___ fluA/B: negative DISCHARGE LABS: ============= none on day of DC MICRO: ====== ___ blood cultures - Negative ___ urine culture - negative ___ urine legionella antigen - negative IMAGING/STUDIES: ================ ___ CXR: Limited evaluation of the lung apices due to patient positioning and overlying structures. Streaky retrocardiac opacity could reflect atelectasis, but infection is not completely excluded. Mild pulmonary vascular congestion. ___ CT AP 1. Large soft tissue defect overlying the distal sacrum and coccyx, which extends down the gluteal cleft and may involve the anorectal region. The defect extends to within 0.9 cm of the coccyx, but no definite underlying bony destruction is demonstrated to suggest osteomyelitis. No focal fluid collections. No subcutaneous emphysema. 2. Opacity in the right lower lobe could represent aspiration versus pneumonia. 3. Diffuse airway wall thickening indicative of chronic bronchitis with scattered areas of mucous plugging. 4. Mild pulmonary edema. 5. Cardiomegaly with a dilated ascending aorta to 4.5 cm. 6. Dilatation of the main pulmonary artery can be seen with pulmonary arterial hypertension. 7. Compression deformity of the T7 vertebral body with approximately 40% of central height loss appears worse from the prior study. 8. Small focus of air within the urinary bladder. Recommend correlation with prior instrumentation. If none recently, recommend correlation with urinalysis as infection is not excluded. 9. Diffuse degenerative changes throughout the visualized spine as above. 10. Diverticulosis without diverticulitis. 11. Cholelithiasis. Brief Hospital Course: ___ chronic fatigue, CHB (s/p PPM), AS (s/p tissue valve replacement), HTN p/w fevers, hypotension c/f sepsis iso chronic sacral decubitus ulcer with plan for non-operative management, plan for home with hospice. ACUTE ISSUES =============== #GOC: as described elsewhere, pt transitioned to hospice with MOLST filled out specifying DNR/DNI/DNH unless need for hospitalization for comfort interventions. Daughter and patient participating at bedside and in agreement. Will go home with son providing bulk of care. # Sepsis # Hypotension # Sacral decubitus ulcer She presented with fevers, mild leukocytosis and grossly elevated CRP in the setting of a large decubitus ulcer concerning for deep tissue infection including osteomyelitis. She was started on vanc/ceftaz/flagyl on admission, switched to vanc/cefepime on ___. She was evaluated by ACS who recommended surgical debridement of her sacral ulcer if within ___. At a family meeting on ___ it was decided that surgery would not be pursued as this would not align with the patient's stated goal of living as independently as possible (effective surgery could only be offered in the OR and would require intubation). She required intermittent norepinephrine over the first 12h on arrival to the ICU, but this was weaned off. The patient's code status was changed to DNR/DNI based on family meeting on ___. Without meaningful biopsy/culture data to guide therapy, ID recommended transition to oral augmentin at the time of discharge in lieu of long term IV antibiotics. Ultimately it was decided to return home with hospice. #Urinary retention: Noted to be retaining >600cc on multiple occasions post foley removal which required ISC 2x in the 24 hr prior to d/c so it was decided to place a foley for comfort. # Hyponatremia Likely hypovolemic in the setting of infection given that it improved after volume resuscitation. Discharge Na 133 (day prior to d/c). # Acute kidney injury Cr 1.3 with BUN 42 on admission from most recent baseline 0.8 in ___. Suspect pre-renal in setting of above, could also be ATN from hypotension. Resolved during hospitalization. # Dysphagia Patient described coughing w/ food and liquids; her chest imaging was concerning for microaspiration. Per patient's daughter, patient swallows pills with applesauce but does not normally have difficulty swallowing. Per discussion with patient and family, would not want restricted diet if recommended by ___, accept risk of possible aspiration. She given a regular diet per these goals of care and SLP evaluation was deferred. # Normocytic Anemia Hgb 8 on admission from normal in ___. Hgb at beginning of ___ along with some black stools in the setting of ibuprofen, received course of omeprazole. Suspect anemia of inflammation in the setting of infection, perhaps superimposed on iron deficiency. Her last hgb prior to discharge was 8.1 CHRONIC ISSUES =============== # CHB s/p PPM Ventricular paced on EKG, telemetry Imaging and prior reports reviewed and it appears there is no ICD function to her cardiac device and thus does not require any deactivation. # AS s/p bioprosthetic valve replacement #CAD s/p CABG #HTN Held home antihypertensives iso sepsis #CODE STATUS: DNR/DNI/DNH #EMERGENCY CONTACT: ___ (son/HCP) ___ >30 minutes were spent in discharge planning and coordination of care on the day of discharge Transitional issues: [ ] Would care recs: Topical Therapy: Commercial wound cleanser or normal saline to cleanse wounds-coccyx and LLE. Pat the tissue dry with dry gauze. Apply Critic Aid Clear Moisture Barrier Ointment to the periwound tissue with each dressing change. Coccyx: Apply Melgisorb AG to the wound bed (silver ion dressing to absorb drainage and odor Cover with Sofsorb Sponge Secure with Medipore tape. Change dressing daily ***If Melgisorb AG is adhered to the wound bed upon removal, please saturate with normal saline to obtain a gel effect and non traumatic removal. LLE: Apply Adaptic dressing, dry gauze, ABD, Kling wrap No Tape on the skin Change daily Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia 2. Metoprolol Tartrate 12.5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Spironolactone 25 mg PO DAILY 7. diclofenac sodium 1 % topical ASDIR 8. PARoxetine 10 mg PO QHS 9. Cyanocobalamin 1000 mcg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. Cyclobenzaprine 5 mg PO Frequency is Unknown Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 3. Cyclobenzaprine 5 mg PO TID:PRN spasm 4. ALPRAZolam 0.25 mg PO QHS:PRN insomnia 5. diclofenac sodium 1 % topical ASDIR 6. Docusate Sodium 100 mg PO BID 7. PARoxetine 10 mg PO QHS 8. Senna 8.6 mg PO DAILY Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: Infected sacral ulcer with sepsis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, Why was I in the hospital? You were having fevers and were noted to have a large infected ulcer on your backside. What happened while I was in the hospital? You received antibiotics to treat infection. The pros and cons of surgery to remove the ulcer on your backside (debridement) were discussed with you and your family, and it was decided that this would not be best for achieving your goals of living as independently as possible. Your care was transitioned towards treating your infection and focusing on your comfort (hospice). Recommendations for your wound care nurse are included in the discharge summary. It was a pleasure taking care of you. We wish you the very best, - Your ___ Care Team Followup Instructions: ___
10086390-DS-25	10,086,390	23,265,953	DS	25	2184-12-29 00:00:00	2184-12-29 16:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Allopurinol And Derivatives Attending: ___. Chief Complaint: Delirium and shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with advanced CLL returning today from ___ where she developed worsening SOB and fatigue.She was recently admitted to ___ on ___ for general decline, weakness, fatigue and low-grade fever. She had a course of p.o. Cipro and 2 units of blood. She was doing better and so went to ___. She went to ___ on ___ with her husband who is also in ___. She rents ___ in ___ for 4 months. Her dtr flew down to ___ on ___ where she was found to be dehydrated, confused and SOB? She was hospitalized with fever to 101. She was told she had PNA and so given Abx of unknown type. Also given blood products and insulin (says she is borderline DM). She spent two days in the hospital and then she flew back to ___ and was brought to the ED. At baseline she is legally blind and has slight memory deficits which are worse in the morning than during the evening. In ER: (Triage Vitals: 98.6 110 126/86 16 100% RA ) Meds Given: Yest 22:38 Levofloxacin 750mg Premix Bag 1 ___. Fluids given: 1L NS Radiology Studies: CXR consults called: none PAIN SCALE: ___ ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [] All Normal [ +] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [+ ] __15___ lbs. weight loss since ___ Eyes [] All Normal [ ] Blurred vision [+ ] Loss of vision- chronic [] Diplopia [ ] Photophobia ENT [ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ x ] Other: dysphagia- often hard for her to swallow and she gags at times. RESPIRATORY: [] All Normal [+] Shortness of breath - per family- pt denies [ ] Dyspnea on exertion [ ] Can't walk 2 flights [ +] Cough- dry- she cannot clearly tell me it's duration [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [ ] Palpitations [+ ] Edema worse than normal [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [] All Normal [ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [ ] Diarrhea [ ] Constipation [ ] Hematemesis [ ] Blood in stool [ ] Melena [ +] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [x] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [X] All Normal [ ] Rash [ ] Pruritus MS: [X] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [x ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache Her son notices that ___ dragging her right food ENDOCRINE: [x] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy HEME/LYMPH: [] All Normal [ ] Easy bruising [+ ] Easy bleeding [ ] Adenopathy PSYCH: [x] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: ALLERGY: [x ]Medication allergies- pcn, allopurinol and sulfa [ ] Seasonal allergies [X]all other systems negative except as noted above Past Medical History: Past Oncologic History: Originally diagnosed in ___. Treatment course: -- Originally treated with chlorambucil. -- Several courses of fludaribine c/b Auto-immune hemolytic anemia after course of fludarabine requiring hospitalization and course of prednisone. -- Combination of rituximab and cyclophosphamide. Baseline CBC: -- Thrombocytopenia between 80 and 130 thousand and anemia HCT around ___. . Other Past Medical History: Macular degeneration, blind since early ___. Diabetes mellitus controlled with diet Cholecystectomy in ___ Social History: SOCIAL HISTORY/ FUNCTIONAL STATUS: I< ___ The patient lives at home with her husband in ___. She has 6 children. - Tobacco: Denies - etOH: Occassional - Illicits: Denies Cigarettes: [ ] never [x ] ex-smoker quit: ___ years ago____ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: none Occupation: ___ Marital Status: [ X] Married [] Single Lives: [ ] Alone [X] w/ family [ ] Other: Sons: ___ ___ ___ ___ ___- main contact >65 ADLS: She needs help with her ADLS including hygiene. She need help with cooking and cleaning, shopping. IADLS: She requires assistance with her IADLs she does not have pre-existent home care services At baseline walks: [x ]independently - but she is unsteady on her feet [ ] with a cane [ ]wutwalker [ ]wheelchair at ___ H/o fall within past year: []Y [x]N Visual aides [ ]Y [ x]N Dentures [ ]Y [x ]N Hearing Aides [ ]Y [x ] N Family History: The patient's father had coronary artery disease as well as her mother. Sister wit CAD. Brother newly diagnosed with CLL. Physical Exam: Admission Exam: 1. VS Tm 96.8 112/69 98 22 98% RAT P BP RR O2Sat on ____ liters O2 Wt, ht, BMI GENERAL: thin emaciated Nourishment : at risk Grooming :ok Mentation Alert, speaking in full sentences 2. Eyes: [] WNL EOMI without nystagmus, Conjunctiva: clear/injection/exudates/icteric 3. ENT [X] WNL [] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [] WNL [X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6, Location: [] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [X] Edema RLE 3+ [] Bruit(s), Location: [X] Edema LLE 3+ [X] PMI [] Vascular access [X] Peripheral [] Central site: 5. Respiratory [ ] [] CTA bilaterally [ ] Rales [ X] Diminshed breath sounds on the L side with crackles present [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [X ] WNL [X] Soft/ [] Rebound [] No hepatomegaly [] Non-tender [] Tender [] No splenomegaly [X] Non distended [] distended [] bowel sounds Yes/No [] guiac: positive/negative 7. Musculoskeletal-Extremities [x] WNL [ ] Tone WNL [ x]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [] Lower extremity strength ___ and symmetrica [ ] Other: [] Normal gait []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [] WNL [ X] Alert and Oriented x 3- She refused to do MOYB. She kept saying that she was tired and she wanted to go to bed. [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [X] WNL [X] Warm [] Dry [] Cyanotic [X] Rash: ecchymoses on L shin when she hit her leg as she got out of her son's truck into the wheelchair [ ] Cool [] Moist [] Mottled [] Ulcer: None/decubitus/sacral/heel: Right/Left 10. Psychiatric [] WNL [] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [X] Agitated [] Psychotic [] Combative TRACH: []present [X]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Discharge Exam: Vitals: T Afebrile HR ___ BP ___ RR ___ Sa 98-99% RA Wt 85 from 89 from 90.6 from 92.6 lbs from 93.5 lbs ___ lbs on ___ I/o 24: ___ last 8: 300/850 General: sitting comfortably in bed, no distress Neck: JVP ~6-7cm Pulm: CTAB good aeration CV: RRR, soft systolic murmur at RUSB, ___ BLE edema to the midshin Abd: soft, nontender, nondistended Ext: warm Neuro: alert, interactive, appropriate, oriented x3 Pertinent Results: Admission Labs: ___ 11:38PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 11:38PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG ___ 11:38PM URINE RBC-12* WBC->182* BACTERIA-MANY YEAST-NONE EPI-3 ___ 11:38PM URINE WBCCLUMP-OCC MUCOUS-RARE ___ 10:06PM LACTATE-1.3 ___ 09:51PM GLUCOSE-141* UREA N-12 CREAT-0.5 SODIUM-135 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 ___ 09:51PM estGFR-Using this ___ 09:51PM TSH-5.0* ___ 09:51PM WBC-165.0* RBC-3.80* HGB-11.4* HCT-34.5* MCV-91 MCH-30.0 MCHC-33.1 RDW-14.3 ___ 09:51PM NEUTS-4* BANDS-0 LYMPHS-94* MONOS-2 EOS-0 BASOS-0 ___ MYELOS-0 ___ 09:51PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ ___ 09:51PM PLT SMR-LOW PLT COUNT-104* ------------------ . EKG: ___: SR at 103. Nl axis. Nl intervals. No atrial enlargement or ventricular hypertrophy. TWI I,aVL,V5,V6 stable. No other ST-T wave abnormalities. Notable Studies: Echocardiogram ___: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis/near akinesis of the basal, mid, and apical anterior and septal segments. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of mild to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction consistent with probable single vessel coronary artery disease of the left anterior descending coronary artery . Mild to moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Microbiology: ___ 11:38 pm URINE Site: CLEAN CATCH *FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 16 I CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 2 S Blood cx: all negative to date Discharge Labs: ___ 06:02AM BLOOD WBC-140.6 RBC-3.21* Hgb-9.9* Hct-29.2* MCV-91 MCH-30.7 MCHC-33.7 RDW-14.6 Plt Ct-73* ___ 06:25AM BLOOD Glucose-155* UreaN-19 Creat-0.4 Na-135 K-4.0 Cl-100 HCO3-29 AnGap-10 ___ 09:51PM BLOOD CK-MB-3 cTropnT-0.06* ___ ___ 06:02AM BLOOD Mg-2.0 ___ 06:30AM BLOOD Triglyc-87 HDL-18 CHOL/HD-5.4 LDLcalc-62 ___ 09:51PM BLOOD TSH-5.0* ___ 06:30AM BLOOD Free T4-1.4 Studies Pending at Discharge: None Brief Hospital Course: ___ y.o. F with a long standing history of CLL s/p multiple treatments who was recently admitted in ___ with fever and fatigue without a clear source who was admitted with confusion, edema and shortnes of breath. Mental status quickly improved after admission. Hospital course was notable for treatment of pneumonia, possible urinary tract infection, and new diagnosis of systolic heart failure and probable coronary artery disease. . #Pneumonia, bacterial: CXR showed bilateral consolidations consistent with pneumonia. Given absence of fever, and overall mild-appearing pneumonia, levofloxacin treatment was initiated with improvement in symptoms. She was treated for a 5 day course with improvement in shortness of breath and resolution of fever. #Urinary tract infection, bacterial: Initially patient was thought to have a urinary tract infection given >182 WBCs on UA. She was treated with levofloxacin with improvement in all symptoms, but urine culture grew 10,000-100,000 colonies of Pseudomonas resistant to Cipro. Repeat UA at this time had 44 WBCs. Given that patient was improving overall, did not have persistent symptoms of UTI, and had improved on levofloxacin to which the Pseudomonas was resistant, it was felt that the Pseudomonas in the urine did not reflect true urinary tract infection and the patient was not treated with intravenous antibiotics. However, should the patient have symptoms suggestive of a UTI, repeat urine studies should be sent to evaluate for evolution. #Acute systolic congestive heart failure and probable coronary artery disease: Patient clinically had heart failure with volume overload, and echocardiogram revealed regional left ventricular dysfunction (likely from coronary artery disease), and LVEF 35-40%. Patient did not carry a prior diagnosis of CHF nor CAD. Treatment with intravenous furosemide, ASA 81 (OK per her oncologist), lisinopril, and metoprolol was initiated. Weight on ___ was 94 pounds. pro-BNP was >33,000 on admission. Initial troponin was 0.06 (normal CK-MB), repeat troponin was 0.03. She had no chest pain or sign of ACS/acute ischemia on EKG. Weight on discharge was 85 pounds. She responded very well to 10mg IV Lasix and was negative 1.5L on Lasix 20mg po BID. On discharge she had a mildly uptrending BUN (Cr was stable) so she was discharged on a regimen 20mg of Lasix every other day with a presumed dry weight of 85 pounds (discharge weight). The patient and rehab were given instructions to weigh the patient daily and if the patient should gain more than 2lbs in 2 successive days the dose of Lasix should be increased and the PCP should be informed. Similarly, if the patient were to lose weight, the dose of Lasix should be reduced. Lasix should be titrated to goal weight of 83-85lbs. Patient was discharged with PCP and ___ outpatient follow up. She should also have her electrolytes and renal function checked 3 days after discharge (___) to make sure they are stable and Lasix and Lisinopril adjusted accordingly. # Atrial fibrillation On ___, she went into afib with RVR (had been in sinus rhythm on admission). Se was asymptomatic. Review of an old EKG also showed atrial fibrillation. Metoprolol was started. She ambulated with HR to the 100-110 range prior to discharge without symptoms or hypoxia. Resting heart rate was ~60s-80s. She was in sinus rhythm prior to discharge. ASA 81 was added as above based on the patients CLL. . # Chronic lymphocytic leukemia: WBC was within her baseline. Her outpatient oncologist is Dr. ___ saw the patient during admission and the patient will follow up in clinic. The plan at this time is not to pursue further treatment of the CLL. . # Anemia: Most likely secondary to underproduction from a primary marrow process. She had a colonoscopy in ___ which demonstrated diverticulosis but was otherwise normal. . # Thrombocytopenia: remained stable during hospitalization . # Diabetes mellitus, type 2, controlled: Patient was maintained on SSI. . #CODE: Patient was full code on admission. DNR/DNI was discussed with the patient by Dr. ___ overall medical conditions. Patient said that she would think about code status further, but maintained full code status upon discharge. . #Disposition: Patient was discharged to rehab and to follow up with her PCP ___ ___ weeks from discharge. An initial cardiology outpatient appointment was also made given new diagnosis of systolic heart failure suggestive of underlying CAD. Medications on Admission: Reviewed with family on admission Megace 400 mg po qd Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 4. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO every other day: Please take first dose on ___. Disp:30 Tablet(s) Refills:2 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Pneumonia, bacterial -Urinary tract infection, bacterial -Congestive heart failure with systolic dysfunction (EF 35-40%) -Probable coronary artery disease -Atrial fibrillation -Generalized weakness -Diabetes mellitus, type 2, controlled, without complications -CLL -Anemia -Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted and treated for pneumonia and a urinary tract infection. You were also found to have evidence of congestive heart failure, and probable coronary artery disease. At times you had an abnormal heart rhythm, called atrial fibrillation, which you have also had in the past. For your congestive heart failure you were treated with a medication called Lasix (furosemide) to minimize swelling in your legs and reduce fluid build up in your lungs. It is very important that you follow up with your PCP to help you adjust the amount of Lasix that you take at home. Your PCP should also follow up your symptoms to make sure that they are improving and check your electrolytes and renal function to make sure that they are stable. Your goal weight is 83-85lbs. You should weigh yourself daily and if your weight goes out of this range you should call your doctor to help adjust your Lasix dose. You should also have your lipid panel rechecked at your next PCP ___. Please also call your doctor if you experience worsening shortness of breath, fevers, cough with sputum production, dizziness, or lightheadedness, or have any other concerning symptoms. Followup Instructions: ___
10086390-DS-26	10,086,390	29,791,446	DS	26	2185-03-26 00:00:00	2185-03-28 14:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Allopurinol And Derivatives Attending: ___. Chief Complaint: Fevers/Confusion Major Surgical or Invasive Procedure: Pessary removal History of Present Illness: Patient is a ___ yo F with h/o of CLL with multiple treatments (most recent w/ bendamustin/rituxan in ___. Pt with recent admission ___ for confusion, edema - found to have likely PNA with possible UTI along with dx of new sCHF. Since admission patient has had fall with admission to rehab - family reported was dx with PNA there and completed treatment with levofloxacin again and was d/c 2 weeks ago from rehab. . Pt otherwise was in her USOH this morning - seen by ___ without issues, then afternoon developed acute chills and confusion with fatigue/weakness. Family came by - son stated he had to carry patient to car due to weakness and confusion - brought to ED here with noted fever of 103. . Pt denies any sob or cough complaints. Denies current HA, photophobia, n/v/ab pain. Pt does describe chronic diarrhea (non-bloody) but per family these sx have not changed over past 6 mo where pt needs to where diappers. Pt denies any urinary changes with no dysuria complaints. Otherwise, no new skin changes, no CP, palpitations, no sweats/NS. . In the ED - pt given 1g tylonol, 1L NS IVF, 1g Vanc and 1g Ceftriaxone (21:15) - pt's fever deferveced by the time pt arrived on floor - sx improving - though per family her MS was not quite yet at baseline. Past Medical History: PAST ONCOLOGIC HISTORY: Originally diagnosed in ___. Treatment course: -- Originally treated with chlorambucil. -- Several courses of fludaribine c/b Auto-immune hemolytic anemia after course of fludarabine requiring hospitalization and course of prednisone. -- Combination of rituximab and cyclophosphamide. Baseline CBC: -- Thrombocytopenia between 80 and 130 thousand and anemia HCT around ___. --3 cycles of bendamustin/rituxan last on ___ . . PAST MEDICAL HISTORY: Macular degeneration, blind since early ___. Diabetes mellitus controlled with diet Cholecystectomy in ___ systolic CHF with CAD (recent dx) Social History: SOCIAL HISTORY/ FUNCTIONAL STATUS: I< ___ The patient lives at home with her husband in ___. She has 6 children. - Tobacco: Denies - etOH: Occassional - Illicits: Denies Cigarettes: [ ] never [x ] ex-smoker quit: ___ years ago____ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: none Occupation: ___ Marital Status: [ X] Married [] Single Lives: [ ] Alone [X] w/ family [ ] Other: Sons: ___ ___ ___ ___ ___ ___- main contact >65 ADLS: She needs help with her ADLS including hygiene. She need help with cooking and cleaning, shopping. IADLS: She requires assistance with her IADLs she does not have pre-existent home care services At baseline walks: [x ]independently - but she is unsteady on her feet [ ] with a cane [ ]wutwalker [ ]wheelchair at ___ H/o fall within past year: []Y [x]N Visual aides [ ]Y [ x]N Dentures [ ]Y [x ]N Hearing Aides [ ]Y [x ] N Family History: The patient's father had coronary artery disease as well as her mother. Sister wit CAD. Brother newly diagnosed with CLL. Physical Exam: ADMISSION GENERAL: NAD, thin appearing elederly woman, AA0x3, though mildly slow to questions SKIN: warm and well perfused, mild stage I pressure ulces in mid-spine HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, No LAD, No JVP CARDIAC: tachy but regular, S1/S2, no mrg LUNG: mildly coarse BS in L base ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, no edema NEURO: CN II-XII intact, grossly intact except mildly slow in response to verbal questions DISCHARGE Vitals - 98.4 121/49 68 16 98%RA GENERAL: NAD, thin appearing elederly woman, AA0x3, though mildly slow to questions SKIN: warm and well perfused, mild stage I pressure ulcers in mid-spine HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, No LAD, No JVP CARDIAC: RRR, S1/S2, no mrg LUNG: bronchial BS at left base with egophony ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, no edema NEURO: CN II-XII intact, grossly intact except mildly slow in response to verbal questions Pertinent Results: ___ 07:55PM BLOOD WBC-244.6 RBC-3.59# Hgb-10.9# Hct-33.8# MCV-94 MCH-30.4 MCHC-32.2 RDW-14.8 Plt ___ ___ 08:15AM BLOOD WBC-130.3 RBC-2.80* Hgb-8.6* Hct-27.2* MCV-97 MCH-30.8 MCHC-31.7 RDW-14.9 Plt Ct-83* ___ 08:35AM BLOOD WBC-100* RBC-2.58* Hgb-7.9* Hct-25.0* MCV-97 MCH-30.8 MCHC-31.8 RDW-15.6* Plt Ct-86* ___ 08:00AM BLOOD WBC-108.9* RBC-2.84* Hgb-8.7* Hct-28.7* MCV-101* MCH-30.7 MCHC-30.4* RDW-15.3 Plt Ct-82* ___ 08:05AM BLOOD WBC-132.3* RBC-2.78* Hgb-8.6* Hct-27.2* MCV-98 MCH-30.9 MCHC-31.6 RDW-15.3 Plt Ct-95* ___ 07:55PM BLOOD Neuts-4* Bands-0 Lymphs-94* Monos-2 Eos-0 Baso-0 ___ Myelos-0 ___ 08:15AM BLOOD Neuts-6* Bands-0 Lymphs-94* Monos-0 Eos-0 Baso-0 ___ Myelos-0 ___ 08:35AM BLOOD Neuts-5* Bands-0 Lymphs-95* Monos-0 Eos-0 Baso-0 ___ Myelos-0 ___ 08:00AM BLOOD Neuts-5* Bands-0 Lymphs-95* Monos-0 Eos-0 Baso-0 ___ Myelos-0 ___ 08:05AM BLOOD Neuts-6* Bands-0 Lymphs-93* Monos-1* Eos-0 Baso-0 ___ Myelos-0 ___ 07:55PM BLOOD Glucose-104* UreaN-30* Creat-0.7 Na-139 K-4.8 Cl-106 HCO3-20* AnGap-18 ___ 08:15AM BLOOD Glucose-95 UreaN-25* Creat-0.7 Na-139 K-3.9 Cl-110* HCO3-18* AnGap-15 ___ 08:35AM BLOOD Glucose-245* UreaN-20 Creat-0.6 Na-136 K-3.7 Cl-109* HCO3-18* AnGap-13 ___ 08:00AM BLOOD Glucose-92 UreaN-17 Creat-0.6 Na-137 K-5.3* Cl-109* HCO3-19* AnGap-14 ___ 08:05AM BLOOD Glucose-133* UreaN-18 Creat-0.6 Na-140 K-4.9 Cl-108 HCO3-22 AnGap-15 ___ 07:55PM BLOOD ALT-13 AST-19 AlkPhos-95 TotBili-0.5 ___ 08:15AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.4* UricAcd-5.4 ___ 07:58PM BLOOD Lactate-1.4 ___ 10:05PM URINE RBC-7* WBC-92* Bacteri-MANY Yeast-NONE Epi-1 ___ 06:18AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ___ 10:05PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 06:18AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CT Abdomen 1. Left lower lobe pneumonia. 2. Fistula tract between sigmoid colon and vagina, new from ___. 3. Rectosigmoid wall thickening with a focus of more extensive thickening which could represent a mass. Direct visualization with sigmoidoscopy is recommended. 4. Small focus of air within bladder raises concern for colovesicular fistula as well. Correlate with urinalysis. 5. No pneumoperitoneum or discrete fluid collection. However, extensive presacral fat stranding is suggestive of ongoing inflammatory process. 6. Stable confluent abdominal lymphadenopathy and splenomegaly, consistent with history of CLL. Brief Hospital Course: ___ yo F with h/o of CLL with multiple treatments with recent multiple episodes of PNA with ? UTI in setting of chronic diarrhea presenting with AMS with Fever with PNA. # Sepsis from pneumonia: tachycardic, febrile, tachypneic with altered mental status. Leukocytosis unreliable due to CLL. CT abdomen with left lower lobe pneumonia. Started on ceftriaxone upon admission with rapid defervescence and return of normal mental status. No sputum cultures were able to be obtained as she was not producing sputum. Blood cultures were negative. Discharged on cefpodoxime to finish course for community acquired pneumonia. # Afib with RVR: hx of this on previous admissions. On only 6.25mg BID lopressor at home. Went into atrial fibrillation with rapid ventricular rate which was asymptomatic and well tolerated. Eventually required digoxin load as rate was not well controlled with just BB/CCB therapy (doses caused hypotension). Her oral BB was uptitrated. She is not anticoagulated due to thrombocytopenia. # Colovaginal fistula: Patient states that over the past year or so she has been incontinent of diarrhea; on admission, when straight cathed for clean UA, the nurse noted the patient to have stool in the vaginal vault. A CT scan was performed which showed a colovaginal fistula from an area of the colon that was edematous, possibly a mass. The patient also had a pessary in place which, per her report, has been changed every 3 months over the past year. Gynecology was consulted who felt that the pessary was highly unlikely to have caused the fistula, but recommended removal which was done. Colorectal surgery was consulted who felt that she was not a surgical candidate and that there was nothing to do from a surgical standpoint as she would not survive the open surgery required. The CT scan findings of a possible mass were discussed with the patient; GI was consulted to offer a flex sig to investigate. However, after lengthy discussion with the primary team, her primary oncologist and her family, the patient decided to not undergo flex sig as she would not want further chemotherapy and would not want an operation to remove the mass. She understands the risks of not undergoing workup for a potential colonic malignancy. # ___: baseline Cr 0.4, presented with 0.7 and BUN 3x her normal. Downtrended with fluid resuscitation. Likely in setting of dehydration and hypovolemia c/b sepsis. # Chronic systolic CHF - pt compensated, given higher counts likely mildly concentrated and with mild volume depletion initially. Noted given 1L IVF in ED - pt with neg orthostatics. She was not overloaded on the admission in spite of fluid resuscitation. Upon discharge, her home dose lasix and lisinopril were restarted. # Diabetes: controlled with diet alone per patient report. Will check finger sticks and start regular sliding scale if elevated BS. # Leukemia: CLL with chronic indolent course. Recieved bendamustin/rituxan ___, no further tx plans per outpatient oncologist (___). Is immunocompromised due to CLL and bendamustine can cause a T-cell deficiency for approximately 6 months after administration. Transitional Issues: - is at risk for recurrent UTI due to colovaginal fistula Medications on Admission: 1. aspirin 81 mg daily 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). (reported per prior records, per pt's home med list - listed as Megace 10 ml daily) - will confirm in am 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO every other day: (Noted was daily after ___, back to QOD as of recent, took last ___ 5. lisinopril 2.5mg daily 6. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 7. MVI 8. Claritin 10mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:6 Tablet(s)* Refills:0 4. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10) mL PO once a day. 5. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO every other day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pneumonia Atrial fibrillation with rapid ventricular rate Acute kidney injury Rectovaginal fistula Rectal mass (undiagnosed due to patient preference) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for fever and delerium. We found that you had a pneumonia. We also discovered that you have a rectovaginal fistula. Your pessary device was removed by gynecology; this can be replaced as an outpatient at some point in the future. The surgeons evaluated you and felt that you would not be a good surgical candidate for a fistula repair; you are at risk for recurrent urinary tract infections in the future due to this fistula. In addition, on the CT scan of your abdomen the radiologists felt that there might be a mass in your colon that caused the fistula to occur. We discussed options for determining what this mass was, but after discussion you felt that you would not want to undergo therapy for the mass if it turned out to be malignant, so we did not pursue a diagnostic workup per your goals of care. Note the following medication changes: START Cefpodoxime 200mg by mouth twice per day for 3 more days (last day ___ Toprol XL 100mg by mouth once per day Otherwise take all medications as prescribed. Followup Instructions: ___
10087092-DS-17	10,087,092	21,411,023	DS	17	2196-05-10 00:00:00	2196-05-10 17:19:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Leukocytosis Major Surgical or Invasive Procedure: Bone Marrow Biopsy History of Present Illness: ___ is a ___ yo equine ___ with no significant medical problems, who presents with 1 month of abdominal bloating, early satiety, and new leukocytosis to 400 with differential concerning for CML. Mrs ___ reports she was in her usual state of health until around ___ when she began to notice abdominal bloating. She first attributed it to eating around the holidays, but over the next few weeks, her abdominal bloating was persistent. She also began to notice slightly decreased appetite, early satiety, and decreased energy level. She scheduled an urgent visit with her PCP for these issues today. Basic labs were sent and remarkable for WBC 370.5 and plt 798. She was immediately referred to ED for evaluation. In the ED ___ \| 103 \| 133/73 97% RA. BMT was consulted. Peripheral smear was remarkable for leukocytosis with myeloid forms in various stages of maturation, eosinophilia, and basophilia. A BM biopsy was performed in ED. She received 1 L LR followed by 125 cc/hr NS, 2g hydrea, and allopurinol ___ mg. On ROS, she denies fevers, chills, night sweats, weight loss. No easy bruising, bleeding, rashes. No headache, vision changes, numbness/tingling/weakness. No chest pain, SOB, abdominal pain, nausea/vomiting, diarrhea, dysuria. Past Medical History: None Social History: ___ Family History: Aunt had acute leukemia in her ___. Cousin had AML in his ___ (he is still living). Sister had breast cancer in her ___, never tested for BRCA. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: 134/77 \| 89 \| 95% RA General: Well appearing young Asian woman sitting up at edge of bed in no acute distress. Neuro: Alert, oriented, provides clear history HEENT: Oropharynx clear, MMM Cardiovascular: RRR no murmurs Chest/Pulmonary: Clear bilaterally Abdomen: Soft nontender nondistended. Active bowel bowel sounds. +Splenomegaly, no hepatomegaly Extr/MSK: WWP, no edema Skin: No obvious rashes Access: PIV DISCHARGE PHYSICAL EXAM VS - 24 HR Data (last updated ___ @ 901) Temp: 98.2 (Tm 99.5), BP: 110/72 (110-138/72-82), HR: 71 (71-94), RR: 16 (___), O2 sat: 96% (95-96), O2 delivery: RA, Wt: 126.4 lb/57.34 kg General: Pleasant, NAD HEENT: Sclera anicteric, MMM CV: rrr, no g/m/r Lungs: ctab, no wheeze, no crackles Abdomen: bowel sounds present, NTND, splenomegaly present Ext: WWP, no pitting edema Neuro: CNII-XII grossly intact Skin: No rashes Pertinent Results: ADMISSION LABS ___ 05:20PM BLOOD WBC-435.8* RBC-3.38* Hgb-10.2* Hct-30.6* MCV-91 MCH-30.2 MCHC-33.3 RDW-17.4* RDWSD-57.1* Plt ___ ___ 05:20PM BLOOD Neuts-27* Bands-26* Lymphs-1* Monos-1* Eos-3 Baso-4* ___ Metas-22* Myelos-13* Promyel-1* Blasts-2* NRBC-0.8* Other-0 AbsNeut-230.97* AbsLymp-4.36* AbsMono-4.36* AbsEos-13.07* AbsBaso-17.43* ___ 05:20PM BLOOD Anisocy-2+* Poiklo-1+* Macrocy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 05:26PM BLOOD ___ PTT-31.5 ___ ___ 05:26PM BLOOD ___ 05:20PM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-140 K-3.1* Cl-101 HCO3-25 AnGap-14 ___ 05:20PM BLOOD ALT-15 AST-30 LD(LDH)-999* AlkPhos-85 TotBili-0.5 ___ 05:20PM BLOOD Albumin-4.8 Calcium-10.1 Phos-4.0 Mg-2.5 UricAcd-7.0* INTERVAL LABS ___ 06:20AM BLOOD HCV Ab-NEG ___ 06:20AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG DISCHARGE LABS ___ 06:15AM BLOOD Albumin-4.1 Calcium-9.1 Phos-5.1* Mg-2.5 UricAcd-4.5 ___ 06:15AM BLOOD ALT-13 AST-25 LD(LDH)-820* AlkPhos-73 TotBili-0.5 ___ 06:15AM BLOOD Glucose-89 UreaN-9 Creat-0.7 Na-143 K-3.8 Cl-104 HCO3-27 AnGap-12 ___ 06:15AM BLOOD Plt ___ ___ 06:20AM BLOOD Neuts-37 Bands-4 Lymphs-13* Monos-7 Eos-3 Baso-2* Metas-19* Myelos-9* Promyel-1* Blasts-5* NRBC-0.7* AbsNeut-122.34* AbsLymp-38.79* AbsMono-20.89* AbsEos-8.95* AbsBaso-5.97* ___ 06:15AM BLOOD WBC-285.1* RBC-3.28* Hgb-9.7* Hct-29.2* MCV-89 MCH-29.6 MCHC-33.2 RDW-17.3* RDWSD-55.6* Plt ___ IMAGING ___ SPLEEN US SPLEEN: The spleen is enlarged. There is normal echogenicity. No focal lesions are identified. Spleen length: 19.1 cm ONCOLOGY STUDIES ___ CYTOGENETICS FINDINGS: An abnormal 46,XX,t(9;22)(q34;q11.2) female chromosome complement with a translocation involving the long arms of a chromosome 9 and a chromosome 22 was observed in each of the 20 mitotic cells examined in detail. Chromosome band resolution was 400. A karyogram was prepared on 3 cells. CYTOGENETIC DIAGNOSIS: 46,XX,t(9;22)(q34;q11.2)[20] INTERPRETATION/COMMENT: Every metaphase peripheral blood cell examined had an abnormal karyotype with the translocation involving chromosomes 9 and 22 that generates the ___ chromosome characteristic of chronic myelogenous leukemia. ___ has confirmed that this translocation has resulted in the BCR/ABL gene rearrangement (see below). ___ BM Biopsy CHRONIC MYELOID LEUKEMIA, BCR-ABL1-POSITIVE; SEE NOTE. Note: Peripheral blood smears showed rare scattered blasts representing 3% of the differential count. A discrete abnormal blast infiltrate is not identified in the aspirate material or core biopsy which are both markedly hypercellular and greatly myeloid predominant. By immunohistochemistry, CD34 highlights rare scattered blasts representing less than 5% of the overall core biopsy cellularity. Corresponding flow cytometry detected a minor population of CD34 positive myeloblasts comprising approximately 3% of total analyzed events and no diagnostic immunophenotypic evidence of an abnormal lymphoblast population (see separate report ___ for full final results). Cytogenetics work-up detected BCR/ABL1 gene rearrangement (see separate report ___-153 for full final results). Taken together, morphologic and immunophenotypic features in conjunction with the cytogenetics results are in keeping with involvement by chronic myeloid leukemia (CML), BCR-ABL1-positive in chronic phase. Correlation with clinical, laboratory and other ancillary findings is recommended. Bone marrow aspirate: The aspirate material is adequate for evaluation and consists of multiple markedly hypercellular spicules. The M:E ratio estimate is greatly increased. Erythroid precursors are relatively proportionally decreased in number and exhibit overall normal maturation. Myeloid precursors are markedly increased in number and show left-shifted maturation. Megakaryocytes are increased in number; abnormal small hypolobated forms are seen. A 300 cell differential shows: 1% blasts, 3% promyelocytes, 30% myelocytes, 9% metamyelocytes, 48% bands/neutrophils, 2% eosinophils, 2% erythroids, 0% lymphocytes, 5% basophils and 0% plasma cells. Brief Hospital Course: ADMISSION STATEMENT =================== ___ is a ___ yo ___ with no significant medical problems, who presents with 1 month of abdominal bloating, early satiety, and new leukocytosis to 400 with differential concerning for CML. ACUTE ISSUES ============ #CML Patient presented w/ one-month of abdominal bloating and some loss of appetite. WBC in the ED was elevated to the ___. She was otherwise asymptomatic with no focal neurological deficits, no headache, shortness of breath. She was give 2mg hydroxyurea in the ED, started on IV fluids, allopurinol and monitored for TLS. FISH was positive for 90% of the interphase peripheral blood cells examined had a probe signal pattern consistent with the BCR/ABL1 gene rearrangement characteristic of chronic myelogenous leukemia. She has a bone marrow biopsy that showed by immunohistochemistry, CD34 highlights rare scattered blasts representing less than 5% of the overall core biopsy cellularity. Corresponding flow cytometry detected a minor population of CD34 positive myeloblasts comprising approximately 3% of total analyzed events and no diagnostic immunophenotypic evidence of an abnormal lymphoblast population. She had an US that measured her spleen at 19.1cm. She was continued on hydrea 500 mg BID pending her f/u appointment. She was started on imatinib on ___ which she tolerate without side effects. CHRONIC ISSUES ============== None TRANSITIONAL ISSUES =================== [] Rx written through ___ for allopurinol [] Rx written through ___ for hydroxyurea CORE MEASURES ============= CODE: Full (presumed) EMERGENCY CONTACT HCP: ___ \| Husband \| ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #5 Tablet Refills:0 2. Hydroxyurea 500 mg PO BID RX hydroxyurea 500 mg 1 capsule(s) by mouth twice a day Disp #10 Capsule Refills:0 3. IMatinib Mesylate 400 md PO DAILY CML RX imatinib 400 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:*0 4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 5. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic Myeloid Leukemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It as a pleasure taking care of you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having abdominal pain. You were found to have an elevated white blood cell count that was diagnosed as Chronic Myeloid Leukemia or CML. WHAT WAS DONE IN THE HOSPITAL? - You were given medication to lower the number of white blood cells in your body. - You had a bone marrow biopsy. - You had an ultrasound to assess the size of your spleen. - We gave your extra fluids and checked your labs frequently to ensure no problems arose from cell breakdown. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - Continue to take your new medication (hydrea, or hydroxyurea). This will help bring down your white blood cell counts in the short term. - Continue to start your new medication (Gleevac, or imatinib). This will help bring down your white blood cell counts in the long term. - Continue to take all other medications as prescribed. - Please don't ride horses until your Oncologist tells you this is OK. This is because your spleen is enlarged. - Follow up with your new oncologist Dr. ___ at your appointment (listed below). - Enjoy the piano recital and flag football superbowl! We wish you the best! Your ___ Care Team. Followup Instructions: ___
10087981-DS-4	10,087,981	26,111,029	DS	4	2159-04-15 00:00:00	2159-04-15 20:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cephalexin / doxycycline / Furazolidone / morphine / naproxen / Macrobid / Oxycodone / prednisone / prochlorperazine / Sulfasalazine / ondansetron / mesalamine / nitrofuran / sulfur dioxide / Benadryl / tramadol Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with h/o osteoporosis and ulcerative colitis presents with one month of progressive low back pain, increased in severity over the past 3 days. Patient's daughter reports she has a history of multiple compression fractures (followed at ___ and bent over last month to retrieve recycling materials when she had sudden onset of low back pain. Three days ago, the pain became severe, limiting patient's ability to ambulate. She denies any numbness, weakness, urinary or fecal incontinence, and denies fever or chills. She was seen at ___ this evening where CT was obtained and showed an L1 compression fracture In the ED, initial vitals were 97.9 110 100/80 19 97% RA. At ___, ___ count was 10.6, creatinine was 1.1. Neurosurgery was consulted and stated that the patient has multiple compression fractures, including L1, L4, and will need pain control and vertebroplasty. They recommended admission to Medicine, and would follow along and consult with ___ for procedure. Vitals on transfer were 97.4 82 129/65 16 100% RA. On the floor, the patient reports no current back pain. There is no current numbness or weakness, retention or incontinence. She has been constipated for two days. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea or abdominal pain. No recent change in bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: Primary sclerosing cholangitis Ulcerative colitis Osteoporosis Diverticulosis Costochondritis Hypertension Tuberculosis Social History: ___ Family History: No history of cancer, heart disease, diabetes Physical Exam: ADMISSION EXAM: Vitals: T: 98.0 BP: 118/56 P: 81 R: 18 O2: 95% on RA GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, o/p clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally on anterior exam, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: muscle strength ___ in all major muscle groups in lower extremities, sensation to light touch intact, toes downgoing bilaterally, non-focal. PSYCH: Appropriate and calm. Discharge exam: afebrile, VSS GEN: Alert, oriented to name, place and situation HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, o/p clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally on anterior exam, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: muscle strength ___ in all major muscle groups in lower extremities, sensation to light touch intact, toes downgoing bilaterally, non-focal. MSK: no midline tenderness over spinous processes, mild point tenderness over left SI joint Pertinent Results: ADMISSION LABS -------------- ___ 06:50AM BLOOD WBC-9.0 RBC-3.46* Hgb-11.5* Hct-34.9* MCV-101* MCH-33.3* MCHC-33.0 RDW-13.2 Plt ___ ___ 06:50AM BLOOD ___ PTT-29.2 ___ ___ 06:50AM BLOOD Glucose-84 UreaN-20 Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-24 AnGap-16 ___ 06:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.___BD PEL ___ Conclusion: 1. Lower L1 compression fracture, slight posterior wall retropulsion, which may be acute or early subacute; new since CT ___. Clinical correlation needed. Chronic L3, L4 compression fractures unchanged. 2. Fluid density contrast, liquid in the large bowel, which might be due to mild enterocolitis, correlate clinically with respect to diarrhea. Suggestion of wall thickening, of rectosigmoid, possibly mild proctocolitis. 3. Uncomplicated gallstone. Limited, uncomplicated colonic diverticulosis. Normal appendix. 4. Other incidental findings listed above. HIP XRAY FINDINGS: Comparison is made to the CT scan from ___. Contrast material is seen throughout the colon. There are severe degenerative changes of the lower lumbar spine with numerous compression deformities, better assessed on the recent CT scan. Since the prior study, compression deformity of L4 was severe. Bilateral hip joint spaces demonstrate mild degenerative changes with some minimal joint space narrowing and spurring superolaterally. There are also proliferative changes of pubic symphysis. No focal lytic or blastic lesions are identified. There is some calcification adjacent to the left greater trochanter which may represent calcific tendinitis. Discharge labs: ___ RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 9.0 3.46 11.5 34.9 101 33.3 33.0 13.2 189 Glucose UreaN Creat Na K Cl HCO3 84 20 1.0 137 4.1 101 24 ECG: sinus, rate ___, normal axis/intervals, no ST-T wave changes Brief Hospital Course: ___ year old female with h/o osteoporosis and ulcerative colitis presents with one month of progressive low back pain. # Back pain: On ___ imaging pt had evidence of chronic L3, L4 compression fractures and a more recent L1 compression fracture. No evidence of cord compromise. She was transfered to ___ for neurosurgical evaluation. The neurosurgical service recommended conservative management with pain control and TLSO brace for comfort. There is no need for neurosurgical follow up. The brace made the patient more uncomfortable, and was discontinued. Her exam was more consistent with left SI joint sprain/inflammation, as there was point tenderness in this area, and not over the spinous processes. She received standing acetaminophen, ibuprofen, lidocaine patch, and heat pads PRN, and was able to work with physical therapy. She was seen by the chronic pain service, and if she needs a left SI joint corticosteroid injection, this can occur on ___ as scheduled. If patient needs more pain control than current regimen, would recommend tramadol 50 mg PO Q4H PRN pain. ___ plan in page 1 worksheet. # HTN- atenolol # Osteoporosis/compression fractures- pain control as above, nasal calcitonin, vitamin D # Hypothyroidisim- Synthroid # Anxiety- at times uncontrolled, continuing triazolam TID PRN # Glaucoma- eye drops Full code Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atenolol 25 mg PO HS 2. Atenolol 50 mg PO QAM 3. Lisinopril 10 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Calcitonin Salmon 200 UNIT NAS DAILY 7. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QHS 8. Hydrocortisone Acetate Suppository ___AILY PRN UC flare 9. Mesalamine Enema ___AILY:PRN UC flare 10. Clorazepate Dipotassium 3.75 mg PO HS:PRN insomnia 11. TRIAzolam 0.25 mg PO QHS:PRN insomnia 12. Vitamin D 4000 UNIT PO DAILY 13. Ascorbic Acid ___ mg PO DAILY 14. Cyanocobalamin 50 mcg PO DAILY 15. Calcium Carbonate 500 mg PO DAILY Discharge Medications: 1. Atenolol 25 mg PO HS 2. Atenolol 50 mg PO QAM 3. Calcitonin Salmon 200 UNIT NAS DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. TRIAzolam 0.125 mg PO TID:PRN anxiety, insomnia 8. Vitamin D 4000 UNIT PO DAILY 9. Acetaminophen 1000 mg PO TID 10. Ibuprofen 400 mg PO TID Duration: 4 Days 11. Lidocaine 5% Patch 1 PTCH TD QAM to left SI joint 12. Omeprazole 20 mg PO DAILY Duration: 14 Days 13. Ascorbic Acid ___ mg PO DAILY 14. Calcium Carbonate 500 mg PO DAILY 15. Cyanocobalamin 50 mcg PO DAILY 16. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QHS 17. Hydrocortisone Acetate Suppository ___AILY PRN UC flare 18. Mesalamine Enema ___AILY:PRN UC flare 19. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnosis: left SI joint sprain/inflammation Secondary diagnoses: anxiety osteoporosis lumbar compression fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with back pain. You had imaging at ___ ___ that showed lumbar spinal compression fractures. You were evaluated by neurosurgery, who suggested a back brace for comfort. Your exam was more consistent with joint inflammation in the left lower back, and the brace made you uncomfortable, so this was stopped. Your pain gradually improved with medications, and you will continue physical therapy at rehab. Please see below for your follow up appointments and medications. Followup Instructions: ___
10087981-DS-6	10,087,981	20,474,591	DS	6	2160-06-20 00:00:00	2160-06-20 11:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: cephalexin / doxycycline / Furazolidone / morphine / naproxen / Macrobid / Oxycodone / prednisone / prochlorperazine / Sulfasalazine / ondansetron / mesalamine / nitrofuran / sulfur dioxide / Benadryl / tramadol Attending: ___. Chief Complaint: RUE and RLE pain due to Right proximal humerus fracture and right intertroch fracture respectively Major Surgical or Invasive Procedure: right femure cephalomedullary nail History of Present Illness: ___ who lives independently and ambulates with a walker, hx HTN, TIAs, s/p ground level mechanical fall suffering immediate pain and inability to bear weight in right upper and right lower extremities. She denied HS/LOC. She presented to ___ where images revealed a right proximal humerus fracture and right intertrochanteric femur fracture. She is transferred to ___ for further orthopaedic care. Past Medical History: Primary sclerosing cholangitis Ulcerative colitis Osteoporosis Diverticulosis Costochondritis Hypertension Tuberculosis Social History: ___ Family History: No history of cancer, heart disease, diabetes Physical Exam: PHYSICAL EXAMINATION in adm: General: A&Ox3, NAD CAM/MINICOG: Negative Heart: Regular rate and rhythm peripherally Lungs: Breathing comfortably on room air. Right upper extremity: - Skin intact with ecchymosis and swelling about the shoulder. - TTP about the shoulder. Soft, non-tender arm and forearm - Unable to range shoulder due to pain. Full, painless active/passive ROM of elbow, wrist, and digits - EPL/FPL/DIO (index) fire - Sensation intact to light touch in axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, fingers warm and well perfused Left upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless active/passive ROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - Sensation intact to light touch in axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, fingers warm and well perfused Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - TTP about the thigh/groin. Soft, non-tender lower leg - Unable to range hip due to pain. Full, painless active/passive ROM of knee, and ankle - ___ fire - Sensation intact to light touch in SPN/DPN/Tibial/saphenous/Sural distributions - 1+ ___ pulses, foot warm and well perfused Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and lower leg - Full, painless active/passive ROM of hip, knee, and ankle - ___ fire - Sensation intact to light touch in SPN/DPN/Tibial/saphenous/Sural distributions - 1+ ___ pulses, foot warm and well perfused Exam on Discharge: AVSS NAD, A&Ox3 RUE - Skin intact with ecchymosis and swelling about the shoulder. - TTP about the shoulder. Soft, non-tender arm and forearm - Unable to range shoulder due to pain. Full, painless active/passive ROM of elbow, wrist, and digits - EPL/FPL/DIO (index) fire - Sensation intact to light touch in axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, fingers warm and well perfused RLE Incision well approximated. Fires ___. SITLT s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally. Pertinent Results: AP pelvis, right hip xrays: R IT fracture Right shoulder xrays: Comminuted proximal humerus fracture, likely 3 part. 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 proximal humerus fracture, right intertroch fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right cephalomedullary nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. the RUE injury will be managed no-op. 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 NWB in splint and WBAT in the RUE and RLE respectively, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO BID 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Atenolol 25 mg PO BID 4. Acetaminophen 650 mg PO Q6H RX acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 5. Enoxaparin Sodium 30 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 30 mg/0.3 mL 30 mg sc once a day Disp #28 Syringe Refills:0 6. Multivitamins 1 TAB PO DAILY 7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 8. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 softgel by mouth twice a day Disp #30 Capsule Refills:0 9. Calcitonin Salmon 200 UNIT NAS DAILY RX calcitonin (salmon) 200 unit/spray 200 unit SP once a day Disp #5 Spray Refills:*0 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Right proximal humerus fracture, right intertroch 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: - Weight Bear as Tolerated in Right Lower Extermity, Non Weight Bearing in Right Upper Extermity in sling 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. Physical Therapy: WBAT RLE, NWB RUE in sling Treatments Frequency: WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Followup Instructions: ___
10088198-DS-11	10,088,198	25,635,144	DS	11	2146-12-29 00:00:00	2146-12-29 19:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Kenalog / shrimp / mango (fresh) Attending: ___. Chief Complaint: cc: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of CAD, remote thyroid presented with abdominal pain which woke her from sleep. She describes the pain as epigastric, ___ in severity and non radiating. She had some associated nausea. Denies shortness of breath, no chest pain. Did not feel light headed or dizzy. She was able to move her bowels a little, without change in pain. Also took two Rolaids without relief so she presented to the ED. She reports she was in her usual state of health yesterday, was able to paint a little. She had a normal BM yesterday morning without blood, not dark. She does not drink alcohol or use NSAIDs. She has not had pain like this previously, but does have a history of a gastric ulcer many years ago in the setting of taking large amounts of NSAIDs. En route, She was given ASA and nitroglycerin without change to her abdominal pain. Per notes, was GUAIAC + in the ED. She was also given Morphine and pain has since resolved. She currently reports she feels better, although tired. Abdominal pain has totally resolved. She denies fevers or chills, denies nausea or vomiting. No diarrhea. No changes in bowel or bladder habits recently. Has lost a fair amount of hair since her recent surgery. Also reports 17 lb weight loss in the setting of illness. She did have problems with thyroid over-replacement which has since resolved. She is able to walk up two flights of stairs without chest pain or shortness of breath. Has not noted lower extremity edema and is able to lay flat without shortness of breath. Remainder of 12- point ROS negative. In the ___ ED: 97.9 76 111/44 16 99% RA Labs notable for BUN/Cr 57/1.6 ALT/AST 90/206 Alk phos 119 Tbili 0.4 H/H 9.7/29.4 INR 2.4 Past Medical History: - Coronary Artery Disease - Cath ___: 80% P-M LAD, nonobstructive RCA/LCX. Echo ___: Mild LVH, normal LV/RV, E/E___ ___ MR/TR. - CVA - ___ with out residual deficits - HTN - HLD - Chronic diastiolic CHF - h/o thyroid ca s/p resections in ___ and ___ c/b right Horner's syndrome and XRT but no chemotherapy in remission on chronic levothyroxine for iatrogenic hypothyroidism - Osteoporosis - OA - Right leg lumbosacral radiculopathy managed by pain clinic with gabapentin with no MRI imaging performed - h/o left calf superficial thrombophlebitis - h/o gastric ulcer in ___ - psoriasis minor and on no treatment -Paroxysmal atrial fibrillation following cardiac surgery PSurgHx: - s/p ovarian cystectomy - s/p hysterectomy - s/p thyroidectomy with resections x2 in ___ - s/p bilateral cataract operations - s/p debridement of Aortic and Mitral valve masses- noted to be organized calcifed thrombus, CABG x ___ Social History: ___ Family History: Mother - died ___ CAD Father - died ___ of an MI Sibs - 2 brothers well; 1 brother died of an MI in his ___ Children - 2 well Physical Exam: Physical Exam: VS 98.3, HR 68, BP 126/48, RR 16, SaO2 96% RA This is a well appearing female in NAD. Age appears younger than stated. HEENT: PERRL, EOMI. Neck with midline abdominal scar, some atrophy of neck muscles on right Lungs: Decreased breath sounds at bases ___: RRR, S1, S2 present Abd: Soft, NT, ND. No rebound or guarding. Negative murphys. No HSM appreciated EXT: Trace edema B/L Physical exam on discharge: Vitals:97.9 BP: 124/52 HR: 60 R: 18 O2: 99% RA Well appearing female in NAD. Age appears younger than stated, in NAD. HEENT: +conjunctival injection on left. EOMI. Lungs: Clear B/L on auscultation ___: RRR, S1, S2 present Abd: Soft, NT, ND, no rebound or guarding Ext: No edema Neuro: AAOx3, moving all extremities. CN II- XII grossly intact Pertinent Results: ___ 02:18AM LACTATE-1.8 ___ 02:15AM GLUCOSE-149* UREA N-57* CREAT-1.6* SODIUM-136 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17 ___ 02:15AM estGFR-Using this ___ 02:15AM ALT(SGPT)-90* AST(SGOT)-206* ALK PHOS-119* TOT BILI-0.4 ___ 02:15AM LIPASE-42 ___ 02:15AM cTropnT-<0.01 ___ 02:15AM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-2.3 ___ 02:15AM WBC-7.6 RBC-3.23* HGB-9.7* HCT-29.4* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 ___ 02:15AM NEUTS-75.0* LYMPHS-14.8* MONOS-6.4 EOS-3.4 BASOS-0.4 ___ 02:15AM PLT COUNT-202 ___ 02:15AM ___ PTT-25.5 ___ Labs on discharge: ___ 08:00AM BLOOD WBC-5.6 RBC-3.39* Hgb-9.9* Hct-31.5* MCV-93 MCH-29.1 MCHC-31.4 RDW-13.4 Plt ___ ___ 08:00AM BLOOD Glucose-105* UreaN-34* Creat-1.2* Na-140 K-4.0 Cl-107 HCO3-24 AnGap-13 ___ 08:00AM BLOOD ALT-304* AST-220* AlkPhos-137* TotBili-0.5 ___ 08:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 Iron-100 ___ 08:00AM BLOOD calTIBC-363 Ferritn-69 TRF-279 ___ 10:25AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:15AM BLOOD cTropnT-<0.01 ================== IMAGING: ================== Chest Xray: UPRIGHT PORTABLE CHEST: Lung volumes are lower than on the prior. There is no focal consolidation, pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are stable with mild-moderate cardiomegaly. The patient is status post median sternotomy. No free intra-abdominal air is seen. IMPRESSION: No free air. Abdominal Ultrasound: ___ FINDINGS: The liver shows no textural abnormality. A 1.4 x 1.1 cm cyst in the right hepatic lobe is similar to CT ___. No concerning focal liver lesion is identified. Doppler assessment of the main portal vein shows patency and normal hepatopetal flow. There is no intra- or extra-hepatic bile duct dilation. The common duct is not dilated, measuring 5 mm. Tiny gallstones or sludge are seen within the gallbladder without gallbladder distention or wall edema. Sonographic ___ sign is negative. The visualized portions of the pancreatic head, body and tail are unremarkable. The pancreatic duct is normal, measuring 2 mm. Visualized portions of the IVC are normal. There is no ascites in the upper abdomen. IMPRESSION: Tiny gallstones or sludge without evidence of acute cholecystitis. MRCP: Preliminary report IMPRESSION: 1. Trace cholelithiasis. No intrahepatic or extrahepatic bile duct dilation. No ductal stones. 2. 5 and 3 mm cystic lesions within the pancreatic neck and body, respectively, likely represent side branch IPMN. At this age, no further dedicated follow up is recommended per departmental guidelines. 3. Mild right lower lobe atelectasis. 4. Benign hepatic cysts or biliary hamartomas Brief Hospital Course: This is an ___ y/o female with history of CAD, remote history of gastric ulcer who presented with acute onset of epigastric abdominal pain, now resolved, elevated LFTs, and increased BUN/Creatinine. #Abdominal pain #Elevated LFTs. The patient presented with acute onset of epigastric abdominal pain. Transaminases were elevated. The patient was seen by gastroenerology who felt her liver function abnormalites may be due to a passed gallstone. The patient underwent MRCP which showed some gallbladder sludge but did not show dilated ducts or stone. Given her pain had improved, diet was advanced which she tolerated well. Her LFTs trended down, although are still elevated at discharge. The patient needs follow up LFTs checked at PCP visit on ___. #Acute renal failure The patient presented with elevation in both BUN/Cr. Her valsartan and furosemide were held. Creatinine improved and is 1.2 on discharge. Given the patient was normotensive throughout her hospitalziation, valsartan was not resumed on discharge. Creatinine should also be checked on follow up with PCP. #Anemia, normocytic HCT stable without signs of active bleeding during hospitalization. Iron studies not consistent with iron deficiency but given GUAIAC positive stools recommend outpatient GI follow up. #CAD, s/p bypass graft History of CAD. Ruled out for ACS with troponins x2 and unchanged EKG. No further episodes of pain. BBlocker, statin continued #Chronic diastolic CHF Currently euvolemic. Lasix resumed on discharge. #Paroxysmal atrial fibrillation Patient was previously on amiodarone. Coontinued Metoprolol and rivaroxiban while hospitalized #Hypertension, benign Hold Valsartan given elevated Cr. Transitional issues: - LFTs have not normalized, please check repeat LFTs with PCP ___ - Cr was elevated on admission, may have been due to hypovolemia. Patient was normtensive therefore Valstartan was not resumed on discharge. Please check BP and re-asses - Cystic lesions, likely IPMN, were seen on MRCP, no follow up recommended given advanced age Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 20 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Metoprolol Tartrate 25 mg PO BID 4. Rivaroxaban 15 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Travatan Z (travoprost) 0.004 % ophthalmic qHS 7. Valsartan 80 mg PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Calcium Carbonate 500 mg PO TID 10. Vitamin D 800 UNIT PO BID 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Metoprolol Tartrate 25 mg PO HS 4. Multivitamins 1 TAB PO DAILY 5. Rivaroxaban 15 mg PO DAILY 6. Simvastatin 20 mg PO DAILY 7. Vitamin D 800 UNIT PO BID 8. Furosemide 20 mg PO DAILY 9. Travatan Z (travoprost) 0.004 % ophthalmic qHS Discharge Disposition: Home Discharge Diagnosis: Abnormal LFTs, possible passed gallstone Acute renal failure Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your recent admission to ___. You were admitted with abdominal pain and found to have elevation in your liver function tests. You were seen by gastroenterology and had an ultrasound and MRI of your gallbladder and liver which showed some very small stones in your gallbladder but no bile duct obstruction. It is possible that you had a small stone in your bile duct which you passed, explaining your abdominal pain and your liver test abnormalities. You should have repeat liver tests as an outpatient. You were also noted to have anemia, you should discuss having an endoscopy and colonoscopy with Dr. ___. Your kidney function tests were slightly elevated when you came to the hospital. You may have been a little dehydrated. These tests improved with holding your valsartan. You should continue to hold this medicaiton until you see your primary care physician next week. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10088198-DS-14	10,088,198	26,124,727	DS	14	2150-01-16 00:00:00	2150-01-18 16:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Kenalog / shrimp / mango (fresh) / shellfish derived Attending: ___ Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: ___ is a ___ year-old right-handed woman who presents with dizziness and unsteady gait. Examination in the ED was concerning for new right leg weakness. Neurology is consulted to assess for stroke. She awoke this morning in her usual state of health but when she got up felt dizzy and unsteady with walking. She has difficulty describing her dizziness but denies room spinning vertigo. There might be some lightheadedness and there might be some sensation of rocking on a boat. It is mostly present when she is walking around and she needed to hold onto objects to walk today. She also has a fullness sensation in her head. At baseline, sometimes she gets mild dizziness after taking her morning medications and she has baseline neuropathy in her feet, though she denies having dizziness like this before. In ___ she was admitted with left-sided weakness including a cortical head and was found to have multiple embolic strokes in R MCA/PCA region. TTE was obtained which showed a large mitral valve vegetation, which was felt to be her stroke source. 2 months later she underwent coronary artery bypass grafting, removal of aortic valve mass and left atrial mass. Her postop course was complicated by paroxysmal atrial fibrillation, for which is on Xarelto. In ___ she was admitted to the stroke service with gait unsteadiness. Brain MRI was negative for new infarct and it was felt that a peripheral vestibulopathy with most likely cause of her symptoms. The patient does not remember this admission so cannot tell me if her symptoms today feel similar or not. Past Medical History: - Coronary Artery Disease - Cath ___: 80% P-M LAD, nonobstructive RCA/LCX. Echo ___: Mild LVH, normal LV/RV, E/E___ ___ MR/TR. - CVA - ___ with out residual deficits - HTN - HLD - Chronic diastiolic CHF - h/o thyroid ca s/p resections in ___ and ___ c/b right Horner's syndrome and XRT but no chemotherapy in remission on chronic levothyroxine for iatrogenic hypothyroidism - Osteoporosis - OA - Right leg lumbosacral radiculopathy managed by pain clinic with gabapentin with no MRI imaging performed - h/o left calf superficial thrombophlebitis - h/o gastric ulcer in ___ - psoriasis minor and on no treatment -Paroxysmal atrial fibrillation following cardiac surgery PSurgHx: - s/p ovarian cystectomy - s/p hysterectomy - s/p thyroidectomy with resections x2 in ___ - s/p bilateral cataract operations - s/p debridement of Aortic and Mitral valve masses- noted to be organized calcifed thrombus, CABG x ___ Social History: ___ Family History: Mother - died ___ CAD Father - died ___ of an MI Sibs - 2 brothers well; 1 brother died of an MI in his ___ Children - 2 well Physical Exam: Discharge Physical Exam: Very alert and interactive. Right chronic Horner's from thyroid surgery ___ years ago. Weak EDBs, TAs strong, EHLs weak bilaterally (chronic neuropathy). Able to get up independently and walk without assistance, but stooped over while walking and often grabs onto furniture for stabilization. Did not lean or fall to one side versus another while getting up. Denied dizziness. Admission Physical Exam: Vitals: 97.1 87 160/58 18 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT Pulmonary: breathing comfortably on RA, lungs clear to auscultation bilaterally Cardiac: RRR, no murmurs Abdomen: soft, nondistended Extremities: no edema, warm. Small toe wound on the tip of her left fourth toe without surrounding erythema or pus Skin: no rashes or lesions noted. NEUROLOGIC EXAMINATION -Mental Status: Alert, oriented. Able to relate history without difficulty. Language is fluent with normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects on the stroke card. Described the cookie jar picture accurately. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, able to name ___ backward without difficulty. There was no evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: Pupil 2->1.5 mm on the right, 3->2mm on the left. There is ptosis on the right. VFF to confrontation with finger wiggling. III, IV, VI: EOMI without nystagmus. V: Facial sensation decreased to light touch on the right (which the patient states is chronic since her thyroid surgery) VII: There is left nasolabial fold flattening though with symmetric activation bilaterally (previously documented) VIII: Hearing intact to voice IX, X: Palate elevates symmetrically. XI: Shoulder shrug is symmetric XII: Tongue protrudes in midline with full ROM right and left -Motor: No pronator drift bilaterally. No tremor noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 4 4+ R ___ ___ ___ 4+ 5 5 5 4+ -The right deltoid weakness is previously documented and chronic per the patient -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 0 R 2 2 2 3 0 - Toes were mute bilaterally. - Crossed abductors are present bilaterally -Sensory: There is a temperature gradient in all 4 extremities and decreased pinprick sensation distally in her legs. She made minor mistakes with position sense to small movements in the left foot. She has decreased vibration sense at the feet. No extinction to DSS. No a graphesthesia. -Coordination: No clear dysmetria on FNF or HKS bilaterally, though the left arm and leg are slightly clumsier compared to the right. She was able to touch her nose with her right finger with her eyes closed accurately, though missed and touched her forehead instead with the left finger. Repetitive heel tapping onto her shin was slightly clumsier with the left foot than the right foot. Rapid alternating movements with normal and symmetric cadence and speed in the hands. -Gait: She stood with a wide base. She was unable to stand with her feet together with her eyes open and became very unsteady when she attempted this. Further gait testing was deferred given risk for fall. Pertinent Results: ___ 03:47PM BLOOD WBC-7.1 RBC-3.94 Hgb-11.6 Hct-36.2 MCV-92 MCH-29.4 MCHC-32.0 RDW-12.1 RDWSD-41.0 Plt ___ ___ 03:47PM BLOOD Neuts-70.6 Lymphs-17.5* Monos-7.2 Eos-4.1 Baso-0.3 Im ___ AbsNeut-5.00 AbsLymp-1.24 AbsMono-0.51 AbsEos-0.29 AbsBaso-0.02 ___ 04:40AM BLOOD ___ PTT-43.2* ___ ___ 03:47PM BLOOD ___ PTT-39.2* ___ ___ 04:40AM BLOOD Glucose-70 UreaN-34* Creat-1.0 Na-139 K-3.6 Cl-101 HCO3-27 AnGap-15 ___ 04:40AM BLOOD ALT-18 AST-19 LD(LDH)-196 AlkPhos-69 TotBili-0.4 ___ 04:40AM BLOOD cTropnT-<0.01 ___ 04:40AM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.5 Mg-2.0 Cholest-115 ___ 04:40AM BLOOD %HbA1c-6.2* eAG-131* ___ 04:40AM BLOOD Triglyc-91 HDL-37 CHOL/HD-3.1 LDLcalc-60 LDLmeas-69 ___ 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Post-hospital items to follow-up: - Patient requesting to see a podiatrist as an outpatient. - Follow-up dizziness as it correlates to her diuretic timing. Brief hospital course: Ms. ___ was admitted in order to obtain an MRI to evaluate for signs of stroke, after she came to ___ with the chief complaint of dizziness. Given her several stroke risk factors, while the dizziness could have been likely light-headedness or peripheral vertigo, stroke remained on the differential. MRI was negative for new stroke (signs of old stroke still present). No signs of intracranial bleeding. Her symptoms resolved by the first day of admission, and she was evaluated by ___ and OT who recommended some home services because of her mild unsteadiness on her feet and tendency to grab furniture while walking. No changes were made to her medications. She was discharged on her home rivaroxaban for afib. She agreed to follow-up as an outpatient as needed for her dizziness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Gabapentin 200 mg PO QHS 3. clotrimazole-betamethasone ___ % topical BID:PRN 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Rivaroxaban 15 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Travatan Z (travoprost) 0.004 % ophthalmic QHS 9. Calcium Carbonate 500 mg PO BID 10. Chlorthalidone 12.5 mg PO DAILY 11. Levothyroxine Sodium 137 mcg PO DAILY 12. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Calcium Carbonate 500 mg PO BID 3. Carvedilol 12.5 mg PO BID 4. Chlorthalidone 12.5 mg PO DAILY 5. clotrimazole-betamethasone ___ % topical BID:PRN rash 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 200 mg PO QHS 8. Levothyroxine Sodium 137 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Rivaroxaban 15 mg PO DAILY 11. Travatan Z (travoprost) 0.004 % ophthalmic QHS 12. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dizziness 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 because of concern for dizziness. You had a brain MRI that showed no stroke. You did not have a stroke. You should continue taking all of your medications as previously prescribed. No changes were made during this hospitalization. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10088198-DS-7	10,088,198	24,942,180	DS	7	2146-04-12 00:00:00	2146-04-12 21:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Kenalog / shrimp / mango (fresh) Attending: ___. Chief Complaint: left upper extremity weakness Major Surgical or Invasive Procedure: Trans esophageal echo History of Present Illness: ___ with a PMH of HTN, HLD and a h/o thyroid ca s/p resections in ___ and ___ c/b right Horner's syndrome and XRT but no chemotherapy in remission on chronic levothyroxine for iatrogenic hypothyroidism presents with left arm weakness on awaking this morning. The patent was in her usual state of health until waking this morning at 05:30 on ___ when she found her left arm was "floppy" and "like a rag doll" and although she could lift it the arm was generally weak and she would drop objects she would hold in her left hand. This was also associated with some tingling in the left hand mainly in the fingers bur confluently which resolved. The patient denied any pain and denied sleeping on her arm in an awkward manner. The weakness improved as the day went on and then deteriorated again this afternoon and sh called her PCP as she was again dropping objects with her left arm and advised presentation to rule out a stroke. She denied any symptoms affecting her left face or leg. She also noted diarrhoea x5 today which has since resolved. She denies any other symptoms save right leg pain which she has been treated at the pain clinic with gabapentin. She recently had her aspirin increased in ___ for a superficial thrombophlebitis on her left calf. She denies any previous similar symptoms. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies numbness. 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, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - HTN - HLD - h/o thyroid ca s/p resections in ___ and ___ c/b right Horner's syndrome and XRT but no chemotherapy in remission on chronic levothyroxine for iatrogenic hypothyroidism - Osteoporosis - OA - Right leg lumbosacral radiculopathy managed by pain clinic with gabapentin with no MRI imaging performed - h/o left calf superficial thrombophlebitis on ___ for which aspirin was increased from 81mg qd to 325mg qd - h/o gastric ulcer - psoriasis minor and on no treatment PSurgHx: - s/p ovarian cystectomy - s/p hysterectomy - s/p thyroidectomy with resections x2 in ___ - s/p bilateral cataract operations Social History: ___ Family History: Mother - died ___ CAD Father - died ___ of an MI Sibs - 2 brothers well; 1 brother died of an MI in his ___ Children - 2 well There is no history of seizures, developmental disability, learning disorders, migraine headaches, strokes less than ___, neuromuscular disorders, dementia or movement disorders. Physical Exam: Physical Exam on Admission: Vitals: T:98.6 P:100 R:22 BP:initially 187/65 currently 160/86 SaO2:100% RA General: Awake, cooperative, complains of left arm weakness. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Significant scarring from prior radical thyroidectomy in particular on the right. Supple, bilateral carotid bruits appreciated. No nuchal rigidity. Decreased neck rotation right>left and flexion/extension. Pulmonary: Some decreased breath sounds at bases. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: Stigmata of OA. No C/C and mild pitting oedema to he mid shins bilaterally, 2+ radial, DP pulses bilaterally. Calves SNT bilaterally. Skin: no rashes or lesions noted. Neurological examination: ___ Stroke Scale score was 1 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 - Mental Status: ORIENTATION - Alert, oriented x 4 The pt. had good knowledge of current events. SPEECH Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. NAMING Pt. was able to name both high and low frequency objects. READING - Able to read without difficulty ATTENTION - Attentive, able to name ___ backward without difficulty. REGISTRATION and RECALL Pt. was able to register 3 objects and recall ___ at 10 minutes. COMPREHENSION Able to follow both midline and appendicular commands There was no evidence of apraxia or neglect - Cranial Nerves: I: Olfaction not tested. II: Anisocoria with chronic right Horner's with right pupil 2.5mm and left 4mm both brisk, right ptosis and right ___ is lighter and green in comparison to brown. VFF to confrontation. Funduscopic exam reveals no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal pursuits and saccades. V: Facial sensation intact to light touch. Good power in muscles of mastication. VII: Right Horner's as above longstanding. Slight facial asymmetry due to extensive scarring but no true weakness. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal velocity movements. - Motor: Normal bulk, tone decreased in left arm. No clear pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___ L 4+ 4 ___ ___ 5 ___ 4+ 5 4 R 4* 5 5 4+ ___ 4 5 ___ 4+ 5 4 * limited right shoulder ROM and disocmfort APB 4- on left and ___ on right. EDBs ___ bilaterally. - Sensory: There is no agrphaesthesia bilaterally. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout in UE and ___. No extinction to DSS. - DTRs: BJ SJ TJ KJ AJ L ___ 2 2 R ___ 2 0 There was no evidence of clonus. ___ negative. Pectoral reflexes present. Plantar response was flexor bilaterally. - Coordination: No intention tremor, clumsier finger tapping on the left. 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 admirably fora age. Romberg absent. Physical Exam on Discharge: Afebrile, hemodynamically stable minimal residual weakness in left lower extremity, 5- in finger extensors trace slowed finger tapping on left Pertinent Results: Admission Labs: ___ 07:50PM WBC-10.2 RBC-3.98* HGB-11.7* HCT-34.8* MCV-87 MCH-29.3 MCHC-33.6 RDW-12.6 ___ 07:50PM PLT COUNT-247 ___ 07:50PM GLUCOSE-177* UREA N-32* CREAT-1.2* SODIUM-139 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 ___ 07:50PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-82 ALK PHOS-80 TOT BILI-0.2 ___ 07:50PM ALBUMIN-4.4 CALCIUM-9.7 PHOSPHATE-3.8# MAGNESIUM-1.9 CHOLEST-200* ___ 07:50PM TSH-0.23* ___ 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 09:31PM URINE HOURS-RANDOM ___ 09:31PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 09:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 09:31PM URINE RBC-<1 WBC-7* BACTERIA-FEW YEAST-NONE EPI-<1 Relevant Labs: ___ 07:59PM %HbA1c-6.1* eAG-128* ___ 07:50PM TRIGLYCER-155* HDL CHOL-54 CHOL/HDL-3.7 LDL(CALC)-115 ___ 07:50PM TSH-0.23* ___ 03:40PM BLOOD RheuFac-PND CRP-2.8 ESR 51 Imaging Studies: MRI brain w/o contrast FINDINGS: There are numerous punctate foci of abnormally slow diffusion, which are predominantly peripheral in location. The largest cluster these foci as noted in the right parietal lobe cub with additional foci also noted in the right frontal operculum. Equivocal foci of slow diffusion are noted in the paramedian aspect of the left occipital lobe (series 702, image 12) as well as in the right cerebellar hemisphere. Susceptibility artifact is noted in a gyriform pattern overlying the right parietal lobe. There is no other evidence of intracranial hemorrhage. Ventricles and sulci are enlarged, reflecting mild parenchymal volume loss. FLAIR hyperintense signal is noted in the right cerebellar hemisphere, pons and in scattered bilateral cerebral foci, consistent with chronic microvascular disease. IMPRESSION: Multiple punctate peripheral areas of abnormally slow diffusion, consistent with multiple embolic infarcts. A small amount of susceptibility artifact overlying the right parietal lobe suggests associated blood products. CTA head/neck 1. No acute territorial infarct or hemorrhage. 2. 40% focal narrowing of the proximal left internal carotid artery due to atherosclerotic disease. 3. Mild narrowing of the origin of the right vertebral artery. 4. Atherosclerotic disease of the cavernous segments of the internal carotid arteries, otherwise unremarkable CTA of the head. TTE IMPRESSION: Preserved biventricular size and systolic function. Increased left ventricular filling pressure. Large mitral valve mass (?posterior mitral valve leaflet) with at least mild to moderate mitral regurgitation, most consistent with a vegetation, but a calcified, ruptured cord cannot be fully excluded. Moderate pulmonary hypertension. A TEE may be obtained to further characterize if clinically indicated. Brief Hospital Course: ___ with a PMH of HTN, HLD and a h/o thyroid ca s/p resections in ___ and ___ c/b right Horner's syndrome and XRT but no chemotherapy in remission on chronic levothyroxine for iatrogenic hypothyroidism presents with left arm weakness on awaking on morning of admission. # Neuro: The weakness was in an upper motor neuron pattern as well as with a cortical hand. MRI brain showed multiple embolic strokes in R MCA/PCA region. TTE was obtained which showed a large mitral valve vegetation. She was started anticoagulation with coumadin with an Aspirin bridge transiently. We did not start heparin given possibility of mycotic aneurysm and bleed if the vegetation is endocarditis. A TEE was attempted for further characterization, but unable to obtain given esophageal atresia. Considered cardiac MRI, but cardiology felt that this would not provide more information about the vegetation. Coumadin was discontinued as was Aspirin, and she was instead started on Plavix 75mg qd. With other risk factors for stroke, HbA1c 6.1, LDL 112. As goal LDL is <70, increased Simvastatin from 10mg qd to 40mg qd. Anti hypertensives were held for permissive hypertension after stroke. # ___: HCTZ and Valsartan held, but restarted on discharge. TRANSITIONS OF CARE: - will follow up in neurology stroke clinic with Drs. ___ - will have repeat TTE prior to appointment above in ___ weeks - will follow up with PCP ___ 1 week Medications on Admission: GABAPENTIN - gabapentin 100 mg capsule. 2 capsule(s) by mouth at bedtime as tolerated HYDROCHLOROTHIAZIDE - hydrochlorothiazide 12.5 mg tablet. 1 Tablet(s) by mouth One daily by mouth LEVOTHYROXINE [SYNTHROID] - Synthroid ___ mcg tablet. 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE [PRILOSEC] - Prilosec 20 mg capsule,delayed release. 1 (One) Capsule(s) by mouth once a day - (Prescribed by Other Provider) SIMVASTATIN - simvastatin 10 mg tablet. 1 (One) Tablet(s) by mouth once a day TRAVOPROST [TRAVATAN Z] - Travatan Z 0.004 % Eye Drops. 1 gtt in each eye at bedtime - (Prescribed by Other Provider) VALSARTAN [DIOVAN] - Diovan 80 mg tablet. 1 Tablet(s) by mouth once a day Medications - OTC ACETAMINOPHEN [TYLENOL] PRN ASPIRIN 325mg daily CALCIUM CARBONATE [CALCIUM 500] - Calcium 500 500 mg calcium (1,250 mg) tablet. 1 (One) Tablet(s) by mouth three times a day - (Prescribed by Other Provider) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 1600units daily per patient IBUPROFEN [ADVIL] - Dosage uncertain - as required Discharge Medications: 1. Gabapentin 200 mg PO HS 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Levothyroxine Sodium 150 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 40 mg PO DAILY RX simvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 7. Valsartan 80 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY 9. Calcium Carbonate 500 mg PO TID 10. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 11. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: embolic ischemic strokes mitral valve vegatation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital for weakness in your left arm. An MRI of your brain showed that you had several small strokes. An ultrasound of your heart showed a vegetation on one of the valves. Most likely, the small strokes were from pieces coming off that vegetation and blocking blood vessels. We did a more detailed ultrasound (trans-esophageal echocardiogram) was attempted but was not successful. The cardiologists agreed that further ultrasound would not give additional information regarding the vegetation on the valves. To prevent more strokes from the vegetation, we started you on a blood thinner called Plavix. Please continue this medication until seen by neurologists as outpatient and discuss whether it needs to be changed. Also, your cholesterol level was slightly elevated, so we increased the dose of your simvastatin as well. We have made the following changes to your medications: START: Plavix (clopidogrel) 75 mg daily STOP: aspirin INCREASE: Simvastatin to 40mg daily On discharge, please follow up with: 1. Your primary care physician ___ 1 week. 2. In neurology clinic with Drs. ___. Call ___ on ___ to schedule an appointment in ___ weeks. You will also need a repeat echocardiogram. Please call ___ to schedule it for ___ weeks - this should be done BEFORE your appointment with Dr. ___. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___
10088799-DS-5	10,088,799	28,732,089	DS	5	2166-09-25 00:00:00	2166-09-25 20:12:00	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: ___ F with h/o HTN, HL, right breast cancer ___ s/p lumpectomy and h/o pneumonia ___ and ___ who now presents with cough and hypoxia. . ___ is a highly functional lady, lives alone at home with her husband and is ADL independent. 6 days ago, out of her usual state of health developed some URT symptoms including rhinitis, sneezing, sore throat and pressure in ears with some mild headaches. Also had diarrhea ___ water BM per day w/o BRBPR or melena, No nausea or vomiting. 4 days ago developed temps to 99.8 and productive cough w/o hemoptysis, saw her PCP the same day who started her clarithomycin 500mg BID and albuterol inhaler. Reported symptomatic improvement in cough and fever on the antibiotic but yesterday started noting DOE and this morning had acute onset of SOB at breath which led her to the ED. . ED Course: - Initial Vitals/Trigger: 98.8 70 136/102 16, Hypoxic to ___ 93% on O2. - labs: hyponatremia to 129, Urin OSM 380, WBC 9.9 w/75% Neu, lactate 0.9. - EKG: non acute [] CXR: possible developing RML pneumonia [] abx: levofloxacin 750 mg IV x1 22:42 [] Most Recent Vitals: ___ . Currently, ___ still coughing, no SOB at rest but gets winded walking to the toilet. Denies chest pain. Denies abdominal pain. No headache currently. She denies any recent immobilization, remained active throughout the week. No sick contacts and no recent travels. She has dog at home but no other exposures. She did have the flu vaccine this year. . She has h/o of pneumonia X 2 in ___ and in ___ at that time was admitted to ___ for 4 days for fever and hypoxia and had CT showing multifocal pneumonia. Subsequently had 3 ___ CT's for stable mutliple pulmonary nodules and a slowly growing RUL spiculated lesion. . REVIEW OF SYSTEMS: + See HPI - See HPI, also denies recent weight loss, night sweats + Has chronic urinary urgency and frequency Past Medical History: HTN Hyperlipidemia Ductal carcinoma ___ - s/p lumpectomy no Rads or chemo. Pneumonia ___ mutliple pulmonary nodules and a slowly growing RUL spiculated lesion. s/p TAH+BSO s/p removal of benight ___ tumor > ___ years ago Social History: ___ Family History: Sister with ovarian ca, sister ___ lung ca, mother with brain ca Physical Exam: ADMISSION EXAM VS - Temp 97.3 F, 146/69 BP , HR 71 , R 21 , 98 ___ % 2L GENERAL - ___ in NAD, comfortable, appropriate, dry cough HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no tonsillar hypertophy or exudate, no sinus tenderness NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - end inspiratory crackles over right mid lung, some scattered wheezing bilaterally. no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Surgical scar over left rib cage. HEART - RRR, no MRG, nl ___ ABDOMEN - vertical scar mid lower abdomen, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs ___ grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact. . DISCHARGE EXAM VS - Temp 97.8 F, BP ___ , HR 65 (___), R 20 , 94 ___ % RA GENERAL - ___ in NAD, comfortable, appropriate, dry cough HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no tonsillar hypertophy or exudate, no sinus tenderness NECK - supple, no thyromegaly, no JVD LUNGS - end inspiratory crackles in bilateral upper lung fields, some scattered wheezing bilaterally, improved. no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Surgical scar over left rib cage. HEART - RRR, no MRG, nl ___ ABDOMEN - vertical scar mid lower abdomen, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs ___ grossly intact, muscle strength ___ throughout, sensation grossly intact throughout. Pertinent Results: ADMISSION LABS ___ 10:00PM BLOOD ___ ___ Plt ___ ___ 10:00PM BLOOD ___ ___ ___ 10:00PM BLOOD ___ ___ ___ 07:50AM BLOOD ___ ___ 10:22PM BLOOD ___ . DISCHARGE LABS ___ 07:50AM BLOOD ___ ___ Plt ___ ___ 07:50AM BLOOD ___ ___ ___ 07:50AM BLOOD ___ . URINE STUDIES ___ 10:35PM URINE ___ Sp ___ ___ 10:35PM URINE ___ ___ ___ 10:35PM URINE ___ Epi- Streptococcus pneumoniae Antigen: Pending . MICROBIOLOGY Blood cultures x 2 ___- pending Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . IMAGING Chest xray There are bibasilar atelectatic changes. However, more focal opacity in the right middle lobe may be representative of a developing right middle lobe pneumonia. Previously visualized right apical spiculated nodule is again identified and continued to follow up as per CT is recommended. Multiple other pulmonary nodules previously visualized on CT are better visualized on prior CT from ___. Cardiomediastinal silhouette is normal. No acute fractures identified. Brief Hospital Course: PRIMARY REASONS FOR ADMISSION ___ F with h/o HTN, HL, right breast cancer ___ s/p lumpectomy and h/o pneumonia ___ and ___ who now presents with sub febrile temps, cough and hypoxia. . # Cough/hypoxia: The ___ presentation was felt to be most consistent with a viral upper respiratory tract infection with possible component of bronchitis. Chest xray was initially concerning for community acquired pneumonia however this was felt to be less likely in the setting mild chest xray findings, normalized white count and no true fever. The ___ exam was not consistent with pulmonary edema. PE was felt to be unlikely given the ___ had not risk factors for pulmonary embolism and denied any chest pain. Urine legionella antigen was negative. S. pneumo antigen and blood cultures were pending at the time of discharge. As above, ___ was initially treated with levofloxacin in the Emergency Department. On admission antibiotics were discontinued. ___ was given PRN ipratropium and albuterol nebulizer treatments as lung exam was notable for wheezes. The ___ was initially hypoxic to the high ___ requiring 2L of nasal cannula oxygen to maintain oxygen saturation in the ___. Her respiratory status and the symptoms improved. At discharge she was able to ambulate without difficulty with maintenance of oxygen saturation in the mid ___. . # Hyponatremia: ___ noted to have mild hyponatremia on admission with sodium of 129. Urinary electrolytes and osmolality was equivocal. The patients HCTZ was initially held. The ___ sodium normalized and her HCTZ was restarted. Sodium remained within normal limits for the remainder of her hospitalization. . # normocytic anemia: ___ HCT was stable at the ___ baseline of 33. Anemia is likely related to the ___ known chronic kidney disease. . # RUL pulmonary nodule: ___ has known RUL pulmonary nodule. This has been stable on multiple CTs. ___ will continue to have CT scans to monitor the nodules. . # Chronic renal insufficiency- Patients creatinine was near her baseline of 1.1- 1.3 throughout this admission. . TRANSITIONAL ISSUES - Blood cultures and S.pneumo antigens were pending at the time of discharge - ___ will need continued monitoring of her known pulmonary nodule - ___ will ___ with her PCP - ___ was DNR/DNI throughout admission Medications on Admission: amlodipine 2.5 mg Tab Oral 1 Tablet(s) Once Daily hydrochlorothiazide 25 mg Tab Oral 1 Tablet(s) once daily lisinopril 20 mg Tab Oral 1 Tablet QD atenolol 50 mg Tab Oral 1 Tablet BID iron Oyster Shell Calcium aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily clarithromycin 500 mg Tab Oral + albuterol + Mucinex + Tylenol - started 4 days ago. Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oyster Shell Calcium 500 mg calcium (1,250 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. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Viral respiratory tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___, It was a pleasure participating in your care you were admitted to ___. As you know, you were admitted because you were having difficulty breathing. We feel that this was most likely due to a viral infection. You should start to feel better within the next week, though it may take longer for symptoms to resolve completely. You should call your doctor if symptoms worsen. In the meantime you can use an albuterol inhaler as needed for wheezing. We made the following changes to your medications 1. STOP clarithromycin 2. START albuterol as needed for shortness of breath Followup Instructions: ___
10088937-DS-12	10,088,937	20,696,600	DS	12	2168-07-09 00:00:00	2168-07-09 14:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Tetracycline / bee stings Attending: ___. Chief Complaint: dyspnea, bradycardia Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENTING ILLNESS: ___ with hx of OSA on CPAP, DM2, HTN, HLD, TIAx2 (due to anti-hypertensive non-compliance) presents with an episode of SOB and bradycardia. The patient awoke this AM with SOB, and feeling like he was "trying to breathe through water" that occurred spontaneously while lying in bed. Pt coughed up white phlegm and had post tussive emesis. Walked to bathroom without difficulty, no worsening SOB. Symptoms persisted X 1 hr, at which point he called EMS who gave him NTG patch, CPAP which provided no relief. At OSH (___) the patient had an episode of bradycardia in the ___, with dizziness, diaphoresis. Was given atropine 0.5mg which resolved his bradycardia. After this, his SOB began to improve. EKG showed T wave flattening and inversions, no ST changes. Was given ASA 324mg, plavix, heparin IV 4000 units. At the OSH his symptoms improved and currently the patient feels well. OSH labs significant for troponin <0.01, CKMB rel index 1.1, plts 83, pro-BNP 453, D dimer <200, INR 1.2. Per the pt, CXR was normal. The patient was transferred here for further workup. Of note pt's BP has been poorly controlled, with recent BP 170s/100s at ___ visit on ___. His lisinopril was discontinued at this visit and he was started on benicar. Otherwise no recent medication changes. Pt had previous TEE and chem stress test in ___ ___ ___ presyncopal episode; per patient workup then was negative for heart disease. Also had cardiac cath ___ yrs ago after PCP saw something concerning on routine EKG and sent pt for stress test that resulted in profound hypotension, prompting cardiac cath. Per pt, cath was normal. Initial VS in the ___: 97.9 56 140/83 20 97% 2L Nasal Cannula. ECG remarkable for: NSR, 54 bpm, NI, no st changes, TWI lead I, AVL, V6. Labs significant for WBC 3.9 (N:53.7 L:36.4 M:8.1 E:0.9 Bas:0.8), H/H 14.2/41.8, plt 83, and lactate 1.6. VS on transfer: 57 137/81 18 99% RA Pt has no SOB, cough or chest pain on arrival to the floor. States that he feels well and hopes to go home tomorrow. REVIEW OF SYSTEMS: denies fevers, chills, blurry vision, headache, dizziness, chest pain, palpitations, nausea, dyspnea on exertion, orthopnea, decreasing exercise tolerance, worsening ___ edema, diaphoresis, abdominal pain, muscle or joint pains, focal numbness or weakness. Past Medical History: Dyslipidemia Hypertension Diabetes OSA on CPAP TIA x2 splenomegaly fatty liver disease BPH LVH GERD obesity syncope peripheral neuropathy Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Father - deceased, cancer Mother - deceased, cancer MGM - Type II DM Sister - alive and healthy Physical Exam: ADMISSION: VS: 97.9 169/105 56 20 98% RA General: Resting comfortably in bed. HEENT: NCAT, PERRL Neck: JVD to mid neck. CV: Bradycardic, regular rhythm. Nl S1, S2. No m/r/g Lungs: CTAB with good inspiratory effort Abdomen: Soft, NT, ND. Nl BS. GU: No Foley Ext: 2+ pitting edema to the knee. wwp. Neuro: Answers questions appropriately. Skin: No rash PULSES: 2+ radial, 1+ DP pulses . DISCHARGE: VS: 97.7 143-177/98-122 ___ 18 98% RA I/O: AM: 190/500 24 hr: 1010/4950 General: Resting comfortably in bed. HEENT: NCAT, PERRL Neck: JVD not elevated. CV: Bradycardic, regular rhythm. Nl S1, S2. No m/r/g Lungs: CTAB with good inspiratory effort Abdomen: Soft, NT, ND. Nl BS. GU: No Foley Ext: wwp with no c/c/e Neuro: Answers questions appropriately. Skin: No rash PULSES: 2+ radial, 1+ DP pulses Pertinent Results: ADMISSION LABS: ___ 02:20PM BLOOD WBC-3.9* RBC-4.49* Hgb-14.2 Hct-41.8 MCV-93 MCH-31.6 MCHC-33.9 RDW-13.3 Plt Ct-92* ___ 02:20PM BLOOD Neuts-53.7 ___ Monos-8.1 Eos-0.9 Baso-0.8 ___ 02:20PM BLOOD ___ PTT-29.8 ___ ___ 02:20PM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-138 K-3.9 Cl-104 HCO3-23 AnGap-15 ___ 02:20PM BLOOD ALT-31 AST-36 AlkPhos-36* TotBili-0.6 ___ 02:20PM BLOOD cTropnT-<0.01 ___ 02:40PM BLOOD Lactate-1.6 . DISCHARGE LABS: ___ 07:20AM BLOOD WBC-4.7 RBC-4.48* Hgb-14.2 Hct-42.3 MCV-94 MCH-31.7 MCHC-33.6 RDW-13.4 Plt Ct-81* ___ 09:10AM BLOOD Glucose-185* UreaN-14 Creat-1.1 Na-139 K-4.4 Cl-102 HCO3-31 AnGap-10 ___ 06:33AM BLOOD CK-MB-4 cTropnT-<0.01 . CXR ___: No evidence of acute cardiopulmonary process. . ECHO ___: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: ___ hx of OSA on CPAP, DM2, HTN, HLD, TIAx2 presents with an episode of SOB and bradycardia. . # Dyspnea, now resolved: Pt's description of "trying to breathe through water" consistent with flash pulmonary edema. Per pt, CXR at ___ was normal. CXR at ___ shows no evidence of pulmonary edema, but dyspnea resolved prior to pt's admission here, so pulmonary edema still most likely etiology of dyspnea. Edema likely ___ poorly controlled HTN. Recommend outpatient stress test to ensure no underlying coronary artery disease as cause for flash pumonary edema once BP well controlled. . # Sinus bradycardia: Responded to atropine at OSH. Ddx includes high vagal tone/vagal episode (especially given h/o syncope)vs beta blocker overdose. No evidence of ischemia on EKG, troponins negative X 2, electrolytes normal. Decreased dose of carvedilol from 6.25mg BID to 3.125mg BID. ECHO shows normal systolic function. # Hypertension: History of SBP > 200. Presented with SBP 170s. Decreased home carvedilol as above in setting of bradycardia, increased benicar from 20mg daily to 40mg daily, started amlodipine 10mg daily. Gave pt lasix 20mg BID PO on ___ with net urine output of 4 liters over 24 hrs. Pt states that he takes his lasix as directed at home, but this is questionable given net urine output of 4 liters. Discharged on home lasix 20mg daily. If pt continues to be refractory to therapy, can consider evaluation for secondary causes, although most likely etiology is OSA and metabolic syndrome. . # Thrombocytopenia: LFTs normal, but pt has h/o fatty liver disease. ___ be ___ splenic sequestration as pt has h/o splenomegaly on imaging and chronic thrombocytopenia with plt 79 in ___, 112 in ___. . # Dyslipidemia: TC 148 LDL 68 HDL 34 ___ 410. Continued home pravastatin, omega 3. . # Type II Diabetes, non-insulin dependent: Last HbA1c 5.3 in ___. Complicated by neuropathy. Maintained on sliding scale insulin this admission, discharged on home metformin. . # OSA: Continued home CPAP during admission. . ## Transitional issues: - recommend outpatient stress test in the next ___ weeks - please check CHEM7 this week as pt had several medication changes this admission - increased home benicar from 20mg qd to 40mg qd - started pt on amlodipine 10mg daily - decreased home carvedilol from 6.25 to 3.125mg BID due to bradycardia (HR in ___ - if hypertension continues to be refractory, pt should be evaluated for secondary causes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Pravastatin 80 mg PO DAILY 3. Benicar (olmesartan) 20 mg oral daily 4. Gabapentin 600 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Multivitamins 1 TAB PO BID 8. Furosemide 20 mg PO DAILY 9. Carvedilol 6.25 mg PO BID 10. Fish Oil (Omega 3) 1200 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carvedilol 3.125 mg PO BID RX carvedilol 3.125 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Fish Oil (Omega 3) 1200 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Gabapentin 600 mg PO BID 6. Multivitamins 1 TAB PO BID 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 80 mg PO DAILY 9. Amlodipine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Benicar (olmesartan) 40 mg oral daily RX olmesartan [Benicar] 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 12. Outpatient Lab Work Please check Chem 7 on ___ Results to be fax to: ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Primary: pulmonary edema, hypertension, sinus bradycardia Secondary: obstructive sleep apnea, type II DM (non-insulin dependent) complicated by peripheral neuropathy, dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted for flash pulmonary edema (fluid in your lungs) caused by high blood pressure. We have adjusted many of your medications to try to get your blood pressure under better control. Please see the attached list of medication changes. Please have blood work done on ___ or ___. The results should automatically be faxed to your PCP. Followup Instructions: ___
10088966-DS-16	10,088,966	24,370,348	DS	16	2131-06-02 00:00:00	2131-06-03 17:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presents with 3 episodes of bilateral lower extremity weakness and one episode of syncope. Notably, the patient has unsteady gait at baseline attributed to peripheral neuropathy secondary to chemotherapy. 3 days prior to admission, the patient's wife reports that Mr. ___ appeared unsteady with his walker after standing up and walking with his walker toward their car; he "was wobbling." He had to use the car for support upon arriving at it. On the day of admission, he had another episode of weakness at 1 ___ where, upon standing, he braced his walker as he gradually brought himself to the ground without trauma. At 5 ___, he had another episode. He finished urinating, stood up, and was raising his pants when he lost consciousness. His wife heard a thud, found him on the floor bleeding around his left eyebrow, after which 911 was called and he was brought to ___. In all cases, he does not endorse prodromal symptoms. He denies headache, diaphoresis, visual symptoms, tongue bleeding, chest pain, dyspnea, nausea, vomiting, or incontinence. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.8 100/74 63 19 100%ra Orthostatic signs: 120/70 lying, 82/55 sitting, 133/71 standing General: very pleasant older male alert and oriented x4, able to do days of week backwards without difficulty HEENT: superficial abrasion L brow, PERRL, EOMI, MMM Neck: JVP to mandible with bed at 45 degrees CV: Irreg irreg, S1 S2, no murmurs Lungs: Clear to bases posteriorly Abdomen: Soft, obese, non-tender, +BS GU: No foley Ext: cool distally in hands and feet, RLE > LLE circ (chronic from lymphedema), 3+ pitting edema bilaterally to knees Neuro: CNII-XII intact, ___ strength upper extremities ___ hip flexors ___ strength Remainder ___ strength ___ Sensory exam in tact to light touch in all extremities Normal FNF, no pronator drift DISCHARGE PHYSICAL EXAM: VS - Tmax 98.0 Tc 98.0 BP 113-152/63-87 HR 66-68 RR ___ 02 98%RA General: well appearing, NAD HEENT: left eyebrow abrasion partially visible underneath gauze, MMM Neck: no JVD, no LAD CV: irregularly irregular rate, S1 and S2 present, no murmurs presen Lungs: CTAB, minor inspiratory crackles, breathing comfortably, no pain with deep inspiration Abdomen: soft, nontender, nondistended, no HSM appreciated GU: deferred Ext: warm and well perfused, pulses, 1+ pitting edema in ___ b/l Neuro: alert and oriented, CN II-XII intact, motor strength ___ throughout except ___ quadriceps, sensation to light touch intact in distal extremities throughout Pertinent Results: ----------------- ADMISSION LABS ----------------- CBC w/ Diff ___ 07:40PM BLOOD WBC-5.8 RBC-4.00* Hgb-12.0* Hct-36.9* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.1* RDWSD-54.1* Plt ___ ___ 07:40PM BLOOD Neuts-74.2* Lymphs-6.7* Monos-9.6 Eos-7.9* Baso-0.7 Im ___ AbsNeut-4.32 AbsLymp-0.39* AbsMono-0.56 AbsEos-0.46 AbsBaso-0.04 Electrolytes ___ 07:40PM BLOOD Glucose-103* UreaN-26* Creat-1.1 Na-135 K-4.0 Cl-94* HCO3-30 AnGap-15 ___ 07:40PM BLOOD Calcium-9.2 Mg-2.3 Anticoagulation ___ 07:40PM BLOOD ___ PTT-39.2* ___ Cardiac ___ 05:45AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:40PM BLOOD cTropnT-<0.01 Urinalysis ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG MICRO: none IMAGING: ___ Noncontrast head CT: No acute intracranial process. ___ervical spine: 1. No acute fracture or traumatic malalignment in the cervical spine. 2. Acute appearing left first rib fracture at the costovertebral junction. 3. Moderate degenerative changes of the cervical spine, better evaluated on prior MRI from ___. No significant interval change. ___ CXR PA and Lat: 1. No acute cardiopulmonary process. 2. Left first rib fracture better appreciated on prior CT. No other displaced rib fractures. ___ Overnight telemetry: Baseline atrial fibrillation/flutter with 3:1 conduction, no other abnormalities noted. ----------------- DISCHARGE LABS ----------------- Electrolytes ___ 05:36AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-133 K-4.2 Cl-97 HCO3-26 AnGap-14 ___ 05:36AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 LFTs ___ 05:36AM BLOOD ___ PTT-37.7* ___ Brief Hospital Course: Mr. ___ is an ___ year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presented with 3 episodes of bilateral lower extremity weakness and one episode of syncope upon standing. ----------------- ACTIVE ISSUES: ----------------- #SYNCOPE: Likely orthostatic hypotensive event given orthostatic vitals signs on admission exam. Though patient appeared hypervolemic with peripheral edema and elevated JVP, we believe syncope was secondary to intravascular volume depletion, beta-blockade, and possible age-related loss of sympathetic response to postural changes. He had been taking torsemide after CABG in ___ and of note lost 5 lb the week of his presentation, the most acute drop of weight since his surgery. Low suspicion for cardiogenic cause with negative consecutive trops, benign exam, unrevealing overnight telemetry. We reduced his metoprolol tartrate dose to 6.25 mg q6h, stopped torsemide, and gave him small boluses of IV fluids which resolved his symptoms. Discharged with metoprolol succinate 25 mg daily for ease of administration. #ATRIAL FLUTTER/FIBRILLATION: Rate controlled on metoprolol and asymptomatic on admission. He was admitted on warfarin, which was held due to supratherapeutic INR. He was subtherapeutic on 2 mg daily, but supratherapeutic on 3 mg daily. Discharge INR was 2.7. We discharged him on 2.5 mg MWF and 2 mg on other days of the week. #LEFT RIB FRACTURE: Seen on CXR without pneumothorax. He was asymptomatic without pleuritic chest pain or respiratory symptoms. We observed him clinically and did not perform any medical interventions. ------------------ CHRONIC ISSUES: ------------------ #GERD: No acute issues arose during this hospitalization. We continued home omeprazole #HISTORY OF HODGKIN'S LYMPHOMA AND DLBCL: In remission, no acute issues during hospitalization. We continued home acyclovir ppx CORE MEASURES: #CODE: "I don't want to be a vegetable". Wants to discuss with wife and doctors. ___ Code in interim. #EMERGENCY CONTACT HCP: wife ___ ___ TRANSITIONAL ISSUES: - Discharge weight: 74.5 kg - Stopped torsemide on discharge - Changed metoprolol tartrate to metoprolol succinate dosage on discharge 25 mg daily - Patient instructed to change positions slowly to allow blood pressure to equilibrate - Daily weights; Restart torsemide PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO TID ___ MD to order daily dose PO DAILY16 3. Torsemide 40 mg PO DAILY 4. Acyclovir 400 mg PO TID 5. Omeprazole 20 mg PO DAILY 6. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 7. Magnesium Oxide 250 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY A-fib/A-flutter RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Warfarin 2 mg PO QOD Take 2 mg SUN, TUES, THURS, SAT RX warfarin 2 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 3. Warfarin 2.5 mg PO QOD Take 2.5 mg MON, WED, FRI RX warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*2 4. Acyclovir 400 mg PO TID 5. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 6. Magnesium Oxide 250 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Syncope secondary to orthostatic hypotension SECONDARY: Atrial flutter 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 a fall at home and hit your head. We did a CT scan of your head and did not find any bleeding. We also did a chest x ray and EKG to look at your heart and did not find anything wrong except a slow heart beat. It appears that your fainting may have been because your body can't control your blood pressure fast enough when changing positions. In the future, the best way to prevent this is to stand or sit up slowly and to wait one minute before moving to allow your blood pressure to catch up. We have also lowered your dose of metoprolol and stopped your torsemide. We are also changing your warfarin dose to alternating doses of 2 mg and 2.5 mg daily. Take 2 mg tonight when you get home. Weight yourself every day and call your doctor if your weight goes up by 3 pounds in one day. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___
10088966-DS-17	10,088,966	23,861,822	DS	17	2131-11-20 00:00:00	2131-11-20 12:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. History is significant for a chronic gait disorder where he is cane dependent. Per oncologist, he likely has some sensory ataxia as a side effect of prior chemotherapy. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to ___ in ___ for orthostatic syncope. His beta blocker dose and diuretic have been on hold recently. He has been working with home ___ to improve mobility. Per ED report, he was using walker at home and went to use the restroom. When trying to go back to bed he slipped and fell and wife heard the fall. Wife reports no ___ and he denied ___ or LOC. Wife could not help him up and called ___. He denied lightheadedness, chest pain, palpitaitons, and nausea prior to the fall. Reported he does not have pain, numbness, weakness in his arms or legs. Of note, he has a hx of hyponatremia (Na 130-132) in the past, that has improved in the fluids. In the ED, initial VS were: 97.5 84 142/84 19 99% RA FAST negative On exam, bruising all over body, L upper arm, R buttock/hip, abdomen and chest Na 126 --> 125 INR 2.3 UA negative Imaging showed: CXR: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance 1. No acute intra-thoracic, abdominal or intrapelvic abnormalities. 2. Evidence of prior fracture with interval healing of the left first rib, right eleventh rib. Stable compression deformity of L1 and L2 since ___. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque at the level of the ___. CT spine No acute fracture or traumatic malalignment. CT head No acute intracranial abnormalities. EKG showed: flutter with 4:1 block, RBBB, right atrial abnormality Patient was given: ___ 15:46 IVF NS ___ Started ___ 17:02 PO Acetaminophen 1000 mg ___ ___ 17:47 IH Albuterol 0.083% Neb Soln 1 NEB ___ ___ 17:47 IH Ipratropium Bromide Neb 1 NEB ___ ___ 17:47 IVF D5W ___ Started ___ 19:22 PO/NG Acyclovir 400 mg ___ ___ 19:22 PO/NG Warfarin 4 mg ___ pt not safe at home, admit for hyponatremia, weakness Transfer VS were: 98.3 73 105/58 16 97% RA When seen on the floor, he is unable to recall the events of the past 24 hours of the last 24 hours. He is oriented to self and time but not place. REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: Admission PE Gen: NAD, A&O x1, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: 3+ edema at ankles, baseline lymphedema Skin: Multiple bruises on upper and lower extremities. No jaundice. Neuro: AAOx1. No facial droop. Discharge PE: 97.3 151 / 92 116 18 95 Ra Gen: NAD HEENT: EOMI, PERRLA, MMM CV: irregular, nl s1s2 no m/r/g, JVP approximately 10 cm Resp: Mild bibasilar crackles Abd: Soft, NT, ND +BS Ext: chronic lymphedema changes, 1+ b/l edema Neuro: CN II-XII intact, ___ strength throughout, AAOx3, slow to answer some questions Psych: normal affect Pertinent Results: ___ 05:55PM URINE UHOLD-HOLD ___ 05:55PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:15PM GLUCOSE-106* UREA N-19 CREAT-0.8 SODIUM-126* POTASSIUM-4.9 CHLORIDE-89* TOTAL CO2-22 ANION GAP-20 ___ 01:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 05:36PM NA+-125* ___ 05:55PM URINE COLOR-Yellow APPEAR-Clear SP ___ CXR ___: IMPRESSION: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance. Enlarged mediastinal silhouette, likely due to positioning and technique. CT head ___: IMPRESSION: No acute intracranial abnormalities. CT C/A/P ___: IMPRESSION: 1. No acute sequelae of trauma. 2. Subacute and chronic fractures, detailed above. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque in the abdominal aorta at the level of the ___. 4. Cardiomegaly with right chamber enlargement and evidence of hepatic congestion. CT C-spine ___: IMPRESSION: No acute fracture or traumatic malalignment. Additional nonemergent findings as described above. Discharge labs: ___ 06:25AM BLOOD WBC-5.9 RBC-4.16* Hgb-12.8* Hct-37.5* MCV-90 MCH-30.8 MCHC-34.1 RDW-16.2* RDWSD-53.4* Plt ___ ___ 06:25AM BLOOD ___ ___ 06:25AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-128* K-4.1 Cl-89* HCO3-23 AnGap-20 ___ 06:45AM BLOOD ___ Brief Hospital Course: ___ year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. # Fall: Similar to prior presentations. Likely driven by chronic sensory ataxia as a side effect of prior chemotherapy as well as probably some proximal muscle wasting. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to ___ in ___ for orthostatic syncope. He continues to be off beta blocker and diuretics. Orthostatics negative after receiving IV fluids. -Discharge to rehab # Acute metabolic encephalopathy: Per wife over last week has had new onset of confusion and fatigue, possibly related to hyponatremia. No evidence of infection and not on any medications that should cause confusion. There may also be a component of underlying dementia given his age and significant volume loss on CT but wife denies significant chronic behavioral or memory issues. Slowly improving and per wife closer to baseline. -Avoid deliriogenic medications # Hyponatremia: Initially he appeared volume depleted, was given IV fluids with initial improvement of hyponatremia from 126 to 131 but then subsequent worsening to 126. He was put on a fluid restriction of 1.5 L with stabilization of hyponatremia. He appeared volume overloaded on ___ with crackles, increased edema and proBNP elevated to 13,211 and was given IV Lasix 20 and 40 mg with improvement in volume status and improvement in hyponatremia to 128. He appeared euvolemic on discharge. - Continue 1.5 L fluid restriction - Recommend checking repeat chem 7 on ___, if worsening hyponatremia consider Lasix 40 mg PO (but would avoid standing diuretics due to history of significant orthostatic hypotension). # Chronic meds - continue home vitamins (Pyridoxine, Riboflavin, Vitamin B Complex, Vitamin D 1000) Regular PIV x2 Full code (presumed) Name of health care proxy: ___ ___: wife Phone number: ___ ___: to STR Expected length to stay less than 30 days. Greater than 30 minutes were spent on discharge related activities on day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Docusate Sodium 100 mg PO DAILY 2. Warfarin 2 mg PO DAILY16 3. Acyclovir 400 mg PO Q8H 4. Omeprazole 20 mg PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. Pyridoxine 100 mg PO DAILY 7. Riboflavin (Vitamin B-2) 50 mg PO DAILY 8. Vitamin B Complex 1 CAP PO BID 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Cyanocobalamin ___ mcg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Pyridoxine 100 mg PO DAILY 6. Riboflavin (Vitamin B-2) 50 mg PO DAILY 7. Vitamin B Complex 1 CAP PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fall Hyponatremia Acute metabolic encephalopathy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted with a fall and confusion. You were found to have worsening low salt levels (hyponatremia). You were put on a fluid restriction and the levels improved. Your confusion slowly improved. You are being discharged to a rehab facility to work on your strength. Followup Instructions: ___
10088966-DS-18	10,088,966	27,318,566	DS	18	2131-12-13 00:00:00	2131-12-13 15:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ yo man with h/o MVR, CABG in ___, afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, who presents with lethargy. Patient was recently admitted to ___ in ___ after a fall. This was thought to be ___ neuropathy from prior chemo with possible contribution of hyponatremia. Sodium was improving with fluid restriction on discharge and he was discharged to rehab. While there he has reportedly had worsening lethargy and weakness, notes indicate "global decline in all areas of functioning". He has been unable to participate in ___ at all due to somnolence and was reportedly oriented only to self. He was seen at ___ on ___ and found to have new patchy opacity in left base concerning for atelectasis vs consolidation. He was treated with azithromycin with last dose planned for ___. However he continued to worsen, unable to eat or take meds properly due to ongoing lethargy, and was sent to ED. In the ED, initial vitals were: 97.0 71 152/100 18 100%RA - Exam notable for: bilateral crackles, +JVD, no pitting edema - Labs notable for: Na 126, sOsms 270, ___ ___. UA with 5 WBCs, uOsms 788 uNa 81. - Imaging was notable for: CXR with mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. CT head without acute intracranial abnormality. - Patient was given: albuterol and ipratropium nebs - Renal was consulted given hyponatremia, and recommended 1L fluid restriction. Upon arrival to the floor, patient is feeling well without complaints. He does not feel weak or short of breath. He notes that he has been sleeping very poorly because he does to feel tired at night. He is otherwise unable to recall much about what has happened over the past few weeks and what brought him into the hospital. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.4 \| 142/92 \| 90 \| 20 \| 97RA GENERAL - Initially agitated, refusing gown, interview, and physical, wanted to get out of bed and call ___. Suspicious of all hospital staff. After haloperidol, somnolent and appropriate. HEENT - PERRLA, sclera anicteric, oropharynx clear, tongue midline. NECK - JVP at mandible with patient at 30 degrees. CARDIAC - Regular rate and rhythm, S4 gallop, no murmurs or rubs. LUNGS - Mild crackles at the bases. ABDOMEN - Soft, non-tender, non-distended. No guarding, tenderness, or distention. EXTREMITIES - 2+ edema at ankle. Pulses intact, no cyanosis. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Intermittently somnolent (s/p Haldol), but oriented to person, place, time, and event. PERRLA, facial muscles bilaterally strong, shoulder shrug ___ bilaterally, tongue midline. Elbow flex and extend ___. Hand grip ___. Hip flex ___ bilaterally. Knee and ankle flex/extend ___. Patellar reflexes unable to elicit. DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: VITALS - 97.4 \| 105-120/83 \| 89 \| 18 \| 98RA GENERAL - Calm, pleasant, alert. Sitting in bed comfortably. HEENT - PERRLA, sclera anicteric, mucus membranes moist. NECK - JVP at midneck with patient at 45 degrees. CARDIAC - Irregular, no murmurs rubs or gallops appreciated. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Soft, non-tender, no distention, guarding, or rigidity. EXTREMITIES - Erythema, edema, and warmth in R foot resolved. No tenderness to palpation in R foot. DP 2+ bilaterally. No edema bilaterally. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Alert. Confused, but appropriate. Oriented to place, year, and month. Pupils equal and reactive, EOM intact, facial muscles symmetrically strong, shoulder shrug equal symmetrically, tongue deviates L and R equally. R shoulder flexion ___, L shoulder flexion ___. Elbow extension ___ R, flexion ___ R. Elbow flexion/extension ___ L. Hand grip ___ bilaterally. Hip flexion ___ R, ___ L. Ankle flexion/extension ___ bilaterally. Pertinent Results: ADMISSION LABS: ___ 05:38PM PH-7.34* ___ 05:38PM K+-5.3* ___ 05:38PM freeCa-1.08* ___ 03:00PM URINE HOURS-RANDOM CREAT-105 SODIUM-81 ___ 03:00PM URINE OSMOLAL-788 ___ 03:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:00PM URINE RBC-3* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 ___ 03:00PM URINE MUCOUS-OCC ___ 01:46PM ___ PO2-33* PCO2-44 PH-7.39 TOTAL CO2-28 BASE XS-0 ___ 01:46PM O2 SAT-56 ___ 01:17PM VoidSpec-SPECIMEN C ___ 01:12PM GLUCOSE-93 UREA N-23* CREAT-0.8 SODIUM-126* POTASSIUM-6.4* CHLORIDE-91* TOTAL CO2-18* ANION GAP-23* ___ 01:12PM estGFR-Using this ___ 01:12PM ALT(SGPT)-31 AST(SGOT)-96* ALK PHOS-178* TOT BILI-1.1 ___ 01:12PM cTropnT-<0.01 ___ ___ 01:12PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.1 ___ 01:12PM OSMOLAL-270* ___ 01:12PM WBC-6.9 RBC-4.80 HGB-14.2 HCT-43.2 MCV-90 MCH-29.6 MCHC-32.9 RDW-16.2* RDWSD-53.7* ___ 01:12PM NEUTS-70.1 LYMPHS-6.1* MONOS-13.8* EOS-7.6* BASOS-1.0 IM ___ AbsNeut-4.86 AbsLymp-0.42* AbsMono-0.96* AbsEos-0.53 AbsBaso-0.07 ___ 01:12PM PLT COUNT-274 ___ 01:12PM ___ PTT-40.7* ___ MICROBIOLOGY: None positive. PATHOLOGY: None IMAGING: CXR (PA AND LATERAL) ___: IMPRESSION: Mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. NON-CONTRAST HEAD CT ___: IMPRESSION: No acute intracranial abnormality. PORTABLE CXR ___: IMPRESSION: In comparison with study of ___, the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. TTE ___: IMPRESSION: In comparison with study of ___, the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. NCHCT ___: IMPRESSION: 1. No evidence of acute intracranial process. 2. Involutional changes and nonspecific ___ matter hypodensities likely representing the sequelae of moderate chronic small vessel ischemic disease. MRI/MRA BRAIN AND NECK ___: IMPRESSION: 1. 1.1 cm focus of slow diffusion with associated FLAIR signal abnormality within the left precentral gyrus is concerning for an acute to subacute infarct. 2. Subtle 0.2 cm focus of high signal within the right frontal lobe, series 6, image 22 without definite correlate on the ADC maps, may be artifactual versus a focal small subacute infarct. Likely 0.2 cm focus of subacute infarction is seen within the right occipital lobe, series 6, image 15. 3. Unremarkable MRA of the head, specifically with normal arborization of the distal left MCA vessels. Moderate intracranial atherosclerotic disease. 4. Limited MRA of the neck without contrast. However, based on the 2D time-of-flight images, the bilateral internal carotid arteries appear to be unremarkable without evidence of significant stenosis by NASCET criteria. 5. Diffuse foci of low signal on the susceptibility weighted sequences within the cortical and subcortical regions may be secondary to hypertensive encephalopathy versus amyloid angiopathy. 6. Severe chronic microangiopathy. DISCHARGE LABS: ___ 05:08AM BLOOD WBC-5.4 RBC-3.75* Hgb-11.3* Hct-35.1* MCV-94 MCH-30.1 MCHC-32.2 RDW-16.1* RDWSD-55.0* Plt ___ ___ 06:30AM BLOOD ___ PTT-34.0 ___ ___ 05:08AM BLOOD Glucose-116* UreaN-32* Creat-0.9 Na-134 K-4.1 Cl-93* HCO3-33* AnGap-12 ___ 05:08AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1 Brief Hospital Course: SUMMARY: Mr. ___ is an ___ with h/o MVR and CABG in ___, afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo in remission, who presents with lethargy, fluid overload, atrial fibrillation with RVR, and hyponatremia, course complicated by CVA. ACTIVE ISSUES: #Lethargy and #Delirium: We considered multiple causes for the patients change in mental status and believe it was multifactorial, with contribution from hyponatremia, fluid overload, and perhaps underlying dementia. Hyponatremia and fluid overload were treated as below. He was given haloperidol and olanzapine for agitation once. We attempted to normalize his sleep/wake cycle with trazadone and ramelteon at night. #CVA: Patient developed acute onset Right shoulder extension palsy on ___. NCHCT was WNL, but MRI on ___ showed 1.1cm left precentral gyrus FLAIR hypodensity concerning for stroke. Neurology was consulted, who felt that patient's CVA may have been related to being briefly subtherapeutic on warfarin, although it was not entirely clear. Patient was briefly transitioned from metoprolol to digoxin for permissive hypertension. His Right shoulder extension improved over the course of the hospitalization, although he continued to have difficulty fully extending Right arm at discharge. As below, he was transitioned to apixaban. #Acute on chronic CHF: Patient was volume overloaded on exam, with a ___ of 20000 and signs of overload on chest x-ray. Of note, TTE showed an EF on 30% (from 50% last ___), with multiple wall motion abnormalities. He notably was not on a statin, and we started him on high-dose statin. Of note, his metoprolol was changed to metoprolol succinate 62.5mg BID. He was diuresed with IV Lasix and then PO torsemide to a weight of 160 lbs. His dry weight is likely 155-160lb. He was discharged with a plan to follow up with his cardiologist. # Atrial fibrillation/flutter with RVR: The patient intermittently had RVR up to 140s on his home metoprolol. It was increased and converted to metoprolol succinate BID dosing. His HR stabilized on this dose of metoprolol in the ___s-90___s with some breakthrough tachycardia particularly in the morning, but uptitration was limited by blood pressure. He was briefly on digoxin immediately after his stroke in an effort to maintain both normal heart rate and sufficient BP. He was then transitioned back to metoprolol. With regards to his anticoagulation, a decision was made to transition patient from warfarin to apixaban in the setting of stroke and for comfort reasons. His INR on the day of discharge was 1.8, and he was started on apixaban 2.5mg BID. #Urinary retention: Patient notably retained urine during this hospitalization. He failed two voiding trials and required a Foley. Foley was removed prior to discharge, and patient was able to successfully void. He was discharged with a plan to follow up with urology. #Hyponatremia: Initially to 126, then improved with fluid restriction and diuresis, thought to be due to SIADH and heart failure. CHRONIC ISSUES: # CAD s/p CABG: home metoprolol was continued and atorvastatin 10mg was started. # GERD: continued omeprazole NEW MEDICATIONS: Metoprolol succinate 62.5mg BID Torsemide 20mg PO QDay Atorvastatin 10mg PO QHS Apixaban 2.5mg PO BID STOPPED MEDICATIONS: -Metoprolol tartrate TRANSITIONAL ISSUES: -f/u with cardiology -f/u with neurology -Please check daily weights in AM. If >3lb weight gain in one day or >5lb weight gain in 1 week, please notify MD -f/u with urology for urinary retention during this hospitalization -Would benefit from outpatient comprehensive geriatric evaluation with cognitive evaluation including MOCA +/- cognitive neurology vs. memory clinic appointment with Dr. ___. -Would benefit from formal hearing assessment outpatient for ?hearing aids. -If patient needs additional blood pressure medication, consider losartan (given HFrEF, ACE-I allergy) # CODE: DNR/DNI # CONTACT: HCP is wife ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H 3. Azithromycin 250 mg PO Q24H 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. Docusate Sodium 100 mg PO DAILY 7. Metoprolol Tartrate 12.5 mg PO TID 8. Miconazole Powder 2% 1 Appl TP BID 9. Omeprazole 20 mg PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Vitamin B Complex 1 CAP PO BID 12. Warfarin 3 mg PO DAILY16 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob or wheezing 14. GuaiFENesin Dose is Unknown PO Q6H:PRN cough Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Succinate XL 62.5 mg PO BID 3. Torsemide 20 mg PO DAILY 4. GuaiFENesin ___ mL PO Q6H:PRN cough 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath or wheeze 6. Acyclovir 400 mg PO Q8H 7. Cyanocobalamin ___ mcg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Miconazole Powder 2% 1 Appl TP BID 10. Omeprazole 20 mg PO DAILY 11. Pyridoxine 100 mg PO DAILY 12. Vitamin B Complex 1 CAP PO BID 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE, HYPONATREMIA, ATRIAL FLUTTER WITH RAPID VENTRICULAR RESPONSE SECONDARY DIAGNOSES: URINARY RETENTION, CORONARY ARTERY DISEASE, GASTROESOPHAGEAL REFLUX DISEASE, HYPERTENSION Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were seen in the hospital for confusion and sleepiness. Your symptoms were due to low sodium and fluid overload. We believe your low sodium is partially caused by an inappropriately high level of anti-diuretic hormone (called SIADH), so we treated you by restricting your fluid intake. We gave you a diuretic to treat your fluid overload and got an echocardiogram to assess any changes in your heart, which showed worsening heart failure. You had a fast heart rate, which we treated by increasing your metoprolol. You were additionally found to have a small stroke, which we treated by increasing your anticoagulation and changing your medications to allow for a higher blood pressure. When you go home, you should make sure to take your medicines and follow up with your doctors at your ___ appointments. It is important to drink less than 1.5 liters of water a day and to limit your salt intake, ideally to less than 2 grams a day. It was our pleasure to take care of you. We wish you the very best! --Your care team at the ___ Followup Instructions: ___
10089076-DS-4	10,089,076	27,132,872	DS	4	2172-05-24 00:00:00	2172-05-24 11:23:00	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 femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on ___. Major Surgical or Invasive Procedure: Right DHS and retrograde femur IMN on ___ History of Present Illness: ___ F pedestrian struck, transferred from ___ with L femoral neck and shaft fractures, and R scapula fracture. She was hit around 7pm last night (___) and is uncertain of exactly how she fell. CT head/face notable only for nasal bone and dental fractures, and remaining imaging including CT neck and torso were unremarkable. She denies any numbness or tingling in the arms or legs. Past Medical History: None Social History: Works in a ___. Occasional alcohol, denies tobacco or illicit drug use. 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 femoral shaft fracture, and Left scapula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Right DHS and retrograde femur 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. During the course of her admission, the patient required transfusion with 2 units of pRBC and repletion of Mg/K which was successful. Patient remained hemodynamically stable. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NVI distally in all extremities, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 1250 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #28 Syringe Refills:0 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q4H; PRN Disp #60 Tablet Refills:0 7. Senna 8.6 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on ___. Discharge Condition: AOX3, ambulating with assistance of ___, overall stable Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - TDWB RLE, WBAT LUE 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. Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Touchdown weight bearing Left lower extremity: Full weight bearing Left upper extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Dressing changes daily. Elevation as tolerated. Staples/sutures will be removed at follow-up. Followup Instructions: ___
10089085-DS-19	10,089,085	29,273,555	DS	19	2118-06-21 00:00:00	2118-06-21 20:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Malignant obstruction Major Surgical or Invasive Procedure: Rigid bronchoscopy (___) History of Present Illness: ___ yo F with a PMH of stage III-B squamous cell lung cancer with malignant airway obstruction of R mainstem bronchus s/p trach who presents with SOB. Plan was for bronchoscopy on ___ but this did not occur due to multiple emergent cases. Patient lives ___ ___ and did not want to drive back due to severe SOB. Per IP, patient is being admitted for monitoring and will undergo rigid bronchoscopy ___ the next few days ___ or ___. Notably, 3 days prior to admission she was at ___ and was treated for a COPD exacerbation with moxifloxacin and steroids. She reports SOB improved after that. She reports no increase ___ sputum through trach. ___ the ED, intial vital signs were 98.2, 72, 99/50, 22, 100% 2L. Labs were significant for WBC 14.1. Patient was given albuterol and ipratropium nebs. Vital signs on transfer were stable. This AM, patient reports that she is comfortable and ___ no pain. She has experienced significant improvement with antibiotics and steroids. She does report some pain around trach but says this is baseline. ROS is otherwise negative. Past Medical History: - Stage III-B squamous cell lung cancer s/p radiation/chemotherapy - Respiratory failure s/p trach with removal and placement of a ___ button - Right mainstem bronchus obstruction s/p stent ___ and subsequent removal (___) - COPD - Hypertension - Hyperlipidemia - Atrial Fibrillation s/p cardioversion Social History: ___ Family History: Multiple family members with cancer Physical Exam: ADMISSION EXAM Vitals: 98.1, 61, 91/57, 18, 98% 2 L General: Middle-aged female with trach ___ NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, left supraclavicular LAD CV: RRR, nl S1/S2, no MRG Lungs: Diffuse wheezing, transmitted upper airway sounds Abdomen: Soft, NTND, normoactive bowel sounds GU: Deferred Ext: Warm, well perfused, no cyanosis/clubbing/edema Neuro: AAOx3, CN II-XII grossly intact DISCHARGE EXAM: Vitals: 98.4, 88-100/42-60, 60-81, 94-99TM General: Alert, oriented x3 HEENT: Sclera anicteric, MMM, oropharynx clear, trach ___ place with trach mask, no erythema around site Lungs: course upper airway sounds with scattered inspiratory and expiratory wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS ___ 08:40PM BLOOD WBC-14.1# RBC-4.80# Hgb-14.6# Hct-45.1# MCV-94 MCH-30.3 MCHC-32.3 RDW-12.7 Plt ___ ___ 08:40PM BLOOD Neuts-84.0 Lymphs-9.8* Monos-4.6 Eos-1.1 Baso-0.5 ___ 08:54PM BLOOD ___ PTT-28.4 ___ ___ 08:40PM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-139 K-4.0 Cl-98 HCO3-28 AnGap-17 ___ 09:29AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.1 ___ 09:03PM BLOOD Lactate-2.2* DISCHARGE LABS ___ 06:15AM BLOOD WBC-8.6 RBC-3.92* Hgb-11.7* Hct-36.8 MCV-94 MCH-30.0 MCHC-31.9 RDW-13.3 Plt ___ ___ 06:15AM BLOOD Glucose-126* UreaN-13 Creat-0.6 Na-138 K-3.9 Cl-102 HCO3-29 AnGap-11 ___ 06:15AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 MICRO ___ 3:30 pm BRONCHIAL WASHINGS RIGHT MAINSTREAM WASH. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD #3. ~3000/ML. Isolates are considered potential pathogens ___ amounts >=10,000 cfu/ml. SENSITIVITIES PERFORMED ON REQUEST.. IMAGING CT chest (___): 1. 2.6 x 1.8 x 2.7 cm ill-defined right perihilar mass, causing effacement and narrowing of the right mainstem bronchus. Surrounding fibrotic changes and atelectasis are likely secondary to radiation therapy and appear improved since prior examination. 2. Stable 4 mm nodule ___ the right upper lobe. 3. Improved moderate sized right sided pleural effusion. CXR (___): Right perihilar opacity compatible with known mass and radiation treatment changes. Previously demonstrated right upper lobe atelectasis is improved but persists. Small right pleural effusion. BRONCHOSCOPY (___) Patient brought to OR where GETA induced and pt intubated with size 12 rigid bronchoscope. Flexible bronchoscope inserted and airwys inspected. Tracheal button visualized with surrounding non-obstructive granulation tissue. RMSB was partiaqlly obstructed by tumor. Otherwise normal to tracheobronchial tree. Flexible and rigid bronchoscopy argon plasma coagulation cryodebriedement balloon dilation BAL tracheal stoma revision. Brief Hospital Course: ___ yo F with a PMH of stage III-B squamous cell lung cancer who presents with malignant airway obstruction of right main-stem bronchus. #OBSTRUCTIVE NSCLC: The patient was diagnosed with squamous cell lung cancer, stage IIIb, approximately ___ year ago. She required right main stem stent placement and trach for malignant airway obstruction at that time. She is s/p XRT and two rounds of chemotherapy. Further chemotherapy was not pursued due to poor tolerability. The patient initially presented with progressive SOB. She was treated for PNA/COPD exacerbation a week prior to admission at ___. She was at the end of her steroid taper and had finished 5 days of Avelox. She underwent a bronch with debridement and dilation during this admission on ___. She was transferred to the Medical Intensive Care Unit due to increased secretions and hypoxia. ___ the MICU, she was broadened to Vancomycin and Cefepime to treat for an 8 day course of HCAP. She was started on 40mg Prednisone for a 5 day burst. She maintained her saturations and was transferred back to the general floor the next day. While on the floor, she continued to improve and was weaned to trach mist without supplemental O2. On ___, her secretions had improved such that she was able to tolerate her trach being capped without difficulty. She did continue to desaturate with ambulation, but this also improved by the time of discharge and ___ felt she was safe to go home independently with services. #LEUKOCYTOSIS: The patient was recovering from pneumonia and presented on steroids. However her mucous production had increased s/p bronch and she had a new leukocytosis while on steroids. Floor team started augmentin for PNA coverage but she was broadened to Vancomycin and Cefepime ___ the MICU for HCAP coverage. She was narrowed to just Cefepime (___) when bronchial washings were consistent with a pansensitive Pseudomonas. She completed a total of 7 day course of IV antibiotics with resolution of her leukocytosis. #COPD: Recovery from COPD exacerbation likely complicated by bilateral main stem bronchus compression. The patient still had diffuse wheezing on exam at transfer to the floor. It was difficult to tell if wheezing was from central or more pheripheral airways. ___ the MICU patient was uptitrated to 40mg prednisone for a total of 5 days. She was transferred to the floor and was given nebulizers prn. Steroids were discontinued and she had only trace, intermittent wheezing that was relieved by albuterol nebulizers. #HISTORY OF ATRIAL FIBRILLATION: The patient was typically ___ a regular rhythm. She had one episode of Afib with RVR to the 140s that easily converted with 5mg IV metoprolol. She was transitioned to Metoprolol Tartrate 25 mg PO/NG TID and Diltiazem Extended-Release 300 mg PO DAILY, and then metoprolol was changed to XL version 50mg daily for ease of dosing and symptomatic hypotension as described below. #HYPERTENSION: Was continued on Diltiazem ER 300 PO daily, metoprolol tartrate was initially changed to 25mg PO TID, however patient experienced some symptomatic hypotension with SBP 80-90s. She was transitioned to metoprolol succinate 50mg PO daily for improved rate control and better ease ___ dosing. #Psych: Stable. Continued Bupropion, Escitalopram, and prn lorazepam. TRANSITIONAL ISSUES: #Should f/u with PCP ___ 1 week to check ___ on respiratory status, trach capping progress #Will f/u with pulmonology ___ about 1 month #Will likely need pulmonary rehab services at home #Should check BP tomorrow AM and should hold dilt/metop if SBP<90 and call her PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. Lorazepam 1 mg PO TID:PRN anxiety 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Cardizem CD 300 mg oral daily 4. Docusate Sodium 100 mg PO BID 5. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL inhalation Q6H:PRN shortness of breath 6. Escitalopram Oxalate 10 mg PO QHS 7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 8. Simvastatin 10 mg PO QPM 9. Aspirin 81 mg PO DAILY 10. Metoprolol Tartrate 25 mg PO BID 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 12. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 13. Guaifenesin ER 1200 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Cardizem CD 300 mg oral daily 4. Docusate Sodium 100 mg PO BID 5. Escitalopram Oxalate 10 mg PO QHS 6. Guaifenesin ER 1200 mg PO Q12H 7. Lorazepam 1 mg PO TID:PRN anxiety 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 9. Simvastatin 10 mg PO QPM 10. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL inhalation Q6H:PRN shortness of breath 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 12. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB or wheezing RX albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg INH q2h Disp #90 Not Specified Refills:0 13. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #30 Packet Refills:0 14. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Malignant airway obstruction Secondary diagnoses: - Squamous cell lung cancer - COPD - Pneumonia 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 while you were a patient at ___. You came to us with airway obstruction due to your lung cancer. This was treated with bronchoscopy and cauterization. You did not require a stent. While you were here you had increasing difficulty breathing we found you had developed pneumonia. We put you on steroids and IV antibiotics and you did very well. Please be sure to take all of your medications as listed below and keep all of your follow-up appointments. Best, The ___ Team TRANSITIONAL ISSUES: Please take your blood pressure tomorrow ___ the morning and DO NOT take your diltiazem or metoprolol if your systolic blood pressure (the top number) is below 90. If this is the case, please also call your PCP ___ and notify them. Followup Instructions: ___
10089119-DS-17	10,089,119	22,582,998	DS	17	2125-01-14 00:00:00	2125-01-14 17:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: polydipsia, polyuria, nausea, weight loss, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: ___ pmhx IDDMI presenting with cc fatigue. Patient reports 1 week polyuria, polydipsia, insulin pump with notification that there is an occlusion for last week. Called PCP, found to have positive ketones, and was sent to ED. In ED initial VS: 97.9, HR 114, BP 117/94, RR 16, 100% RA Glucose 326 Labs significant for: hgb 16.7, Na 131, Cl 89, Bicarb 10, BS 392, pH 7.2, pCO2 33, U/A +ketones Patient was given: 2L NS, started on insulin drip Imaging notable for: clean CXR On arrival to the MICU, she confirms the above history. Past Medical History: ADHD Anxiety Social History: ___ Family History: She has a second cousin with Type 1 diabetes. No other family member with Type 1. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: Reviewed in metavision GEN: well appearing, NAD HEENT: MM tacky CV: RRR, nl s1/s2, no mrg PULM: CTA b/l no wrc GI: S/ND/NT, no HSM, BS normoactive EXT: WWP DISCHARGE PHYSICAL EXAM: ========================= VITALS: 24 HR Data (last updated ___ @ 817) Temp: 98.0 (Tm 98.2), BP: 116/74 (103-116/70-74), HR: 81 (66-96), RR: 18, O2 sat: 99% (97-100), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL. Sclera anicteric and without injection. Moist mucous membranes. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Breathing comfortably in ra. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Distal pulses 2+ SKIN: Warm and well perfused. No rash. NEUROLOGIC: CN2-12 intact. Strength and sensation intact throughout. Gait deferred. AOx3. Pertinent Results: ADMISSION LABS ============== ___ 01:53PM PLT COUNT-255 ___ 01:53PM NEUTS-61.4 ___ MONOS-3.8* EOS-1.3 BASOS-0.8 IM ___ AbsNeut-4.85 AbsLymp-2.56 AbsMono-0.30 AbsEos-0.10 AbsBaso-0.06 ___ 01:53PM WBC-7.9 RBC-5.29* HGB-16.7* HCT-47.3* MCV-89 MCH-31.6 MCHC-35.3 RDW-12.5 RDWSD-41.1 ___ 01:53PM %HbA1c-10.7* eAG-260* ___ 01:53PM GLUCOSE-392* UREA N-20 CREAT-1.1 SODIUM-131* POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-10* ANION GAP-32* ___ 02:02PM O2 SAT-53 ___ 02:02PM PO2-33* PCO2-33* PH-7.20* TOTAL CO2-13* BASE XS--14 ___ 03:55PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 03:55PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-1000* KETONE-150* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 03:55PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:55PM URINE UCG-NEGATIVE ___ 06:40PM GLUCOSE-226* UREA N-15 CREAT-0.9 SODIUM-133* POTASSIUM-5.2 CHLORIDE-106 TOTAL CO2-12* ANION GAP-15 ___ 06:54PM O2 SAT-62 ___ 06:54PM GLUCOSE-207* NA+-133 K+-4.4 CL--107 TCO2-14* ___ 06:54PM ___ PH-7.23* ___ 09:57PM GLUCOSE-211* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-15* ANION GAP-17 ___ 10:12PM ___ TEMP-36.1 PO2-28* PCO2-39 PH-7.26* TOTAL CO2-18* BASE XS--9 IMAGING: ========= +CHEST (PA & LAT) ___ IMPRESSION: No acute cardiopulmonary process. DISCHARGE LABS =============== ___ 05:02AM BLOOD WBC-4.8 RBC-4.47 Hgb-13.8 Hct-39.3 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.7 RDWSD-40.7 Plt ___ ___ 05:02AM BLOOD Glucose-225* UreaN-15 Creat-0.8 Na-139 K-3.5 Cl-105 HCO3-24 AnGap-10 ___ 05:02AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8 Brief Hospital Course: Ms. ___ a ___ year old female with a past medical history of Type 1 DM diagnosed in ___, who presented with nausea, polyuria, polydipsia, weight loss, and fatigue, who was found to be in DKA ___ malfunctioning insulin pump, insufficient subcutaneous insulin, and overall poor compliance to diabetes management. She was initially admitted to the ICU, started on an insulin drip and transitioned to SC insulin based on ___ recommendations. ACUTE ISSUES: ============= # Diabetic Ketoacidosis # T1DM: The patient presented with DKA in setting of occlusion in pump tubing and insufficient supplemental subcutaneous insulin. Of note, her A1c was 10.7, suggesting poor control overall. Her anion gap closed and FSBG ranging from 100 to low 200s on discharge. The patient requested to be switched from an insulin pump to injections. Per ___ recommendation, she will be on Glargine 13U BID (AM and ___, Humalog 8U with all meals, and ISS. She was seen by diabetes educator for education with blood sugar checks and insulin injections. She will be seen by ___ shortly after discharge. CHRONIC ISSUES: =============== # ADHD: The patient has not been on Ritalin for 1 month due to losing her home prescription. She states she was diagnosed with ADHD ___ years ago and has been doing well with Ritalin overall. She did not receive Ritalin while inpatient, but should follow up with her PCP to refill her prescription and continue monitoring her symptoms. She is motivated to taper off this medication eventually. # Anxiety: The patient has not been on Lexapro for >1 week due to not filling her home prescription. She did not require Lexapro during this hospitalization and denied any symptoms of anxiety. She was able to refill her prescription at discharge. TRANSITIONAL ISSUES: ==================== []Please continue to monitor for symptoms of DKA, including nausea, vomiting, diaphoresis. []Please encourage carb counting and close monitoring of her BG []The patient will be following up for further management of her T1DM with ___ []At discharge, her insulin regimen is: Glargine 13U BID (AM and ___, Humalog 8U with all meals, and ISS []FYI: the patient requested to be switched from an insulin pump to SC injections []Please continue to monitor ADHD symptoms and prescribe Ritalin as clinically indicated []her UA on admission showed 30 protein. Would monitor proteinurea for evidence of diabetic nephropathy iso uncontrolled DM. [] make sure she also has a annual fundus exam and neuropathy check Pt was seen and examined w residents on am rounds on ___. Pt with reasonable blood sugar control and no longer with increased anion gap. Pt wants to leave and I agree she can be safely discharged to home w close f/u in ___ and w her pcp. Okay to DC. >30 min spent on DC related activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 10 mg PO DAILY 2. Methylphenidate SR 30 mg PO QAM 3. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal rate minimum: 1 units/hr Target glucose: 80-180 Discharge Medications: 1. Glargine 13 Units Breakfast Glargine 13 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 13 Units before BKFT; 13 Units before BED; Disp #7 Syringe Refills:0 RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 10 Units QID per sliding scale 8 Units before LNCH; Units QID per sliding scale 8 Units before DINR; Units QID per sliding scal Disp #9 Syringe Refills:0 2. Escitalopram Oxalate 10 mg PO DAILY 3. Methylphenidate SR 30 mg PO QAM 4.test strips one touch verio Sig: check BG 8 times daily Disp# 100 (one hundred) strips Refills: 2 (zero) 5.Insulin pen needles 32G, ___ (4 mm nano) Sig: use to inject 5 times daily Disp# 100 (one hundred) needles Refills: 2 (zero) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: =================== 1. Diabetic ketoacidosis 2. Type 1 DM SECONDARY DIAGNOSES: ================== 1. Generalized Anxiety Disorder 2. ADHD 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 DID I COME TO THE HOSPITAL? You were feeling nauseous and weak at home. You were found to have diabetic ketoacidosis (DKA), which is when your blood glucose becomes very high due to a lack of insulin. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? We gave you insulin and other medications to treat the DKA. At the time of discharge, your sugars and electrolytes were back in the normal range. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -You should follow up with your primary care doctor and outpatient endocrinologist. -Please continue to take all of your medications and follow up with all of your doctors. -___ continue to monitor your symptoms, and seek medical attention if you experience any nausea, vomiting, sweating, lightheadedness, or any other symptom that concerns you. -Please continue to monitor your sugars, and take your insulin as prescribed. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10089199-DS-21	10,089,199	27,816,056	DS	21	2123-10-14 00:00:00	2123-10-14 17:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with a PMH of asthma and crohn's disease which has been usually affecting her ilium. Pt's first line of treatment was Pentasa but she continued to have symptoms so she was switched to Humira in ___. She developed skin lesions and Humira was stopped ___. Pt was started on ustekinumab (Stelara) in ___, which was initially given via injection every 8 weeks. She had improvement on Stelara but continued to have some mild ileitis so her Stelara was increased to every 6 weeks. Last MR ___ in ___ showed: 1. Compared to ___, there has been interval improvement in disease involving a short segment of distal terminal ileum. Otherwise, there is a similar extent of active inflammatory disease involving a 22 cm long segment of distal ileum and proximal terminal ileum. 2. No evidence of fistula, abscess or obstruction. The pt reports that she usually does not drink alcohol. Yesterday she had half a glass of wine and two bottles of ___ hard lemonade. That night, she began to develop ___ periumbilical pain which she initially attributed to eating Taco Bell. The pain then worsened around 1 or 2 am, waking her from sleep. The pain continued to worsen throughout the morning, so she eventually went to urgent care for evaluation. She reports that the pain is ___ only, sharp/stabbing, and feels different than prior Crohn's flares which were usually lower abd pain. She denies nausea, vomiting, diarrhea, or blood in her stool. She denies black stool. She denies dysuria or hematuria. At the urgent care, a CT abd/pelvis was performed which showed ileitis consistent with her Crohn's. Pt was asked to go to the ER for further evaluation. In the ER, she as found to be hemodynamically stable with normal renal function, unremarkable LFTs, normal WBC, no anemia, and elevated CRP to 7.3. Pt was evaluated by GI in the ER who recommended the following (quoted from the ER note): - if develops loose stools, please check C. Diff - keep NPO for now - please start Cipro/Flagyl - please avoid NSAIDs and opiates if possible. Try IV tylenol for pain - on floor, please ensure patient getting DVT ppx ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL HISTORY: Asthma Crohn's disease 11 surgeries on her foot after a trauma Family History: FAMILY HISTORY: Mother: ___, diverticulosis Maternal grandfather: Stomach cancer Physical Exam: Physical Exam Gen: Well appearing, well groomed, no apparent distress HENT: NCAT. Mucus membranes moist. No oral lesions or ulcer. Eyes: Conjuctiva clear. No periorbital edema. CV: RRR. No m/r/g. Resp: Lungs CTAB. Good air movement. Breathing non-labored. Abd: Soft, non-distended, normoactive BS. Tender directly over the umbilicus. No guarding, no rebound. GU: No suprapubic or CVA tenderness Ext: No ___ edema or erythema Skin: No rashes or skin lesions Neuro: Face symmetric. Ox4. Normally conversant. Moves all four extremities. Psych: Normal tone and affect . discharge exam: well appearing, minimal abdominal tenderness. Pertinent Results: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: - Normal WBC - Normal Hb - Normal renal function - Unremarkable LFTs - CRP 7.3 - Negative UA CT abd/pelvis on ___ at outside facility (available in CHA records): 1. Distal ileitis extending into the proximal portion of the terminal ileum, consistent with known Crohn's disease. 2. Normal appendix. 3. Left adnexal 3 cm cystic lesion. Pelvic ultrasound recommended for further evaluation when the patient is stable. Re-read here (second opinion of same CT): 1. Active Crohn's disease involving an approximately 25 cm contiguous segment of mid and distal ileum, similar in extent and appearance when compared to the prior MR enterography from ___. No evidence of bowel obstruction, abscess, or fistulizing disease. No new sites of inflammatory bowel disease identified. 2. Normal appendix. discharge labs: ___ 06:31AM BLOOD WBC-3.8* RBC-3.98 Hgb-10.7* Hct-34.5 MCV-87 MCH-26.9 MCHC-31.0* RDW-13.4 RDWSD-42.8 Plt ___ ___ 06:31AM BLOOD Glucose-90 UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-110* HCO3-20* AnGap-10 ___ 06:31AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8 Brief Hospital Course: SUMMARY/ASSESSMENT: Ms. ___ is a ___ female with the past medical history and findings noted above who presented with abdominal pain, likely related to dietary indiscretion, but on a background of likely persistently active Crohn's disease. #Abdominal pain #Crohn's disease with proximal terminal ileitis The pt p/w ___ pain, quite rapid onset, no nausea/vomiting/diarrhea/melena/hematochezia. CT shows her known Crohn's disease which is active in the terminal ileum. Her acute symptoms resolved with bowel rest, and antibiotics were stopped. Her acute symptoms were not felt to represent a flare of her Crohn's disease, but rather a reaction to the dietary indiscretions. In regards to her Crohn's disease, her imaging remains unchanged since ___ despite treatment with stellara at increasing dose, so the GI consult advised start of budesonide and follow up regarding changes in her chronic treatment for Crohn's. #Asthma Currently asymptomatic, usually seasonal. - she was treated with Duonebs PRN # GYN OCPs continued Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 2. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D ___ UNIT PO DAILY 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Crohn's disease Acute abdominal pain Chronic asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to ___ with abdominal pain after some alcohol consumption and fast food consumption. Your acute pain went away with bowel rest and time. You were seen by the GI doctors who ___ that your underlying Crohn's disease was not adequately treated with your present regimen of medication and they advised that we start you on budesonide daily. Followup Instructions: ___
10089894-DS-16	10,089,894	27,964,500	DS	16	2169-04-19 00:00:00	2169-04-20 21:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / morphine Attending: ___. Chief Complaint: Left femur fracture Major Surgical or Invasive Procedure: ORIF left periprosthetic femoral shaft fracture with internal fixation. History of Present Illness: ___ with hx of advanced dementia, atrial fibrillation on pradaxa, b/l hip fractures, PRV vs. essential thrombocytosis, ___ resident at ___, who pw L ___ femur fracture. 1d PTA, pt was found to have an unwitnessed fall. On DOA, patient had LLE pain. Nursing home performed x-ray which showed L femur fracure and she was sent to the ED for further eval. Pt unable to provide menaingful hx. Per ___, at baseline, pt ambulates with walker and is A+Ox1. On arrival the ED, initial VS were: 98.6 77 147/74 14 97% RA. Labs were significant for INR 1.8, PTT 90, creatinine 2.3, potassium 5.6. EKG showed coarse a. fib. X-ray showed left ___ hip fracture. CT head and neck were unremarkable. She received 0.5mg iv dilaudid for pain. Past Medical History: - Advanced dementia - S/P bilateral hip fractures after falls. - HTN - Polycythemia ___ vs. Essential Thrombocytosis (No JAK2 as per Hematologist) - Hypothyroid s/p thyroidectomy - H/O hyponatremia - Atrial fibrillation (on pradaxa) - Hx of CVA - S/P bilateral THR Social History: ___ Family History: unable to obtain Physical Exam: ADMISSION PHYSICAL EXAM: VS: Tm 98, 125/60, 81, 20, 100% RA GENERAL: Elderly chronically ill-appearing in NAD HEENT: NC/AT, sclerae anicteric, poor dentition, dried blood in mouth NECK: Supple LUNGS: CTA bilat over anterior chest, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: Irregularly irregular, no MRG, nl S1-S2 ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, 2+ DP/ ___ pulses intact bilaterally, left leg sl shorter than right, significant swelling, warmth a severe ttp at L thigh. 2+DP pulses bl. Pt able to move toes bl. Sensation grossly intact. NEURO: A+O x 1, resting tremor of bilateral upper extremities and mouth, left eye deviated to the left, right pupillary reflex intact, no pupillary reflex in left eye, EOMI, sensation intact throughout, grip strength ___, moves toes DISCHARGE PHYSICAL EXAM: Tm 98.6, BP 154/85, P 73, R 18, O2 Sat 100% RA GENERAL: Elderly chronically ill-appearing in NAD; A+O x 1 HEENT: Still very poor dentition NECK: no JVD LUNGS: CTA-bl HEART: Irregularly irregular, no MRG, nl S1-S2 ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, 2+ DP/ ___ pulses intact bilaterally, decreased swelling and warmth and persistent ttp at L thigh. 2+DP pulses bl. Sensation grossly intact. NEURO: A+O x 1, resting tremor of bilateral upper extremities and mouth, left eye exotropia, absent L pupilary reflex, EOMI, sensation intact throughout Pertinent Results: ADMISSION LABS: ___ 03:45PM BLOOD WBC-6.3 RBC-3.30* Hgb-11.6* Hct-35.6* MCV-108* MCH-35.2* MCHC-32.7 RDW-17.7* Plt ___ ___ 03:45PM BLOOD Neuts-66.9 ___ Monos-6.6 Eos-1.2 Baso-0.4 ___ 03:45PM BLOOD ___ PTT-90.3* ___ ___ 03:45PM BLOOD Glucose-131* UreaN-38* Creat-2.3* Na-134 K-5.6* Cl-96 HCO3-28 AnGap-16 ___ 03:45PM BLOOD cTropnT-0.02* ___ 03:58PM BLOOD Lactate-2.0 ___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 04:40PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 PERTINENT LABS: ___ 09:05AM BLOOD CK(CPK)-24* ___ 06:26AM BLOOD Calcium-7.9* Phos-4.6* Mg-2.3 ___ 09:05AM BLOOD ___ DISCHARGE LABS: ___ 06:10AM BLOOD WBC-7.2 RBC-2.62* Hgb-8.9* Hct-27.5* MCV-105* MCH-34.1* MCHC-32.5 RDW-20.1* Plt ___ ___ 06:10AM BLOOD ___ PTT-59.2* ___ ___ 06:10AM BLOOD Glucose-121* UreaN-18 Creat-1.1 Na-137 K-3.7 Cl-107 HCO3-21* AnGap-13 ___ 06:10AM BLOOD Calcium-7.4* Phos-2.6* Mg-2.6 ___ 05:51AM BLOOD Lactate-1.9 MICRO: URINE CULTURE ___: NEGATIVE BLOOD CULTURE ___: PENDING IMAGING: CT HEAD ___: IMPRESSION: 1. No intracranial hemorrhage or calvarial fracture. 2. Aerosolized secretions in the left sphenoid and ethmoidal air cells suggest acute sinus disease. CT C-SPINE ___: IMPRESSION: 1. No cervical spine fracture or prevertebral soft tissue abnormality. 2. Slight rotation of C1 on C2 is likely positional. 3. 3.1 cm minimally calcified right thyroid lobe nodule, for which thyroid ultrasound may be obtained for further evaluation. FEMUR AP/LAT PELVIS AP ___: FINDINGS: Total of 10 views were provided including AP view of the pelvis, AP and lateral views of the left femur. Bilateral hemiarthroplasties are noted at the hip. Bones are demineralized. The bony pelvic ring is intact. On the left, there is a fracture traversing the subtrochanteric segment of the left proximal femur which involves the lateral cortex. The prosthesis is intact through the left proximal femur. Distally, the left femur is intact. Limited views of the left knee are unrevealing. IMPRESSION: Periprosthesis fracture of the left proximal femur. CXR ___: IMPRESSION: No acute findings in the chest. TTE ___: The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate mitral regurgitation. Mild pulmonary artery hypertension. Brief Hospital Course: Ms. ___ is a ___ with PMHx of advanced dementia, A. fib on pradaxa, b/l hip fractures, polycythemia ___ (vs. essential thrombocytosis), who was admitted with ___, elevated coags and L femur fx sp fall. # L femur fx: Patient sustained a L ___ femur fracture after a fall. On admission, pt had elevated coag studies in the setting of taking Pradaxa and having renal failure. She underwent a TTE which showed no evidence of heart failure. Her coagulopathy improved and she underwent ORIF of L femur on ___. She tolerated the procedure well. # Anemia Presenting Hct was 35.6 and Hct trended to 26.2 during admission, before rising (HCT 27.5 on discharge). Anemia was most likely from thigh hematoma and dilution in the setting of IVF. Hydroxyurea was held in the setting of anemia. # ___: Baseline was fluctuating prior to admission (Per ___, it was 1.0 in ___ 1.3 in ___ and 1.7 on ___. K was elevated at 5.6 on admission (in the setting of potassium supplementation at ___ but had no EKG changes. Cr trended down spontanouely, suggesting also a possible component of rhabdomyolysis (pt found down). Furosemide was held during this admission. At discharge, patient's creatinine was 1.1. The patient's urine output trended down during admission and she required fluids for maintenance of urine output. Re-starting diuresis in the future may facilities urine production. She was clinically euvolemic on day of discahrge. # Coagulopathy/Afib - AC Elevated INR/ PTT on admission (INR 1.8; PTT 90). INR and PTT may also have been elevated, partially, due to poor nutrition. Pradaxa was held prior to surgery. After surgery, given a CHADS2 score of 4, pt was started on Lovenox as a bridge to Coumadin. Because of the patient's age and changing renal function, decision was made to switch pt to Coumadin in favor of Pradaxa at this time. On discharge, patient's INR was 1.7 and PTT was 59.2. # Afib - rate: Rate control achieved with diltiazem and metoprolol. Lasix was held during admission. # Polycythemia ___ vs. Esstential Thrombocytosis: HCT was not elevated during admission and hydroxyurea was held. Dr. ___ was called to notify him of the change and to request arrangement for follow up. Following discharge, Dr. ___ the ___ facility where Ms. ___ was transferred and instructed her caretakers regarding dosing for hydroxyurea. # Hypothyroid s/p thyroidectomy: continued on levothyroxine TRANSITIONAL ISSUES: - Please arrange for follow-up thyroid ultrasound for calcified nodule noted on CT - Please note, Lasix was held on discharge. Please evaluate volume status and re-start furosemide as needed - Please check INR daily and adjust Coumadin dose on a daily basis. Goal INR is ___. Patient is being bridged on Lovenox (current dose accounts for decreased creatinine clearance; please be sure to adjust dose as necessary if creatinine clearance changes) - Please follow up final blood cultures from ___ - Please note, hydroxyurea was held in the setting of anemia but patient has essential thrombocytosis. Please re-start hydroxyurea as per Dr. ___. Please arrange follow-up with Dr. ___ at ___ - addendum - Dr. ___ to establish follow-up regarding appropriate hydroxyurea dosing Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxyurea 1000 mg PO 4X/WEEK (___) 2. Hydroxyurea 500 mg PO 1X/WEEK (FR) 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Acetaminophen 650 mg PO Q4H:PRN pain/ fever 5. Bisacodyl ___AILY:PRN constipation 6. Fleet Enema ___AILY:PRN constipation 7. Milk of Magnesia 30 mL PO DAILY:PRN constipation 8. Senna 2 TAB PO DAILY:PRN constipation 9. traZODONE 12.5 mg PO HS:PRN insomnia 10. Dabigatran Etexilate 75 mg PO BID 11. Diltiazem Extended-Release 360 mg PO DAILY Hold for SBP< 100, HR<60 12. Vitamin D 1000 UNIT PO DAILY 13. Calcium Carbonate 500 mg PO BID 14. Metoprolol Tartrate 12.5 mg PO BID hold for SBP<100, HR<60 15. Furosemide 40 mg PO DAILY 16. Guaifenesin 10 mL PO Q6H:PRN cough 17. Potassium Chloride 30 mEq PO DAILY Duration: 24 Hours Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/ fever 2. Bisacodyl ___AILY:PRN constipation 3. Calcium Carbonate 500 mg PO BID 4. Diltiazem Extended-Release 360 mg PO DAILY Hold for SBP< 100, HR<60 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Metoprolol Tartrate 12.5 mg PO BID hold for SBP<100, HR<60 7. Milk of Magnesia 30 mL PO DAILY:PRN constipation 8. Senna 2 TAB PO DAILY:PRN constipation 9. Vitamin D 1000 UNIT PO DAILY 10. Fleet Enema ___AILY:PRN constipation 11. Guaifenesin 10 mL PO Q6H:PRN cough 12. traZODONE 12.5 mg PO HS:PRN insomnia 13. Enoxaparin Sodium 60 mg SC Q24H Please discontinue when INR is ___. Please check INR daily. 14. Warfarin 2.5 mg PO DAILY16 Please check INR daily and adjust dosing as needed to keep INR ___. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - Left periprosthetic femur fracture - Acute renal failure - Dabigatran toxicity - Acute blood loss anemia Secondary: - Atrial fibrillation - Polycythemia ___ - Hypothyroidism - Hypertension - Recurrent falls - Dementia - S/P Bilateral THR - S/P Thyroidectomy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure to participate in your care at ___. You were admitted for a left leg fracture after a fall. You underwent surgery for correction of this. Your blood clotting studies were found to be abnormal. This was likely due to an increased level of your blood thinning medication. You are being discharged in an improved state. We wish you all the best. Followup Instructions: ___
10089922-DS-21	10,089,922	20,015,409	DS	21	2189-05-28 00:00:00	2189-05-31 19:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue. Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: ___ year old woman with history of HTN, HLD, GERD who presents for evaluation of fatigue. The patient endorses a flulike illness approximately one month ago. She felt better for about a week and then experienced a progressive decline. She's been increasingly more fatigued since that time. She is also noted that her eyes looked pale. She's also noted dark colored urine. She denies any other questions or complaints. She specifically denies any hematuria, bloody or dark bowel movements, hemoptysis, abdominal pain or distention. No recent travel. Is originally from ___. In the ED, initial vitals were: 99.4 103 153/74 12 Labs notable for: profound normocytic anemia with H/H 6.3/20.6, clumped platelets, INR 1.1, PTT 24.6, fibrinogen 574, mild transaminitis with LDH 684 T bili 1.6, normal chem, hapto <10. Smear positive for parasites, burden 1.4%. CXR negative. RUQ U/s normal gallbladder, no cystic lesions, + splenomegaly Patient was given: no medications Vitals prior to transfer: 98.1 97 126/73 16 97% RA On the floor via ___ phone interpreter patient is feeling fatigued without any specific complaints. ROS as above. Past Medical History: HTN HLD GERD Social History: ___ Family History: Parents both died in ___ of CVAs. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.3 PO 141 / 78 L Lying 97 18 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, slightly pale conjunctiva, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: regular 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 , no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no joint swelling, crepitus, pain on palpation Neuro: CNII-XII grossly intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM ======================= Vital Signs: Tmax 98.3 BP 100-130/50-70s HR 70-80s RR 18 ___ on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities evenly and well Pertinent Results: ADMISSION LABS ============== ___ 10:24AM BLOOD WBC-4.7 RBC-2.23# Hgb-6.6# Hct-21.7# MCV-97# MCH-29.6 MCHC-30.4 RDW-17.1* RDWSD-58.1* Plt Ct-UNABLE TO ___ 10:24AM BLOOD Neuts-68.0 Lymphs-18.7* Monos-12.3 Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.20 AbsLymp-0.88* AbsMono-0.58 AbsEos-0.01* AbsBaso-0.01 ___ 11:02PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ ___ 11:02PM BLOOD ___ PTT-24.6* ___ ___ 11:02PM BLOOD ___ ___ 10:24AM BLOOD Ret Aut-5.4* Abs Ret-0.12* ___ 11:02PM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-136 K-4.0 Cl-102 HCO3-24 AnGap-14 ___ 11:02PM BLOOD ALT-54* AST-52* LD(LDH)-684* CK(CPK)-59 AlkPhos-472* TotBili-1.6* ___ 11:02PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.2 ___ 10:24AM BLOOD %HbA1c-5.4 eAG-108 ___ 10:24AM BLOOD TSH-0.95 ___ 11:07PM BLOOD ___ pH-7.42 Comment-GREEN TOP ___ 11:07PM BLOOD freeCa-1.06* PERTINENT LABS ============== Parasite smear positive throughout admission, 1.2% on ___ decreased to 0.1% on ___ MICROBIOLOGY ============== ___ (LYME)Lyme IgG-PRELIMINARY; Lyme IgM-PRELIMINARYINPATIENT Lyme IgG (Preliminary): Sent to ___ Laboratories for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to ___ Laboratories for Lyme Western Blot testing. ___ CULTUREBlood Culture, Routine-FINALINPATIENT ___ CULTUREBlood Culture, Routine-FINALINPATIENT ___ (Malaria)Malaria Antigen Test-FINALINPATIENT ___ (Malaria)Malaria Antigen Test-FINAL IMAGING ============== ___ CXR: The lungs are well-expanded and clear. The cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax, pleural effusion, or consolidation. ___ RUQ US IMPRESSION: 1. Normal gallbladder. 2. No cystic lesions identified. 3. Splenomegaly. DISCHARGE LABS ============== ___ 04:20AM BLOOD WBC-5.2 RBC-2.36* Hgb-7.1* Hct-22.5* MCV-95 MCH-30.1 MCHC-31.6* RDW-18.7* RDWSD-60.4* Plt Ct-UNBALE TO ___ 04:20AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNBALE TO ___ 03:16AM BLOOD Parst S-POSITIVE ___ 03:16AM BLOOD Glucose-101* UreaN-14 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 ___ 03:16AM BLOOD ALT-29 AST-26 LD(LDH)-509* AlkPhos-276* TotBili-1.2 DirBili-0.3 IndBili-0.9 ___ 03:16AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1 ___ 03:16AM BLOOD Hapto-<10* Brief Hospital Course: Ms. ___ is ___ old generally healthy female who presented to her PCP with fatigue and profound anemia, was admitted to ___ with a Hb 5.6, found to have parasites on smear and treated for babesiosis. Patient received one unit of blood on ___ with good response and was started on atovaquone, azithromycin, and doxycycline (day 1 = ___ for treatment of babesia and empirically for parasitic co-infection. Patient had expectedly elevated hemolysis labs and also elevated LFTs, especially alk phos (and GGT). Patient was generally asymptomatic after blood transfusion, felt as baseline with no symptoms. Blood smear on admission ___ showed 1.2% parasitemia, by discharge on ___ smear showed only 0.1% parasitemia. Per recommendation from infectious disease, patient should continue blood smears for parasite until there are no parasites, after which the patient will continue azithromycin and atovaquone for 7 more days. Patient will get CBC and parasite smear at ___ ___ on ___ and ___. Regardless of blood smears patient should continue taking doxycycline empirically for 14-day course (until ___. ACTIVE ISSUES ============= #Parasites: Patient with smear positive for parasites. Night-float review of smear no evidence of malaria or specific ___ crosses. Given no recent travel history, patient's hemolytic anemia, elevated LFTs and splenomegaly most likely diagnosis is babesiosis. Started at___ 750mg PO BID and azithromycin, 500mg PO first day, then 250mg PO (D1 = ___. Starting doxycycline 100mg PO BID (D1 = ___ given high possibility of co-transmitted parasitic diseases, will take for 14 day course. Medications delivered to patient at bedside. Checked Babesia PCR, Lyme serology, Anaplasma PCR and serology; pending at time of discharge. Trended parasite smear, decreased burden to 0.1% on ___, will recheck at ___ office on ___ and ___ to ensure elimination, and will take azithromycin and atovaquone for 7 days post-clearance. ID will see patient next week outpatient on ___. #Anemia: Hemolytic with elevated LDH, retic, bili and low haptoglobin. Most likely secondary to acute parasitic infection. Patient responded well to PRBC transfusion on admission, Hb stable afterwards and at discharge (Hb 7.1). #Transaminitis and splenomegaly: No evidence of biliary obstruction on RUQ u/s. Most likely ___ acute parasitic infection which was worked up and treated (see above). ___ GGT elevated along with alk phos indicating GI source, no anatomic cause seen in RUQ US, minimal elevation and asymptomatic so no further inpatient w/u needed, will be transitional issue at d/c to track after infection resolves CHRONIC MEDICAL ISSUES ====================== #HTN: Initially held anti-hypertensives in setting of acute hemolytic anemia, restarted home metoprolol on ___, patient stable after restarting. #HLD: Continued home statin. #GERD: Continued home PPI. Transitional issues =================== [] CBC and parasite smear at ___ on ___ [] Follow up with primary care physician ___ on ___, should recheck CBC, parasites, and LFTs to ensure hemoglobin stable and that elevated LFTs (especially alk phos) have declined; if they have not, patient would merit further workup of these elevations [] Follow up with Dr. ___ infectious disease at ___ on ___ at 10:00 AM [] Continue taking atovaquone and azithromycin for 7 days AFTER no longer any parasites on smear, will need new prescription beyond current medications [] Continue doxycycline for 2 week course (last day ___ for empiric coverage of any other parasites Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Lisinopril 10 mg PO DAILY 5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY Discharge Medications: 1. Atovaquone Suspension 750 mg PO BID ___ po bid RX atovaquone 750 mg/5 mL 750 mg by mouth twice a day Refills:0 2. Azithromycin 250 mg PO Q24H 250 mg po qd RX azithromycin 250 mg 1 tablet(s) by mouth once per day Disp #7 Tablet Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice per day Disp #22 Tablet Refills:0 4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis -Babesiosis -Anemia Secondary diagnosis -Hypertension -Hyperlipidemia -Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had anemia, also known as low blood counts of something called hemoglobin. We believe this anemia was caused by an infection called Babesia, which is spread by ticks. We started you on three strong antibiotics to fight this infection: atovaquone, azithromycin, and doxycycline. You will continue to take the doxycycline for 14 days total (until ___. You will get your blood checked for parasites on ___ and ___ with Dr. ___ checking your blood until there are no more parasites. After they are all gone, you will keep taking the azithromycin and atovaquone for another 7 days. You will need an additional prescription from Dr. ___ these pills. You also have an appointment with the infectious disease doctors here at ___ on ___ at 10:00 AM. We also noticed that you high blood tests of chemicals from your liver. This may be caused by the Babesia infection, but just in case, we would like your primary care doctor Dr. ___ to repeat those tests to make sure they go down as we treat your infection. Please follow up with all medical appointments and take all medications as prescribed. It was a pleasure to help take part in your medical care. Sincerely, Your ___ Health Team Followup Instructions: ___
10090148-DS-12	10,090,148	26,354,377	DS	12	2153-08-11 00:00:00	2153-08-12 07:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tamsulosin / amoxicillin / dutasteride / nicotine Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD, macular degeneration, hearing impairment, pAF on asa daily transferred from an outside hospital after a fall on the night of ___ with a CT scan notable for a small right frontal intraparenchymal hemorrhage, pericardial effusion, and a right lower lung effusion. Patient reports that last night he was getting up from his computer when he is right leg felt numb, which occasionally does, and he fell hitting his left chest and the left side of his head. Patient reports that when he woke up this morning, he noted that he had pain in his left chest and bruising on his face and went to ___ for evaluation. Reports feeling intermittently short of breath during the last few weeks. Denies chest pain, fever, chills. Patient was recently discharged from ___ for a congestive heart failure exacerbation ___ weeks ago. On arrival, patient reports pain in his left face, left rib cage. Denies any visual changes, weakness, numbness, confusion. In the ED, initial vitals were: T98.4, HR 86, RR18, BP 117/64, PO2 92% on RA - Exam notable for: Neuro: GCS 14. Moving all extremities without any problems. Oriented and talking with fluent speach. No gross deficits. Walking about department. Neck: supple neck, no tenderness. No JVD. Resp: Decreased lung sounds on right CV: RRR, no murmur, non-tender chest wall. - Labs notable for: WBC 3.0, Hgb 9.3, Hct 31.6, Plt 59, INR 1.2, Alb 2.6. UA with 5 RBC's and 43 WBC's per HPF with Few bacteria. - Imaging was notable for: Normal left wrist XR CT head + for 1.6x1cm right frontal IPH w/o edema CT torso: +moderate right pleural effusion, w/ consolidation and radiodense material, enlarged heart w/ 14 mm effusion, 4.4 cm aortic aneurysm - Patient was given: IV CefTRIAXone amLODIPine 5 mg ___ Finasteride 5 mg ___ Furosemide 60 mg ___ Sotalol 120 mg ___ Tiotropium Bromide 1 CAP ___ Cyanocobalamin 100 mcg ___ Upon arrival to the floor, patient reports feeling well. Denies SOB, CP, palpitations, nausea, vomiting, abdominal pain, dizziness, headache, weakness, numbness/tingling. He believes his volume status is under control. Patient confirmed above history and believes his fall was mechanical. Denies suprapubic pain, dysuria, urinary hesitancy/frequency. Past Medical History: CAD s/p ___ PLMI Dilated ischemic cardiomyopathy w/ HFrEF HTN HLD COPD Ascending aortic aneurysm Bladder cancer Colonic polyps Diverticulitis Asymptomatic gallstones CRI VT ___, maintained on sotalol ICD implant ___ GIB s/p gastric ulcer clipping ?pAF Macular degeneration Hearing loss History of asbestos exposure with pleural plaques Social History: ___ Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITAL SIGNS: T98.5, BP 141 / 64, HR 90, RR20, ___ NC GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor; some white residue on soft palate NECK: JVP up to mandible CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions DISCHARGE PHYSICAL EXAM: ========================== VITAL SIGNS: reviewed in OMR GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor NECK: JVP to mid-neck CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles improved; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions ___: erythematous and swollen left wrist with black sutures in place, no purulence: unable to clench fist ___ swelling, TTP; some numbness Pertinent Results: ADMISSION LABS: ================ ___ 03:20PM BLOOD WBC-3.0* RBC-3.55* Hgb-9.3* Hct-31.6* MCV-89 MCH-26.2 MCHC-29.4* RDW-16.9* RDWSD-54.4* Plt Ct-59* ___ 03:20PM BLOOD ___ PTT-33.2 ___ ___ 03:20PM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-145 K-4.1 Cl-106 HCO3-28 AnGap-11 ___ 03:20PM BLOOD ALT-9 AST-19 LD(LDH)-245 CK(CPK)-54 AlkPhos-54 TotBili-0.5 ___ 08:08AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 DISCHARGE LABS: ================ ___ 07:05AM BLOOD WBC-2.1* RBC-3.08* Hgb-8.0* Hct-27.2* MCV-88 MCH-26.0 MCHC-29.4* RDW-17.0* RDWSD-54.2* Plt Ct-49* ___ 07:05AM BLOOD Glucose-85 UreaN-24* Creat-1.0 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-8* ___ 07:05AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 MICRO: ====== ___ 3:29 pm URINE TAKEN FROM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM POSITIVE BACTERIA. >100,000 CFU/mL. IMAGING: ========= Xray left wrist: Significant swelling over the left ___ and wrist within no evidence of subcutaneous gas or radiographic evidence of osteomyelitis. EKG ___ irregularly irregular, rate 75, PVCs, no acute ST changes TTE ___ The left atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with severe hyypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The estimated cardiac index is normal (>=2.5L/min/m2). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate (___) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Suboptimal image quality. Left ventricular cavity cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild aortic regurgitation. Small circumferential pericardial effusion. Dilated aorta. ___ ICD Interrogation Interrogation: Battery voltage/time to ERI: 75%/3.12 V Presenting rhythm: AS/VS Underlying rhythm: AS/VS Mode,base and upper track rate: DDD 50/120 Lead Testing P waves: 2.2 mv A thresh: 1.2 V@ ms A imp: 505ohms R waves: 19 mv RV thresh: 1.0 V@ ms RV imp: 404ohms shock impedance: 43 ohms Diagnostics: AP: 6% VP: 7% Events: none Summary: 1. Pacer function normal with acceptable lead measurements and battery status 2. Programming changes: none 3. Unable to verify abnormal rhythms by ED physicians as telemetry deleted. 4. Follow-up: as per ED, follows up at ___ for device OSH IMAGING: ============ CT CHEST: IMPRESSION: 1. Moderate size right pleural effusion. Hounsfield units near 20 are less than expected for hemorrhagic fluid. No acute bony abnormality. 2. Right lower lobe consolidation with radiodense material within the consolidated area lung. 3. There is lung emphysema. Bilateral pleural calcifications suggest asbestos exposure. 4. Enlarged heart with pericardial effusion measuring 14 mm thick. Aortic root measures 4.4 cm in diameter. 5. No acute finding in the abdomen and pelvis. 6. Renal and pancreatic cysts. Prostate is 6.9 cm in diameter. Spleen is 13.8 cm in length. Cranial CT scan: There is an area of high density towards the high right frontal lobe adjacent to the interhemispheric fissure which measures 1.6 x 1 cm most likely representing parenchymal hemorrhage although a small component of extra parenchymal hemorrhage cannot be excluded. There is no edema within the region. There is diffuse atrophy. There is no evidence of mass effect. Cervical spine CT scan: There are degenerative changes throughout the cervical spine. No fractures are seen. There is a right-sided pleural effusion. Maxillofacial CT scan: No fractures are appreciated. There is soft tissue swelling along the right side of the mandible and over the left supraorbital rim. There is a small amount of mucosal thickening within the right maxillary sinus is and portions of the ethmoidal sinus. Xray L wrist: IMPRESSION: Normal left wrist. Brief Hospital Course: Mr. ___ is a ___ with ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD on O2 overnight intermittently, macular degeneration, hearing impairment, pAF on ASA who initially presented to an outside hospital after suffering a fall found to have a small intraparenchymal hemorrhage on CT head and a left ___ laceration (repaired at OS___) prompting transfer to ___. Upon arrival to ___, she was evaluated by the neurosurgery team who deemed that no further intervention or imaging was needed. He was admitted to the medicine service for further monitoring. His hospital course was complicated by cellulitis of the left ___ laceration site initially on vancomycin/clindamycin (severe PCN allergy) later transitioned to clindamycin alone per ___ Surgery recommendation. # Intraparenchymal hemorrhage: Patient found to have small right frontal intraparenchymal hemorrhage 1.6cm s/p fall. Evaluated by neurosurgery, with recommendations for no acute intervention and no keppra prophylaxis. Patient without headache or focal neuro deficits. Held home aspirin in the setting of thrombocytopenia and bleed. Will need to discuss restarting aspirin as an out-patient given underlying risks of bleed with fall and thrombocytopenia versus known CAD. # Fall # ?Syncope As per patient report, fall sounds mechanical in nature as patient says his right leg tripped on the side of the rug in the setting of neuropathy in that leg. Denied prodromal or neurologic symptoms prior to or after the incident. No SOB, CP, palpitations, dizziness, warmth, post-ictal confusion, incontinence, or other concerning symptoms. With history of VT and pAF but no arrhythmias or therapies detected on ICD interrogation. EKG without concerning findings other than PVCs. TTE with EF 40% and mild-mod MR but no other significant valvular pathology. Trop negative and no ischemic signs on EKG to suggest MI. No hypoxia/tachycardia to suggest PE. No report of LOC, patient remembers falling and getting up. Monitored on telemetry with no acute events. Orthostatics negative, ___ cleared for discharge. Will need close monitoring as an out-patient. # Left wrist laceration c/b cellulitis: Patient suffered a left ___ laceration with the fall (injury caused by the watch he was wearing) which was repaired at the OSH. He developed increased swelling, pain and erythema along the ___ and suture site with concern for cellulitis. ___ surgery was consulted and xray imaging was negative for any fracture, subcutaneous gas, or osteo. He was initially on Clinda/Vanc IV later transitioned to clindamycin PO for planned 7 day course (clinda chosen as he cannot take beta lactams given allergy, or fluoroquinolone given QTc concerns on sotalol, and Bactrim would not adequately cover streptococci), and clindamycin monotherapy would cover CA-MRSA, MSSA, streptocci, and anaerobes. Will continue to apply ACE-wraps and elevate the ___ to ensure swelling improves. Will need stitches to be removed ___ with planned follow-up with PCP and ___ surgery for further monitoring. Of note, patient received tetnus booster while at ___. # Positive UA: asymptomatic with no dysuria, hesitancy, frequency. Afebrile, HDS. In the setting of the fall treated empirically with ceftriaxone in the ED. Given lack of symptoms, however, further antibiotics for UTI were held. Urine culture positive for gram positive bacteria, speciation with mixed flora and the patient remained asymptomatic. His home finasteride and terazosin were continued for his BPH. # pAF: patient with history of PAF on past device checks, not on most recent interrogation but irregularly irregular on exam. High risk to start anticoagulation due to history of hematuria, thrombocytopenia, and bladder cancer. CHADsVASc 5. Continued sotalol. Held aspirin in the setting of thrombocytopenia and fall with hemorrhagic bleed. # Thrombocytopenia: patient with history of thrombocytopenia/pancytopenia of unclear etiology, however, have a high suspicion for MDS given relative pancytopenia. Last plt count 74 in ___. Now down to 40-50s. Held subQ heparin with plat<50, and held aspirin with ICH. Will need repeat CBC within 1 week of discharge and consider further work-up as out-patient if within goals of care. He is pancytopenic, and this is most likely due to MDS given his age - it was our understanding that he had previously declined bone marrow biopsy and further evaluation, which seems reasonable (to defer) given his age and comorbidities. # HFrEF (EF 40%): Stable during this admission and continued on home furosemide 40mg daily, lisinopril 40mg daily, and sotalol 120mg BID. Desatted to the ___ with ambulation so will discharge on home oxygen 2L to be used continuously. # VT s/p ICD placement on sotalol: patient with no events or therapies recorded on recent ICD interrogation. Patient denies LOC or palpitations. PVCs on EKG. Maintained on home sotalol. # Small pericardial effusion: noted on TTE, HDS stable without concern for tamponade physiology. Unsure etiology but could be malignant vs transudative volume from CHF. Stable from prior TTE imaging. # Pleural effusion: Known moderate right sided pleural effusion on CT torso. Etiology unclear but likely volume from HFrEF or malignant effusion in the setting of lung nodules. Patient was discharged on 2L NC with plans to follow-up with PCP and cardiologist for further monitoring. CHRONIC ISSUES ================ # CAD: continued rosuvastatin daily. Held aspirin iso thrombocytopenia and ICH # COPD: continued albuterol prn, symbicort BID, Spiriva daily # HTN: continued amlodipine and lisinopril # CT Chest Findings: moderate right sided pleural effusion with RLL relaxation atelectasis, moderate pericardial effusion, re-demonstration of bilateral pleural plaques. Also with LLL nodule mildly increased in size since ___ (15mm), 10mm nodule in RUL unchanged since ___. Patient has been on oxygen and discharged on oxygen with ambulation. Hemodynamically stable with no findings of diastolic LV/RV/RA collapse concerning for tamponade on echo. Will need outpatient follow up for nodules. TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 158.07 lb NEW MEDICATION: home oxygen continuously Clindamycin (___) STOPPED MEDICATION: aspirin 81mg daily [] discharged to use oxygen at home continuously [] left wrist laceration stitches to be removed by ___, follow up ___ clinic [] will need to have left limb wrapped from ___ up to elbow with ACE compression, with dry gauze dressing underneath, and careful surveillance by ___ of the edema and erythema for resolution of cellulitis. [] follow up of CT torso findings including nodules, pleural effusion, and small pericardial effusion [] follow up neuro exam to monitor for changes in the setting of ICH [] follow up CBC in 1 week to monitor pancytopenia, stable this admission [] please have ___ monitor for headache, dizziness, vision changes, focal neurologic findings (concern for worsening of IPH iso thrombocytopenia); also look for increase in weight, shortness of breath for HF signs; worsened arm swelling, erythema, tenderness, fevers (to suggest progression of skin and soft tissue infection) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 7. Finasteride 5 mg PO QHS 8. Furosemide 40 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Rosuvastatin Calcium 20 mg PO QPM 11. Sotalol 120 mg PO BID 12. Terazosin 2 mg PO QHS 13. Tiotropium Bromide 1 CAP IH DAILY 14. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Clindamycin 450 mg PO Q6H Duration: 7 Days 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB 4. amLODIPine 5 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Finasteride 5 mg PO QHS 7. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 8. Furosemide 40 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rosuvastatin Calcium 20 mg PO QPM 12. Sotalol 120 mg PO BID 13. Terazosin 2 mg PO QHS 14. Tiotropium Bromide 1 CAP IH DAILY 15.Outpatient Lab Work Please check CBC for platelet stability. Send results to Dr. ___ at ___ ICD: ___ Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS ================== Intraparenchymal hemorrhage Fall Left wrist laceration Positive UA Paroxysmal Atrial Fibrillation Thrombocytopenia SECONDARY DIAGNOSES =================== HFrEF (EF 40% VT s/p ICD placement on sotalol Small pericardial effusion Pleural effusion CAD COPD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, WHY YOU WERE ADMITTED TO THE HOSPITAL - You had a fall after which you developed a small bleed in your brain WHAT WE DID FOR YOU HERE - We checked your imaging and had the neurosurgeons evaluate you. They said the bleed was stable and there is no need for intervention or further imaging - We stopped your aspirin with the bleed and your low platelet counts - You were monitored on telemetry and had your ICD interrogated that showed no abnormal heart rhythms - You had an echocardiogram of your heart that was stable from your prior echocardiograms - Your ___ laceration showed evidence of infection and you were evaluated by the ___ Surgeons. An xray of the ___ was negative for any fracture or infection in your bone. You will take a 7 day course of an antibiotic called Clindamycin to treat the infection and continue an ACE-wrap ___ elevation to help with your swelling. WHAT YOU SHOULD DO WHEN YOU LEAVE - You should continue taking all your medications as prescribed - You should follow up with your primary care doctor, ___, and ___ specialist - You will need to keep an ACE compression bandage on your left wrist and elevated your ___ as much as possible to help relieve the swelling in your left ___. Please follow-up with the ___ Surgeons for monitoring of your wound. -Please use your 2L of oxygen at all times to ensure your oxygen levels stay at a safe level WHEN YOU SHOULD COME BACK - If you are experiencing headache, dizziness, weakness, paresthesias, visual changes, shortness of breath, chest pain, fevers, chills, worsening left ___ swelling, pain, redness, or any other symptoms that concern you It was a pleasure caring for you here! Sincerely, Your ___ Team Followup Instructions: ___
10090190-DS-13	10,090,190	21,564,652	DS	13	2186-01-05 00:00:00	2186-01-05 16:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: Exploration, D5 FDS/FDP repair, DA/Neurorrhaphy History of Present Illness: ___ yo RHD M with BPH presents 8 hours after a table saw injury to the L ___ webspace Past Medical History: BPH Social History: ___ Family History: Noncontributory Physical Exam: Left Hand: Surgical dressing clean and dry Dorsal blocking splint in place at 30 deg wrist flexion, 50 degrees MCP flexion. Decreased sensation at ___ digits, otherwise NVID All digits WWP Pertinent Results: ___ 07:06AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:03AM WBC-10.7* RBC-5.13 HGB-13.9 HCT-43.1 MCV-84 MCH-27.1 MCHC-32.3 RDW-14.5 RDWSD-44.6 ___ 03:03AM NEUTS-62.0 ___ MONOS-7.5 EOS-10.1* BASOS-0.9 IM ___ AbsNeut-6.66* AbsLymp-2.04 AbsMono-0.81* AbsEos-1.08* AbsBaso-0.10* ___ 03:03AM PLT COUNT-172 ___ 03:03AM ___ PTT-33.4 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have deep laceration to his left ___ web space and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for I+D, repair of nerves, vessels, tendons, 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 and a dorsal blocking splint was made. A Bair hugger was in place for the first 3 days after surgery. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient will be discharged on ASA 121 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. OT worked with Mr. ___ consistently throughout his hospital stay and was diligent, through the use of an interpreter, in ensuring that he understood his rehab precautions and instructions for home exercises as part of a Zone 3 tendon repair protocol. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Aspirin 121.5 mg PO DAILY Duration: 30 Days RX aspirin 81 mg 1.5 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BID PRN Disp #40 Capsule Refills:0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth Q4 PRN Disp #30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Tamsulosin 0.4 mg PO DAILY 6.Outpatient Occupational Therapy NWB LUE, Dorsal blocking splint, OT in morning for dorsal blocking splint - flexor tendon protocol - wrist at 30, MCP at 50. Zone 3 protocol. Discharge Disposition: Home Discharge Diagnosis: Traumatic table saw injury to left hand Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Do not lift anything with your left hand. Keep arm elevated as often as possible. Keep dorsal blocking splint in place. 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 daily aspirin 121mg daily (will continue for 30 days postop) WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10090242-DS-18	10,090,242	24,992,688	DS	18	2151-09-16 00:00:00	2151-09-16 14:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Hydroxychloroquine / Penicillins / Amoxicillin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: EUS/ERCP History of Present Illness: ___ year old female who complains of ABD PAIN. The patient has a history of recent biliary obstruction, status post ERCP at ___ ___, and ERCP here first in placement one week ago. She was in ___ today for a CT scan of the abdomen, at which point she was feeling well. On her way home, she developed significant RUQ pain radiating the back, associated with Nausea. She went to outside hospital where she had reassuring labs, and U/S reportedly showed dilated CBD with question of a pseudocyst. She denies any fevers, chills, nausea, vomiting, diarrhea, constipation, melena or hematemesis. Past Medical History: PMH: RA, ischemic colitis (on colonoscopy, resolved after polypectomy?), cholelithiasis PSH: open appendectomy (remote) Social History: ___ Family History: noncontributory Physical Exam: Gen: NAD, WDWN, pleasant HEENT: WNL CV: RRR, no M/R/G PULM: CTAB, no W/R/R ABD: Soft, tender to palpation RUQ and RLQ, no rebound/guarding, nondistended, no masses Ext: WWP, no edema Pertinent Results: ___ 03:20AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-143 K-4.0 Cl-107 HCO3-27 AnGap-13 ___ 03:20AM BLOOD ALT-26 AST-29 AlkPhos-116* TotBili-0.9 ___ 03:20AM BLOOD Lipase-24 ___ 03:20AM BLOOD Albumin-3.7 ___ 08:10AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.8 ___ 08:10AM BLOOD CEA-2.1 ___ EUS: Stent in the major papilla (stent removal) The bile duct appeared normal. The previously noted biliary stricture of the intra-ampullary portion of the bile duct has resolved. The biliary sphincterotomy appeared incomplete with residual sphincter still present - therefore decision to perform sphincteroplasty was made. A balloon sweep was performed with extraction of sludge, small stone fragments and bile. Given the previous atypical brushings, the decision was made to dilate the biliary sphincter and perform repeat brushings. Balloon sphincteroplasty was successfully performed with a 10mm . Cytology samples were obtained for histology using a brush in the common bile duct. Otherwise normal ercp to third part of the duodenum ___ ERCP: EUS: Several small sub-centimeter cysts, were noted in the body and tail of the pancreas. The pancreas was otherwise normal. The main PD was normal. The bile duct was followed to the ampulla - no mass lesion or wall thickening was noted. The ampulla was normal. Otherwise normal upper eus to second part of the duodenum Brief Hospital Course: Ms ___ was admitted to the ___ surgery service. Upon presentation, she had normal vital signs with RUQ pain only to deep palpation. Her labs were all within normal limits including LFTs with only a mildly elevated ALP 116. Her Tbili was 0.0. Given the presence of known gallstones and positive exam findings, she was started on empiric IV-cipro and flagyl. GI consult was obtained for EUS and ERCP. She was made NPO. On HD1, patient underwent EUS and ERCP. There was no mass in the head of the pancreas, only non-concerning small cysts in the body and tail. The previously seen stricture was found to be resolved after removal of the stent. Brushings were sent for cytology. The procedure was without complications and patient tolerated it well. On HD3, she was advanced to clears with normal post ERCP LFTs. She had small amount of emesis after advancing diet without any sustained nausea and had normal bowel function. On HD4, patient was advanced to a regular diet without difficulty. She continued to have pain in the RUQ with mild but sustained improvement. Given her clinical exam, her antibiotics were changed to Zosyn to broaden coverage with significant clinical improvement. On HD5, patient was transitioned to oral antibiotics which consisted of seven days of ciprofloxacin. By the time of discharge, patient remained afebrile with normal vital signs, she reported much improved pain, her laboratory results were within normal limits, she was tolerating a regular diet with normal bowel and bladder function and was ambulating independently. She expressed full comfort to continue to her recovery at home. She is to follow up with us in 2 weeks to discuss interval cholecystectomy as detailed in her discharge instructions. Medications on Admission: 1. morphine PRN Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet extended release(s) by mouth q6hr prn Disp #30 Tablet Refills:0 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q ___ hrs Disp #15 Tablet Refills:0 3. Nystatin Oral Suspension 5 mL PO QID:PRN thrush Duration: 14 Days RX nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp #280 Milliliter Refills:0 4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 5. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #15 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after having abdominal pain. You underwent an endoscopic ultrasound and ERCP. You were advanced to a regular diet and improved with antibiotics. You are now safe to continue your recovery at home. Please call your doctor or nurse practitioner if you experience 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 is 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. . General Discharge Instructions: 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, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: ___
10090737-DS-14	10,090,737	29,582,629	DS	14	2119-07-12 00:00:00	2119-11-16 13:41:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: iodine / Penicillins / Amoxicillin Attending: ___. Chief Complaint: arm paresthesias and hyperesthesia C5 after injury playing football Major Surgical or Invasive Procedure: none cervical orthosis History of Present Illness: The patient is a ___ yo M who presents after running head on into another football player. He states they hit mask to mask and that immediately after he took a step and fell to the ground. He then felt his arms and legs were too heavy to move. He then felt paresthesias in his upper and lower extremities. The heaviness and paresthesias disipated after a few seconds and he then felt paresthesias and hyperesthesias in bilateral upper extremities. Denies loss of bowel or bladder control. Past Medical History: none Social History: ___ Family History: NC Physical Exam: PE: NAD, A&Ox3 UE C5 C6 C7 C8 T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) R hyperesthesia intact intact intact intact L hyperesthesia intac intact intact intact T2-L1 (Trunk) intact ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R intact intact intact intact intact intact L intact intac intact intact intact intact Motor: UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8) FinAbd(T1) R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ Per(S1) ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Reflexes Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1) R 2 2 2 2 2 L 2 2 2 2 2 no tenderness to palpation of C/T/S spine perianal sensation intact, normal rectal tone No clonus Toes downgoing bilaterally negative ___ bilaterally Pertinent Results: ___ 04:15AM WBC-10.5 RBC-5.31 HGB-15.3 HCT-44.6 MCV-84 MCH-28.8 MCHC-34.2 RDW-12.8 Brief Hospital Course: Uncomplicated. Admitted for observation. C-collar maintained. Vitals remained stable. Able to ambulate. Seen by physical therapy and cleared. Paresthesias and hyperesthesia persists. Tolerated Dexamethasone dose, Neurontin initiated. No foley was placed as patient intact except for paresthesia, hyperesthesia Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #80 Tablet Refills:0 2. Dexamethasone 4 mg PO Q8H RX dexamethasone 2 mg 2 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 3. Gabapentin 300 mg PO Q8H RX gabapentin 300 mg 1 (One) capsule(s) by mouth every eight (8) hours Disp #60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: paresthesia from spinal cord contusion from cervical trauma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for observation after a cervical injury -Activity: You should not lift anything greater than 5 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. -Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. -You should resume taking your normal home medications. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. -Follow up: oPlease Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. Please call the office if you have any changes in your function or symptoms, or have any questions. Followup Instructions: ___
10090755-DS-7	10,090,755	23,765,179	DS	7	2110-10-26 00:00:00	2110-10-26 18:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right pleural effusion Major Surgical or Invasive Procedure: ___ right chest tube placed History of Present Illness: In brief, ___ is a ___ year old man w/PMH HBV on tenofovir c/b HCC s/p R hepatic lobectomy ___, HTN, and BPH who presented on ___ with two weeks of chest pain/tightness and subjective fevers with increased sputum production. He was admitted to the transplant surgery service. CTA showed large R pleural effusion w/associated RML and RLL collapse and pleural nodules suggestive of metastatic HCC. IP was consulted and placed pigtail catheter. 800cc of serosanguinous fluid was removed and fluid studies were consistent with transudative effusion (LDH 669, cholesterol 66). Cytology returned negative for malignancy and cultures are no growth to date. IP is considering MT/pleurodesis/TPC for definitive diagnosis and management. On surveillance staging imaging ___, patient was found to have pleural nodules suspicious for metastases, a new nonocclusive filling defect in the suprahepatic IVC which could represent thrombus or tumor thrombus, and multiple new small pulmonary nodules with mediastinal LAD concerning for metastases. On evaluation this evening, Mr. ___ is feeing well and is without complaint. He states that his pain medication is adequately controlling his pain from the chest tube. Denies cough, fever, chills, chest pain, shortness of breath. He denies personal or family history of blood clots. Past Medical History: PMH: HCC Hepatitis B HTN BPH Diverticulosis PSH: cataract surgery R hepatic lobectomy, diaphragmatic resection for ___ Social History: ___ Family History: Family History: Possible colon cancer in father Physical ___ Physical Exam: GENERAL: [x]NAD [x]A/O x 3 [ ]intubated/sedated [ ]abnormal CARDIAC: [x]RRR [ ]no MRG [ ]Nl S1S2 [ ]abnormal LUNGS: [x] CTA in RUL, diminished/absent breath sounds in RML and RLL lung fields. L lung CTA [x]no respiratory distress [ ]abnormal ABDOMEN: [ ]NBS [x]soft [x]Nontender [ ]appropriately tender [x]nondistended [ ]no rebound/guarding [ ]abnormal WOUND: [x]CD&I [x]no erythema/induration [ ]JP [ ]abnormal EXTREMITIES: [x]no CCE [ ]Pulse [ ]abnormal Discharge Physical Exam: GENERAL: Primarily ___ speaking. Alert and interactive. In no acute distress. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Decreased breath sounds throughout, absent in RLL ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Surgical incision in midline and RUQ from hepatic lobectomy EXTREMITIES: No clubbing, cyanosis, or edema. WWP. NEUROLOGIC: Face symmetric, moving all extremities spontaneously. AOx3 Pertinent Results: ___ Chest CT: The previously large right pleural effusion drained by a basal pigtail catheter, is much smaller and contains small air collections incidental to drain placement. High attenuation pleural nodules are likely metastases, but some could be clot. Image guided transthoracic needle aspiration should be feasible. A nonocclusive filling defect is new or newly apparent in the supra hepatic IVC and could be thrombus or tumor thrombus. Doppler ultrasound evaluation could better differentiate these. Small pulmonary nodules are new since ___ and more prominent though small mediastinal lymphadenopathy are likely metastases. ___ CT A/P: 1. Moderately-sized nonocclusive filling defect in the suprahepatic inferior vena cava approximately at the bifurcation of the middle and left hepatic veins. The middle and left hepatic veins are widely patent. 2. The patient is status post right hepatectomy with expected postsurgical changes. 3. There are no hepatic lesions that meet OPTN 5 criteria for hepatocellular carcinoma. 4. Moderate right pleural effusion with subcutaneous drainage catheter in place. 5. Fusiform dilatation of the right renal artery at the bifurcation in the right hilum measuring 2.2 x 1.5 x 1.1 cm. ___ AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: The right basilar chest tube has been removed. The small to moderate right pleural effusion with locules of air and compressive atelectasis of the right middle lobe and right lower lobe are not significantly changed compared to prior study, allowing for differences in patient's respiratory effort. There is no new consolidation. No pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. There are no acute osseous abnormalities. Brief Hospital Course: Mr ___ was admitted to the Transplant Surgery service on ___ with a large right sided pleural effusion. Interventional Pulmonology was consulted and a ___ chest tube was placed, draining 800 of serosanguinous fluid. This was sent for pleural studies. Pleural studies revealed a lymphocytic exudative effusion. Upon further review of the CT chest obtained on admission, pleural nodules were noted, concerning for metastasis of hepatocellular carcinoma. An AFP was sent; this was 31, increased from 19 prior to his hepatic lobectomy. Cytology from the pleural fluid did not show any malignant cells. Nonetheless, given concerns for metastatic disease, a staging CT scan (already previously scheduled as an outpatient) was performed. This demonstrated pleural nodules, again concerning for metastasis, as well as a suprahepatic IVC thrombus (bland). The patient was started on therapeutic Lovenox for this. Given these findings, the patient was therefore transferred to Medicine for further oncologic workup. Pt had the chest tube removed by IP and continued to have mild right sided chest pain and low grade fevers without any N/V/D or urinary symptoms. Repeat CXR was stable and pt was eager to get home for Christmas with his family. We spoke at length with patient and family (daughter who is a ___) about our concerns for recurrent cancer. We also explained the lack of diagnostic certainly and need for close follow up as outlined below. We emailed his primary oncologist who was able to get him in for follow-up right after ___. Pt was given teaching and was discharged on lovenox 60mg SubQ BID. Lovenox was chosen because he will likely need additional procedures with IP in the next ___ weeks and wouldn't want them delayed by the washout time required of a DOAC. Follow Up: - Interventional pulmonology: Follow up in ___ clinic w/ Dr. ___ in 2 weeks for thoracoscopyand biopsy of pleural nodules - Oncologist: Dr. ___ on ___ at 11:30 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 4. Aspirin EC 81 mg PO DAILY 5. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 0.6 mL SubQ twice a day Disp #30 Syringe Refills:0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed Disp #12 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17g powder(s) by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Pleural effusion h/o ___ s/p right hepatic lobectomy Pulmonary nodules Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: WHY WERE YOU ADMITTED: Chest pains and cough WHAT HAPPENED WHEN YOU WERE HERE: We discovered that you had fluid around your right lung, which we drained by placing a catheter. We also did a CT scan that showed some nodules/masses in your lungs most concerning for spread of cancer, although no diagnosis can be made until the lung doctors ___ the ___, which they are planning on doing in a few weeks. We have scheduled you an appointment with your oncologist on ___ and the lung doctors ___ to schedule an appointment very soon. You were also noted to have a small dilation in the artery going to your kidneys, we recommend that you follow up with vascular surgery in the next few months. (you can contact their office at ___ WHAT SHOULD YOU DO WHEN YOU GO HOME: - You should take your medications as prescribed. - You will inject 60mg enoxaparin under the skin twice daily - We will also give you some oxycodone for the chest pain you are having REASONS TO COME BACK TO THE HOSPITAL: Please come back to the hospital if you experience worsening chest pain, shortness of breath, fevers, chills, confusion, or any other concerning symptoms. It was a pleasure meeting you and providing care for you during your hospital stay. Sincerely, Your ___ Healthcare Team Followup Instructions: ___
10090755-DS-8	10,090,755	21,527,537	DS	8	2110-11-15 00:00:00	2110-11-15 18:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ - ___ pleural drain ___ - IP bedside chest tube placement VATs/Decortication/Pulmonary Nodule Biopsy Bronchoscopy History of Present Illness: HPI: The patient is a ___ male w/PMHx including hepatitis B (on tenofovir) complicated by hepatocellular carcinoma, and a 6mm solid right lower lobe nodule lung, s/p right hepatic lobectomy (at which time it was found the tumor infiltrated the diaphragmatic muscle, but did not extend to the inked margin of the diaphragm), who was admitted ___ with right-sided pleural effusion and negative cytology. Now presenting with subjective fevers, shortness of breath, and tachycardia. The patient started to have subjective fevers ~1mth ago, and then 1.5 weeks ago (around the time of his ___ admission), started to have low-grade temperatures, for which he began to take standing acetaminophen. During the patient's ___ admission to the transplant surgery service, he had quite a few temps in the ___, up to 100.6 at most (on ___. During that admission he was found to have a large right pleural effusion, interventional pulmonology placed a chest tube, which drained 800 cc of serosanguineous fluid. Pleural fluid studies revealed a lymphocytic exudative effusion, and CT imaging showed pleural nodules, all concerning for metastases of HCC. AFP was recent, and had increased from 19 prior to his hepatic lobectomy to now 31. However, cytology was negative. Given concerns for metastatic disease, a staging CT was performed, and in addition to the pleural nodules, this showed a supra-hepatic IVC thrombus, for which the patient was started on enoxaparin and transferred to medicine. He was then scheduled to follow-up in the interventional pulmonology clinic for a thoracoscopy and biopsy of the pleural nodules and with his oncologist today, ___. When he was seen by his oncologist today (Dr. ___, through an interpreter, with his wife and daughter present, he reported fever on a daily basis taking acetaminophen every 6 hours, with temperatures as high as 100.6. He also noted sweats, reportedly profuse, no chills. He noted chest discomfort in the right side and mild and intermittent cough but no shortness of breath. He was found to be tachycardic, heart rate 122, with an O2 saturation of 94%, and respirations of 16, temperature 99.3. Labs showed a white count of 13.1 and chest x-ray imaging showed "Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis." He was then referred to the ED: There he spiked a fever to 101.8, with associated tachycardia 130s, and was found to have tachypnea ___, satting 96% on 2 L, his heart rate improved to 107. His labs showed flu swab negative, blood culture was collected, ECG showed sinus tachycardia with left anterior fascicular block. He was given acetaminophen, piperacillin-tazobactam and vancomycin. He was also seen by interventional pulmonary who recommended ___ consultation for CT-guided chest tube placement. OMED declined admission, deferring to Medicine. Seen on the floor: through an interpreter on speaker phone we discussed his situation. He felt ok, noted a bit of bilateral chest discomfort, stable from prior, but denied shortness of breath or cough. He understood the plan to remove fluid from the chest tomorrow, and to have him be NPO, get IVF, IV antibiotics, and lab studies on the fluid. He asked me to speak with his daughter-in-law or son who would then distill the details of his care and interpret them for him. I then spoke with ___, his dtr-in-law and reviewed the above history and the plan of care. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Past Medical History: PMHx: #Hepatitis B on tenofovir #HCC s/p R hepatic lobectomy, with concerns for metastases to chest (pleural nodules, mediastinal lymphadenopathy, recurrent R sided pleural effusion) #Supra-hepatic IVC thrombus, on enoxaparin #HTN #DM #BPH #Anxiety #Constipation #Diverticulosis #Osteopenia PSHx: #Cataract surgery ___ and ___ Social History: ___ Family History: ? colon cancer in father Physical ___: ADMISSION VS: T 99.0, BP 142/87, HR 108, RR 20, O2 sat 98% on 2L NC, FSBG 152 Lines/tubes: PIV Gen: older man lying in bed, alert, cooperative, NAD HEENT: anicteric, MMM Chest: equal chest rise, limited air movement bilaterally ___ effort), but with a few inspiratory crackles on the R in the mid and lower lung zones, no other adventitial sounds Cardiovasc: RRR, slightly tachyc, no m/r/g Abd: well healed R subcostal scar, injection sites consistent with enoxaparin usage, soft, mild TTP in the RUQ, otherwise NTND GU: no CVAT Extr: WWP, no pitting edema Skin: no significant rashes on limited exam Neuro: CN II-XII intact (IX and X not specifically tested), strength ___ throughout, sensation to light touch intact throughout, reflexes symmetric Psych: normal affect DISCHARGE 24hr data: Temp: 97.9 (Tm 98.9), BP: 138/83 (102-138/51-83), HR: 84 (84-104), RR: 18, O2 sat: 98% (97-99), O2 delivery: Ra Gen: No distress, pleasant and conversant HEENT:MMM, No visible blood at nares/oropharynx CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: decreased breath sounds at right base and ___ up the right posterior lung fields, otherwise clear to auscultation. no increased work of breathing CHEST: all chest tubes removed, dressing in place with minimal sanguinous drainage. No erythema, warmth surrounding dressing. ABDOMEN: no distension. RUQ surgical site from prior hepatic lobectomy well-healed. tenderness to palpation in RUQ without guarding EXTREMITIES: 2+ radial pulses. SKIN: Warm and well perfused. No rash. Pertinent Results: ADMISSION LABS: ============== ___ 01:02PM BLOOD WBC-13.1* RBC-3.77* Hgb-10.8* Hct-34.8* MCV-92 MCH-28.6 MCHC-31.0* RDW-14.2 RDWSD-48.3* Plt ___ ___ 01:02PM BLOOD UreaN-8 Creat-0.7 Na-136 K-4.1 Cl-98 HCO3-27 AnGap-11 ___ 02:43PM BLOOD ___ PTT-25.5 ___ DISCHARGE LABS: ============== ___ 06:28AM BLOOD WBC-7.8 RBC-2.88* Hgb-8.4* Hct-27.4* MCV-95 MCH-29.2 MCHC-30.7* RDW-15.1 RDWSD-51.8* Plt ___ ___ 06:28AM BLOOD ___ PTT-34.3 ___ ___ 06:28AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-10 ___ 06:28AM BLOOD ALT-15 AST-25 LD(LDH)-209 AlkPhos-116 TotBili-0.3 ___ 06:28AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3 CXR ___ Compared to chest radiographs since ___ most recently ___. Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis. Left lung clear. Heart size normal. CT CHEST W/O CONTRAST ___ Again redemonstrated is a complex right small to moderate pleural effusion with multiple locules of gas. The overall volume of the pleural effusion has decreased in comparison to the prior examination, however, hyperattenuating areas appear to be slightly larger. Given the 8 day interval between the two CT examinations and the increase in size it is favored that these represent areas of hemothorax and blood clot (also given reported prior negative cytology results). PET/CT could be of value after acute symptoms have resolved to evaluate for the degree of possible metastatic disease. Stable small pulmonary nodules, suspicious for metastatic disease. CT INTERVENTIONAL PROCE ___ Successful CT-guided placement of ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. CT CHEST - ___ IMPRESSION: 1. Slight increase in size of moderate right loculated pleural effusion containing high-density material suggestive of blood products, and foci of air. 2. Additional small hydropneumothorax along the right upper lobe is new from prior CT. Status post chest tube removal. 3. Small simple left pleural effusion. 4. Unchanged 6 mm right upper lobe nodule and 9 mm left upper lobe nodule, indeterminate. 5. New visualization of small sub segmental pulmonary embolism of the right upper lobe. PATHOLOGY: ========== Pleural Fluid: DIAGNOSIS: PLEURAL FLUID, RIGHT: NEGATIVE FOR MALIGNANT CELLS. Many red blood cells, neutrophils, lymphocytes, and rare mesothelial cells. Pleura Biopsy/Excision: PATHOLOGIC DIAGNOSIS: 1. Exudate, right hemothorax, decortication: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 2. Nodule, right pleura, excision: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 3. Right pleura, decortication: - Pleural tissue with METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. Note: The tumor cells in these specimens are morphology similar to those present in the prior liver resection ___, reviewed). Brief Hospital Course: BRIEF HOSPITAL COURSE =================== ___ h/o HepB on tenofovir, ___ s/p recent R hepatic lobectomy with cholecystectomy and partial excision and repair of right hemidiaphragm, with recent readmission for R sided exudative pleural effusion of unclear etiology, also found to have pulmonary nodules and a supra-hepatic IVC thrombus prompting initiation of lovenox, readmitted ___ with sepsis and empyema, requiring operative management with course complicated by pulmonary abscess, hemoptysis and ___. # Acute hypoxic respiratory failure # Sepsis # Empyema # RLL abscess Patient with recent admission for pleural effusion of unclear etiology, status post drainage readmitted with fevers and dyspnea, imaging showing complex effusion, with fluid studies consistent with empyema. Patient started on broad spectrum antibiotics, had pleural drain placed by ___ with minimal sanguinous drainage, followed by chest tube placed by IP also with minimal sanguinous drainage. During this time patient had minimal clinical improvement, remained with loculated effusion and ongoing fevers. Patient was seen by ID consult service and thoracic surgery consult service who recommended surgical management. Patient transferred to thoracic surgery service when he underwent RLL VATS/decortication/pulmonary nodule biopsy. His surgery was complicated by transient hypotension and blood loss for which he received albumin and blood products respectively; he was subsequently transferred to the medicine service. While on the medicine service, pleural tissue pathology resulted and was consistent with metastatic hepatocellular carcinoma. Pleural fluid was without malignant cells. However, it was thought that the patient's pleural effusion was most likely malignant in nature. Placement of a PleurX was discussed with thoracic surgery given concern for recurrent pleural effusions, but deemed unnecessary, given that the decortication procedure performed during the patient's hospitalization was akin to a mechanical pleurodesis. The patient was maintained on vancomycin and zosyn for the majority of his hospitalization excepting a 2 day interruption in antibiotics which was accompanied by recurrent leukoctysis. Vancomycin was discontinued on ___ after MRSA swab resulted negative. Patient was transitioned to augmentin (D1: ___, with plan for ___ week course in the setting of concern for RLL parenchymal abscess raised by Interventional Pulmonology after re-review of patient's CT chest and bronchoscopy. Patient was discharged on augmentin with plan for follow up with Interventional Pulmonology as outpatient for monitoring of possible abscess. #Hemoptysis #Epistaxis #Bleeding around chest tube Hospital course was complicated by low volume hemoptysis in the setting of recent heparin administration which persisted for several days. Thoracic surgery was consulted and recommended Interventional Pulmonology involvement. Interventional pulmonology recommended CT chest, which did not reveal etiology. IP also recommended bronchoscopy which indicated that the RLL was the source of bleed. Per IP, no acute intervention was warranted. On re-review of chest CT, IP was concerned for intraparenchymal abscess. In line with IP recommendations, we proceeded with antibiotic treatment as above, with patient discharged on ___ week course of augmentin with planned follow up with IP. Heparin gtt was reinitiated after bronchoscopy and tolerated well with patient transitioned to lovenox prior to discharge. ___ Patient with baseline Cr ~0.7, increased to max 1.4 in the setting of blood loss, poor PO intake, nephrotoxic antibiotic regimen. Blood products and fluids were given as needed with mild improvement in creatinine. Urine lytes obtained near the end of ___ hospital course were consistent with intrarenal etiology, with improvement in creatinine after removing vancomycin and zosyn from patient's medication regimen. Patient was discharged with creatinine of 1.0 with plan for outpatient BMP. #TB rule out ID with concern that pulmonary nodules seen on patient's CT chest could represent TB. As such patient underwent TB rule out. Respiratory precautions were put in place. Acid fast smear/culture from induced sputum was negative x3 and respiratory precautions were lifted. Pulmonary nodules were biopsied and found to be consistent with metastatic hepatocellular carcinoma. # Chronic IVC thrombus Diagnosed during previous admission in ___, concerning for possible tumor thrombus. Was treated with lovenox, bridged with IV heparin periprocedurally. Reinitiated heparin gtt on ___ in s/o stable CBC which was held intermittently with concern for new onset hemoptysis. After bronchoscopy performed as above, heparin was reinitiated at weigh- based protocol. Patient was transitioned to lovenox without adverse event. # Pulmonary nodules # Hepatocellular Carcinoma Patient has known pleural nodules suspicious for metatatic HCC disease. Now pathology confirmed. See above. #Nutrition Patient has minimal appetite in the setting of metastatic disease. No associated nausea/vomiting. His meals supplements were supplemented with Glucerna shakes. Patient was initiated on mirtazapine to assist with appetite. # Chronic Hepatitis B Continued home tenofovir # Hepatocellular Carcinoma Continued prn oxycodone # Diabetes type 2 Continued insulin sliding scale # BPH Continued Finasteride, Tamsulosin TRANSITIONAL ISSUES ==================== [] Patient with hospital course complicated by ___ thought to be of mixed etiology (prerenal/intrarenal). Improved creatinine on discharge but not back to baseline of 0.7. Please obtain BMP as outpatient to monitor and ensure continued improvement. [] Patient with likely intraparenchymal abscess. Plan for outpatient follow up with IP, Dr. ___. Patient should have CT scan within ___ weeks for monitoring of abscess (to be scheduled by IP). If no response to prolonged antibiotic course, will likely need surgical intervention. [] Patient should continue with 6 week course of Augmentin (Day 1: ___ - ___ [] Patient with metastatic hepatocellular carcinoma. Will need close follow up with outpatient oncologist for treatment planning. [] Patient with decreased appetite and poor PO intake throughout hospitalization. Primary oncologist should monitor nutrition as outpatient. [] Patient has had elevated fasting blood glucose this hospitalization but has required <1u Novolog per day. Please evaluate for outpatient management of likely DM with oral medications. #CODE: Full #CONTACT: ___ (daughter-in-law) ___ ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. tenofovir disoproxil fumarate 300 mg oral DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. Polyethylene Glycol 17 g PO DAILY 6. Acetaminophen 1000 mg PO Q8H 7. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: ___ Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #80 Tablet Refills:0 2. Mirtazapine 7.5 mg PO QHS RX mirtazapine 7.5 mg 1 tablet(s) by mouth every night Disp #30 Tablet Refills:0 3. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 60 mg SC every 12 hours Disp #60 Syringe Refills:0 6. Finasteride 5 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 8. Polyethylene Glycol 17 g PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================= METASTATIC HCC IVC THROMBUS PULMONARY ABSCESS EMPYEMA MALIGNANT PLEURAL EFFUSION HEMOPTYSIS SECONDARY DIAGNOSES: =================== HEPATITIS B ELEVATED FASTING GLUCOSE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you had an infection in your lungs. What did you receive in the hospital? - In the hospital, our thoracic surgeons performed a procedure to allow your lungs to better expand and minimize the risk of fluid accumulation in the lungs. - You also received antibiotics to treat a pulmonary abscess (an area of infection). You were discharged on these antibiotics as this type of infection requires a long course of treatment. - You were started on a medication to increase your appetite as our nutritionists feel you would greatly benefit from more food intake. - You were reinitiated on your anticoagulation therapy (blood thinners) which you are on for your increased risk of blood clots. You currently have blood clots in one of your large blood vessels and in your lungs. The anticoagulation therapy should stabalize these clots. What should you do once you leave the hospital? - Make sure to continue to take your medications as prescribed and follow up with your outpatient providers. - If you develop any fevers, lethargy, shortness of breath, please go to the emergency room immediately We wish you all the best! - Your ___ Care Team Followup Instructions: ___
10090768-DS-6	10,090,768	28,397,943	DS	6	2148-11-09 00:00:00	2148-11-13 19:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Compazine Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female undifferentiated spondyloarthropathy on etanercept, history of uncomplicated diverticulitis x 2. She presents with LLQ abdominal pain x 2 days. Patient states that she has had 2 prior episodes of uncomplicated diverticulitis, both of which were treated as an outpatient with clear liquid diet and oral abx. Was in usual state of health until two days ago when she noted vague lower abdominal pain. Pain described as mild to moderate and located in LLQ and suprapubic areas. No alleviating/aggravating factors. Describes pain as similar to prior diverticulitis but more severe. Associated w constipation and chills. Was on vacation in ___ pain worsened during car-ride home. Sought evaluation at ___ ED when pain worsened. Surgery consult obtained. On surgery evaluation, patient relays history as above. Pain currently mild to moderate. No BM x 4 days. Tolerating diet but appetite poor. +Chills. No other associated symptoms. Denies fever, chest pain, shortness of breath, nausea, vomiting, blood per rectum, diarrhea, dysuria, pneumaturia. Last c-scope ___ years ago w report of diverticulosis but no other abnormality Past Medical History: HTN, undifferentiated spondyloarthropathy, Hx diverticulitis Social History: ___ Family History: non-conbtributory Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 97.7 HR: 80 BP: 111/70 Resp: 20 O(2)Sat: 98 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Extraocular muscles intact Oropharynx within normal limits Abdominal: Soft, Nondistended, mild,LLQ tenderness GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent, GCS 15, full strength Psych: Normal mood, Normal mentation ___: No petechiae Physical examination upon discharge: GENERAL: NAD vital signs: 98.3, hr=63, bp=126/62, rr=16, 100% room air CV: ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, non-tender, no hepatomegaly, no splenomegaly EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 04:35AM BLOOD WBC-5.2 RBC-3.72* Hgb-11.0* Hct-33.4* MCV-90 MCH-29.6 MCHC-32.9 RDW-12.3 RDWSD-40.2 Plt ___ ___ 04:40AM BLOOD WBC-5.7 RBC-3.88* Hgb-11.6 Hct-34.5 MCV-89 MCH-29.9 MCHC-33.6 RDW-12.3 RDWSD-39.5 Plt ___ ___ 10:10AM BLOOD Neuts-67.6 ___ Monos-11.9 Eos-0.4* Baso-0.8 Im ___ AbsNeut-7.42# AbsLymp-2.09 AbsMono-1.31 AbsEos-0.04 AbsBaso-0.09* ___ 04:35AM BLOOD Plt ___ ___ 04:35AM BLOOD Glucose-142* UreaN-11 Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-23 AnGap-15 ___ 10:10AM BLOOD ALT-17 AST-20 AlkPhos-81 TotBili-1.1 ___ 04:35AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 ___ 02:37PM BLOOD Lactate-1.4 ___: cat scan of abdomen and pelvis: 1. Diverticulitis of the sigmoid colon with multiple pockets of peripheral air in the deep pelvis, which may represent large diverticula or small foci perforations. Trace free fluid in the pelvis is identified. No walled off fluid collection is identified within the pelvis. 2. Moderate perisigmoid fat stranding. ___: cat scan of abdomen and pelvis: 1. Improvement in sigmoid diverticulitis without evidence of fluid collection. 2. Resolution of previously seen trace pelvic free fluid. Brief Hospital Course: ___ year old female who was admitted to the hospital with abdominal pain. She reportedly has a history of RA which has been managed with embrel. She underwent a cat scan of the abdomen which showed perforated diverticulitis. She was made NPO, given intravenous fluids and started on antibiotics. Her abdominal pain began to resolve and she had a repeat cat scan on HD #3 which showed improvement in the sigmoid diverticulitis without evidence of fluid collection. The patient was started on a regular diet. She had no recurrence of pain. On HD #4, the patient was discharged home in stable condition. She was afebrile and ambulatory and voiding without difficulty. She was discharged on a 14 day course of ciprofloxacin and flagyl with 12 days remaining. She was instructed to follow-up with her Rheumatologist regarding her embrel and to discuss when to resume it. She was informed of the need for a colonoscopy in ___ weeks after discharge and was given the telephone number of the GI service. A follow-up appointment was made with the acute care service, Dr. ___. Dishcharge instructions were reviewed with the patient and she conveyed understanding. Medications on Admission: ETANERCEPT [ENBREL] - Enbrel 50 mg/mL (0.98 mL) subcutaneous syringe. 1 once weekly (___) FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth once a day LISINOPRIL - lisinopril 30 mg tablet. 1 tablet(s) by mouth once a day Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days last dose ___ RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #24 Tablet Refills:0 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 12 Days last dose ___ RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #36 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID hold for diarrhea RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. Senna 8.6 mg PO BID:PRN constipation 5. Lisinopril 30 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: sigmoid diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain. You underwent imaging and you were reported to have diverticulitis with concern for perforation. You were placed on bowel rest and given intraveous fluids. Your abdominal pain resolved and you had repeat imaging which showed marked improvement of the diverticulitis. You resumed a regular diet without recurrence of your abdominal pain. Your white blood cell count has been normal. You are preparing for discharge with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: ___
10090787-DS-7	10,090,787	20,628,099	DS	7	2172-01-20 00:00:00	2172-01-20 23:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain/palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o CAD s/p CABG in ___, Cath with stent placement ___ presenting from ___ with anterior chest pressure similar to prior MI. He reports that the pain was constant after lifting a heavy toilet yesterday. On arrival to the ___ the patient was noted to be in SVT. The patient has prior episodes of SVT that have occurred during various presentations to the hospital. Most notably in ___ when the patient received his last ___. There was also report of ST elevation changes in II, aVL. The patient was given aspirin, Plavix, heparin and morphine and sent for evaluation at ___ for emergent cardiac evaluation. On arrival patient denies any chest pain, sob. States it resolved after receiving the medication at ___. The patient's EKG was reviewed by the cardiology fellow and determined to be ECG w/ non-specific changes. No evidence of STEMI. In the ED initial vitals 0 97.7 60 129/42 22 100% RA. The patient had normal troponin and was back into sinus rhythm. He was well appearing and breathing comfortably on RA. The patient's heparin gtt was held and he was admitted to the ___ service. On the floor the patient's vitals were 99.1 151/58 73 18 96 on RA. The patient was NAD with no active complaints. On further review of his history the patient reports that since ___ his exercise capacity has increased. He is able to walk ___ miles with his dog without significant symptoms. He also reports that he is able to walk up the stairs without stopping and without symptoms. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. Denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: - palpitations w/ chest pain episodes for last ___ years. States these have gotten better since his CABG in ___ lasting only up to 1 hr as opposed to up to 2 hrs prior to surgery. - s/p ___ LIMA to left anterior descending, SVG to obtuse marginal. Post op course complicated by SVT's requiring cardioversionx2. Cardiac Cath ___ with angiplasty and stenting of LMCA with 3.05 Cypher DES. - Prostate ca- Diagnosed ___, s/p Prostatectomy - HTN - Hyperlipidemia - GERD - S/P appendectomy - MVA ___- pt states this resulted in temporary back pain. -GIB- ? source stomach after CABG in ___ Social History: ___ Family History: Brother died at ___ of MI. Mother and father had coronary artery disease at ages ___ and ___, respectively, passed away. Physical Exam: Admission Physical ================== VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 9 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. regular rhythm with premature beats, 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. Decreased breath sounds in the right lower lobe ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric Discharge Physical ================== VS: 98.2 115-153 64-69 18 96-99\|RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. regular rhythm with premature beats, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric Pertinent Results: Admission Labs ============== ___ 11:58AM BLOOD WBC-8.9 RBC-4.58* Hgb-13.6* Hct-41.4 MCV-90 MCH-29.7 MCHC-32.9 RDW-12.8 RDWSD-42.2 Plt Ct-75* ___ 11:58AM BLOOD Neuts-86.3* Lymphs-8.1* Monos-4.5* Eos-0.0* Baso-0.4 Im ___ AbsNeut-7.68* AbsLymp-0.72* AbsMono-0.40 AbsEos-0.00* AbsBaso-0.04 ___ 11:58AM BLOOD Plt Smr-VERY LOW Plt Ct-75* ___ 11:58AM BLOOD Glucose-106* UreaN-20 Creat-1.2 Na-134 K-3.8 Cl-95* HCO3-24 AnGap-19 ___ 11:58AM BLOOD cTropnT-<0.01 ___ 04:55PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8 ___ 04:55PM BLOOD TSH-0.40 Pertinent Interval Labs ======================= ___ 04:55PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:11AM BLOOD CK-MB-<1 cTropnT-<0.01 Discharge Labs ============== ___ 05:35AM BLOOD WBC-7.4 RBC-4.48* Hgb-13.2* Hct-40.1 MCV-90 MCH-29.5 MCHC-32.9 RDW-13.2 RDWSD-43.8 Plt Ct-77* ___ 05:35AM BLOOD Plt Ct-77* ___ 05:35AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-134 K-3.9 Cl-97 HCO3-26 AnGap-15 ___ 05:35AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 Imaging & Studies ================= CXR ___ FINDINGS: Sternotomy. Mildly tortuous thoracic aorta. Aortic calcification. Normal heart size, pulmonary vascularity Suggestion of tiny pleural effusion or thickening posterior costophrenic angle. IMPRESSION: Tiny pleural effusion or thickening TTE ___ The left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (3D LVEF = 58%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Dilated ascending aorta. Mild pulmonary hypertension. Stress ___ INTERPRETATION: ___ yo man with HL and HTN; s/p CABG in ___ with PCI to LM in ___ was referred to evaluate an atypical chest discomfort in the presence of SVT. The patient completed 13.25 minutes of a Gervino protocol representing an average exercise tolerance; ~ ___ METS. The exercise test was stopped due to fatigue. No chest, back, neck or arm discomforts were reported. No significant ST segment changes were noted. The rhythm was sinus with frequent isolated APBs noted early in exercise. With increasing levels of exercise only rare isolated APBs were noted. The blood pressure response to exercise was appropriate. In the presence of beta blocker therapy, the peak exercise heart rate was blunted. IMPRESSION: Average exercise tolerance for age. No anginal symptoms or ischemic ST segment changes. No exercise-induced arrhthmia. Appropriate blood pressure response to exercise. Blunted heart rate response. Nuclear report sent separately. Cardiac Perfusion ___ Exercise protocol: Gervino Exercise duration: 13.25 minutes Reason exercise terminated: Fatigue. Resting heart rate: 71 bpm Resting blood pressure: 84/50 Peak heart rate: 89 bpm Peak blood pressure: 150/60 Percent maximum predicted HR: 63% Symptoms during exercise: Fatigue otherwise no symptoms. ECG findings: No ST segment changes or exercise-induced arrhythmia. Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. At peak exercise, approximately three times the resting dose of Tc-99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging Protocol: Gated SPECT FINDINGS: Left ventricular cavity size is normal with end-diastolic volume of 85 mL. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 55%. IMPRESSION: 1. Normal cardiac perfusion for local stress achieved. 2. Normal left ventricular cavity size an ejection fraction Microbiology ============ None Brief Hospital Course: Mr. ___ is a ___ male with PMH significant for CAD s/p CABG in ___, PCI with placement ___ 1 to ___ in ___ and symptomatic supraventricular tachycardia who presents with palpitations and anterior chest pressure similar in nature to prior MI. # CAD s/p CABG (___) ___ 1 to ___: Patient noted pain after lifting a heavy object and was noted to be in SVT upon arrival to ED, concerning given prior h/o SVT when patient received cardiac cath. Patient was transferred from ___ to ___ on aspirin, plavix, heparin ggt, and morphine. At ___, EKG demonstrated non-specific changes with negative troponins x 2. Heparin ggt was stopped in setting of resolution of chest pain and normal findings. Patient had last had coronary angiogram in ___ during PCI that demonstrated LAD small and patent, patent LIMA, and SVG-OM widely patent. He received a ___ 1 to ___ with no residual stenosis. Exercise stress test and P-MIBI were performed that were normal. Chest pain felt to more likely related to SVT as opposed to CAD. Patient was continued on ASA 81, atorvastatin 80mg. Metoprolol and diltiazem were increased for improved nodal blockade in the setting of SVT with angina. His clopidogrel was discontinued in the setting of thrombocytopenia. # SVT with angina: Patient had SVT consistent with prior episodes extending back ___ years or so. Episode was initiated by lifting a heavy object and lasted until he arrived at the hospital. Patient spontaneously returned to ___ and chest pain improved. Patient had several similar episodes of SVT captured on telemetry that lasted ___ - ___. Episode was initiated by PAC. At this point differential diagnosis is AVNRT, AVRT, sinus tachycardia. Given onset with PAC and initiation during sleep and during lifting, AVNRT seems likely. Retrograde P wave not visualized although may be embedded in T wave. Patient's nodal blockage was increased to metoprolol succinate 150mg daily and diltiazem ER 240mg daily. He was discharged with ___ of Hearts for follow up with Dr. ___ in 2 weeks. If patient does not have adequate improvement, may require electrophysiology follow up and possible ablation. # Thrombocytopenia. Patient with thrombocytopenia during this admission with PC from ___ to ___ verified by smear. No evidence of bleeding or other complications with last platelet count 221 in ___. Plavix was discontinued. Other cell lines constant so infiltrative process less likely. ITP possible. If no improvement after discontinuing Plavix, patient will need HCV, HIV, H. Pylori testing and referral to Hem/Onc. # HTN: Patient continued on metop/dilt with doses increased per above # HLD: Patient continued on atorvastatin 80mg daily TRANSITIONAL ISSUES: - Patient discharged with ___ Monitor, with results monitored by outpatient cardiologist Dr. ___. - Medication changes: metoprolol increased to 150mg ; diltiazem increased to 240mg. STOPPED Plavix due to thrombocytopenia and no current indication. - Noted to have thrombocytopenia on admission, stable on discharged at 77K. Please continue to monitor as outpatient and work up as indicated clinically. # CODE: Full # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 240 mg PO DAILY RX diltiazem HCl [Cardizem CD] 240 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. Metoprolol Succinate XL 150 mg PO DAILY RX metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. FoLIC Acid 1 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Intermittent supraventricular Tachycardia - Angina Secondary issues: - thrombocytopenia - HTN - HLD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted for evaluation of your chest pain. You underwent two studies, an exercise stress test and a pMIBI scan, both of which were NOT concerning for significant underlying blocked vessels. You were noted to have an intermittent fast heart rate that can cause the symptoms you experienced. In order to treat this, we increased your medications metoprolol and diltiazem. You will need to follow up with Dr. ___ further management of your heart. You were also noted to have a low platelet count and so we stopped your Plavix. Please follow up with your PCP and cardiologist for ongoing management of this issue. Please continue to take all medications as prescribed in this discharge summary and follow up with all scheduled appointments. If you develop any of the danger signs listed below, please contact your doctors ___ return the hospital immediately. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
10090787-DS-8	10,090,787	27,982,098	DS	8	2174-03-30 00:00:00	2174-03-30 11:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Tachycardia and chest pain Major Surgical or Invasive Procedure: AVNRT ablation ___ History of Present Illness: ___ with history of CABG in ___, who presents with a complaint of palpitations and chest pain. Patient endorsed chest pain for one day duration, waxing and waning. Earlier today, patient had more sustained chest pain and went to see his PCP. An ECG was performed and revealed tachycardia. PCP referred the patient to the ED. Upon arrival to the ED, patient endorsed nonradiating chest pain. He triggered for tachycardia >130; ECG revealed SVT. Vagal maneuvers were unsuccessful. He was given 6mg adenosine followed by 12mg adenosine and converted to sinus rhythm. His chest pain dissipated after conversion of his rhythm. In the ED initial vitals were: Temp 96, HR 145, BP 120/77, RR 18, 100% Ra EKG: Initial ECG with narrow complex regular tachycardia consistent with SVT. Repeat ECG after conversion with adenosine NSR with borderline 1st degree block, TWI in V1 and V2, no ST segment changes. Labs/studies notable for: 144 104 20 --------------< 118 4.5 23 1.4 11.8 > 14.2/44.7 < 171 ___: 11.2 PTT: 26.4 INR: 1.0 Ca: 10.1 Mg: 1.9 P: 3.3 CK: 82 MB: 2 Trop-T: <0.___lood and 30 protein Patient was given: Adenosine 6mg followed by 12mg ASA 243mg (for full 325 load) 500mL NS Vitals on transfer: HR 55 \| BP 144/69 \| RR 17 \| SpO2 97% RA On the floor he endorses story above, not having any current chest pain or shortness of breath or palpitations. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope, or presyncope. On further review of systems, denies fevers or chills. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Hypertension - Dyslipidemia - CABG in ___ for LMCA stenosis with a LIMA to LAD and SVG to OM - PCI with DES to LCMA in ___ -Prostate cancer -GERD Social History: ___ Family History: Brother died at ___ of MI. Mother and father had coronary artery disease at ages ___ and ___, respectively, passed away. Physical Exam: Admission PE: VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ============================================== Discharge PE: VS: Temp 98, BP 115-163/69-75, HR 61, RR 16, O2 sat 95% on room air Tele: rate 59-66, SR, prolonged PR Discharge weight: 186.29 lbs/ 84.5 kg ================ GENERAL: NAD. Oriented x3. Mood, affect appropriate. NECK: Supple. JVP not elevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Access sites: B/L groin sites C/D/I. No ooze or hematoma. B/L ___ palpable. Pertinent Results: Admission Labs: ___ 03:00PM BLOOD WBC-11.8* RBC-4.91 Hgb-14.2 Hct-44.7 MCV-91 MCH-28.9 MCHC-31.8* RDW-14.6 RDWSD-48.8* Plt ___ ___ 03:00PM BLOOD Neuts-57.1 ___ Monos-7.3 Eos-2.4 Baso-0.5 Im ___ AbsNeut-6.74* AbsLymp-3.82* AbsMono-0.86* AbsEos-0.28 AbsBaso-0.06 ___ 03:00PM BLOOD ___ PTT-26.4 ___ ___ 03:00PM BLOOD Glucose-118* UreaN-20 Creat-1.4* Na-144 K-4.5 Cl-104 HCO3-23 AnGap-17 ___ 03:00PM BLOOD CK(CPK)-82 ___ 03:00PM BLOOD CK-MB-2 ___ 03:00PM BLOOD Calcium-10.1 Phos-3.3 Mg-1.9 ========================================================= Discharge Labs: ___ 08:26AM BLOOD UreaN-27* Creat-1.1 K-4.1 ___ 08:26AM BLOOD Mg-2.0 ============================== Results: CXR PA/Lat ___: IMPRESSION: Lower lung opacities likely atelectasis though difficult to exclude a developing pneumonia especially at the left lung base. ============================================================ TTE ___: CONCLUSION: The left atrial volume index is moderately increased. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is a centrally directed jet of moderate [2+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate functional aortic regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. Compared with the prior TTE (images not available for review) of ___, the severity of aortic regurgitation is now increased. = ================================================================ EP Brief Procedure Note ___: Findings ___ with frequent SVT referred for EPS. Incessant AVNRT induced. Ablation performed in slow pathway region with junctional beats noted. Conduction intact afterwards, noninducible with and without isuprel and 20 minute wait period. No complications. Brief Hospital Course: Assessment/Plan: Mr ___ is an ___ man with hx of CABG in ___, PCI s/p DES to LCMA in ___, HTN, who presented with SVT and chest pain, converted with adenosine, admitted to cardiology floor in NSR and remained bradycardic to 40-50's on the floor. # SVT with angina: Patient had SVT consistent with prior episodes. Was bradycardic 47-52 at rest on the floor. HR increases to 56-69 with ambulation. EP consulted for SVT management. EP recommended AVNRT ablation after reviewing ekg's and strips. -s/p successful AVNRT ablation - stop dilt - Start metop tartrate 25 mg bid - Home with ___ - F/U with Dr. ___ on ___ AT 11:30 AM and PCP on ___ AT 10:00 AM # CAD s/p CABG (___) ___ 1 to ___ in ___, presented initially with chest pain in the setting of SVT which resolved in the ED. trop/MB negative x3, no ischemic changes on EKG. - continue atorvastatin, ASA - start metop tartrate 25 mg bid - plavix had previously been stopped at prior admission because of thrombocytopenia # HTN: - Stop dilt - Resume ibesartan 300 mg daily # HLD: - continue atorvastatin 80mg daily # DISPO: discharge home today Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral DAILY 2. Metoprolol Succinate XL 100 mg PO QAM 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. Aspirin 81 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO QHS Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID 2. Aspirin 81 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. irbesartan 300 mg oral DAILY 5. Pantoprazole 40 mg PO Q24H 6. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: AVNRT CAD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of chest pain and tachycardia. Your rhythm was converted to normal sinus rhythm with use of medication in the Emergency room. EP was consulted and you were found to have AV nodal re-entry tachycardia (AVNRT). You had an ablation to treat AVNRT. Activity restrictions and information regarding care of the procedure site on your groin are included in your discharge instructions. Please continue your current medications with the following change: - Stop metoprolol succinate. Instead, start metoprolol succinate 25 mg twice a day. This dose change will help in preventing your heart rate from going too low. - Stop diltiazem. You do not need this medication after ablation. - Continue irbesartan at 300 mg without any changes. You will be wearing a heart monitor for the next ___ will be able to monitor your heart rate and rhythm. If you have any urgent questions that are related to your recovery from your medical issues or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner It has been a pleasure to have participated in your care and we wish you the best with your health! Your ___ Cardiac Care Team Followup Instructions: ___
10091225-DS-15	10,091,225	28,005,563	DS	15	2163-11-23 00:00:00	2163-11-23 16:57:00	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: Ms. ___ is a ___ year old female s/p ventral hernia repairs x 4, most recently in ___ for ___,presenting with pain over her hernia site since ___. She reports nausea, but no vomiting and no fevers or chills. Last bowel movement was on ___ after the onset of pain and she continues to have flatus. NGT placed by ED put out minimal clear fluid. Past Medical History: Diabetes Mellitus Type 2 Hypertension H.Pylori uterine fibroids HLD obesity urinary incontinence PSH: ventral hernia repairs x4 (component separation ___, most recent for ___ ___, ex lap/appendectomy (age ___, C-section, rhinoplasty, vein stripping (RLE ___, b/l ___, R breast biopsy (benign, ___, uterine artery embolization (___) Social History: ___ Family History: NC Physical Exam: Admission Physical Exam: ___ Vitals: 97.4 76 141/61 18 100% RA GEN: A&Ox3, NAD, nontoxic appearance HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, mild-mod distention, lower midline (slightly R of midline) well-healed incision w/ reducible hernia - large fascial defect - somewhat tender, no rebound or guarding, normoactive bowel sounds Ext: No ___ edema, ___ warm and well perfused Discharge PE: ___ Vitals: 98.6, 62, 114/64, 18 95% RA General: comfortable woman, NAD LUNGS: LSCTAB CV: RRR, No murmurs or gallops ABD: soft, nontender, nondistended Extrem: Warm, Well perfused, + PP Neuro: alert and oriented, PERRL Pertinent Results: ___ 02:15AM PLT COUNT-414 ___ 02:15AM ___ PTT-32.7 ___ ___ 02:15AM NEUTS-82.8* LYMPHS-11.3* MONOS-4.2 EOS-1.5 BASOS-0.2 ___ 02:15AM WBC-11.2* RBC-4.54 HGB-12.3 HCT-37.7 MCV-83 MCH-27.1 MCHC-32.7 RDW-14.7 ___ 02:15AM ALBUMIN-4.4 ___ 02:15AM LIPASE-38 ___ 02:15AM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-73 TOT BILI-0.2 ___ 02:15AM GLUCOSE-151* UREA N-21* CREAT-0.9 SODIUM-137 POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-23 ANION GAP-22* ___ 05:48AM K+-4.2 ___ 05:05AM BLOOD WBC-5.1 RBC-4.32 Hgb-11.3* Hct-36.3 MCV-84 MCH-26.2* MCHC-31.2 RDW-14.6 Plt ___ ___ 05:05AM BLOOD Glucose-103* UreaN-12 Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-29 AnGap-11 ___ 05:05AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0 ___: CT ABD/Pelvis: 1. Dilated loops of distal small bowel leading up to an anastomosis in the lower right abdominal quadrant. Stool is seen throughout the colon. The constellation of these findings are suggestive of either a partial or early complete small bowel obstruction. No convincing evidence of bowel ischemia. 2. Small volume ascites, nonspecific in nature. 3. Fluid containing large ventral hernia, not significantly changed. 4. Enlarged fibroid uterus, as before. ___: KUB: Multiple distended loops of small bowel with some gas seen in the colon, consistent with early or partial small bowel obstruction. Brief Hospital Course: Ms. ___ is a ___ y.o. female s/p ventral hernia repairs x 4, most recently in ___ for SBO presenting on ___ with one day of pain over her hernia site. Pt. reports nausea but no vomiting. Her last bowel movement was the prior to the onset of pain. A nasogastric tube was placed by ED and put out minimal clear fluid. On admission a CT scan of the abdomen pelvis revealed a small bowel to small bowel anastomosis in the right lower abdominal quadrant with there is dilatation and fecalization of loops of small bowel just distal to this sitesuggestive of either a partial or early complete small bowel obstruction. The patient has remained hemodynamically stable and afebrile. Her nausea resolved over the next ___ hours and her abdominal exam was benign. On ___, her NGT was clamped and had no residual. It was removed and she tolerated a clear diet which was advanced to regular. She was passing bowel movements. She was ambulating independently without pain. It was decided that she would follow up with the Acute Care Surgery clinic to discuss surgical options as an outpatient. This was explained to the patient to discharge and she will follow up on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. MetFORMIN (Glucophage) 500 mg PO BID 3. Losartan Potassium 25 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO 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 - Independent. Discharge Instructions: Ms. ___, You were admitted to ___ with a small bowel obstruction, which has now resolved. You are ready to recover at home. You will have a follow up with the Acute Care Surgery Clinic as follows. At this time they will discuss surgical planning. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10091327-DS-11	10,091,327	26,480,651	DS	11	2148-07-17 00:00:00	2148-07-17 13:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right calf pain Major Surgical or Invasive Procedure: Right knee washouts and right calf debridement ___, ___ and ___. Left knee washouts with orthopedic surgery ___ and ___ History of Present Illness: ___ with a history of IgG multiple myeloma s/p ___ Velcade/Dex, C1D1 and a history of bilateral knee replacement joint space infections presents to the ___ ER with right calf pain. THe pain began 5 days prior to admission after he spent the day walking more than usual. The pain then subsided somewhat but reappeared 2 days prior to admission but improved when he rubbed cream on it. The day of presentation to the ER, the pain was ___ in intensity and impaired his walking. He denies any joint pain in either of his knees or ankles, stating this feels nothing like the times when he presented with joint infections. He denies feeling or hearing a pop or snap. He has no fevers or chills (despite other consult notes saying otherwise), but did have T 100.6 in the ER. He denies direct trauma. Past Medical History: Recent PMH: He had come back from a long- term antibiotic completion very prior to his most recent operation by Dr. ___ ___ after being on p.o. oral suppression therapy but had recurred with a left knee infection (Group B strep). He underwent bilateral aspirations of knees with open irrigation and debridement, with complete synovectomy and direct liner exchange left total knee replacement for recurrent sepsis left revision total knee replacement ___, ___. Postoperatively, infectious disease had patient on with completion of 6 weeks of IV PCN and an additional 2 weeks of Linezolid with transition to po Clinda suppressive therapy. He will be on chronic lifelong suppression antibiotics for the possibility of recurrence of infection. His past medical history is also significant for borderline diabetes, h/o DVT LLE ___, PE RLL ___, increased cholesterol, anemia, hyperlipidemia, Multiple TKA revisions bilateral knees for infection (___) IgG Multiple myeloma s/p ___ Velcade/Dex, C1D1 Social History: ___ Family History: Mother died at ___ of colon cancer (also had diabetes). Father has ___ disease. Sister had chronic renal failure. Physical Exam: ADMISSION EXAM: Vitals: T 98.0 bp 126/85 HR 99 RR 18 SaO2 100 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, no joint effusions, right medial gastroc muscle is very tender with no overlying skin changes; distal motion, sensation, and perfusion are intact. SKIN: warm, dry NEURO: AOx3, no focal sensory or motor deficits aside from patient having difficulty with weight bearing on right leg PSYCH: calm, cooperative ___________________________________________________ DISCHARGE EXAM: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples (Bilateral knees, R medial calf) * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:06AM BLOOD WBC-6.6 RBC-2.55* Hgb-7.5* Hct-22.9* MCV-90 MCH-29.4 MCHC-32.7 RDW-17.3* Plt ___ ___ 03:04PM BLOOD Hct-23.2* ___ 06:00AM BLOOD WBC-6.1 RBC-2.33* Hgb-6.8* Hct-21.0* MCV-90 MCH-29.3 MCHC-32.5 RDW-17.8* Plt ___ ___ 05:45AM BLOOD WBC-7.4 RBC-2.55* Hgb-7.6* Hct-22.8* MCV-90 MCH-29.8 MCHC-33.3 RDW-17.8* Plt ___ ___ 06:48AM BLOOD WBC-6.8 RBC-2.69* Hgb-7.8* Hct-23.5* MCV-88 MCH-29.1 MCHC-33.2 RDW-18.3* Plt ___ ___ 09:38PM BLOOD Hct-27.3* ___ 08:00AM BLOOD WBC-7.3 RBC-2.78* Hgb-8.6* Hct-25.5* MCV-92 MCH-31.1 MCHC-33.9 RDW-18.1* Plt ___ ___ 07:15AM BLOOD WBC-6.8 RBC-2.51* Hgb-7.7* Hct-22.6* MCV-90 MCH-30.8 MCHC-34.3 RDW-18.6* Plt ___ ___ 07:25AM BLOOD WBC-8.2 RBC-2.52* Hgb-7.8* Hct-22.8* MCV-90 MCH-31.0 MCHC-34.3 RDW-18.8* Plt ___ ___ 01:10PM BLOOD WBC-8.3 RBC-2.93# Hgb-9.1# Hct-26.2* MCV-89 MCH-31.0 MCHC-34.7 RDW-18.8* Plt ___ ___ 06:00AM BLOOD Neuts-53.4 ___ Monos-7.9 Eos-4.6* Baso-0.4 ___ 08:00AM BLOOD Neuts-44.8* Lymphs-43.9* Monos-6.6 Eos-4.2* Baso-0.4 ___ 06:00AM BLOOD ESR-140* ___ 08:15AM BLOOD ESR-140* ___ 06:38PM BLOOD ESR-139* ___ 06:06AM BLOOD Glucose-89 UreaN-12 Creat-0.9 Na-134 K-4.4 Cl-102 HCO3-27 AnGap-9 ___ 07:20AM BLOOD Glucose-58* UreaN-9 Creat-0.6 Na-133 K-3.9 Cl-102 HCO3-21* AnGap-14 ___ 06:00AM BLOOD Glucose-88 UreaN-13 Creat-0.9 Na-135 K-4.4 Cl-102 HCO3-26 AnGap-11 ___ 07:15AM BLOOD ALT-22 AST-39 AlkPhos-103 ___ 07:50AM BLOOD ALT-21 AST-27 AlkPhos-97 TotBili-0.2 ___ 07:00AM BLOOD ALT-67* AST-53* LD(LDH)-194 CK(CPK)-268 AlkPhos-128 TotBili-0.4 ___ 07:20AM BLOOD CRP-71.9* ___ 06:00AM BLOOD CRP-73.4* ___ 08:00AM BLOOD CRP-42.8* ___ 08:15AM BLOOD CRP-249.6* ___ 06:38PM BLOOD CRP-121.4* ___ 07:15AM BLOOD PEP-ABNORMAL B IgG-3694* IgA-40* IgM-21* ___ 02:20AM BLOOD IgG-3508* IgA-42* IgM-28* ___ 08:05AM BLOOD PEP-ABNORMAL B IgG-3300* IgA-45* IgM-30* ___ 08:15AM BLOOD IgG-2885* IgA-25* IgM-25* ___ 8:52 am TISSUE Site: KNEE LEFT KNEE SYNOVIUM. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: SERRATIA MARCESCENS. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. Brief Hospital Course: ___ yo male with multiple myeloma C1D11 Velcade/dex on admission and history of multiple prosthetic and native joint infections who presents with right calf swelling and pain found to have gram negative right knee and calf infection, left knee infection, concominant bacteremia and discitis/osteomyelitis with epidural abscess at L2. #Septic left and right knee infections: He has had numerous joint infections with group b strep (GBS) c/b bacteremia. His joint infections include recurrent GBS infections to both knees which are prosthetic, cervical and lumbar osteomyelitis s/p washout and diskectomy, and left wrist wash out. He has been on suppressive clindamycin treatment since ___ given the recurrent infections. He presented with worsening right calf swelling and pain. Tmax 100.6 in the ED. An MRI of his right leg demonstrated marked calf edema and inflammation. Aspiration of his right knee joint and calf by interventional radiology demonstrated cell counts in the knee c/w bacterial infection. Given concern for mild inflammation of left calf seen on same MRI, in spite of asymptomatic left knee, aspiration of left knee performed showing bacterial infection and growing pan-sensitive serration. Unclear source of infection and abdominal CT scan performed to rule out intraabdominal infection was negative. Patient went for 6 washouts of right calf and knee and 5 washouts of left knee with placement of antibiotic spacers in knees between procedures. Washouts revealed slowly improving purulence and growth of serratia with no evidence of serratia on culture in ___ or ___ washouts. Patient returned to OR for replacement of bilateral knees on ___ with understanding that it may never be able to fully clear the infections with continuous washouts and without performing bilateral AKAs. He was initially treated with Zosyn and transitioned to cefepime once sensitivities returned for Serratia. He was transitioned to meropenem per ID recs on ___ given concern for serratia developing resistance to cefepime. Patient's pain was controlled with oxycontin, oxycodone and dilaudid for breakthrough pain while inpatient. ID following and recommended XXXXXX for ongoing antibiotic therapy. . #Serratia Bacteremia: Patient with fevers on admission. Blood cultures through ___ growing pansensitive serratia (as seen in joint fluid and tissue). Surveillance cultures negative since ___. Patient defervesced with antibiotics and following several joint washouts. He was started on cefepime and transitioned to meropenem on ___. Source of Serratia in blood and prosthetic knees unclear. No evidence of pneumonia or intra-abdominal infection. . #Anemia: Patient with baseline anemia reportedly iron deficiency anemia but with normal MCV on admission. On iron at home. Likely due to anemia of chronic disease. Anemia worsened during this admission likely due to ongoing OR blood losses with repeat washouts. Patient required many pRBC transfusions throughout his stay. He bumped his Hct appropriately with transfusions. No other evidence of bleeding on exam. Hct on discharge was XXXXX. Patient was asymptomatic from his anemia. . #Discitis/osteomyelitis of L2 with Epidural abscess: Patient developed worsening low back pain with tenderness to palpation over L2 on ___ at sight of previous epidural abscess. MRI of L-spine showed discitis/osteomyelitis of L2 with anterior epidural abscess. Given that patient had asymptomatic infection of left knee, MRI of T and C spine performed without evidence of additional foci of infection. Discussed with both spine and ID who were comfortable with conservative management of epidural abscess without drainage given size and location of abscess. Patient treated with cefepime then transitioned to meropenem as above for treatment of serratia and known previous Group B strep. . #IgG Multiple Myeloma: s/p Velcade/Dex on ___. Repeat IgG in ___, IgA and IgM both 25 which was improved from prior to Velcade initiation. However, IgG began to rise during admission raising question of restarting velcade during this admission. Patient concerned about restarting Velcade given temporal relationship between velcade/steroids and infection though likely infections worsened by steroids more so than velcade. Decision made to hold off on velcade inspite of rising IgG but to give IVIg for possible help in fighting infection. IVIg given at 0.2g/kg on ___ and ___ with approximately 200 point bump in IgG following each dose. Patient was pretreated with fluids, tylenol and benadryl. He had borderline fever to 100 on ___ following IVIg but otherwise tolerated the infusions well. He should follow-up with outpatient oncologist about restarting velcade in the future. . #Thrombocytosis: Patient with worsening thrombocytosis starting ___. Likely reactive in setting of ongoing infection, surgeries and myeloma. However, thrombocytosis was likely delayed initially due to recent Velcade which is known to cause thrombocytopenia. Thought not to be new infection as patient had many reasons for reactive thrombocytosis and was afebrile with normal WBC count at time of rising thrombocytosis. . #Parainfluenza 3 Virus: Patient w/ symptoms of congestion on admission. Has been wheezy with occasional SOB on exertion. CXR clear. Echo w/in normal limits. Parainfluenza type 3 from ___ pos. Patient's wheezing improved after several days and repeat respiratory viral screen on ___ negative. . #Hx of group B strep joint infection s/p 6 weeks of IV ABX. Patient was supposed to be on long-term suppressive therapy with clindamycin though unclear how long this was taken for. Given treatment with cefepime then meropenem during this admission, clinda was held. Clindamycin should be restarted when patient is no longer on broad spectrum antibiotics which cover group B strep. . #Hyponatremia: Intermittent. Asymptomatic, no altered mental status. Transitional Issues: [ ] f/u final cultures from right and left knee tissue and synovial fluid [ ] Patient will need to be restarted on clindamycin for suppression of group B strep when no longer on broad spectrum antibiotics [ ] Patient should follow-up with ID to continue to discuss long term antibiotic therapy. [ ] Patient should continue to discuss with ortho, ID and outpatient oncologist when to resume treatment for multiple myeloma Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Clindamycin 300 mg PO TID 3. OxycoDONE (Immediate Release) 5 mg PO QID:PRN pain 4. Tylenol 8 Hour NF (acetaminophen) 650 mg Oral q8 PRN pain 5. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness 6. Ferrous Sulfate 325 mg PO DAILY 7. Calcium Carbonate 500 mg PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO QID:PRN pain 3. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness 4. Ferrous Sulfate 325 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN fever or pain 6. Acyclovir 400 mg PO Q8H 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 8. Cepastat (Phenol) Lozenge ___ LOZ PO Q2H:PRN sore or dry throat 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks 11. ertapenem NF 1 gram Injection DAILY Duration: 6 Weeks Reason for Ordering: 1st dose prior to d/c 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush 13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 14. Lidocaine 5% Patch 1 PTCH TD DAILY 15. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H 16. Pantoprazole 40 mg PO Q24H 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation. 18. Ondansetron ___ mg PO Q8H:PRN nausea 19. Senna 1 TAB PO BID:PRN constipation. 20. Labs Labs via PICC - Check weekly - CBC/diff, ESR/CRP, chem7, LFTs, CK - Fax results to ID at ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Bilateral prosthetic knee septic arthritis, Serratia bacteremia, right gastrocnemius abscess, osteomyelitis, discitis at L2 with epidural abscess, Anemia Secondary: Multiple Myeloma 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 ___ with right calf pain. You were found to have infections in both of your knees as well as in your blood and in your spine. Your infections were treated with cefepime (an antibiotic) and then you were switched to meropenem (a different antibiotic) to prevent antibiotic resistance. A PICC line was placed to provide antibiotics outside of the hospital. You should continue taking meropenem was changed to ertapenum for 6 weeks. Please follow-up with infectious disease as an outpatient as below. You had several operations by orthopedics on both knees to help get rid of the infection. Your cultures were no longer growing bacteria following your last surgery but there was still evidence of pus in your knees. Your knees were replaced on ___. You should follow-up with orthopedics as below. Because of your infection, further treatment of your multiple myeloma was held while you were admitted. You did receive IVIg to help your body fight the infections. You should follow-up with your outpatient oncologist about when to restart Velcade for treatment of multiple myeloma. You were found to be anemic (low red blood cells) on this admission. This was worsened by the continued operations. You were transfused several units of blood which you tolerated well. During this admission, you were also found to have a mild respiratory virus which was gone prior to discharge. It was a pleasure taking care of you during your admission. Good luck with your recovery. Physical Therapy: BLE WBAT Knee immobilizers as needed for stability when OOB ___ progress ROM to 40 degrees maximum starting ___ progress ROM to 60 degrees maximum starting ___ Mobilize Treatments Frequency: DSD daily to both knees and medal right calf prn drainage Wound checks Ice and elevation TEDs PICC line management per facility protocol Labs via PICC - Check weekly - CBC/diff, ESR/CRP, chem7, LFTs, CK - Fax results to ID at ___ Staples will be removed at follow-up appt Followup Instructions: ___
10091327-DS-9	10,091,327	21,172,588	DS	9	2148-01-25 00:00:00	2148-01-25 15:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: knee pain Major Surgical or Invasive Procedure: ___: s/p Aspiration/I&D of L septic wrist, open I&D (B) septic knees, removal of bilateral liners, antibiotic spacers placement and wound VAC placement ___: s/p (B) knee I&D with abx spacer and VAC exchange ___: s/p (B) knee I&D with abx spacer and VAC exchange ___: s/p Anterior Cervical Discectomy C5-C6 ___: s/p (B) knee I&D, insertion tibial liners, and primary closure History of Present Illness: ___ with prior bilateral knee replacements c/b history of GBS bacteremia and bilateral knee joint infections s/p resection and antibiotics spacers who presents with 5 days of fever, back and knee pain. He notes he was in his usual state of health until ~1 week prior to presentation. At that time he had back pain, fevers and "shaking". He felt progressively worse. The pain then spread to bilateral knees and later to his left wrist. He presented to the ED in the ___ and he was treated with tylenol and codeine. A few days later he presented to his PCP who started him on ciprofloxacin in addition to tylenol. He later contacted Dr. ___ recommended evaluation at ___. He also notes that he hasn't been eating or drinking, decreased urination and shortness of breath since Thusday. He states he has had right leg weakness and numbness/burning sensation which is new. He also reports being constipated with is last BM on ___. +flatus. ROS: Per above: Denies GU, nausea, vomiting, headache, sick contacts, chest pain, cough, HA, diarrhea, abdominal pain, shoulder or elbow pain. He states he feels slightly better this AM. Past Medical History: OA s/p bilateral knee replacements ___ s/p lipoma removal HLD - not on treatment H/o DVT LLE ___, PE RLL ___ GBS bacteremia s/p 6 weeks pcn, bilateral total knee infections ___ s/p resection abx spacer, TTE/TEE neg for vegetatations, L wrist pain s/p I&D gastritis anemia Social History: ___ Family History: Mother died at ___ of colon cancer (also had diabetes). Father has ___ disease. Sister had chronic renal failure. Physical Exam: Admission Examination: General: well appearing male, sitting in bed Vitals: 98.6, 133/87, 100, 24, 96% RA, ___ pain HEENT: EOMI, PERRL, OP without lesions Cardiac: RR, nl rate, no r/g/m Lungs: shallow, tachypneic, no crackles, slight prolongation of expiratory phase, able to speak full sentances Abd: Soft, nontender, mild distended, decreased bowel sounds Ext: warm, no edema, well perfused Joints/Neuro: left wrist warm, no erythema, pain and limited range of motion. right wrist, bilateral elbows and bilateral shoulders without signs/symptoms. Bilateral hips without symptoms. Knee no pain upon palpation, limited range of motion with some pain upon movement. Bandages over joint aspiration area from ED. Prior well healed scars at site of surgery. Ankles without warmth or pain (although patient notes pain upon standing). Back with pain over low lumbar area/superior sacrum. Able to lift legs 4+/5 bilateral. Arms with ___ bilateral. Sensation grossly intact to light touch. Subjectively notes weakness in right lower extremity. No evidence of sores, rashes or lesions on hands or feet. Skin: warm upon palp, no evidence of rash GU: no foley, no CVA tenderness . Discharge PE Tm:99 Tc:98.7 130/82 96 16 99 RA General: AAOX3 in NAD HEENT: MMM, OP clear CV: RRR, no RMG Lungs: CTAB, no WRR Abdomen: NTND, active BS X4, no HSM Extremities: WWP, LUE-wrist has minimal edema and is non erythematous, not TTP Neuro: MS and CN wnl strength: ankle flexion/extension ___, knee flexion and extension ___, hand grip ___ in lue, ___ in rue sensation: grossly intact Psyc: mood and affect wnl . Pertinent Results: ___ 11:18PM BLOOD WBC-11.6# RBC-3.61 Hgb-12.4* Hct-36.8* MCV-102# MCH-34.5 MCHC-33.8 RDW-12.5 Plt ___ ___ 11:18PM BLOOD Neuts-89.1* Lymphs-8.0* Monos-2.8 Eos-0.1 Baso-0.1 ___ 12:44AM BLOOD ___ PTT-35.1 ___ ___ 11:18PM BLOOD Glucose-106* UreaN-25* Creat-1.2 Na-123* K-4.3 Cl-90* HCO3-24 AnGap-13 ___ 11:18PM BLOOD CK(CPK)-38* ___ 11:18PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-681* ___ 11:18PM BLOOD UricAcd-4.9 ___ 11:18PM BLOOD CRP-GREATER TH ___ 11:39PM BLOOD Lactate-1.5 Xrays- L wrist: Frontal, oblique and lateral views of the left wrist were obtained. The appearance of the wrist is unchanged since ___. Widening of the scapholunate interval is again seen compatible with scapholunate dissociation with advanced collapse (SLAC wrist). Secondary osteoarthritis at the radiocarpal joint with joint space narrowing and subchondral sclerosis is similar. There is no acute fracture or dislocation. No erosion is seen. No significant soft tissue swelling. IMPRESSION: No acute abnormality. SLAC (scapholunate dissociation with advanced collapse) wrist with secondary osteoarthritis, similar in appearance to ___. ___ CXR CXR report: FINDINGS: Frontal AP and lateral views of the chest were obtained. Low lung volumes results in bronchovascular crowding. There is no focal consolidation, pleural effusion or pneumothorax. The heart size is normal. Mediastinal silhouette and hilar contours are normal. There is gaseous distention of large bowel. IMPRESSION: No pneumonia, edema or effusion. R Ankle: RIGHT ANKLE: Frontal, oblique and lateral views of the right ankle were obtained. There is no fracture or dislocation. The ankle mortise is congruent. No soft tissue swelling. There is no cortical erosion or periosteal reaction to suggest osteomyelitis. No erosions. IMPRESSION: No fracture or dislocation. No radiographic evidence of osteomyelitis. Bilateral Knee: RIGHT KNEE: Frontal, oblique, and lateral views of the right knee were obtained. The patient is status post hinged total knee arthroplasty. There is no evidence of hardware loosening or complication. Anterior tibial plateau suture anchors are also unchanged. There is no fracture or dislocation. Heterotopic ossification about the knee joint has minimally increased. A large ossific fragment adjacent to the medial femoral condyle may represent injury of the medial collateral ligament. Possible right knee joint effusion. LEFT KNEE: Frontal, oblique and lateral views of the left knee were obtained. The patient is status post left hinged total knee arthroplasty. There is no evidence of hardware loosening or complication. There is no fracture or dislocation. Heterotopic ossification at the knee joint has increased at the medial border and decreased at the lateral border. The horizontal lucency in the distal femoral metadiaphysis is less apparent. No joint effusion. IMPRESSION: No fracture or dislocation. No evidence of hardware loosening or complication. ___ Bilateral ___: IMPRESSION: No bilateral lower extremity deep venous thrombosis. Peroneal veins not visualized bilaterally. ___ TEE No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: Normal biventricular function. No masses or vegetations seen. ___ MRI No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: Normal biventricular function. No masses or vegetations seen. ___ 11:18 pm BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES Sensitivity testing performed by Sensititre. CLINDAMYCIN ( <= 0.12 MCG/ML ) . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___ 14:51. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Brief Hospital Course: ___ with TKR ___ c/b bilateral knee septic joints/bacteremia in ___ who presents with septic bilateral knees, left wrist, bacteremia secondary to group B strep. He is s/p washout of knees and betadine soaks of left wrist (___). Wound vacs were in place and then removed by Ortho. He has had significant blood loss requiring 12u prbc which is thought to be secondary to washout and blood loss from bilateral knees (no evidence of pulm, leg compartment, gi or gu bleed). Last repeat washout ___. TEE was negative. MRI was grossly abnormal with epidural abscess in c-spine with cord compression. S/p neurosurg c-spine decompression. # Sepsis, group b streptococcus bacteremia He was initially treated with vancomycin which was then switched to penicillin G after sensitivities and speciation. The source of the bacteremia was though to be due to spetic arthritis. Subsequent blood cultures were negative. ID was consulted and helped with recommendations. The patient will be discharge on Penicillin G 4 million units Q4 hours through his LUE picc line. Start Date was ___ (day of last surgical procedure) and stop date between ___ (between ___ weeks). The patient should follow closely with the ID physicians and get weekly labs as detailed in the discharge instructions. The patients WBC was wnl and the patient had been AF for 24 hours prior to discharge. # Bilateral septic prosthetic knee joints, septic wrist joint: Both Ortho and Plastics/Hand was involved in the patients care. Orthopedic surgery performed multiple washouts including spacer removal and reinsertion (please see multiple op-notes for further details). Plastics performed a wrist tap and then multipled Betadine soaks for treatment of the septic wrist. He also underwent aggressive ROM exercises with OT for his left wrist. The patient will be continue on lovenox 40 SC QD for DVT prophylaxis. Stop date is ___. The staples from the patients knees should be removed ___ weeks after his last surgery which was on ___. The patient should also follow with hand surgery in ___ weeks as an outpatient. A zinc level was checked and it was at the low level of normal. The patient was started on zinc to maximize wound healing. # epidural abscess, osteomyelitis, discitis, The patient was followed closely with the Neurosurgery team. He had an MRI which showed epidural abscess with spinal cord compression (no signal enhancement or clear neurologic signs) and neurosurgery was consulted. They performed a urgent/emergent cervical spine decompression surgery with removal of 2 discs and the epidural abscess (please see op-note from neurosurgery). He should not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc for 2 weeks. He is required to wear his cervical collar as instructed for 4 weeks. # Anemia, acute blood loss: He required significant transfusions which were thought to be secondary to blood loss from bilateral knee wound vacs. There was no evidence of GI, pulm, hematoma, GU or other blood loss (hemolysis labs were negative). He was transfused a total of 17u pRBC. Calcium was repleted aggressively. The patient was placed on replacement dose iron and vitamin C for a relative iron deficiency anemia. Hgb 8.1 on the day of discharge. # Thrombocytosis This is likely reactive in the presence of multiple infections. # Hyponatremia This is likely due to SIADH after spinal manipulation. The patient was free water restricted and this improved. His Na on the day of discharge was 130. # Transitional Issues: - Patient should follow up with ID, Neurosurgery, Ortho and Plastic Hand for routine follow up in ___ weeks - Patient should have labs drawn weekly while on IV antibiotics and faxed to ___ clinic . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q12H prescribed a few days prior to admission 2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain prescribed a few days prior to admission Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 2. Ascorbic Acid ___ mg PO TID 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC Q 24H 5. Ferrous Sulfate 325 mg PO TID 6. Multivitamins W/minerals 1 TAB PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 8. Penicillin G Potassium 4 Million Units IV Q4H 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Zinc Sulfate 220 mg PO DAILY 11. Calcium Carbonate 500 mg PO BID 12. Outpatient Lab Work please check a weekly CBC, Chem 7, BUN/Creatinine, AST/ALT, total bilirubin, ESR/CRP faxed to the ___ R.N.s at ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: group B strep sepsis/bacteremia prosthetic septic knees septic elft wrist joint C5/C6 epidural abscess ostemyelitis discitis with cord compression 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: You were admitted to ___ with complaints of knee pain and your were found to have an infection of your knee joint and left wrist. You were also found to have bactermia in your blood and a abscess near your spine. You had multiple surgical procedures for your knee's, wrist and spine and have been on antibiotics for your infections. You have slowly improved. In addition, you have had a low red cell count and have required multiple transfusions in house. This should be followed at your rehab facility. Please be sure to follow closely with Ortho, Infectious Disease and Spine surgery teams as an outpatient. . Medication changes-see below Followup Instructions: ___
10091385-DS-16	10,091,385	28,374,166	DS	16	2142-07-25 00:00:00	2142-07-25 21:44:00	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: ___: Liver biopsy History of Present Illness: ___ presenting with findings of new liver mass and omental implants on CT scan. Patient has had night sweats for 3 months, 20 lb weight loss over 2 months (recently gave birth and is losing maternity weight), and 1 month of abdominal pain. The pain is always in the RUQ and intermittently in various other areas of her abdomen. At worst, it is ___ with varying character including sharp, dull, stinging, and crampy. The pain is relieved when she gets in fetal position and worsened with abrupt movement. She has had no changes in her bowel or bladder habits, no blood in her stool, and no changes in appetite. At the onset of her pain one month ago, she presented to an OSH ED that performed an abdominal US which according to her was negative. She was sent home, however, has since never "felt right." Her pain worsened yesterday, which prompted her to be seen by her PCP ___. She was sent to ___ for a CT scan which showed a 6.2cm x 4cm mass in segments ___ of her liver and omental implants, largest being 6.2 x 2.7cm in the left pelvis. She was sent to ___ after these results were discovered for further workup. Past Medical History: PMH: PPD positive with negative CXR, hemorrhoids PSH: uterine polypectomy Social History: ___ Family History: No h/o cancer, mother with HTN and mildly elevated cholesterol, father with DM Physical Exam: DISCHARGE PHYSICAL EXAM: A.V.S.S. N: Alert and oriented x3, non-icteric CV: RRR Pulm: CTAB, unlabored Abd: Soft non-tender, non-distended Ext: warm and well perfused Pertinent Results: ___ 06:15AM BLOOD WBC-10.8 RBC-4.07* Hgb-12.0 Hct-37.1 MCV-91 MCH-29.5 MCHC-32.4 RDW-11.6 Plt ___ ___ 06:15AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-139 K-4.2 Cl-103 HCO3-26 AnGap-14 ___ 11:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE ___ 12:09AM BLOOD CEA-<1.0 AFP-1.1 CA125-32 ___ 11:15AM BLOOD HCV Ab-NEGATIVE ___ 12:09AM BLOOD CA ___ -PND CT chest on ___: pending final read. Brief Hospital Course: Ms. ___ was admitted on ___ after being transferred from ___ with new finding of liver mass and omental implants on CT scan. On admission, a full set of labs were drawn which were all within normal range. Notably her LFT's were normal. On HOD1, she went for a liver biopsy which she tolerated well. She reported only minimal pain around the puncture site. Tumor markers were sent which were negative (CA ___ was still pending). She was seen by social work to deal with this new likely cancer diagnosis in the setting of having young children at home. She remained anxious throughout the hospital stay. On HOD2, she was discharged with plans to follow up with oncology as well as the transplant teams once the biopsy results were available. At the time of discharge, her abdominal pain had improved, she was tolerating a regular diet, ambulatory, and voiding freely. She was afebrile with stable vital signs. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Acetaminophen 325 mg PO Q6H:PRN pain 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain No driving if taking this medication RX oxycodone 5 mg 1 capsule(s) by mouth q 6 hours Disp #20 Tablet Refills:*0 4. DiphenhydrAMINE 25 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Milk of Magnesia 30 mL PO DAILY:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Liver mass, Omental implants; Pathology pending Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr ___ office at ___ office at ___ if you develop fever or chills, increased abdominal pain, pain or swelling at the biopsy site, yellowing of the eyes or other concerning symptoms. Dr ___ is facilitating your oncology follow up for next week and has access to all results in the ___ computer system You may shower, pat area near biopsy site dry, may be left open to the air Followup Instructions: ___
10091385-DS-17	10,091,385	21,340,038	DS	17	2142-08-14 00:00:00	2142-08-14 17:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: vancomycin Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: hepatic drain placement ___, removal ___ History of Present Illness: ___ w/ findings of liver mass and omental implants on CT scan, now s/p liver biopsy ___ which has been negative, followed by biopsy of liver mass and L pelvic mass on ___, which have also shown only inflammatory cells without carcinoma. She presents to the ER today with acutely severe RUQ that started two days ago. She also has fevers up to 102.7 in the ER. She feels some nausea but no vomiting. She notes a chronic dry cough which is unchanged. No dysuria/hematuria. Past Medical History: PMH: PPD positive with negative CXR, hemorrhoids PSH: uterine polypectomy Social History: ___ Family History: No h/o cancer, mother with HTN and mildly elevated cholesterol, father with DM Physical Exam: PE: 102.7 113 127/59 18 97% ra GEN: NAD CV: RRR tachy Abd: Soft, mildly distended, RUQ is tender to palpation. No other tenderness, no rebound or guarding Ext: no c/c/e Labs: 132 \| 94 \| 7 AGap=15 -------------<144 4.1 \| 27 \| 0.6 14.3>10.___.2<428 N:91.2 L:5.9 M:2.6 E:0.2 Bas:0.1 Pertinent Results: ___ 02:10PM BLOOD WBC-14.3* RBC-3.87* Hgb-10.9* Hct-34.2* MCV-88 MCH-28.3 MCHC-32.0 RDW-12.3 Plt ___ ___ 05:30AM BLOOD WBC-10.4 RBC-3.66* Hgb-10.3* Hct-32.3* MCV-88 MCH-28.1 MCHC-31.8 RDW-13.0 Plt ___ ___ 05:30AM BLOOD ___ ___ 02:10PM BLOOD Glucose-144* UreaN-7 Creat-0.6 Na-132* K-4.1 Cl-94* HCO3-27 AnGap-15 ___ 05:30AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-138 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 02:10PM BLOOD ALT-89* AST-41* AlkPhos-286* TotBili-0.5 ___ 05:30AM BLOOD ALT-25 AST-24 AlkPhos-113* TotBili-0.2 ___ 21:35 EBV PCR, QUANTITATIVE, WHOLE BLOOD Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL ___ 21:35 ASPERGILLUS GALACTOMANNAN ANTIGEN Test Result Reference Range/Units INDEX VALUE 0.06 <0.50 ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected A negative result does not exclude invasive aspergillosis. Follow-up testing may be indicated for high-risk patients. RESULT INTERPRETATION: An Index <0.50 is considered to be negative. An Index >=0.50 is considered to be positive. ___ 21:35 SCHISTOSOMA ANTIBODIES Test Result Reference Range/Units SCHISTOSOMA IGG ANTIBODY, <1.00 FMI (SERUM) REFERENCE RANGE: <1.00 INTERPRETIVE CRITERIA: <1.00 Antibody Not Detected > or = 1.00 Antibody Detected ___ 21:35 ENTAMOEBA HISTOLYTICA ANTIBODY Test Result Reference Range/Units ENTAMOEBA HISTOLYTICA IGG NEGATIVE ___ REFERENCE RANGE: NEGATIVE ___ 21:35 B-GLUCAN Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- 37 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL ___ 21:35 FASCIOLA HEPATICA ANTIBODY Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Fasciola Hepatica Antibody , ___ ___ Hepatica Ab 1:2 POS =>1:32 Negative NEG <1:32 ___ 10:05 pm WORM Source: Jp drain fluid. *FINAL REPORT ___ O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORMS SEEN. ___ Urine culture: negative ___ Blood culture: negative ___ Blood culture: pending ___ Abscess: 4+ pmn, 2+ GPR, AFB negative, culture negative, Acid fast: pending ___ Blood culture: pending ___ Stool O&P:no O&P, no worms ___ Blood culture: pending ___ Stool O&P: Brief Hospital Course: ___ F liver mass and omental implants on CT scan, s/p liver biopsy ___ which were negative, followed by biopsy of liver mass and L pelvic mass on ___, which demonstrated only inflammatory cells without carcinoma represented with fever and RUQ pain. She was pan-cultured and CT scanned. CT demonstrated new lobulated hypodensities in the region of the ill-defined mass in the right lobe of the liver concerning for abscesses. The hepatic mass seemed slightly bigger, right portal vein branch thrombus was unchanged and there was slight enlargement of the peritoneal soft tissue nodules. In the anterior midline of the pelvis, along the left lower quadrant peritoneal implants, there was a new 2.6 cm rim enhancing low density fluid collection, also concerning for an abscess. She was started on Vancomycin in the ED, however, she developed s/o allergic reaction (subjective throat swelling and rash). She was treated with Benadryl and antibiotics were changed to Zosyn and Flagyl. Daily surveillance cultures were sent. She continued to be febrile. On ___, she underwent U/S-guided percutaneous drainage of right hepatic fluid collection with bloody material aspirated consistent with hematoma possibly related to the recent biopsy. Fluid was sent for culture. Gram stain showed 4+ PMN with 2+ gram positive rods. Culture was negative and acid fast smear was negative. Acid fast culture was not finalized. Admission blood and urine cultures were negative. Subsequent blood cultures were negative to date and un finalized. On ___, a repeat ultrasound was done showing resolution of the abscess. Therefore, the drain was removed. She had been requiring Dilaudid for pain at the drain site. Pain was much less after drain removal. ID was consulted and recommended w/u for pathogens like liver flukes and mycobacteria as well as EBV. Given prominence of plasma cells on pathology, concern for non-infectious processes was raised. Possible diagnoses such as inflammatory pseudotumor, inflammatory myofibroblastic or follicular dendritic cell tumor were amongst the differentials. Allergy/immunology were consulted and a f/u appointment arranged for ___ with Dr. ___. She will undergo a repeat ultrasound on ___ to assess for interval change. In addition, recommendations per ID were to switch to oral ciprofloxacin and Flagyl with stop date of ___. At the time of discharge, she was afebrile with stable vital signs. She was ambulatory and voiding freely. She did have mild pain in the RUQ near her biopsy site however this was improving. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain do not take more than 2000mg per day 2. Ciprofloxacin HCl 500 mg PO Q12H until ___ RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #23 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #34 Tablet Refills:0 5. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #60 Tablet Refills:0 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Fever liver abscess liver mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, or any other concerning symptoms. No driving if taking narcotic pain medication Followup Instructions: ___
10091535-DS-19	10,091,535	27,661,378	DS	19	2171-08-07 00:00:00	2171-08-14 20:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma: ___ Major Surgical or Invasive Procedure: Repair of facial lacerations ___ History of Present Illness: This ___ male was involved in a single car MVC versus a tree. He reports no ___ medical problems prior to the accident. Patient had a head strike with multiple facial traumas, was evaluated at an outside hospital, notable for multiple facial lacerations, possible foreign body around his right eye, no intracranial pathology, pulmonary contusions, as well as a possible liver problem as well. Patient was transferred after her total body CT. Past Medical History: unknown Social History: ___ Family History: unknown Physical Exam: Physical examination upon admission: ___ Constitutional: See trauma flow sheet. Uncomfortable, painful distress HEENT: Multiple facial lacerations involving a stellate 3 cm laceration of the forehead, linear laceration over the right eyebrow and the right eyelid. The right ear has gross treatments with partial dictation. Patient has bilateral hemotympanum. Mid face stable and intact, dentition is normal no malocclusion. Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds , tender to palpation throughout the anterior thorax Abdominal: Soft, Nondistended Rectal: Heme Negative GU/Flank: No costovertebral angle tenderness 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: t=98, hr=77, bp=116/66, rr=16, oxygen sat 98% General: NAD HEENT: right pupil dilated related to exam, left pupil 3-4mm, full EOM's, limited mandibular opening, trachea midline, no cervical spine tenderness, full ___, facial laceration/abrasions, right ear abrasion, right eye upper lid laceration CV: ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, non-tender EXT: no calf tenderness, right mid-arm tenderness, right knee tenderness, abrasions knee bil. NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 08:48PM BLOOD Plt ___ ___ 08:48PM BLOOD UreaN-7 Creat-0.8 ___ 08:48PM BLOOD Lipase-72* ___ 08:48PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:58PM BLOOD pH-7.31* Comment-GREEN TOP ___: chest x-ray: No acute cardiopulmonary process. ___: cat scan of sinus and mandible: Multiple punctate hyperdensities within the soft tissues of the forehead, 4 Preliminary Reportmm hyperdensity along the right orbit and a punctate hyperdensity the left Preliminary Reportorbit, consistent with known foreign bodies, related to recent trauma. No Preliminary Reportretro-orbital hematoma or abnormal preseptal soft tissue swelling. Preliminary Report2. No acute fracture identified. ___: right elbow: No fracture given limited views ___: cat scan of the chest: . Focal ground-glass opacities in the right upper and lower lobes most Preliminary Reportcompatible with pulmonary contusions. Preliminary Report2. Subtle small irregular hypodensities within hepatic segments 7 and 8, Preliminary Reportwhich are too small to further characterize, however in the setting of trauma Preliminary Reportthese findings could reflect liver lacerations. ___: cat scan of abdomen and pelvis: Wet Read Audit # 1 NRS SUN ___ 11:14 ___ 1. Focal ground-glass opacities in the right upper and middle lobe compatible with pulmonary contusions. 2. Subtle small linear hypodensities within segment 7 and 8 of the which are too small to further characterize, however in the setting of trauma could reflect liver lacerations. ___: cat scan of the c-spine: . Motion degraded examination of the head. However, no acute intracranial Preliminary Reportabnormality. Multiple foreign bodies as seen on subsequent facial and sinus Preliminary ReportCT performed at ___. Preliminary Report2. Incomplete evaluation of the cervical spine. If desired repeat CT Preliminary Reportexamination can be obtained. ___: cat scan of the head: . Motion degraded examination of the head. However, no acute intracranial Preliminary Reportabnormality. Multiple foreign bodies as seen on subsequent facial and sinus Preliminary ReportCT performed at ___. Preliminary Report2. Incomplete evaluation of the cervical spine. If desired repeat CT Preliminary Reportexamination can be obtained. ___: x-ray of right humerus: no fracture ___: x-ray of right knee: supra-patella effusion Brief Hospital Course: ___ year old gentleman admitted here from an outside hospital after he was involved in a motor vehicle accident. He reportedly sustained multiple facial lacerations to the left temple, right eyelid, chin, and a near complete avulsion of the right ear lobule. On review of the imaging, the patient was reported to have a pulmonary contusion, and a liver laceration. The Plastic surgery service washed and closed his facial lacerations. Imaging studies of his head showed no intra-cranial process. The cervical spine was not completely viewed, but there was no evidence of limited neck range of motion. Cat scan imaging of the abdomen showed hypodensities within segment 7 and 8 which could be reflective of liver lacerations. Of note, the patient was found to have multiple chards of glass beneath the right eyelid for which opthalmology was consulted. Initial ophthalmology examination was limited related to the patient's pain. A follow-up dilated eye examination was done and recommendations were made for the patient to be seen by Eye Plastic surgery for repair of a upper eye-lid tear. During the hospitalization, the patient's vital signs remained stable and he was afebrile. His pain was controlled with oral analgesia. He was voiding without difficulty. On tertiary examination, the patient was noted to have right upper arm tenderness and right knee pain. X-ray imaging was done and no fracture was reported in the right upper arm or right knee. The social worker met with the patient and provided the patient with outreach community services. The patient was discharged home in stable condition with an appointment with Eye Plastic Surgery today. Follow-up appointments were made with the acute care service and Plastic surgery service. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 3. Acetaminophen 650 mg PO Q6H RX acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #25 Tablet Refills:0 4. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE Q1H 5. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Trauma: MVC forehead laceration Right earlobe laceration Chin laceration foreign body Right and Left eyelid RUL, RML pulmonary contusion hypodensities in Seg 7 and 8 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 involved in a motor vehicle accident. You sustained facial lacerations and well as eye trauma. You had the facial lacerations repaired and you were seen by Ophthamology for eye examination. You reported right arm and right knee pain during your hospitalization. Imaging was done which showed which did not show any fracture of your right arm or knee. You are now being discharged from the hospital. You have an appointment today at 4pm at Mass Eye and Ear where you will undergo repair of your right eyelid. You are being discharged with the following instructions: Please keep your follow-up appoinments as scheduled. Please notify us of the following: fever chills change in vision shortness of breath dizziness difficulty breathing weakness upper ext. generalized weakness fainting nausea/vomitting *inability to tolerate food Please inform us of any other symptoms which concern you If you continue to have pain in your right arm, please follow-up with your primary care provider. You may apply warm compresses to the right arm as needed for pain. Followup Instructions: ___
10091535-DS-21	10,091,535	23,107,691	DS	21	2175-02-05 00:00:00	2175-02-05 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: back pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ previously healthy male s/p MVC with C6/7 disc disruption and ALL injury. Now s/p ACDF C6/7 on ___ with Dr. ___. Presents with back pain and hematoma. The patient had a recent cervical fusion on ___ by Dr. ___ for vertebral fractures sustained in MVC on ___ patient was discharged from the hospital on ___, and has had progressively worsening pain across his upper back over the past 24 hours. The pain is localized to this area and has been constant. It has been associated with moderate redness and swelling. It is not associated with fevers or lightheadedness. Movement of any kind exacerbates the pain. He has had minimal relief at home with oxycodone, Tylenol, and ibuprofen. In the ED, CT neck and torso shows 9 x 2 x 14 cm fluid collection, without rim enhancement, extending from C5-T5 in the posterior subcutaneous tissue. WBC 9.7, lactate 1.5, hematocrit 38. The ED discussed the case with the spine team, the collection seen on CT likely represents a hematoma, for which no urgent operative intervention is planned, and for which the patient does not require hospitalization. Pain control with PO medications in the ED was inadequate prompting admission. Past Medical History: No PMH prior to aforementioned MVC and previous MVC requiring facial surgery Social History: ___ Family History: No family history of DM or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. No injuries to this area. NEURO: Sensation intact, motor function intact, no hyperreflexia. PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: ========================= Vitals: 97.6PO 116/73 53 18 97 RA GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. Continues to improve from prior and significantly regressed from prior skin marking/outline. NEURO: Sensation intact, motor function intact. PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: =============== ___ 12:15AM BLOOD WBC-9.7 RBC-4.43* Hgb-13.2* Hct-38.3* MCV-87 MCH-29.8 MCHC-34.5 RDW-11.7 RDWSD-36.9 Plt ___ ___ 12:15AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-99 HCO3-27 AnGap-13 ___ 12:15AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0 IMAGING: ======== ___. Status post ACDF at C6-C7. While this exam is not technically optimized for evaluation of the osseous structures, there is no evidence for hardware related complications or fracture. 2. Small amount of prevertebral fluid without rim enhancement from C6-C7 through T1-T2, extending anteriorly to the right sternocleidomastoid with mild sternocleidomastoid edema, compatible with postsurgical change. 3. Partially visualized fluid without rim enhancement in the posterior paravertebral muscles extending from C5-C6 inferiorly at least to T3 and beyond the inferior margin of the field of view, also compatible with postsurgical change. 4. The spinal canal is not well assessed, particularly at the level of the hardware, but could be better assessed by MRI if clinically warranted. ___ CT Chest: 1. Low density fluid collection in the posterior interfascial layers measuring at least 9.1 x 2.1 x 13.8 cm extending from the cervical spine at C5 to T5 thoracic level. No rim enhancement. Please clinically correlate. 2. Likely postsurgical changes at the base of neck from anterior fixation at C6-7 with residual prevertebral edema. 3. Mild compression fractures from C7 through T1, overall unchanged when compared to MRI from ___. ___ CXR: No acute cardiopulmonary abnormalities aside from very small pleural effusions or pleural thickening. Compression fractures of thoracic spine are better seen on the MRI from ___. DISCHARGE LABS: ================= ___ 07:16AM BLOOD WBC-7.2 RBC-4.35* Hgb-13.0* Hct-38.0* MCV-87 MCH-29.9 MCHC-34.2 RDW-11.6 RDWSD-37.1 Plt ___ Brief Hospital Course: Mr. ___ is a ___ year-old-male with a history of a recent motor vehicle accident complicated by vertebral fractures with recent cervical fusion who presented with back pain with associated swelling and erythema. CT scan showed likely hematoma and pt was seen by spine, without indication for surgical management and pt was admitted for pain control requiring IV morphine and PO oxycodone. He remained neurologically intact with improvement of hematoma on exam and stable H/H. He was weaned to home oxycodone prior to discharge. TRANSITIONAL ISSUES: ==================== []F/U with spine clinic on ___, C collar to stay in place until until follow up []pt set up with new PCP []pt states he does not need oxycodone rx as he has not filled one recently given by spine surgery []plan for surgery with ortho on ___ for facial fracture repair Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bacitracin Ointment 1 Appl TP BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID constipation Discharge Medications: 1. Bisacodyl 10 mg PO DAILY constipation RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #20 Tablet Refills:0 2. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine 5 % apply one patch every monirng Disp #30 Patch Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 17 g by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 5. Bacitracin Ointment 1 Appl TP BID 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #20 Capsule Refills:0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 8. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: hematoma SECONDARY: recent vertebral fracture s/p cervical fusion facial fracture constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with back pain. You were found to have a blood collection, called a hematoma, that is causing your pain. Your hematoma improved and your pain also improved with oxycodone. You can continue to take this medication as prescribed. Please also use ice packs as needed for the pain and swelling. Please do not drive or drink while taking oxycodone. You can also use the lidocaine patch for 12 hours at a time for pain control. Please take stool softeners or laxatives as needed to prevent and treat constipation while on oxycodone. Please continue to keep your C collar in place until your follow up with spine on ___ (see the appointment below). You also have surgery for your facial fractures on ___. We have also set you up with a primary care doctor, please see the appointment below. We wish you the best, Your ___ Care Team Followup Instructions: ___
10091873-DS-20	10,091,873	25,541,989	DS	20	2194-07-10 00:00:00	2194-07-10 20:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. ___ is a ___ year old man with locoregionally advanced HPV positive oropharyngeal cancer stage is T2N2M0, Stage ___ on XRT with concurrent cisplatin who is admitted with N/V. Patient with multiple recent admissions attributed to chemotherapy. His most recent episode began ___ when he developed intractable N/V with an po intake. He has associated sore throat. Due to his symptoms he presented to the ED. In the ED, initial VS were pain 9, T 99, HR 120, BP 98/76, RR 16, O2 98%RA. Labs were notable for WBC 2.2 (ANC 1550), HCT 36.3, PLT 356. Na 136, K 4.7, HCO3 19, Cr 1.0. ALT 10 AST 11 ALP 99, TBIli 0.4, Lipase 23, lactate 1.0. Patient was given 1L NS, IV Zofran, and IV Ativan prior to transfer for further management. On arrival to the floor, patient notes intractable nausea and vomiting as above. Denies Fevers or chills. No abdominal pain, No diarrhea. Last BM on ___ was normal. Chronic sore throat due to radiation. Past Medical History: Mr. ___ is a very pleasant ___ gentleman with history of Grave's disease, kidney stones and anxiety, who first noticed some sore throat in mid ___. At that time he saw his PCP but no lesions were found on physical exam and he was oriented to monitor symptoms and seek further evaluation in case of no resolution. Over time the sore throat did not improve and he went to see Dr. ___ in ___ for further evaluation. He was found to have a right oropharyngeal mass and upon biopsy was diagnosed with invasive squamous cell carcinoma, moderately differentiated, invading into skeletal muscle, positive for p16, suggestive of HPV associated (___). He underwent staging testing with CT neck on ___ which showed a 3.5 x 2.5 mass in the right tonsillar region and bilateral enlarged level 2 a lymph nodes with intrinsic hyperdensities indicative of metastasis. On ___ he underwent a PET scan which showed that the right oropharyngeal mass had an SUV max of 24.56 and the bilateral cervical LNs also had increased SUV ranging from 6.91 to 15.00. No distant metastatic disease was identified. The patient was referred to our clinic to discuss treatment options for his locally advanced HPV positive oropharyngeal cancer, for which we recommended definitive radiation therapy combined with cisplatin q3weeks. - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ======================== Admission Physical Exam: ======================== VS: T 98.8 HR 119 BP 101/69 RR 18 SAT 98% O2 on RA. GENERAL: Well developed, but appears older than stated age. Uncomfortable appearing on his side retching during exam. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. 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, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. ======================== Discharge Physical Exam: ======================== VS: Temp 97.9, BP 119/80, HR 76, RR 18, O2 sat 96% RA. GENERAL: Appears comfortable, in no acute distress. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. 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, non-tender, nondistended, no hepatomegaly, no splenomegaly. BACK: No flank tenderness to palpation. EXT: Warm, well perfused, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. Pertinent Results: =============== Admission Labs: =============== ___ 01:44AM BLOOD WBC-2.2* RBC-4.03* Hgb-12.3* Hct-36.3* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.8 RDWSD-44.0 Plt ___ ___ 01:44AM BLOOD Neuts-71.4* Lymphs-6.9* Monos-19.8* Eos-0.5* Baso-0.5 Im ___ AbsNeut-1.55* AbsLymp-0.15* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01 ___ 01:44AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-136 K-4.7 Cl-94* HCO3-19* AnGap-28* ___ 01:44AM BLOOD ALT-10 AST-11 AlkPhos-99 TotBili-0.4 ___ 01:44AM BLOOD Lipase-23 ___ 01:44AM BLOOD Albumin-4.2 Calcium-10.0 Phos-2.9 Mg-1.9 ___ 07:38AM BLOOD TSH-0.37 ___ 08:33AM BLOOD ___ pO2-193* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 ___ 08:33AM BLOOD Lactate-1.0 =============== Discharge Labs: =============== ___ 07:45AM BLOOD WBC-3.3# RBC-3.39 Hgb-10.3* Hct-30.2* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 RDWSD-45.3 Plt ___ ___ 07:45AM BLOOD Glucose-106* UreaN-23* Creat-0.8 Na-140 K-4.1 Cl-102 HCO3-28 AnGap-14 ============= Microbiology: ============= None. ======== Imaging: ======== Head CT w/o Contrast ___ 1. No acute intracranial abnormality, with no definite evidence of intracranial mass. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct or intracranial masses. 3. Paranasal sinus disease as described. CT Abdomen/Pelvis w/ Contrast ___ 1. Since ___, a mid left ureteral stone has enlarged in the CC dimension and there is mildly worsened left hydronephrosis, now moderate to severe. 2. Curvilinear calcifications in the dependent portion of the urinary bladder may represent small stones. Brief Hospital Course: Mr. ___ is a ___ year old man with locoregionally advanced HPV positive oropharyngeal cancer stage ___ on XRT with concurrent cisplatin who is admitted with N/V. # Nausea/Vomiting secondary to Nephrolithiasis: Previous episodes thought due to chemotherapy, although he notably has not had chemo since ___. He was recently admitted for similar symptoms and was treated with anti-emetics and oropharyngeal candidiasis with fluconazole and nystatin. LFTs and lipase normal. Head CT without abnormality. His nausea was initially treated with Zofran, Compazine, Zyprexa, Ativan, and Scopalamine. However, patient passed large kidney stone with subsequent improvement in his symptoms. His nausea and vomiting was likely secondary to nephrolithiasis. He required no further anti-emetics, feeling significantly improved without nausea, and was tolerating a regular diet at time of discharge. His outpatient Urologist Dr. ___ was contacted and the patient will have close follow-up after discharge given finding of enlarging renal stone and slight worsening of hydronephrosis after discharge. He was urinating well with normal renal function. # Radiation-Induced Pharyngitis: Continued home magic mouthwash and viscous lidocaine. # Oropharyngeal Cancer: Missed his C3 appt for Cisplatin. Per Dr. ___, may not be able to tolerate any additional chemo. He will follow-up with Dr. ___ discharge. # Hyperthyroidism: Repeat TSH normal. Continued home methimazole. # Anxiety/Depression: Continued home citalopram and clonazepam. ==================== Transitional Issues: ==================== - Please note enlarging mid-left ureteral stone with mildly worsened left hydronephrosis. Patient will follow-up with Dr. ___ scheduled lithotripsy and stent placement. - Please follow-up pending renal stone analysis form ___. Code Status: Full Code Contact: ___ (wife/HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 2. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 3. Methimazole 10 mg PO QHS 4. Senna 8.6 mg PO BID 5. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 6. Multivitamins 5 mL PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Citalopram 20 mg PO QHS 9. Ondansetron ODT 8 mg PO Q8H 10. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 11. LORazepam 0.5-1 mg SL Q4H:PRN nausea 12. Scopolamine Patch 1 PTCH TD ONCE 13. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 2. Citalopram 20 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. LORazepam 0.5-1 mg SL Q4H:PRN nausea 7. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 8. Methimazole 10 mg PO QHS 9. Multivitamins 5 mL PO DAILY 10. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 11. Ondansetron ODT 8 mg PO Q8H 12. Scopolamine Patch 1 PTCH TD ONCE 13. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Nephrolithiasis - Nausea/Vomiting Secondary Diagnosis: - Oropharyngeal Cancer - Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to the hospital with nausea and vomiting. You were treated with anti-nausea medications. You had imaging of your head which was normal. You then passed a kidney stone and your symptoms improved. It is likely that your nausea was due to the kidney stone. You had a scan of your abdomen which showed an enlarging left kidney stone with worsening swelling of your left kidney. After discussion with your Urologist Dr. ___ would like you to return for a procedure on ___. All the best, Your ___ Team Followup Instructions: ___
10091873-DS-23	10,091,873	20,326,539	DS	23	2194-11-10 00:00:00	2194-11-10 14:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Note Date: ___ Signed by ___, MD on ___ at 11:08 pm Affiliation: ___ ============================================================= ONCOLOGY ___ ADMISSION NOTE ___ Time: 1800 ============================================================= PRIMARY ONCOLOGIST: ___ PRIMARY DIAGNOSIS: HPV+ Oropharyngeal Squamous Cell Cancer TREATMENT REGIMEN: CC: ___ and vomiting HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with nausea, vomiting, and diarrhea. Patient admitted ___ to ___. At the time he had recurrent jaw pain and poor po intake with weight loss. He was treated empirically for ___ esophagitis and aspiration pneumonia. Also had G-tube placed ___ and initiated TF's. During hospitalization there was concern for localized tumor recurrence. Repeat PET-CT showed increased FDG avidity, although unclear if recurrence of if post-radiation effects. CT scan of neck shows evidence of mass, could include recurrence of disease or scar tissue or post-treatment changes. CT shows overall decrease in size of previously seen mass but with an area of necrosis. Previous PET scan done that did show some residual activity. No visible ulceration on fiberoptic exam performed by ENT but did see cavitary lesion with fibrinous debris. No evidence of significant infection seen grossly but patient did spike a fever and he was started on unasyn and switched to Augmentin for total treatment course of 5 days. Given concern for recurrence of disease, MRI was obtained which showed "Peripherally enhancing and centrally non-enhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded". Biopsy was not obtained. He was given his MRI images to bring to evaluation at Mass Eye and Ear ___. His pain was controlled with fentanyl patch 25 mg, po oxycodone ___ mg q4hours, gabapentin 300 TID. He was evaluated by ___ and ENT and inpatient workup was further deferred with plan for referral to Mass Eye and Ear. On discharge, patient was tolerating small amount of po along with 1 can TF's daily. He was discharged on aggressive bowel reg due to constipation. ___ night went home had nonbloody diarrhea (first BM in a while). Yesterday nurse came and he threw up the tube feeds. 6 AM woke up with vomiting, tried po Zofran, at 8 AM again with diarrhea. Cans went in yesterday no problem no abd pain but 15 min later vomited it up. Today slightly dizzy with standing but not currently. Most of his pain is in his right jaw area and neck at site of mass, pain remains at ___ which is about where it was during his last admission. This is largely stable, but continues to be severely bothersome and impairing his ability to eat or swallow pills well but his primary reason for returning to hospital is nausea/vomiting/diarrhea. Since discharge, patient has felt "generally awful", including nausea and vomiting and diarrhea. Reports ___ episodes of non-bloody diarrhea daily along with inability to tolerate any po (difficulty swallowing due to pain, but also as above he vomited up the tube feed cans within 15 minutes of administration). He was prescribed Zofran last night without effect. Due to symptoms he presented to the ED today. In the ED, initial VS were pain 3, T 97.3, HR 118, BP 97/78, RR 18, O2 100%RA. Labs notable for ALT 39, K 4.6 HCO3 24, Cr 0.7, ALT 39, AST 3, ALP 88, TBIli 0.3, Alb 4.1, WBC 4.6 HCT 38.9, WBC 468. Plain film of abdomen showed G-tube in place with tip pointing to fundus. ___ was consulted who felt tube was in appropriate position. Patient was given 2L NS and IV Zofran. VS prior to transfer were pain 0, T 98.6, HR 89, BP 113/82, RR 18, O2 99%RA. On arrival to the floor, patient states he feels largely well as hi slast episode of nausea vomiting and diarrhea were all around 6 AM today and he has had none since. All other 10 point ROS neg including fevers, dysuria, flank pain, headache, visual changes. No sick contacts. No recent travel. No fevers or abodminal pain. Otherwise, no CP, no SOB. Patient was supposed to go to Mass Eye and Ear today to work up recurrence of cancer. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - ___ - Completion of RT. PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features 5. Oropharyngeal cancer Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.3 HR 89 BP 102/78 RR 18 SAT 100 % O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; HEENT: Oropharynx difficult to examine as cannot open mouth wide due to pain, but thrush on tongue visible. Pt in excruciating pain to the point of tears at even light palpation of the right side of the neck though no external erythema or skin breakdown at that area CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. No erythema/drainage around G tube insertion site MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM 98.3PO 98 / 58 R Lying 90 16 99 RA Heart RRR S1 and S2 normal No MRG Lungs- CTAB, No crackles or wheezes Abdomen- Soft NT ND Extremities No edema Mouth- unable to open mouth completely, out of visualized portion no thrush noted. Pertinent Results: ___ 07:00AM BLOOD WBC-2.8* RBC-3.57* Hgb-11.0* Hct-32.6* MCV-91 MCH-30.8 MCHC-33.7 RDW-11.4 RDWSD-38.0 Plt ___ ___ 07:00AM BLOOD Glucose-93 UreaN-10 Creat-0.6 Na-140 K-4.6 Cl-102 HCO3-28 AnGap-15 ___ 2:15 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). Brief Hospital Course: Mr. ___ is a ___ year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with 3 days of nausea, vomiting, and diarrhea, also with persistent severe right sided neck pain. His symptoms improved by itself and infectious workup for noro and c diff was negative. He was evaluated by ___ while inpatient as he was unable to attend outpt ENT Appointment and he will be seen at their ___ facility for a biopsy and possible surgery. # Nausea/vomiting/diarrhea - Resolved. Likely viral etiology seen by ___ and G tube seems to be in correct place. TF were resumed yesterday 480cc bolus TID of OSmolite 1.5 patient tolerated tube feeds well. C.Diff and Noro virus PCR negative # Right neck pain/Cancer associated pain # Trismus: # Right Neck Swelling/Lymphadenopathy: # Right Jaw Pain: Regular US of neck was essentially normal. Pain well controlled with his current regimen. - Con't home fentanyl 25mcg - Oxycodone PRN - Gabapentin - crushed and through PEG tube. - trial lido patch over right neck # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake. See above for question of recurrence under neck pain. # Thrush: Treated with fluconazole for total course of 7 days (ended on ___ # Severe Malnutrition # Weight Loss: ___ to difficulty with eating because of pain, as well as likely underlying malignancy. Patient has lost 50 pounds since diagnosis with loss of 20 pounds in last three weeks. A PEG tube was placed on ___ and he was started on tube feeds. TUBE FEED PLAN on dishcarge: bolus 480 mL (2 cans) Osmolite 1.5 TID daily (2160 calories, 90 grams protein, 1097 mL free water). His tube feeds were resumed on D2 of hospitalization and he tolerated it well without any nausea or adverse events # Graves Disease: Methimazole able to be crushed, cont methimiazole 10 mg qhs. # Anxiety/Insomnia: Cont clonazepam # Depression with features of OCD: refused citalopram since he has not been taking it at home for sometime. Will stop citalopram. Summary, ___ y M with HPV + R oropharyngeal carcinoma presents with nausea , vomiting and diarrhea and inability to tolerate tube feeds well. Sx resolved on admission. Infectious workup for C diff and Noro negative. Seen by OMFS and he will follow with them as outpt for further management of the R oropharyngeal mass. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe 2. Fentanyl Patch 25 mcg/h TD Q72H 3. ClonazePAM 0.5 mg PO QHS:PRN insomnia 4. Methimazole 10 mg PO QHS 5. Bisacodyl 10 mg PO DAILY constipation 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 600 mg PO TID 8. Senna 8.6 mg PO BID constipation 9. Citalopram 20 mg PO DAILY Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM 2. Ondansetron 8 mg PO Q8H:PRN nausea 3. Bisacodyl 10 mg PO DAILY constipation 4. ClonazePAM 0.5 mg PO QHS:PRN insomnia 5. Docusate Sodium 100 mg PO BID 6. Fentanyl Patch 25 mcg/h TD Q72H 7. Gabapentin 600 mg PO TID 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe 10. Senna 8.6 mg PO BID constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Nausea, vomiting and diarrhea R facial pain from oropharyngeal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted for increasing pain in your R face and nausea and diarrhea after takig tube feeds. Your symptoms resolved while you were inpatient and you tolerated the tube feeds well. You were evaluated by oromaxillofacial surgeons who will see you as an outpatient to perform a biopsy to help guide your treatment. It was a pleasure taking care of you. Sincerely ___ MD ___ Followup Instructions: ___
10091873-DS-24	10,091,873	25,427,289	DS	24	2194-12-13 00:00:00	2194-12-15 08:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Nausea, vomiting, neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ M PMHx notable for metastatic invasive oropharyngeal squamous cell carcinoma s/p chemotherapy/radiation (___), Grave's disease, kidney stones, and anxiety who presents with vomiting, neck pain, and neck swelling. Patient states that he was in his usual state of health, as recently as two days ago. Yesterday he began having anterior neck tenderness and swelling; it is described as "tender" and does not radiate. Pain is exacerbated by palpation of the exterior anterior neck, and mildly by swallowing; it is not relieved by anything. Pt tried to feed himself as usual through his G-tube, whereupon he began having vomiting. After several episodes of vomiting clear liquid, he noticed a scant amount of blood on his lips (though never saw any bright red in his emesis). Pt has been unable to keep anything down since that time, vomiting with even small sips of liquid at home. His nausea was not significantly improved with home ondansetron. Pt notes an episode of chills on the night prior to arrival (though he slept with the heat off). He denies overt fevers, cough, chest pain, shortness of breath, palpitations, diarrhea, urinary Sx, lightheadedness/dizziness, and numbness/tingling/focal weakness. In the ED, initial vitals: 97.4 111 119/73 16 100% RA - Labs were notable for: 13.2>12.6/37.1<239 Na 136 K 3.9 Cl 94 HCO3 23 BUN 27 Cr 0.9 Gluc 180 Lactate:2.3 - Imaging: CXR (___): IMPRESSION: No acute cardiopulmonary process. MRA Neck w/ and w/o contrast (___): Pending - Patient was given: Vanc/zosyn Morphine 1L NS - Consults: ___ and ENT were consulted. - Decision was made to admit to ___ for management of sepsis - Vitals prior to transfer were 99.1 93 201/66 18 98% RA Of note, patient had two recent admissions: 1) Patient was admitted ___ to ___. At the time he had recurrent jaw pain and poor po intake with weight loss. Imaging was concerning for possible recurrence, with CT showing neck mass. He was treated empirically for ___ esophagitis and aspiration pneumonia. Due to poor po intake, he had a G-tube placed ___ and initiated TF's. 2) Patient admitted ___ to ___ for nausea, vomiting, and pain. He received uptitrated pain medications with improvement. He was seen by his Oncologist, Dr. ___ follow up on ___. He also follows with Dr. ___ from ___, who performed a neck biopsy for R neck swelling on ___. He underwent outpatient direct laryngoscopy and biopsy by ___ on ___ procedure was uncomplicated. Biopsy showed "Necro-inflammatory debris with focal bacterial overgrowth. Granulation tissue with focal atypical cells". On arrival to the floor, Pt endorses the above history. He states he feels "very dehydrated" and is asking for more IV fluids. Does not have an appetite, though is willing to try some ice cubes to moisten his mouth. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - ___ - Completion of RT. PAST MEDICAL HISTORY: -Graves disease -Kidney stones -Sleep apnea -Anxiety with OCD features PAST SURGICAL HISTORY: -Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION: Vitals: T 99.3 BP 110/73 HR 101 RR 20 O2 96% on RA GENERAL: Thin Caucasian gentleman, lying in bed and uncomfortable appearing. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist, with some white patches on tongue that clear with swallow. Palpable area of tensor tympani spasm bilaterally, which Pt endorses is tender. EOMI, PERRLA. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender. Soft 3cm x 4cm mass visible above the sternal notch, which is tender to palpation but not firm or fixed or truly discernable on palpation. No subcutaneous emphysema in the neck space. Thyroid nonpalpable. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. No hepatosplenomegaly. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch. NEURO: CN II-XII intact. ___ strength in the upper and lower extremities bilaterally. A&O x3, appropriate thought content. ACCESS: PIV DISCHARGE: Vitals: 98.7 ___ 18 97% RA I/O: 1280/2450 / NR GENERAL: Thin Caucasian gentleman, lying in bed and somewhat uncomfortable. Able to drink sips of water demonstrably without difficulty. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender and stable from prior exam. Soft 3cm x 4cm mass visible above the sternal notch, no longer tender to palpation; very soft to the touch. No subcutaneous emphysema in the neck space. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch, extending to line of medial clavicles. No warmth or tenderness to palpation of this skin change. NEURO: A&O x3. Moves all four extremities spontaneously. Endorses "tingling" R jaw pain, stable from prior. ACCESS: PIV Pertinent Results: ADMISSION LABS: ___ 08:36AM BLOOD WBC-13.2# RBC-4.07 Hgb-12.6* Hct-37.1* MCV-91 MCH-31.0 MCHC-34.0 RDW-13.4 RDWSD-44.4 Plt ___ ___ 08:36AM BLOOD Neuts-93.6* Lymphs-2.4* Monos-3.3* Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.31# AbsLymp-0.31 AbsMono-0.44 AbsEos-0.00* AbsBaso-0.02 ___ 08:36AM BLOOD Glucose-180* UreaN-27* Creat-0.9 Na-136 K-3.9 Cl-94* HCO3-23 AnGap-23* ___ 07:05PM BLOOD ALT-16 AST-14 LD(LDH)-102 AlkPhos-53 TotBili-0.6 ___ 07:05PM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8 PERTINENT LABS: Iron-15* ___ 07:05PM BLOOD calTIBC-229* Hapto-238* Ferritn-579* TRF-176* ___ 08:00AM BLOOD TSH-1.1 ___ 08:00AM BLOOD T4-7.7 IMAGING: -CXR (___): IMPRESSION: No acute cardiopulmonary process. -MRI NECK SOFT TISSUE ___, final report): 1. Slight interval decrease in size of a 19 x 19 mm ill-defined heterogeneously enhancing right tonsillar mass, which may represent posttreatment change, though residual tumor is not excluded. *ALTHOUGH IT IS GETTING SMALLER, IT WOULD BE SURPRISING IF THERE WERE NO RESIDUAL TUMOR. MORE LIEKLY THE DECREASE REFLECTS RESPONSE TO THERAPY BUT THE LESION WE SEE IS TUMOR.* 1. Diffuse edema throughout the anterior superficial soft tissues of the neck, leading to the upper chest and may represent post radiation effect, though cellulitis remains a possibility. This does not appear to contiguously extend into the deep spaces of the neck. 2. Minimal edema in the retropharyngeal space appears unchanged to the ___ examination, and may be a result of posttreatment effect. 3. No organizing/drainable fluid collection. -ECG (___): Sinus rhythm. Non-specific anterior repolarization abnormalities. Compared to the previous tracing of ___ no diagnostic interim change. MICRO: ___ 8:13 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:55 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 11:25 am BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: CANCELLED. Culture negative as of: 17:20 ___ ON ___. Test canceled/culture discontinued per: ___. PATIENT CREDITED. __________________________________________________________ ___ 11:25 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): Brief Hospital Course: ___ with metastatic invasive R oropharyngeal squamous cell carcinoma (s/p chemotherapy and radiation for 2 cycles), Grave's disease, and malnutrition requiring G-tube placement (___) who presented with sudden-onset nausea, vomiting, and neck pain one day prior to arrival. He had inability to tolerate anything by mouth or G-tube due to vomiting, so he came to the ED for further evaluation. He was found to have leukocytosis to 13, soft pressures, and a mild lactate elevation to 2.3. He was given IV fluids, IV ondansetron, and metoclopramide - to eventual relief of his nausea. For his neck pain, he was given IV morphine while unable to tolerate PO. An MRI neck was performed to evaluate for deep neck space infections; it did not show any abscesses or fluid collections, but did comment on some possible residual tumor in the R tonsillar area. After close monitoring, the pt's diet was gradually advanced to his home tube feeding regimen, and he was able to take oxycodone by mouth to control his pain. He was discharged with close follow-up with his PCP, as well as plan for follow-up with his primary oncologist. ============= ACTIVE ISSUES ============= # NECK PAIN, SWELLING: With somewhat prominent anterior neck soft tissue mass, soft to palpation and without subcutaneous emphysema; also a small 1cm x 1cm firm fixed nodule in the R submandibular area where Pt states his previous tumor was. MRI neck performed due to concern for abscess/deep neck space infection; no infection noted, though possible residual tumor present in the R tonsillar area. DDx for his pain includes residual tumor (as noted on MRI neck), post radiation-treatment change/pain. Pain improved with IV morphine in-house, and was well controlled with his home PO oxycodone (and an uptitrated dose of his home gabapentin) prior to discharge. - Continued home fentanyl 25mcg patch and home oxycodone. - Uptitrated home gabapentin 600mg TID -> 800mg TID. # VOMITING: With sudden onset and rapid resolution. Pt reported small amount of blood streaking in his emesis after several bouts of retching, consistent with small ___ tear. Possibly due to some viral gastroenteritis vs. constipation. Started metoclopramide, to improvement of constipation and possibly nausea. Briefly entertained possibility of kidney stones (with hematuria, see below), though unlikely given no flank pain. -Discharged on metoclopramide 5mg QIDACHS -Discharged with zofran # HEMATURIA: Urine grossly appeared yellow. Pt without flank pain, though has h/o kidney stones and this could represent chronic renal calculi. On further review, Pt has had hematuria to this degree for several years without workup. He should be referred to Urology for further evaluation. ===================== CHRONIC/STABLE ISSUES ===================== # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake, and MRI neck during this admission with possible residual tumor. Pt states he would be willing to undergo another cycle of chemo/radiation if needed. He will need a referral for a PET scan. He will follow up with Dr. ___ ongoing discussion. # Severe Malnutrition: # Weight Loss: Chronic and baseline. Tolerated bolus tube feeds at home rate prior to discharge. # Graves Disease: His TFTs were within normal limits with TSH 1.1, T4 7. He was continued on methimazole # Anxiety/Insomnia: He was continued on his home clonazepam # Depression with features of OCD: No longer on treatment. He should have ongoing PHQ-9 monitoring and discussion re: referral for therapy. =================== TRANSITIONAL ISSUES =================== # HCP/Contact: ___ (wife) ___, ___ # Code: Full [ ] MEDICATION CHANGES: - Added metoclopramide 5mg QIDACHS - Uptitrated gabapentin from 600mg TID -> 800mg TID [ ] HEMATURIA: - Consider referral to urology for outpatient workup. [ ] OROPHARYNGEAL SQUAMOUS CELL CARCINOMA: - Pt with possible residual tumor based on his MRI during this hospital stay. - Will need assistance with scheduling PET scan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Methimazole 10 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 5. Fentanyl Patch 25 mcg/h TD Q72H 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Gabapentin 800 mg PO TID RX gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 2. Metoclopramide 5 mg PO QIDACHS RX metoclopramide HCl 5 mg 5 mg by mouth QIDACHS Disp #60 Tablet Refills:3 3. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:1 4. Gabapentin 800 mg PO TID RX gabapentin 300 mg/6 mL (6 mL) 15 mL by mouth three times a day Disp #1350 Milliliter Refills:1 5. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 6. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 7. Fentanyl Patch 25 mcg/h TD Q72H 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======= Nausea and vomiting Neck pain SECONDARY ========= History of metastatic tonsillar squamous cell carcinoma, with possible recurrence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at the ___ ___. =============================== WHY WAS I SEEN IN THE HOSPITAL? =============================== - You were seen because you were having nausea and vomiting after eating. - You also had new pain and swelling in the front of your neck, which made us worried about a neck infection. ========================================== WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We gave you medicine through the IV ("Zofran") for your nausea. - We also started a new medicine by mouth called "metoclopramide" (or "Reglan"), which can help with nausea and constipation. - We gave you pain medicine through the IV to help with your neck pain. - We gradually increased your diet, until you were back on your home tube feeding regimen. - We took a special picture of your neck ("MRI") to look for abscesses or deep infections in the neck. It did not show any signs concerning for infection. However, our radiologists are not sure if there is any remaining tumor in your neck after your recent round of chemo and radiation. ==================================== WHAT SHOULD I DO WHEN I RETURN HOME? ==================================== - Continue to eat and drink as you usually do. - Continue to take the metoclopramide for your nausea and constipation before you eat or give yourself tube feeds. You can also take zofran as needed for nausea - Your pharmacy will be able to order the liquid gabapentin for you. Please take the pills at a dose of 800mg three times daily until the liquid formulation is available. - Please follow up with your primary care physician (Dr. ___ next week. Dr. ___ will help set up an appointment for the following week to discuss the next steps in following up your symptoms. We wish you the best, Your ___ Oncology Care Team Followup Instructions: ___
10092020-DS-18	10,092,020	22,096,323	DS	18	2135-06-17 00:00:00	2135-06-18 16:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with history of A. fib on Eliquis, recent diagnosis of TIA (altered awareness and aphasia in ___ presented to the ED with complaints of an episode of loss of consciousness and right arm pain. Patient does not recall the episode and history is provided by his wife at bedside. As per the patient and wife he returned from work around 11 ___ after an 8-hour shift. He went to bed at 1130 and fell asleep soon after. At around 3:45 AM patient heard his husband screaming loud which woke her up. She tried to call his name but he was not responding to her. After the screaming, he made gurgling/howling loud sounds with heavy breathing which lasted for up to a minute and his head was turned to left. She noticed that his fists were clenched but his arms were lying next to him flaccid. Following this he remained unconscious, trembling in bed for up to 15 minutes. He then started to wake up, she noticed him blinking but was not acknowledging or responding to her. He was holding his right arm and is in pain with movement. EMS arrived by this time and brought him to the ED. Right upper extremity weakness was suspected and a code stroke was called but upon arrival to the ED he was noted to have significant right shoulder extremity pain suspected to be from right humeral dislocation/fracture. His mental status returned to baseline and no other noted deficits were observed. CT head was negative for acute process. Blood work showed an elevated lactate of 4 given the suspicion of right humeral dislocation and seizure was suspected. Patient denies any recollection of this event. He remembers going to bed at night and woke up in the ambulance. He does complain of right shoulder pain and it is difficult for him to move it. He reports of having bilateral rotator cuff problems and he had a repair done on his left shoulder and has been monitoring his right. He denies any recent fevers or chills or nausea or vomiting or abdominal pain no chest pain or shortness of breath or recent medications. No bowel or bladder problems. No prior history of similar episode. He has been missing some of his Eliquis doses as he keeps forgetting to take it. Wife does report of him acting out his dreams and sleep talking at times but she has never seen him have an episode similar to above in the past. Patient notes that him and his wife had a huge fight the day before and he attributes current episode to that. Past Medical History: Afib. Has been on Eliquis for the past month Prostate cancer Social History: ___ Family History: Daughter with migraines No other family hx of seizure disorder, stroke, muscular, movement, or neurological disorders Physical Exam: On admission: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred On discharge: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred Pertinent Results: ___ 05:38AM BLOOD WBC-7.3 RBC-4.17* Hgb-13.1* Hct-39.4* MCV-95 MCH-31.4 MCHC-33.2 RDW-12.3 RDWSD-42.7 Plt ___ ___ 05:38AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-143 K-4.1 Cl-109* HCO3-23 AnGap-11 ___ 04:35AM BLOOD ALT-17 AST-24 AlkPhos-49 TotBili-0.3 ___ 05:38AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 ___ 08:24AM BLOOD VitB12-382 ___ 08:24AM BLOOD TSH-1.9 ___ 04:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 11:23AM BLOOD Lactate-1.4 EEG: This is an abnormal continuous video-EEG monitoring study due to: 1. Seizure arising from the left temporally, characterized clinically by mouth automatism (chewing) and other brief and non-specific movements (brief head turn to the left and brief hand movements). There are no pushbutton events. No definite epileptiform discharges MRI brain w and w/o There is no evidence of acute intracranial process or hemorrhage. 2. There is no evidence of abnormal enhancement after contrast administration. Brief Hospital Course: ___ M with PMH of A. fib on Eliquis, recent history of transient lack of awareness and aphasia suspected to be TIA, presented to the ED with complaints of an episode of impaired consciousness(screaming, guttural sounds, clenched fists generalized trembling followed by 15-min period of unresponsiveness) associated with possible right shoulder pain (suspicious for dislocation) and labs significant for lactic acidosis. Exam in the ED without any neurological deficits. Possible etiology of the episode was suspected to be seizure. He was admitted for further evaluation, underwent continuous video EEG monitoring. No metabolic/infectious/trauma etiologies identified. MRI with and without contrast did not show any abnormalities. Video EEG revealed 90 second seizure with L temporal onset associated with staring and chewing. He was subsequently started on Keppra 1g BID and continuous EEG did not show any further seizure activity. Lumbar puncture was not performed as MRI brain was unrevealing, seizures were well controlled with Keppra, and clinical suspicion for an infectious/inflammatory process was therefore low. His clinical status and neurological exam remained stable and he was ambulating in the hallways without issues. He was discharged home to follow-up with outpatient neurology as above. We recommended that he do not drive for at least 6 months and to avoid handling heavy/mechanical equipment/baths when he is by himself. Right shoulder pain was evaluated with an x-ray which did not reveal any fracture or dislocation. Suspect chronic degenerative changes and rotator cuff issues with possible acute injury?. He is to follow-up with his PCP ___ 1 week and to follow-up with his orthopedic surgeon for further evaluation. Transitional issues: -Follow-up with orthopedic team for evaluation of right shoulder pain, likely due to rotator cuff pathology. Referral for outpatient ___ was provided to him. -Follow-up with neurology-will require further outpatient work-up to determine the cause of seizure (no structural/metabolic/infectious causes identified so far and no history of memory loss to suggest temporal sclerosis). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Pravastatin 20 mg PO QPM Discharge Medications: 1. LevETIRAcetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*3 2. Apixaban 5 mg PO BID 3. Pravastatin 20 mg PO QPM 4.Outpatient Physical Therapy Evaluate and treat Diagnosis: Rotator cuff strain, right Discharge Disposition: Home Discharge Diagnosis: Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized d for evaluation of an episode of impaired consciousness. Based on the description of the event, we suspected that you may have had a seizure prior to arrival. You underwent continuous video electrical brainwave activity monitoring (called EEG) and you were found to have abnormal changes during an episode of chewing and staring consistent with a seizure. You were started on levetiracetam (Keppra) and antiseizure medication with continuous monitoring of brain wave activity. You did not have any further seizures for 24 hours after initiation of medication. You are being discharged home to follow-up with neurology as outpatient. You also complained of right shoulder pain, x-ray did not show fracture or dislocation and showed some degenerative changes. It is possible that you have a rotator cuff injury and we recommend you follow-up with your outpatient orthopedic surgeon for further management. According to ___ law, you cannot drive for 6 months after your last seizure. You should also avoid heights/ladders, bathing or swimming unsupervised, or power tools/dangerous machinery. New medication added Keppra 1000mg oral twice daily Please continue home apixaban as previous Please follow-up with Dr. ___, neurologist ___ ___ as previously scheduled ___. Also follow-up with primary care physician ___ 1 to 2 weeks. It is a pleasure taking care of you! Your sincerely, ___ Neurology team Followup Instructions: ___
10092110-DS-13	10,092,110	22,808,156	DS	13	2113-02-27 00:00:00	2113-02-28 17:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with no significant past medical history presenting as a transfer from ___ with transverse process fractures of L2-L3 L4-L5 after a fall. Patient reports that he locked himself out of his house and was climbing through the bathroom window when he fell approximately 4 feet into the bathtub. Head strike with loss of consciousness (uncealr duration). Complained of head pain and right hip pain on arrival to ___. A head CT was performed which showed no acute ICH. X-ray of the lumbar spine showed the transverse process fractures of L2-L5. Right hip x-ray was unremarkable. Patient was transferred to the BI for further care. Patient was neurologically intact. He was seen by spine who recommended pain control and physical therphy and no indication for surgery. Patient was unable to walk and was not able to sit up without significant pain. He was placed in observation in the ED and finally admitted to Medicine, since he did not have anyone at home to help him get around. Currently on the floor patient reports right flank pain level ___. Denies any numbness tingling, weakness in his extremities. Past Medical History: None Social History: ___ Family History: No family history of early fractures. Physical Exam: Admission Physical Exam: 98.4 128/83 79 18 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, mild tenderness to plapation on the left side of head. Neck: supple, no tenderness on upper spine level. Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-tender, non-distended. Swelling and significant tenderness in the right flank. MSK: Mild tenderess at the lumbar spine. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact. Sensation intact to light touch. Patient able to move in his lower extremities; able to abduct and adduct his hips. . Discharged Physical Exam: 98 120/47 ___ 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no obvious hematomas or bleeding in the scalp. Neck: supple, no tenderness on upper spine level. Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-tender, non-distended. Swelling and significant tenderness in the right flank. Spine: Mild tenderess at the lumbar spine. New area of swelling and tenderness around L1 -L2 spine. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact. Sensation intact to light touch. Patient able to move in his lower extremities; able to abduct and adduct his hips. Pertinent Results: Pertinent Labs: ___ 06:00PM BLOOD WBC-7.6 RBC-4.76 Hgb-14.4 Hct-42.8 MCV-90 MCH-30.3 MCHC-33.7 RDW-12.8 Plt ___ ___ 05:25AM BLOOD WBC-6.3 RBC-4.46* Hgb-13.5* Hct-39.9* MCV-90 MCH-30.2 MCHC-33.7 RDW-12.7 Plt ___ ___ 12:40PM BLOOD Hgb-14.1 Hct-42.7 ___ 06:00PM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 . CT spine w/o contrast: ___ IMPRESSION: No fracture or malalignment with normal prevertebral soft tissues. . CXR: ___: IMPRESSION: No acute thoracic injury. . CT abdomen/Pelvis w/o Contrast: IMPRESSION: 1. Right flank retroperitoneal hemorrhage extending along and slightly expanding the right psoas muscle with a trace of blood along the retroperitoneal fat planes. 2. Right transverse process fractures of L1-L5. 3. Unremarkable appearance of solid viscera of abdomen and pelvis, allowing for noncontrast technique. Brief Hospital Course: ___ with no significant past medical history presented as a transfer from ___ with right transverse process fractures of L1-L5 after a fall and subsequently found to have right psoas muscle hematoma. . # Transverse fracture (L1-L5): Patient presented after falling 4 feet into bathtub from top of window to ___ where he was found to have multiple lumbar transverse fracture. Head CT did not show any intracranial bleed. X-rays of the hip and pelvis per report did not show any fractures. He was transferred to ___ for further evaluation. He remained neurologically intact. He was seen by ortho spine who recommended pain control, physical therapy and lumbar corsette for comfort. Per ACS there was no need for surgical intervention for these fractures. He did not have any tenderness on the lumbar spine. He however did complain of significant pain and had swelling in his right flank concerning for hematoma therefore CT abdomen/pelvis was obtained (see below). On the day of discharge he had lumbar corsette placed and worked with physical therapy who felt patient was safe to go home. He will follow up in the ortho spine clinic for further care. . # Right Flank Hematoma: Since patient had swelling and tenderness in the right flank area, CT abdomen/pelvis was obtained which in addition to revealing the L1-L5 transverse process fracture also showed "right flank retroperitoneal hemorrhage extending along and slightly expanding the right psoas muscle with a trace of blood along the retroperitoneal fat planes." He has slight drop in his hematocrit to 39.9 which on recheck remained stable. On the day of discharge the swelling had remained stable with pain adequately controlled on oxycodone. He was discharged with oxycodone and Tylenol for pain control and senna for bowel regimen. He was advised to follow up with PCP for further care or seek emergent care if he feels lightheaded or presyncopal. . Transitions of care: - Patient will follow up with ortho spine for transverse process fractures within one week of discharge. - Patient will also follow up with PCP for further evaluation of his right flank hematoma. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO TID RX acetaminophen 650 mg 1 tablet(s) by mouth Every 6 hours Disp #30 Tablet Refills:0 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Please hold for sedation or RR<12. RX oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #40 Tablet Refills:0 3. Senna 1 TAB PO BID:PRN Constipation RX sennosides [senna] 8.6 mg 1 Tablet by mouth Every 12 hours Disp #20 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID:PRN Constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every 12 hours Disp #20 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. L1-L5 right transvere process fractures. 2. Right retroperitoneal/flank 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: Dear Mr. ___, it was a pleasure taking care of you during your hospitalization at ___. You initially presented to ___ after suffering from a 4 feet fall. You were found to have fractures in your lumbar spine and then transfered to ___ for further care. You were seen by our spine orthopedic specialist and surgery specialist who did not believe surgical intervention was necessary and recommended pain control and lumbar brace for support. Please follow up at ___ clinic (see below) for further care. Since you were complaining of significant pain on your right flank area, we also obtained further imaging which showed bruising and blood collection (hematoma) in and around your right psoas muscle. We observed you for one night and the hematoma did not increase in size. You were also seen by physical therapy who believed you were safe to go home with someone who can assist you at home. Please seek urgent care if the swelling in your right flank worsens or if you feel lightheaded and/or short of breath. Please also make a follow up appointment with your primary care physician for further care. Following changes were made to your medications: STARTED Oxycodone 5mg every ___ hours as needed for pain. Please avoid drinking alcohol and driving while you are taking this medication. STARTED Acetaminophen 650 mg every 6 hours for pain as needed. Please take this first in an effort to reduce your need for oxycodone. STARTED Senna(stool softner) to help with any constipation as result of taking oxycodone. Followup Instructions: ___
10092201-DS-8	10,092,201	28,030,798	DS	8	2183-02-19 00:00:00	2183-02-20 19:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Breakthrough seizure activity Major Surgical or Invasive Procedure: Cerebral angiogram History of Present Illness: Mr. ___ is a ___ old right-handed man with a past medical history of IV drug use, chronic back ___ c/b Gabapentin abuse, remote febrile seizure who presents with two events concerning for seizure. Patient reports waking up with a headache yesterday morning. It is described as bifrontal pressure, with associated nausea and phonophobia, initially mild and then progressively worsened over the course of the day. He took Tylenol with some relief. This was in the setting of a few days of feeling "off," with poor appetite, nausea and chills but no fever. Around 1am, he and his girlfriend were lying on the couch and had just fallen asleep. His girlfriend awoke to a grunting noise. She looked over and saw the patient stiff, with eyelid fluttering, grinding his teeth and completely rigid for one minute without incontinence. He was sleepy and quiet afterwards. EMS arrived 5 minutes later and the patient became combative and agitated, confused about why people were in the house. He returned to normal about 30 minutes later after arrival to the OSH ED. At ___, he had basic labs checked, including BG 122, wbc 10.4, Cr 1.3. He had a second seizure, lasting about 1 minute, which resolved prior to Ativan administration. He was then loaded with Dilantin 15mg/kg around 2:30am. He was post-ictal for about 10 mins. He had a head CT which showed a hyperdense focus in the left parietal lobe concerning for venous anomaly. He was therefore transferred for further management. On arrival, he was evaluated by neurosurgery who recommended CTA and MRI. Neurology was consulted for management of his seizures. Of note, there are documentations of patient taking Wellbutrin recently, but he has not taken this medication in ___ months. Additionally, he reports abusing Gabapentin due to significant back ___. He will buy it on the street and take approximately 10 pills per day of Gabapentin 800mg. On the day of the seizure, he thinks he took slightly less Gabapentin than usual, though he is not sure how much. He denies any other drug use. He has not used heroin in over ___ years. Seizure risk factors: -Febrile seizure: only 1 when he was ___ year old. He was placed on Phenobarbital x ___ year. No other seizure medications required and he has never had another seizure. -Head trauma: reports multiple fights with blows to the head and probable concussions in the past -No meningitis or encephalitis -Reports a "bleed" in his brain found on imaging approximately ___ years ago. Presented to doctor for episodes of dizziness and had head imaging which apparently initially looked like a tumor, then told it was a "bleed." There is a head CT in our system from ___ showing a left parietal hemorrhage with mild surrounding edema in the same location. Past Medical History: Back ___ secondary to lumbar disc disease s/p L5 surgery (unclear what was done) Substance abuse (Gabapentin as outlined above) History of IV drug use, quit ___ years ago Depression ADHD Febrile sz s/p appendectomy Social History: ___ Family History: No seizures. Physical Exam: ADMISSION EXAM: General: Sleepy but arousable HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Back: ___ on palpation of thoracic paraspinals R > L, mild midline ___ Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x to self, ___ ___ Able to name his girlfriend in the room. Inattentive, unable to ___ backwards. 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. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. -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. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred due to ___ DISCHARGE EXAM: Difficulty w/ MOYB, otherwise nonfocal Pertinent Results: ___ 05:00AM BLOOD WBC-6.8 RBC-5.03 Hgb-15.4 Hct-45.7 MCV-91 MCH-30.6 MCHC-33.7 RDW-11.8 RDWSD-39.3 Plt ___ ___ 03:51AM BLOOD WBC-20.7* RBC-4.78 Hgb-15.2 Hct-42.9 MCV-90 MCH-31.8 MCHC-35.4 RDW-11.9 RDWSD-39.0 Plt ___ ___ 05:00AM BLOOD ___ PTT-27.8 ___ ___ 05:00AM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-139 K-4.1 Cl-100 HCO3-27 AnGap-16 ___ 03:51AM BLOOD Glucose-136* UreaN-11 Creat-1.0 Na-137 K-3.7 Cl-102 HCO3-19* AnGap-20 ___ 03:51AM BLOOD ALT-26 AST-33 AlkPhos-25* TotBili-0.2 ___ 05:00AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.0 ___ 08:10AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.3 ___ 03:51AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ H&N 1. Curvilinear hyperdense lesion within the left parietal lobe, with extension to the left parafalcine region is likely secondary to calcification, which may be secondary to a partially thrombosed AVM, cavernous malformation, or sequelae of prior hemorrhage. No definite acute intracranial hemorrhage or acute large territorial infarction. 2. Unremarkable CTA of the head without evidence of stenosis or aneurysm. No evidence of vascular malformation. ___ Head w/ and w/o contrast 1. THe left parietal lesions is most likely an occult vascular malformation. ___ Angiogram 5 vessels diagnostic cerebral angiogram did not demonstrate any vascular abnormalities. Brief Hospital Course: Mr. ___ was hospitalized at ___ due to two tonic events concerning for seizure activity. He underwent imaging including CTA Head and Neck and MRI Brain which were concerning for R parietal vascular malformation. He was evaluated on EEG and started on Keppra which was uptitrated due to persistent events. Due to hx of Gabapentin abuse, he was started on gabapentin regimen to prevent withdrawal. He underwent cerebral angiogram by NSGY on ___ which did not show a vascular abnormality. Per Neurosurgery, likely that pt does not have vascular abnormality but rather has abnormalities seen on imaging related to previous TBI in ___. Due to appearing clinically stable, patient was discharged from the hospital. ******************* Transition Issues: -Pt will need to follow up with new PCP and ___ -Pt will need to follow up in First Time Seizure Clinic -Pt will need to continue taking Keppra 1500mg BID -Pt will need to take Gabapentin taper starting at 800mg TID and tapering down by 100mg every week -Pt will need to obtain MRI in 6 months to ensure that vascular anomaly seen on previous imaging is not apparent Medications on Admission: Gabapentin 800mg TID (often up to 10 pills per day) Prozac Adderall ___ pills per day Discharge Medications: 1. Gabapentin 800 mg PO TID 2. LevETIRAcetam 1500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Breakthrough seizure activity 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 ___ and treated by Neurology due to events concerning for seizure activity. You underwent neuroimaging of the brain as well as EEG which suggested occult vascular anomaly in brain. However, cerebral angiogram did not reveal this abnormality. Due to appearing stable on Keppra started on admission with no continued seizures, you will be discharged from the hospital. Please continue taking Keppra 1500mg twice daily. Please continue to taper down on Gabapentin as follows: Gabapentin 800mg (1 800mg tablet) three times daily x 1 week, then Gabapentin 700mg (1 600mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 600mg (1 600mg tablet) three times daily x 1 week, then Gabapentin 500mg (1 400mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 400mg (1 400mg tablet) three times daily x 1 week, then Gabapentin 300mg (3 x 100mg tablets) three times daily x 1 week, then Gabapentin 200mg (2 x 100mg tablets) three times daily x 1 week, then Gabapentin 100mg (1 x 100mg tablet) three times daily x 1 week, then stop Please follow up in First Time Seizure Clinic in near future (to be contacted with appointment information). Please plan for follow up MRI Brain in 6 months to determine if intracerebral vascular anomaly has resolved. Please follow up with new PCP and ___ based on information provided by social worker. It was pleasure taking care of you, ___ Neurology Team Followup Instructions: ___
10092227-DS-14	10,092,227	23,138,040	DS	14	2158-07-23 00:00:00	2158-07-23 18:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: CVL placement (removed) PICC line placed (removed on ___ Bronchoscopy History of Present Illness: ___ with unclear medical history (?COPD) presenting from out of hospital for unresponsiveness. Patient had a fall yesterday. EMS was called; however, the patient declined transfer at that time. Patient today was found unresponsive by friend. Brought to outside hospital where she was in respiratory distress. Hypotensive with systolics in the ___. Patient was intubated and started on norepinephrine. Patient found to have transaminitis (2000s); trop 0.04. Pan scan results showed concern for temporal and occipital stroke. ___ pancreatic inflammation on CT scan although with normal lipase level. Patient received vancomycin and Zosyn for concern for pneumonia. OG tube with coffee ground material returning. Patient given pantoprazole. Transferred here for further management. Right femoral line placed at outside hospital (___). In the ED, initial vitals: 98.0, 87, 129/77, 15, 100%vent Labs were significant for: VBG: 7.13, 86, O2 44, HCO3 30 CBC: 18.4>14.9/51.2<98 Chem (whole blood): Na 148, K 4.4, Cl 106, Glu 149, freeCa 1.08 Lactate: 2.9 INR 2.2, ___ ___ Fibrinogen 168 ALT 2550, AST 5098, AP 124, Tbili 2.1, Alb 3.2 Lipase: 12 Serum tox: negative APAP tox: negative Imaging was significant for: CXR 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Her imaging is notable for right lung collapse, possible pneumonia, pulmonary nodule, and ___ stranding in addition to the reported subacute right temporal occipital stroke seen on head CT (currently unable to access). CT head non-con (___): 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. Consults: Neuro, toxicology, RT On transfer, vitals were: On arrival to the MICU, Review of systems: unable to obtain as patient is intubated. (+) Per HPI Past Medical History: COPD; ?skin cancer of nose (no other hx available) Social History: ___ Family History: Unknown Physical Exam: ADMISSION EXAM: --------------- Vitals: T: 98.2 NR BP: 80/62 P: 78 R: 42 O2: 99%Vent GENERAL: Intubated/sedated HEENT: Sclera anicteric NECK: supple LUNGS: coarse breath sounds bilaterally, no wheezes 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 GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 2+ edema bilaterally in lower extremities SKIN: large macular rash underneath breasts. NEURO: Intubated/sedated -- deferred ACCESS: PIVs DISCHARGE EXAM: --------------- General: No acute distress. AOx3. HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple. No JVD Lungs: Clear lung in left. Decreased breath sounds of RLL fields CV: RRR, normal S1 + S2, no significant murmurs, rubs or gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, trace edema around legs bilaterally. Neuro: moving all 4 extremities Skin: 4cm circular scar on back from prior procedure. R nare with 1cm round lesion with pearly red borders, R thigh with dressing over erythematous skin lesion. Pertinent Results: ADMISSION LABS: --------------- ___ 04:45PM BLOOD WBC-18.4* RBC-5.37* Hgb-14.9 Hct-51.2* MCV-95 MCH-27.7 MCHC-29.1* RDW-17.9* RDWSD-58.8* Plt Ct-98* ___ 04:45PM BLOOD ___ PTT-24.7* ___ ___ 04:45PM BLOOD Plt Smr-LOW Plt Ct-98* ___ 04:45PM BLOOD UreaN-35* Creat-1.6* ___ 04:45PM BLOOD ALT-2550* AST-5098* AlkPhos-124* TotBili-2.1* ___ 04:45PM BLOOD Albumin-3.2* ___ 05:08PM BLOOD pO2-44* pCO2-86* pH-7.13* calTCO2-30 Base XS--3 ___ 05:08PM BLOOD Glucose-149* Lactate-2.9* Na-148* K-4.4 Cl-106 ___ 05:08PM BLOOD freeCa-1.08* DISCHARGE LABS: --------------- ___ 05:32AM BLOOD WBC-10.4* RBC-2.98* Hgb-8.5* Hct-27.7* MCV-93 MCH-28.5 MCHC-30.7* RDW-18.1* RDWSD-60.6* Plt ___ ___ 05:32AM BLOOD Plt ___ ___ 05:32AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-144 K-3.6 Cl-101 HCO3-35* AnGap-12 ___ 04:16AM BLOOD ALT-84* AST-17 LD(LDH)-303* AlkPhos-103 TotBili-0.9 ___ 06:34PM BLOOD CK-MB-1 cTropnT-0.01 ___ 05:32AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 IMAGING: -------- CXR ___: IMPRESSION: In comparison with the study of ___, there is little overall change. Again there is extensive opacification at the right base consistent with pleural fluid and substantial volume loss in the right lower lobe. The cardiomediastinal silhouette is unchanged and there again is tortuosity of the descending aorta. There may be mild elevation of pulmonary venous pressure. The tip of the central catheter again extends into the right atrium. CXR ___: FINDINGS: Compared to ___, there is re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. The left lung and left PICC line position are unchanged. IMPRESSION: Compared to ___, re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. CT Chest ___: 1. Complete collapse of the right lung with rightward mediastinal shift secondary to volume loss. Extensive intraluminal airway secretions with near complete distal airway opacification on the right. Suggestion of 2 cm low-attenuation nodule in the right lower lobe. 2 rounded areas of aerated lung parenchyma in the right upper lung, or, if there is clinical symptoms of pneumonia, cavitated pneumonia could have similar appearance. Right hilar or perihilar Masse cannot be excluded on a noncontrast scan. 2. Probable pulmonary hypertension. 3. Moderate right pleural effusion. 4. Unchanged 11 mm left upper lobe nodule. 5. Nonspecific old surgical skin defect overlying the upper-mid thoracic spine. MRI/MRA Head/Neck ___: 1. Chronic right temporo-occipital infarct and chronic small vessel ischemic changes. No evidence of acute or subacute vascular territorial infarction. 2. 18 x 23 mm indeterminate mass at the junction of the nose and right upper lip as described above, unchanged from the recent CT scan of ___. 3. Moderately motion degraded brain MRI shows grossly patent circle of ___. 4. Nondiagnostic contrast enhanced neck MRA, but appears grossly patent on moderately motion degraded time-of-flight MRA of the neck. Portable CXR IMPRESSION: 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Non-con Head CT ___: 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. ___ Non-con Neck CT: IMPRESSION: 1. Significant amount of debris and secretions in the lower trachea and extending to the imaged portion of the proximal right main bronchus. The imaged portion of the right lung is collapsed, as seen earlier today. Bilateral pleural effusions, greater on the right. 2. Approximately 2.6 cm right thyroid nodule. Thyroid ultrasound recommended. 3. 8 mm left upper lobe pulmonary nodule. 4. Marked enlargement of main pulmonary artery, consistent with pulmonary artery hypertension. 5. Indeterminate 2.4 cm right pre antral soft tissue mass. RECOMMENDATION(S): 1. 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. In the case of nodule size >6 - 8 mm: For low risk patients, initial follow-up CT at ___ months and then at ___ months if no change. For high risk patients - initial follow-up CT at ___ months and then at ___ and 24 months if no change. 2. Nonurgent thyroid ultrasound. MICROBIOLOGY ============== No growth on any cultures ___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 CFU/mL. ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT Brief Hospital Course: SUMMARY: ___ h/o COPD, depression, likely ___ transferred from outside hospital for unresponsiveness, found to be in shock with respiratory failure. She was initially admitted to the MICU where she required three pressors for shock and was intubated. For her respiratory failure, she was treated for a COPD exacerbation, HCAP, and pulmonary edema with eventual extubation and weaning to 3L. For her shock, thought to be septic, she was treated with antibiotics and improved. After transfer to the floor, she was additionally managed for complete right lung collapse with chest ___, as well as atrial fibrillation with RVR using rate control agents. A MRI of her head showed old infarcts and she was started on anticoagulation with apixaban. She was discharged to a rehab facility for continued chest ___ and rehabilitation. A bronchoscopy was deferred given improvement with chest ___. She will need repeat CXR in ___ weeks to assess for resolution of RLL collapse along with CT to revaluate for possible malignancy causing lung collapse. #Respiratory failure: As above, patient presented in mixed hypoxemic and hypercarbic respiratory failure requiring intubation. She quickly improved after intubation. She was treated for a COPD exacerbation with methylprednisone, azithromycin 5-day course, and nebulizers. She was also treated for pneumonia with HCAP coverage, completing an 8-day course of vanc/zosyn then levofloxacin. She was also treated for pulmonary edema with boluses of IV furosemide and albumin (her albumin was 2.5). With these interventions she improved and stabilized on nasal canula. She was found to have collapse in her R lung, thought to be in the setting of mucus plugging versus obstructive mass. Pulmonology was consulted and bronchoscopy was deferred in setting of improvement with chest ___, which patient had initially refused. She remained on 2L O2 on nasal canula. She will need continued chest ___ at rehab along with repeat CXR in ___ weeks to assess for resolution in right lower lung collapse. She will need repeat CT after resolution of lung collapse to evaluation for possible mass causing collapse. She did not have cytology performed on initial bronchoscopy in the ICU. # Afib with RVR: Patient with no prior diagnosis of Afib, found to be in Afib with RVR on several occasions during this admission. She was placed on a rate control agent with verapamil, which was uptitrated to 120mg q8h. Her heart rates stabilized on this dose. She was also started on anticoagulation with apixaban 2.5mg BID, which was increased to apixaban 5mg BID after kidney function improved. # Shock: Resolved. As above, suspected to most likely be septic shock. CVL was placed at OSH. She initially required 3 pressors, but eventually weaned off completely. Blood, urine and sputum cultures were unremarkable. Patient had some shock-related laboratory abnormalities including troponin elevation, transaminase elevation, coagulopathy however these improved/resolved as she improved clinically. CVL was removed. # ___: Patient came in with Cr 1.6 and peaked at 3.6. Urine sediment showed muddy brown casts suggestive of ATN. Her Cr was monitored closely and over time downtrended to baseline of ___. # Skin lesions: Patient has a large nodule abutting her right nares which is suspicious for a BCC. Will require biopsy and further follow up as outpatient. # Sub-acute/chronic strokes: CT head showed late subacute to chronic infarcts in the right occipital, temporal lobes. Neurology was consulted. Stroke risk factors were unremarkable. A MRI/MRA was subsequently performed which showed areas of chronic infarcts. Patient was started on ASA 81mg and anticoagulation. No residual deficits on exam. # UGIB: Coffee ground material seen from OG tube at OSH. Patient started on IV PPI and a type/screen was maintained. Ultimately Hb remained stable and clinical suspicion for bleed was low. PPI was discontinued in setting of unlikely bleed. TRANSITIONAL ISSUES: [] Afib with RVR - Patient with new diagnosis of Afib with RVR - Started on verapamil 120mg q8h for rate control, apixaban 5mg BID for anticoagulation. Switched to verapamil SR 360mg daily as outpatient - SHOULD received 360mg SR starting ___. [] Chronic strokes - Chronic infarcts in R occipital and temporal lobes seen with no residual deficits - Will follow up with neurology in clinic in ___ weeks - this appointment needs to be made [] Skin lesion - R nares lesion likely ___ will require outpatient dermatology biopsy and follow-up in ___ weeks (this appointment needs to be made) [] Right lung collapse - Patient with right lung collapse, bronch deferred given improvement with CHEST ___ - Patient will need to continue aggressive chest ___ in rehab. - Repeat CXR in ___ weeks to assess for resolution and f/u with pulmonary at that time. Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires further evaluation. - Patient remained on 2L of oxygen during inpatient. Continue to wean as tolerated while patient undergoing aggressive chest ___. - Patient should follow up with Pulmonology in ___ weeks (this appointment needs to be made). - Patient should have a repeat CT Chest in 3 months to assess for right lung collapse after chest ___ and acute issues resolve [] Incidental imaging findings - 2.6cm right thyroid nodule, recommended THYROID ULTRASOUND as soon as possible - 8mm left upper lobe pulmonary nodule, will require 6-month follow-up CT scan- - Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires f/u CT scan of chest in ___ weeks after resolution of right lower lung collapse. # Code status: DNR/DNI # Contact: Proxy name: ___ Relationship: friend Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 2. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain - Moderate 3. FLUoxetine 20 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH ___ BID Discharge Medications: 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Verapamil SR 360 mg PO Q24H 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 5. FLUoxetine 20 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Sepsis Pneumonia Right lung collapse Acute tubular necrosis Atrial fibrillation Stroke Skin lesion SECONDARY DIAGNOSIS: COPD Depression 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 being unresponsive and very sick. WHAT HAPPENED TO YOU IN THE HOSPITAL? - You were first in the ICU. You were intubated and we gave you support for your blood pressures - You improved and were taken care of on the regular medical floor - We treated you with antibiotics, nebulizers, and steroids to improve your lung status - We did a bronchoscopy which showed collapse of your right lung, without evidence of masses or tumor, although you will need another chest x-ray and CT scan of your chest to better evaluate once your lung opens back up. - You developed a fast heart rhythm called Afib. We slowed your heart rate with a medication called verapamil and put you on a blood thinner called Eliquis. - On a MRI, we saw that you had old strokes. The blood thinner will help prevent strokes in the future. You should see a neurologist in clinic - We saw that you have a lesion on the right side of your nose that is concerning for a basal cell tumor. You should follow up with dermatology for evaluation once you leave the hospital. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - You must follow up with dermatology to have your nose lesion biopsied - You must continue taking your medications, including the new medications we have prescribed. These are very important - You should follow up with a neurologist and your primary care doctor - You will need to have another chest X-ray in ___ weeks to make sure that your right lung has opened back up. Once the lung has opened up, we will need to repeat a CT scan of your chest to check for any masses or tumors in the lungs that may have caused the lung to collapse. It is very important that you follow up with the lung doctors for this ___. We wish you all the best! - Your ___ care team Followup Instructions: ___
10092572-DS-3	10,092,572	29,709,457	DS	3	2139-05-30 00:00:00	2139-05-30 13:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: None History of Present Illness: ___ Critical is a ___ female who presents to ___ on ___ with a moderate TBI. Per report patient fell in the bathroom at 0415, with + LOC and head strike. Patient was initially unresponsive and EMS was called. Per EMS patient became responsive around 0505 but was unable to answer questions about the fall. She was transferred to ___ where CT revealed SAH. Patient takes Plavix and ASA for atrial fibrillation. She is demented at baseline, only oriented x2. At ___ became more altered and was intubated for airway protection. She was transferred to ___ for Neurosurgical evaluation. Mechanism of trauma: fall Past Medical History: Atrial Fibrillation Cancer Dementia R foot drop GERD Hyperlipidemia Diabetes Social History: ___ Family History: NC Physical Exam: Upon admission: Intubated No EO PERRL ___ +Corneal/gag/cough Briskly withdraws all four extremities to noxious No commands Some intermittent purposeful movement with BUE Pertinent Results: Please see OMR for pertinent results Brief Hospital Course: Ms. ___ was admitted to the Neurosurgical service after a fall on Plavix and ASA, NCHCT revealed SAH. She was transferred from ___ to ___. Intubated at the OSH for airway protection. #___ Patient was admitted to the ICU ___. She was started on Keppra 500mg BID for seizure prophylaxis. Repeat CT 6 hours after initial was stable. CTA was done which revealed carotid stenosis but no aneurysm. Mental status remained poor. She was extubated on ___ and transferred to the ___. On ___ mental status somewhat improved. He exam continued to wax and wane. On ___, a family meeting was held and it was decided to proceed with comfort measures only and discharge home with hospice. The patient was discharged to home in stable condition for the ambulance ride on ___. #Respiratory Failure Patient was intubated at the OSH for airway protection secondary to altered mental status. Her ABG on arrival was normal. She was successfully extubated ___. #Dysphagia ___ patient failed a S&S evaluation. The evaluation was repeated on ___ and again was felt to be inappropriate for a PO diet. Given her advanced dementia and the likelihood for her dysphagia to worsen significantly, the patient's family had a goal of care meeting and made her NPO. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D ___ UNIT PO DAILY 2. Atorvastatin 40 mg PO Q24H 3. Clopidogrel 75 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. RisperiDONE 1 mg PO DAILY 7. RisperiDONE 2 mg PO QHS 8. Vesicare (solifenacin) 5 mg oral DAILY 9. galantamine 8 mg oral DAILY 10. Sotalol 80 mg PO BID 11. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Medications: 1. Atropine Sulfate 1% ___ DROP SL ASDIR Secretions 2. Haloperidol ___ mg PO Q4H:PRN agitation 3. LORazepam 0.5 mg PO Q6H RX lorazepam 0.5 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN Pain - Moderate RX morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth every one (1) hour Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid Hemorrhage Altered mental status Dementia Hypertension UTI Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Ms. ___, You were admitted to ___ Neurosurgery after sustaining a fall which resulted in an traumatic subarachnoid hemorrhage. Your hospital course was complicated by altered mental status, hypertension, a UTI, and inability to meet nutritional goals. Disposition: Discharge home with hospice care and family. Followup Instructions: ___
10093120-DS-18	10,093,120	28,669,551	DS	18	2119-12-06 00:00:00	2119-12-09 09:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal distention Major Surgical or Invasive Procedure: paracentesis diagnostic laparoscopy, explorative laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, omentectomy, appendectomy, left pelvic lymphadenectomy, pelvic peritonectomy, oversew of bowel serosa and cystoscopy History of Present Illness: Ms. ___ is a lovely ___ G0 transferred from ___ to ___ ED on ___ for partial small bowel obstruction, pelvic masses, and carcinomatosis on CT scan. She was admitted to the medicine service from the ED, where she has been managed. She initially presented to ___ with abdominal distention and nausea that developed over the past week. She reports decreased appetite and nausea with dry heaving, no vomiting because she feels her stomach has been empty from minimal PO intake. She also reported abdominal pain throughout her abdomen. At ___, she had CT A/P that was read as follows: 1. 8 x 12 cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy. Malignant ascites and peritoneal enhancement suggesting peritoneal carcinomatosis. 2. Partial SBO likely secondary to small bowel into by pelvic tumor. She was then transferred to ___ for further evaluation and management. In the ED here, she was initially mildly tachycardic but afebrile. Her HR normalized with hydration. Her vitals have remained normal in the floor. Her SBO has been managed conservatively NPO/IVFs. She has not required an NG tube. She states today that her nausea has completely improved and she has not had vomiting or dry heaving since being in the hospital. She has continued to pass gas throughout the past week, including today, and feels like she is going to have a BM soon. Her last BM was on ___. She did undergo a paracentesis for 2L of clear, straw-colored fluid on ___, and states she felt much better after paracentesis but is already feeling fluid re-accumulate. Peritoneal fluid was sent for cytology which is pending. ___ was consulted by medicine to consider ___ biopsy of omental nodules, but felt that the nodules were too small to successfully and safely biopsy with ___ so this was deferred. On ROS, patient states she had a 15lb weight-loss over the past year but has been trying to lose weight. She denies CP, SOB, fever, chills, changes in bowel movements or urination, vaginal bleeding, or abnormal discharge. ROS: full review of systems was negative except as above Past Medical History: Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ Social History: ___ Family History: Father: ___ Mom: osteoporosis Physical Exam: Physical Exam on Admission ___: T 98.0 HR 108 BP 130/82 RR 18 O2Sat 98% RA Gen: A&O, NAD CV: RRR Resp: CTAB Abd: somewhat hypoactive BS, softly distended, nontender, no rebound or guarding Ext: calves nontender bilaterally SSE: Normal vaginal mucosa with pink tinge, no lesions, Cervix unable to be visualized due to patient discomfort even with small size speculum BME: Small smooth cervix, exam limited due to ascites, large pelvic mass palpated, nontender Rectovaginal exam: no nodularity, again large pelvic mass palpated Physical Exam on Day of Discharge: ___ 0731 Temp: 98.5 PO BP: 127/79 HR: 88 RR: 18 O2 sat: 95% O2 delivery: Ra ___ 0506 Temp: 98.1 PO BP: 145/75 HR: 94 RR: 18 O2 sat: 98% O2 delivery: RA ___ Total Intake: 60ml PO Amt: 60ml ___ Total Intake: 300ml PO Amt: 300ml ___ Total Output: 1100ml Urine Amt: 1100ml ___ Total Output: 3370ml Urine Amt: 3350ml Emesis: 20ml General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: + bowel sounds. Soft, nontender to palpation, minimally distended. No rebound/guarding. Vertical midline incision closed with staples and c/d/I without surrounding erythema, induration, or exudate. GU: No blood on pad. MSK: Lower extremities with 2+ edema to knee bilaterally; no erythema or TTP, compression stocking on Pertinent Results: ___ 02:00AM BLOOD WBC-8.8 RBC-4.92 Hgb-12.9 Hct-39.9 MCV-81* MCH-26.2 MCHC-32.3 RDW-12.8 RDWSD-37.3 Plt ___ ___ 06:10AM BLOOD WBC-7.4 RBC-4.36 Hgb-11.6 Hct-36.4 MCV-84 MCH-26.6 MCHC-31.9* RDW-12.8 RDWSD-38.8 Plt ___ ___ 02:00AM BLOOD Neuts-62.2 ___ Monos-13.0 Eos-0.8* Baso-0.7 Im ___ AbsNeut-5.47 AbsLymp-1.98 AbsMono-1.14* AbsEos-0.07 AbsBaso-0.06 ___ 06:10AM BLOOD ___ ___ 02:00AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-139 K-4.3 Cl-96 HCO3-23 AnGap-20* ___ 02:00AM BLOOD ALT-<5 AST-9 AlkPhos-66 TotBili-0.4 ___ 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 ___ 02:00AM BLOOD Albumin-3.1* ___ 02:00AM BLOOD CEA-0.6 ___* - CT chest (___): anterior supradiaphragmatic lymph nodes are 0.9cm, concerning for possible metastatic involvement, for further follow-up. - CT A/P: 12cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy, malignant ascites, and peritoneal carcinomatosis Brief Hospital Course: Ms. ___ is a ___ year old woman without significant past medical history presenting with partial small bowel obstruction, pelvic masses, carcinomatosis, who was initially admitted to medicine for further workup and was transferred to gynecologic oncology service on hospital day #2 given concern for ovarian malignancy. In regards to her partial small bowel obstruction, patient had a CT abdomen/pelvis which demonstrated a dilated small bowel with transition point in pelvis. Per radiology, the small bowel was likely entrapped and dilated by tumor. Patient did not endorse any nausea and continued to pass flatus. Acute care surgery was consulted and patient was made NPO with IV fluids, anti-emetics, and narcotics as needed. Patient tolerated sips on hospital day #2, Ensure clear/toast/crackers on hospital day #3, and a regular diet on hospital day #4. In regards to the concern for ovarian malignancy, she had a CT which demonstrated a 12cm cystic and solid pelvic soft tissue mass, ascites, and peritoneal carcinomatosis. A CT chest revealed 0.9cm supradiaphragmatic lymph nodes, which could possibly represent metastases. ___ was Tumor markers revealed elevated CA-125 of 522 and CEA level of 0.6. She had a paracentesis performed in the emergency room for 2 liters of ascites, and cytology was sent for analysis. Interventional radiology was consulted, however her omental lesions were too small to biopsy. On hospital day #6, patient underwent a TAH/BSO, appendectomy, omenectomy. Afterwards she was admitted to ___ for mild hypotension post-op requiring neo. She was treated with unasyn for purulent fluid from one ovary as well as imaging concerning for pneumonia, and her blood pressure improved. She had an NGT placed intra-operatively which was removed without issue on post-operative day 3. Her post-operative course was complicated by an elevated INR, for which she received vitamin K with resolution. Her pain was initially managed with an epidural and was then transitioned to oral medications. Her diet was advanced slowly due to post-operative ileus. Her foley catheter was removed on post-operative day 3 and she voided spontaneously. By post-operative day 10 she was voiding, tolerating a regular diet, ambulating independently with good pain control. She was then discharged home with ___ services to continue lovenox for prophylactic anticoagulation. Medications on Admission: Loratadine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hrs RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #50 Tablet Refills:1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:1 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #19 Syringe Refills:0 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea may be constipating, call MD if needing to use frequently RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #10 Tablet Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate do not drive or drink alcohol, may cause sedation RX oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #20 Tablet Refills:0 6. Loratadine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: partial small bowel obstruction pelvic mass and carcinomatosis left tuboovarian 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 the gynecology oncology service for a partial small bowel obstruction and were found to have a pelvic mass. You then underwent the procedure listed below. You have recovered well after your procedure, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. Followup Instructions: ___
10093120-DS-20	10,093,120	21,033,575	DS	20	2121-08-14 00:00:00	2121-08-14 16:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: seasonal / candle fragrances and heavy perfumes / lidocaine Attending: ___. Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a pleasant ___ years old Female who presents to ___ ED for the further evaluation of nausea, vomiting, abdominal pain for the past two days associated with poor PO intake. Pt states she was in her usual state of health until 2 to 3 days ago when these symptoms started that have gradually been worsening. She endorses NBNB vomiting each time she attempts PO intake. Abdominal pain is described as crampy, although can be sharp at times, currently a ___ at time of exam, and improved by sitting upright. Last BM noted to be yesterday (___) morning. Denies passing any gas today. No recent fevers, chills, diarrhea, UTI sxs, recent prolonged traveling, or known exposure to sick contacts. She called her oncologist's office who advised her come to the ED for further evaluation. In the ED, initial vitals: 97.3 92 119/74 16 94% RA REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ Social History: ___ Family History: Father: ___ Mom: osteoporosis Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: ___ 0004 Temp: 97.4 PO BP: 129/84 HR: 90 RR: 18 O2 sat: 97% O2 delivery: RA Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted SKIN: intact NEURO: AOx3 ACCESS: R POC DISCHARGE PHYSICAL EXAM: ======================== Vitals: 24 HR Data (last updated ___ @ 2349) Temp: 98.0 (Tm 98.0), BP: 131/83 (114-131/79-83), HR: 82 (82-99), RR: 18, O2 sat: 95% (95-96), O2 delivery: Ra Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted NEURO: AOx3 ACCESS: R Port Pertinent Results: ADMISSION LABS ============== ___ 01:02PM BLOOD WBC-10.2* RBC-4.70 Hgb-12.8 Hct-41.1 MCV-87 MCH-27.2 MCHC-31.1* RDW-16.7* RDWSD-52.7* Plt ___ ___ 01:02PM BLOOD Glucose-101* UreaN-13 Creat-0.4 Na-141 K-4.1 Cl-97 HCO3-23 AnGap-21* ___ 01:02PM BLOOD ALT-<5 AST-14 AlkPhos-90 TotBili-0.3 ___ 01:02PM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.7 Mg-1.9 ___ 01:07PM BLOOD Lactate-1.8 DISCHARGE LABS =============== ___ 05:51AM BLOOD WBC-4.3 RBC-3.80* Hgb-10.1* Hct-32.9* MCV-87 MCH-26.6 MCHC-30.7* RDW-16.5* RDWSD-51.8* Plt ___ ___ 10:55AM BLOOD ___ ___ 05:56AM BLOOD Glucose-94 UreaN-2* Creat-0.3* Na-142 K-3.9 Cl-105 HCO3-27 AnGap-10 ___ 05:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 IMAGING ======= ___ CT ABD PELVIS W CONTRAST 1. Small-bowel obstruction with likely transition point in the lower pelvis. No definite mass or specific etiology identified. 2. Interval increase in small to moderate volume ascites. Peripheral thickening/rim enhancement of the ascites, slightly increased in conspicuity, may be related to the ___ malignancy although infectious peritonitis cannot be excluded. 3. Thickening of few small loops of small bowel. Unclear if this is related to infection or ___ underlying malignancy. Ischemia cannot be excluded. 4. Partially occlusive thrombus extending from the right common iliac vein to the visualize right femoral vein, increased in conspicuity compared to prior. 5. Interval increase in small to moderate nonhemorrhagic left pleural effusion which is likely loculated. 6. Interval decrease in small nonhemorrhagic right pleural effusion. MICROBIOLOGY ============= ___ 1:45 pm URINE CLEAN CATCH. *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: TRANSITION ISSUES: ================== [ ___ DVT was treated with heparin drip. She was transitioned to lovenox 50mg BID, which she will continue upon discharge. She will pick up a 12-day supply on discharge due to cost. She will need a new prescription during her next follow-up appointment. [ ___ pleurex drainage schedule changed to 2x per week (___) from 3x per week, after discussion with Dr. ___. [ ___ Mg was 1.6 on the morning of discharge and was repleted. Please recheck a chem10 at next follow-up appointment. [ ]Ensure patient continues standing bowel regimen at home SUMMARY: ======== ___ PMH of stage IIIB (pT3bN0) ovarian carcinoma (low grade serous & endometrioid; ER-) and stage II (pT2N0) endometrioid endometrial adenocarcinoma, grade 1 (Genetics: CHEK2, VUS BRCA2 on 47 Gene) who presents for eval of nausea, vomiting, abd pain x2days a/w poor PO intake, found to have SBO and DVT on imaging. ACTIVE/ACUTE ISSUES: ==================== # SBO Patient was aferile and stable on admission. She has a history of SBO, most recently in ___ and was managed conservatively at that time. SBO likely ___ known metastatic disease and CT AP found SBO with likely transition point in lower pelvis, no definite mass. She was made NPO and received fluids; she did not require NGT placement. She received Ativan and Reglan for nausea. She was able to pass gas and advance her diet to solids without pain or nausea. She had not yet had a bowel movement on day of discharge, but opted to leave the hospital with plan to continue taking standing bowel regimen at home. # DVT CT A/P had incidental finding of partial occlusive thrombus extending from R common iliac to R femoral. She was started on a heparin drip and was transitioned to lovenox 50mg BID, which she will continue upon discharge. Due to insurance issues, she was discharged with 12d supply and e-mail was sent to outpatient oncologist Dr. ___ to ensure she continues to receive lovenox. # Ovarian cancer, platinum refractory The patient has stage IIIb ovarian carcinoma and stage II endometrioid endometrial adenocarcinoma s/p 6 cycles of adjuvant chemotherapy with ___ (c/b neuropathy) with refractory disease and a malignant pleural effusion s/p 5 cycles of ___. Recently, she is s/p C2D1 Topotecan on ___. Dr ___ primary oncologist, was updated by email. CHRONIC/STABLE ISSUES: ====================== # Malignant Pleural Effusion Patient has a pleurex catheter. Initially, it was drained per her home schedule, 3x per week (MWF). After discussion with Dr. ___ Interventional ___, her schedule was changed to 2x weekly (___) given low volume output (70-80cc) during drainage. # GERD - Continued home Famotidine PO qAM and pantoprazole 20mg PO qHS # Neuropathy - Continued home B12 supplementation monthly injections Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 2. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 3. Pantoprazole 20 mg PO QHS 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Calcium Carbonate 500 mg PO DAILY 6. Famotidine 20 mg PO DAILY 7. Loratadine 10 mg PO DAILY:PRN allergy 8. ___ ___ mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 50 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 50 mg SC twice a day Disp #24 Syringe Refills:0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Calcium Carbonate 500 mg PO DAILY 4. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 5. Famotidine 20 mg PO DAILY 6. Loratadine 10 mg PO DAILY:PRN allergy 7. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 8. Pantoprazole 20 mg PO QHS 9. ___ ___ mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: small bowel obstruction, deep vein thrombosis, ovarian carcinoma, endometrioid endometrial adenocarcinoma Secondary diagnoses: osteoarthritis, gastroesophageal reflux, peripheral neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had nausea and vomiting, and were unable to keep any food or liquids down. - The CT scan showed that you had a small bowel obstruction. - The CT scan also showed that you had a blood clot in your leg. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received fluids to keep you hydrated and medications to help with your nausea. - Your diet was slowly advanced until you were able to eat regularly. - You received medications to treat your blood clot. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed. It is extremely important that you continue taking your blood thinner (lovenox) twice daily EVERY DAY. This medication will prevent you from forming additional blood clots. If you stop taking this medication, you could develop more blood clots, which could travel to your lungs and cause you to have SERIOUS problems with your breathing. If you have any difficulty filling your lovenox prescription, you should call your doctor immediately! - Please follow up with all the appointments scheduled with your doctor. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
10093362-DS-11	10,093,362	25,322,183	DS	11	2169-12-31 00:00:00	2170-01-04 11:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness, nausea, unsteady gait, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: per Dr. ___ note: Ms. ___ is a ___ year old female with a past medical history of an episode of vertigo in ___ who presents to the ___ ED after 1 hour of dizziness, nausea, vomiting, and unsteady gait. She reports that her alarm woke her up at 430am and, as soon as she opened her eyes, she felt that the room was spinning. This worsened as she reached over to her alarm. She states that she tried to close her eyes to make the spinning would go away, but her symptoms continued. She felt nauseous during this time and intermittently walked to the bathroom to vomit (water, non-bloody, ~x4). According to Ms. ___, when she walked to the bathroom, she felt unsteady and had to balance herself on objects in her room. She remained in bed hoping that her symptoms would resolve, but the sense that the room was spinning continued. She states that small movements worsened her dizziness and sense that the room was spinning. She tried to sleep for another hour in bed and put an ice pack on her head. At around 5:30am, she called her father and then ___ (___), who advised that she go to the hospital. She then called an ambulance, who brought her to the ___ ED. In the ED, BP was 134/73. Pt was given 2 doses of 12.5mg meclizine PO, with mild relief of symptoms. She denies use of OCPs or tobacco. She reports that, in ___, she had an episode of vertigo after lunch while at ___, for which she was prescribed meclizine. This lasted ___ hours and there was significant relief with meclizine. She took the medication for several days and has not had any other episodes since. According to her, her present symptoms are "very similar, but somewhat worse" compared to those in ___. Of note, she also endorsed having a runny nose, without fevers, chills, cough, or vomiting, several days before this episode of dizziness. She believes the symptoms were related to allergies. On neurologic review of systems, pt endorses difficulty with walking, dizziness, vomiting and nausea. Denies difficulty with comprehending speech. Denies loss of vision, diplopia, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence. On general review of systems, the patient denies fevers, chest pain, palpitations, dyspnea, or cough. Denies diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Past Medical History: Episode of vertigo (___) Social History: ___ Family History: Endorses family history of heart attacks. According to father, there is a family history of clotting. Pt not aware of any history of miscarriages, strokes, or DVTs in family. Physical Exam: ADMISSION EXAM: PHYSICAL EXAMINATION Vitals: T97.5 HR84 BP134/73 RR18 SaO2100%RA General: Young female reclined in hospital stretcher, NAD HEENT: NCAT, no oropharyngeal lesions, anicteric. Strabismus. ___: RRR, no elevated JVP on gross exam Pulmonary: Breathing comfortably Abdomen: NTND Extremities: no CCE Skin: Erythematous lesions on left anterior tibial region. Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and month. Attention to examiner easily maintained. Recalls a coherent history. Able to recite months of year backwards. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - PERRL 2.5->2 brisk. VF full to finger wiggling. EOMI with no nystagmus. V1-V3 without deficits to light touch bilaterally. No evidence of facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Trapezius and SCM strength ___ bilaterally. Tongue midline and moves left/right appropriately. - Motor - Normal bulk and tone. Exam is effort dependant but she is able to give full strength on encouragement. No pronation or drift. 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 or temperature bilaterally. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 unable to obtain R 2 2 2 unable to obtain Plantar response downgoing bilaterally. - Coordination - Mild dysmetria with finger to nose testing on the left. Heel-to-shin tapping task intact bilaterally. States that the room appears to be spinning. Worsened with head movement. - Gait - Normal initiation and normal based. Normal stride length and arm swing. Able to perform toe ___. No ataxia. Romberg negative. Able to tandem walk without difficulty. Unterberger negative. DISCHARGE EXAM: No diplopia. EOMI with no mystagmus (L exotropia noted). Weber and ___ consistent with mild R conductive hearing loss. No evidence of dysmetria. Finger following with no overshoot. Pertinent Results: ADMISSION LABS: ___ 08:35AM BLOOD WBC-9.2 RBC-4.59 Hgb-13.3 Hct-38.7 MCV-84 MCH-28.9 MCHC-34.3 RDW-13.2 Plt ___ ___ 08:35AM BLOOD Neuts-73.9* ___ Monos-4.3 Eos-1.6 Baso-0.6 ___ 08:35AM BLOOD ___ PTT-31.8 ___ ___ 08:35AM BLOOD Glucose-106* UreaN-11 Creat-0.5 Na-138 K-4.0 Cl-104 HCO3-23 AnGap-15 ___ 06:48AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.9 ___ 06:48AM BLOOD TSH-2.6 ___ 08:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ 09:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG MRI (read finalized after discharge): IMPRESSION: Mildly increased T2/FLAIR signal hyperintensity in the periventricular white matter with an additional nonenhancing tiny focus of T2/FLAIR signal hyperintensity in the subcortical white matter of the left temporal lobe-subinsular location. These findings are nonspecific and could be seen with demyelinating disease, inflammation, etc amongst other and entities. Clinical correlation and follow up is recommended to assess for interval change. No priors. No acute infarct or mass effect or enhancing lesions. Brief Hospital Course: ___ was admitted to the general neurology service in stable condition. She had improvement in her vertigo with meclizine. Her mild ataxia resolved. Her clinical exam was normal. She underwent MRI which did not show any lesions consistent with her symptoms. She was though to have a viral vestibulitis versus BPPV. She was discharged to complete vestibular therapy. After discharge her formal MRI read noted several FLAIR hyperintensities which did not enhance with contrast. These were reviewed with the General Neurology team and were thought to be unlikely to represent demyelinating disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Meclizine 12.5 mg PO Q8H:PRN dizziness RX meclizine 12.5 mg 1 tablet(s) by mouth Q8H:PRN Disp #30 Tablet Refills:1 2. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #12 Tablet Refills:0 3. Multivitamins 1 TAB PO DAILY 4. Outpatient Physical Therapy ___ ICD-9 386.1 Discharge Disposition: Home Discharge Diagnosis: peripheral vertigo Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you were having the sensation of vertigo. We looked for dangerous causes of vertigo. You had an MRI of your brain which appears normal. The final interpretation by our radiologists is still pending; we will alert you if anything else is identified on the final interpretation. We think the cause of your vertigo is located in your inner ears. This can happen with a viral infection which affects the vestibular nerve. It can also happen when small particles inside your inner ears which help you to feel motion become dislodged. This condition is known as Benign Paroxysmal Positional Vertigo (BPPV) which is a common cause of recurrent vertigo. For this reason we think you would benefit from vestibular physical therapy. This will teach you maneuvers to help reposition any of these particles should your symptoms arise again. It has been a pleasure taking care of you. Followup Instructions: ___
10093425-DS-12	10,093,425	26,667,861	DS	12	2162-08-31 00:00:00	2162-08-31 14:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest/throat discomfort Major Surgical or Invasive Procedure: ___ - Cardiac Catheterization ___ - Coronary artery bypass grafting x5 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the first diagonal artery and obtuse marginal artery, and sequential saphenous vein graft to the posterior descending artery and the posterior left ventricular branch artery. History of Present Illness: Mr. ___ is a ___ year old man with with history of hyperlipidemia and pulmonary sarcoidosis. He presented with a 6 month history of chest/throat discomfort with exercise. He noted that this ___, when out in the cold, he experienced tightness in his throat. He also noted similar symptoms when mowing the lawn. He stated that his symptoms were not severe enough to cause him to stop and rest. He denied associated chest pain, palpitations, shortness of breath. He discussed his symptoms with his PCP, and was referred for a stress test. During the stress test he was asymptomatic however at 5 minutes noted to have EKG changes, 2mm ST elevations in aVR and 3-5mm ST depressions V4-V6, II, III, and aVF. He was given a full dose aspirin and was referred to the emergency department for further evaluation. Troponin was negative. Cardiac catheterization demonstrated severe multivessel coronary artery disease. He was referred to cardiac surgery for revascularization. Past Medical History: Colonic Polyps Hematuria Hyperlipidemia Lymphadenopathy Nephrolithasis Sarcoid Skin Cancer Surgical History: Cholecystectomy Vasectomy Social History: ___ Family History: Father with DM. No other family history of HTN, HLD, cardiac disease or sudden cardiac death. Physical Exam: Physical Exam on Admission: VS: T=98.3 BP=130/83 HR=71 RR=18 O2 sat=97% on RA Weight 84.8 kg GENERAL: WDWN gentleman speaking in full sentences in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 6 cm. 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: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric Discharge Exam: T: 99.1 HR: 70-___'s SR BP: 90-110/60 RR 18 ___: 97 RA Wt: 85.4 Kg BS: 70-100 General: ___ year-old male in no apparent distress HEENT: normocephalic mucus membanes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: clear breath sounds GI: benign Extr: warm no edema Wound: sternal and left lower extremity clean dry intact no erythema sternum stable Neuro: awake, alert oriented Pertinent Results: ==ADMISSION LABS== ___ WBC-8.2# RBC-4.97 Hgb-13.7 Hct-42.0 MCV-85 MCH-27.6 MCHC-32.6 RDW-13.4 RDWSD-41.0 Plt ___ ___ Neuts-74.2* Lymphs-17.4* Monos-6.8 Eos-0.5* Baso-0.7 Im ___ AbsNeut-6.09# AbsLymp-1.43 AbsMono-0.56 AbsEos-0.04 AbsBaso-0.06 ___ ___ PTT-32.6 ___ ___ 05: Glucose-91 UreaN-24* Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-22 ___ ALT-18 AST-19 LD(LDH)-115 AlkPhos-69 TotBili-1.2 ___ cTropnT-<0.01 ___ CK-MB-2 cTropnT-<0.01 ___ CK-MB-2 cTropnT-<0.01 ___ Calcium-9.1 Phos-3.0 Mg-2.1 ___ Albumin-4.4 ___ %HbA1c-5.6 eAG-114 Discharge Labs: ___ WBC-9.8 RBC-3.35* Hgb-9.3* Hct-28.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.8 RDWSD-42.8 Plt ___ ___ ___ ___ Glucose-90 UreaN-22* Creat-0.7 Na-139 K-4.0 Cl-102 HCO3-26 ___ Mg-2.1 ==OTHER RESULTS== Stress Echocardiogram ___ The patient exercised for 4 minutes 41 seconds according to a ___ treadmill protocol ___ METS) reaching a peak heart rate of 134 bpm and a peak blood pressure of 190/84 mmHg. The test was stopped because of ischemic ST changes (see exercise report for details). This level of exercise represents a fair exercise tolerance for age. In response to stress, the ECG showed ischemic ST changes (see exercise report for details). The blood pressure response to stress was abnormal/mildly hypertensive. There was a normal heart rate response to exercise. Resting images were acquired at a heart rate of 75 bpm and a blood pressure of 118/80 mmHg. These demonstrated normal regional and global left ventricular systolic function. Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated mild mitral regurgitation with no aortic stenosis, aortic regurgitation or significant resting LVOT gradient. . Echo images were acquired within 70 seconds after peak stress at heart rates of 104 - 86 bpm. These demonstrated new regional dysfunction with apical hypokinesis. The remaining segments augment appropriately. There was augmentation of right ventricular free wall motion. IMPRESSION: fair functional exercise capacity. Marked ischemic ECG changes with 2D echocardiographic evidence of inducible apical ishemia at achieved workload. Cardiac Catheterization ___ LM: 90% and hazy LAD: ___ 40%, mid 40%, distal 60%; diag 60% LCX: 40% RCA: ___ 20%, distal 70%; PDA 50% Transesophageal Echocardiogram ___ Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Chordal ___ seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Tip of IABP in good position. Dr. ___ was notified in person of the results on ___ at 1230pm. Post bypass Patient is AV paced and receiving an infusion of Phenylephrine. Biventricular systolic function is unchanged. Mild mitral regurgitation persists. Aorta is intact post decannulation. Rest of examination is unchanged. Discharge Labs: ___ WBC-9.8 RBC-3.35* Hgb-9.3* Hct-28.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.8 RDWSD-42.8 Plt ___ ___ ___ ___ Glucose-90 UreaN-22* Creat-0.7 Na-139 K-4.0 Cl-102 HCO3-26 ___ Mg-2.1 Brief Hospital Course: Mr. ___ was admitted to ___ on ___. Cardiac catheterization demonstrated severe multivessel coronary artery disease. He was referred to cardiac surgery for revascularization. He underwent routine preoperative testing and evaluation. He remained hemodynamically stable. An IABP was placed preoperatively due to his tight left main lesion. He was taken to the operating room on ___ and underwent coronary artery bypass grafting x 5. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated on POD 1. He was weaned from inotropic and vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He developed several episodes of post-operative AFib coverted to sinus rhythm. He was started on Amiodarone and Warfarin. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5, he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged to home with ___ services in good condition with appropriate follow up instructions. He will follow-up with cardiac surgery, cardiology and his PCP for warfarin management Transitional Issues: - Pt has chornic hematuria and requires outpt f/u for this Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, fever 2. Amiodarone 200 mg PO BID ___ mg twice daily x 1 week then 200 mg daily RX amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #50 Tablet Refills:0 3. Aspirin EC 81 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 5. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 ___ MD to order daily dose PO DAILY16 RX warfarin 2 mg as directed tablet(s) by mouth daily Disp #100 Tablet Refills:0 7. Docusate Sodium 100 mg PO BID 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary artery bypass grafting Colonic Polyps Hematuria Hyperlipidemia Lymphadenopathy Nephrolithasis Sarcoid Skin Cancer Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___
10093609-DS-18	10,093,609	29,765,478	DS	18	2164-03-08 00:00:00	2164-03-08 16:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / Cocaine / Compazine / Augmentin / Ergotamine / Bactrim / Shellfish / Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ w/hx of hypothyroidism, HLD, and ?vasculitis who initially p/w DOE, transferred from ___ after being found to have b/l L>R pleural effusions and pericardial effusion Pt states has felt generally unwell for the past 1wk, markedly fatigued. +Night sweats and chills. No overt SOB, though patient says her breathing has felt "different, there is something happening in my chest." +Non productive cough. She also notes intermittent R chest and back discomfort, no association with movement/exertion. She has been sleeping upright for comfort. The pt was feeling particularly unwell today, presented to urgent care. She was noted to be tachycardic. Labs were notable for neg trop/BNP and D-dimer 5722. Flu swab was Neg. Pt was HDS and in NAD. She was noted to desat to 88% when ambulating but is NAD at rest. Initial CXR w/evidence of a left pleural effusion. Pt expressed Rt sided pleuritic CP, investigated further with EKG demonstrating TWI aVL/I as well as V2 and TWF laterally with low voltage in the inferior leads, no obvious alternans and no STEMI criteria. CTA was obtained, w/pericardial effusion w/evidence of R heart strain & ?tamponade, L>R pleural effusions, no PE. Pt was given IVF, transferred from ___ to ___ for further eval. No recent travel, Pt w/o hx of breast cancer. Up to date on mammograms. No recent travel. Sigmodioscopy neg in ___. Neg thyroid scan. In the ED, initial vitals were: T98.6 105 153/75 18 98% RA - Exam notable for: Slightly anxious, circumferential in speech. Decreased bibasilar lung sounds. Tachycardic, regular rhythm, soft systolic ejection murmur best heard at ___, no rubs. No elevated JVP. Abd benign. Pretibial edema L>R. WWP. - Labs notable for: WBC 7.9, Hb 13.3, Plt 252, BNP 121, Na 135, Cr 0.7, Trop neg, D-dimer 5722, Flu rapid Ag neg - Imaging was notable for: CXR w/Lt pleural effusion, CT-A w/Small to moderate amount of pericardial the fusion with evidence of right heart strain. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. -No evidence of pulmonary embolism. - Patient was given: Klonopin 1mg, Montelukast 10mg Upon arrival to the floor, patient reports that Sx started 1.5 wks prior, developed chest soreness, achiness. didn't feel like the flu but muscle aches. diff breathing and pain w/breathing. felt more uncomfortable lying flat. DOE but no SOB at rest. pt's Sx had been steadily improving over the week after last weekend, but then this weekend Sx had worsened again. +C/NS, didn't check for fevers. Dec appetite/PO intake. No sick contacts. +flu vaccine this yr. No abd pain, no n/v/d/c. no rashes. no dysuria/urinary changes. weak, rare dry cough. Had migraine HA in ED, better with midron. No recent med changes, except for ___ med & mild change in thyroid meds. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: PAST MEDICAL HISTORY: ASTHMA CERVICAL SPONDYLOSIS HYPERTRIGLYCERIDEMIA MANIERE'S DISEASE MIGRAINE HEADACHES OLECRANON BURSITIS,LEFT OSTEOPENIA,SPINE SINUSITIS ? VASCULITIS FASTING HYPERGLYCEMIA OSTEOPENIA THYROID NODULE HYPOTHYROIDISM H/O TAH/BSO PAST SURGICAL HISTORY: s/p L oophorectomy for cysts s/p total hysterectomy ___ GYN HISTORY: no h/o abnl paps s/p L oophorectomy for cysts s/p total hysterectomy ___ ___ due in ___. h/o fibroadenomas Social History: ___ Family History: father: CAD, htn, sarcoma, testicular ca, aneurysms mother: lung cancer (smoker) one brother died of ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.9, 147/89, 98, 18, 96 RA, 89.9kg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, NCAT Neck: Supple. No JVD. CV: RRR. Normal S1+S2, no murmurs, rubs, gallops. Pulsus <5. Lungs: Decreased bibasilar breath sounds Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation Skin: no rashes observed. Discharge exam: VS: 99 105/68 93 16 92-94% RA resting and ambulating GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, JVP 12cm HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, decreased breath sounds bilaterally ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission: ___ 04:15PM NEUTS-74.4* LYMPHS-12.0* MONOS-10.8 EOS-1.9 BASOS-0.5 IM ___ AbsNeut-5.85# AbsLymp-0.94* AbsMono-0.85* AbsEos-0.15 AbsBaso-0.04 ___ 04:15PM WBC-7.9 RBC-4.50 HGB-13.3 HCT-39.7 MCV-88 MCH-29.6 MCHC-33.5 RDW-14.0 RDWSD-45.0 ___ 04:15PM CRP-109.6* ___ 04:15PM FREE T4-1.1 ___ 04:15PM TSH-1.9 ___ 04:15PM D-DIMER-5722* ___ 04:15PM ALBUMIN-4.3 CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.4 ___ 04:15PM CK-MB-<1 proBNP-121 ___ 04:15PM cTropnT-<0.01 ___ 04:15PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-335* CK(CPK)-64 ALK PHOS-59 TOT BILI-0.7 ___ 04:15PM GLUCOSE-131* UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 IMAGING & STUDIES: - CXR ___ --Small left pleural effusion with overlying atelectasis; underlying left base consolidation is not excluded. - CT-A Chest ___ --Moderate pericardial effusion with straightening of the interventricular septum raising concern for underlying right heart strain which could be further assessed for on echocardiogram. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. --Small bilateral pleural effusions, left greater than right. Subtle perihilar ground-glass opacities could relate to respiratory motion versus mild pulmonary edema. --No evidence of pulmonary embolism. - ECG ___ --HR 104, SR, NA, TWI aVL/V1-V2, diffuse TW flattening, lower end voltage, no priors to compare TTE ___ The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small circumferential pericardial effusion, most promient (1cm) inferolateral to the left ventricle and anterior to the right ventricular free wall and right atrium. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Small circumferential pericardial effusion without echocardiographic evidence for tampmonade physiology. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. ___ CXR IMPRESSION: Compared to chest radiographs since ___ most recently ___. Moderate left pleural effusion and moderately severe left lower lobe atelectasis have worsened since ___. Pneumonia left lower lobe would be difficult to exclude under the circumstances. No change in diameter of the top-normal cardiac silhouette or distension of mediastinal veins to suggest either cardiac tamponade or substantial increase in pericardial effusion. Right lung and left upper lung are clear. No appreciable right pleural effusion. No pulmonary vascular abnormality. Discharge labs: ___ 07:00AM BLOOD WBC-6.3 RBC-4.29 Hgb-12.5 Hct-38.3 MCV-89 MCH-29.1 MCHC-32.6 RDW-14.4 RDWSD-46.4* Plt ___ ___ 07:00AM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-23 AnGap-18 ___ 07:00AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 ___ 03:09AM BLOOD HIV Ab-Negative ___ 04:15PM BLOOD ___ * Titer-1:40 CRP-109.6* Brief Hospital Course: Ms ___ is a ___ w/hx of hypothyroidism, HLD, and possible prior ANCA vasculitis who initially presented with dyspnea with exertion, transferred from urgent care after being found to have bilateral L>R pleural effusions and pericardial effusion. # Pericardial Effusion # DOE/Pleural Effusion Presented with dyspnea associated with non-positional chest aching during respiration. Also with night sweat/chills, fatigue over the last week, although no URI symptoms. Labs with elevated CRP, D-dimer, and CT-A w/moderate pericardial effusion. Mildly low voltage on EKG, though w/o electrical alternans. Hemodynamically stable with no clinical signs of tamponade. TTE shows small pericaridial effusion without tamponade physiology. No history of malignancy, no lesions seen on CT-A. Viral pericarditis is the most likely etiology. Given possible vasculitis history, she was seen by the rheumatology team, who agreed that a viral process is most likely given that she has no symptoms consistent with an active vasculitis or connective tissue disease. No active urine sediment and normal urine protein: creatinine. ___ borderline high (1:40), which can also be elevated during a viral infection. Hypothyroidism unlikely to be contributing with normal TSH, FT4. Trops neg x2. Flu, HIV neg. During the hospitalization she required some supplemental oxygen of ___ L at night for mild hypoxemia likely due to pleural effusions and atelectasis. This improved with incentive spirometry and likely improvement in the pleural effusions. On discharge, her resting and ambulatory O2 saturations were 92-94% on room air. Patient felt significantly better at time of discharge without significant intervention. # Fever Fever to 101.1 on ___ with increasing O2 requirement. CXR with worsening pleural effusion with hard to exclude PNA. No further fevers since. Repeat UA bland. Urine and blood cultures with no growth. Likely due to viral process. No antibiotics were given. CHRONIC ISSUES ============== # Hypothyroidism: c/w home levothyroxine # Psych: c/w home Klonopin # HLD: c/w home statin # Asthma: c/w home singulair, cetirizine # MEDREC: c/w home VitD, MVI ==================== Transitional issues: ==================== - Please repeat oxygen saturation at upcoming visits. - Recommend repeat urinalysis with protein to creatinine ratio if symptoms persist - Recommend CT chest to evaluate for resolution of pleural effusion and pericardial effusion. If persistent or worsening, consider a diagnostic and therapeutic paracentesis. - Updated cancer screening and malignancy workup is deferred to the primary outpatient providers. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN 3. ClonazePAM 0.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. Montelukast 10 mg PO DAILY 6. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 7. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK 8. Cetirizine 10 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 11. GuaiFENesin ER 600 mg PO Q12H 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 15. ClonazePAM 1 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Cetirizine 10 mg PO DAILY 3. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 4. ClonazePAM 0.5 mg PO DAILY 5. ClonazePAM 1 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. GuaiFENesin ER 600 mg PO Q12H 8. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 9. Montelukast 10 mg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Simvastatin 20 mg PO QPM 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN wheeze 13. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK (MO) 14. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Pleural effusion Pericardial effusion Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted because you had fluid around your heart and around your lungs. This was probably a result of "serositis" which is an inflammation of the lining around the heart and lungs. As we discussed, the most likely cause of this is a viral infection and it will probably improve with time. You were also evaluated by the rheumatology team while you were here, and they agree that this is most likely due to a viral infection. If your breathing and other symptoms do not improve over the next few weeks, it is a good idea to return to your primary care provider for more diagnostic workup. Please follow up with your PCP as scheduled. Your ___ team Followup Instructions: ___
10093718-DS-25	10,093,718	21,604,509	DS	25	2193-10-17 00:00:00	2193-10-17 19:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: AMS/overdose/SI Major Surgical or Invasive Procedure: ___ Tracheal Intubation ___ - Right IJ placement ___ - Right radial arterial line ___: Lumbar puncture ___: R PICC placement History of Present Illness: The patient is a ___ male with complicated psychiatric history including borderline/antisocial personal disorder with multiple prior suicide attempts via drug overdose, history of drug abuse (cocaine, benzos, heroin, hallucinogens all documented) as well as untreated hepatitis C who presents with altered mental status and ___ the setting of drug overdose, intubated for airway protection ___ the ED and admitted to the medical ICU for monitoring and treatment. Per ED documentation, on arrival he endorsed SI. His initial vitals were: 97.1 \| 110 \| 123/77 \| 19 \| 100% RA. He reported a plan to take lithium, and using heroin and crack cocaine as well as benzodiazepines, from which he was requesting detoxification. He is quoted as having taken "a few" extra gabapentin earlier today, though unclear amount. At the time, ED exam noted HR 88 \| BP 121/76 \| RR 13 \| 97% RA, with "pupils mid range equal and reactive, sleepy but arousable to voice. No rigidity or clonus." Tox screen was positive only for cocaine (serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc negative; Urine Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone negative). When he was reassessed 2 hours later, his exam noted "more difficult to arouse, continuous clonus, reddened skin, ocular clonus." He was intubated for airway protection. ___ the ED, he was given: - 2L NS - propofol, fentanyl and rocuronium for intubation Imaging notable for: ___ CXR: AP portable supine view of the chest. An endotracheal tube is seen with its tip located 3.8 cm above the carina. An NG tube courses into the left upper abdomen, tip outside of field of view. Lung volumes are low. No large consolidation, effusion or pneumothorax seen. Cardiomediastinal silhouette appears grossly unremarkable allowing for supine portable technique. No acute osseous abnormality seen. Consults: psychiatry (unable to assess prior to intubation) VS prior to transfer: 97.2 \| 62 \| 118/53 \| 15 \| 100% Intubation On arrival to the MICU, he is intubated and sedated. He does not rouse to voice although he had received rocuronium. Past Medical History: Hepatitis C, untreated Kyphosis and scoliosis (no surgical interventions); c/b chronic back pain History of benzodiazepine withdrawal seizures Asthma Denies history of head injury Social History: ___ Family History: -Father- depression requiring inpatient hospitalization (___), bipolar, h/o chemical dependency -Denied other family history of psychiatric illness, completed suicides, suicide attempts, or addiction. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.6 \| 50-66 \| 113/75 \| 18 \| 98% on CMV GENERAL: Intubated, sedated, not rousing to voice HEENT: Sclera anicteric, MMM LUNGS: Clear to auscultation bilaterally ___ lateral and anterior fields without wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Blanching sunburn sparing shirt straps, no other rash NEURO: Pupils dilated but sluggish and reactive, 30 seconds at least of sustained clonus at bilateral ankles DISCHARGE PHYSICAL EXAM: VS: 98.8, 118/70, 110, 18, 96% RA GENERAL: Sitting ___ chair, appears anxious an sweating, calm and appropriate. HEENT: AT/NC, EOMI, PERRL, anicteric sclera,, MMM NECK: nontender supple neck, no JVD, R CVL ___ place HEART: tachycardia, RRR, S1/S2, no M/R/G LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND, normal bowel sounds, no rebound or guarding EXTREMITIES: Warm, well-perfused, no edema, vein ___ R arm is hard to palpation NEURO: CN II-XII grossly intact SKIN: warm and well perfused. Scattered red papules over back. Pertinent Results: ADMISSION LABS ------------------ ___ 07:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:00PM WBC-8.9 RBC-4.99 HGB-14.2 HCT-42.0 MCV-84 MCH-28.5 MCHC-33.8 RDW-13.2 RDWSD-40.4 ___ 08:00PM NEUTS-53.0 ___ MONOS-12.9 EOS-5.0 BASOS-0.7 IM ___ AbsNeut-4.73 AbsLymp-2.52 AbsMono-1.15* AbsEos-0.45 AbsBaso-0.06 ___ 08:00PM PLT COUNT-261 ___ 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:00PM LITHIUM-<0.1* ___ 08:00PM CK-MB-9 cTropnT-<0.01 ___ 08:00PM GLUCOSE-80 UREA N-13 CREAT-1.0 SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 ___ 10:35PM TYPE-ART PO2-511* PCO2-56* PH-7.29* TOTAL CO2-28 BASE XS-0 PERTINENT LABS: ---------------- ___ 02:56AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HCV VL-6.9* ___ 05:10AM BLOOD HCV Ab-Positive* DISCHARGE LABS ------------------- ___ 08:20AM BLOOD WBC-9.7 RBC-4.30* Hgb-12.0* Hct-36.4* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.6 RDWSD-41.8 Plt ___ ___ 08:20AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-103 HCO3-19* AnGap-22 IMPORTANT MICRO -------------------- ___ 05:10AM BLOOD HIV Ab-Negative ___ 02:56AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HCV Ab-Positive* ___ 03:17PM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-74* Polys-0 ___ ___ 03:17PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-3 ___ ___ 03:17PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-70 __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP. Enterovirus Culture (Preliminary): No Enterovirus isolated. __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP. FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. Results should be evaluated ___ light of culture results and clinical presentation. __________________________________________________________ ___ 6:40 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: __________________________________________________________ ___ 6:30 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:20 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:10 am URINE Source: Catheter. FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, ___ infected patients the excretion of antigen ___ urine may vary. __________________________________________________________ ___ 6:23 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). __________________________________________________________ ___ 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 4:56 pm SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. ESCHERICHIA COLI. MODERATE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. MODERATE GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. 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 __________________________________________________________ ___ 5:28 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:26 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:56 pm SPUTUM Source: Endotracheal. *FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. NEGATIVE CSF HSV PCR IMPORTANT IMAGING ___ EEG This telemetry captured no pushbutton activations. The widespread ___ Hz activity ___ all areas suggested the effect of sedating medications. It may have obscured normal and abnormal findings. There were no areas of prominent focal slowing. There were no clearly epileptiform features or electrographic seizures. ___ ___ 1. No evidence of an acute intracranial abnormality on noncontrast head CT. 2. Apparent mild diffuse cutaneous thickening and subcutaneous fat stranding of uncertain etiology. 3. Paranasal sinus disease. ___ EEG This is an abnormal continuous ICU monitoring study because of generalized slowing of the background, with epochs of background attenuation, and bursts of frontally-predominant alpha activity, with diffuse superimposed beta. Such findings are consistent with a moderate-to-severe encephalopathy, which is likely secondary to pharmalogic effect (i.e. propofol). No epileptiform discharges, electrographic seizures, or pushbutton activations were recorded. ___ LEFT UPPER EXTREMITY ULTRASOUND Deep vein thrombosis which is nonocclusive is visualized ___ the two left brachial veins and also within the left basilic vein. ___ Imaging MR HEAD W & W/O CONTRAS IMPRESSION: 1. No evidence of infarction, hemorrhage, enhancing mass or abnormal enhancement. 2. Moderate paranasal sinus disease as above, with nonspecific fluid opacification of the bilateral mastoid air cells. Brief Hospital Course: MICU COURSE (___) ___ with extensive psychiatric history and drug abuse who presented with SI and tox screen positive for cocaine who became progressively altered ___ the ED and developed sustained clonus and ocular clonus, was intubated ___ the ED for airway protection and was admitted to the MICU w/ concern for serotonin syndrome. He was extubated on ___ after weaning proofol/midazolam with improvement ___ his mental status and clonus. Patient was subsequently transferred to the medical floor for further management. # Altered Mental Status # Intentional overdose # Serotonin Syndrome: presented to the ED admitting of intentional overdose. Became obtunded ___ the ED requiring intubation. Was noted to have sustained clonus concerning for serotonin syndrome. Urine tox was positive for cocaine and his medication list includes fluoxetine and bupropion. Toxicology/neurology was consulted and their exam was consistent with serotonin syndrome. He was sedated with propofol and midazolam. His clonus decreased on these medications. He was weaned off these medications and extubated on ___. At discharge from the MICU, he had ___ beats of clonus ___ his LEs. Neurology consulted, EEG showed no seizure, MRI negative. Psychiatry was consulted and will continue to follow the patient after discharge from the ICU with possible discharge to inpatient psych after medical stabilization. Patient had a ___ male sitter during his ICU stay. # Fevers: Patient began spiking fevers on ___ with intermittent high fevers through sedation on ___. Spiking to 104 on ___. His fevers seemed to briefly respond to uptitration on midazolam and propofol and were associated with increased clonus and spontaneous rigors vs tremors. Started on empiric antibiotics- CFTX and vancomycin. Was switched to zosyn from CFTX then back to CFTX as he was spiking through regardless of antibiotic. Toxicology reevaluated and thought that these fevers were of another etiology rather than serotonin syndrome. LP was performed and was negative. ID was consulted and recommended discontinuing antibiotics given negative CSF and MRI findings, making infectious causes of his CNS encephalopathy presentation unlikely. There was no other clear infectious source per ID and patient was treated with a sufficient course of antibiotics to treat CAP/acute sinusitis. #Ileus: Post-extubation pt developed vomiting and an NGT was placed to suction. = = = = = = = = = = = = = = = = = = = = = ================================================================ FLOOR COURSE (___): #Altered mental status: Completely resolved upon arrival to the floor. No further fevers. #Suicidal ideation: Upon arrival to the floor, pt evaluated by psychiatry again and expressed explicitly that polypharmacy was an attempt to get high and NOT a suicide attempt. 1:1 and ___ discontinued. Patient provided with resources for outpatient management of psychiatric illness and substance abuse. Patient discharged with plans to enroll ___ PAATHS. #Ileus: NGT pulled upon arrival to the floor and patient tolerated a regular diet, had regular bowel movements. #LUE DVT: ___ MICU pt developed LUE DVT and was started on heparin gtt ___, converted to rivaroxaban. He was discharged with medication to complete a ___lthough instructed that should he see a PCP ___ the interim and have a repeat ultrasound showing resolution of the clot, it would be reasonable for him to stop anticoagulation. #Hepatitis C: Pt w/hx untreated hepatitis C. HCV Ab positive, viral load 6.9. Pt with mild transaminitis during hospital stay, with normal bilirubin and synthetic function. Will need treatment as an outpatient. TRANSITIONAL ISSUES: ==================== - Discharged to complete a 3 month course of rivaroxaban: Will need to complete 2 more weeks of rivaroxaban 15 mg BID, then will continue on 20 mg daily thereafter to complete a 3 month course. - Can consider stopping duration of rivaroxaban treatment early, consider obtaining ultrasound to evaluate for clot. - Pt will need to establish care with new PCP and psychiatrist. - Not discharged on ANY psych meds. Please evaluate need for psych meds. - Patient had been hypertensive during hospital stay and was given labetalol while ___. Please monitor BPs as an outpatient. - Patient with history of untreated hepatitis C, will need treatment as a outpatient. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion 150 mg PO BID 2. CloNIDine 0.2 mg PO TID:PRN anxiety 3. Gabapentin 800 mg PO QHS 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea 5. OLANZapine 5 mg PO BID 6. FLUoxetine 20 mg PO DAILY Discharge Medications: 1. Rivaroxaban 15 mg PO BID RX rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day Disp #29 Tablet Refills:0 RX rivaroxaban [___] 20 mg 1 tablet(s) by mouth Daily Disp #63 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - Polysubstance use and accidental overdose - Toxic-metabolic encephalopathy - Serotonin syndrome - Acute hypoxic/hypercarbic respiratory failure - Provoked catheter-associated left upper extremity DVT Secondary: - Antisocial personality disorder - Major depression/Anxiety disorder - Polysubstance and opioid use disorder - Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Why were you here? -You had a drug overdose. Your breathing was compromised and you needed a breathing machine. You had evidence of toxicity from the medications you took. What did we do for you? - We improved your breathing and consulted psychiatry and social work to help with your mood symptoms and drug problem. What do you do now? -Do not take SSRIs, benzos, other drugs that you were not given by a doctor -___ will need to continue taking your blood thinner rivaroxaban for 3 months, unless you are seen by a doctor before then and told to stop. You will take 15 mg twice a day (with food) for 2 weeks, and then 20 mg daily (with food) after that, to complete a 3 month course. This medication taken ___ overdose can cause life threatening bleeding. -You will be going to the ___ program to get help. We wish you the best! -Your ___ Team Followup Instructions: ___
10094132-DS-14	10,094,132	27,883,799	DS	14	2192-09-03 00:00:00	2192-09-03 20:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: CC: abdominal pain HPI: ___ G3P3 with a PMH of fibroids presented to the ___ ED with RLQ pain x 2 days. Pt states pain is constant, sharp in nature, and radiates down to the right leg/groin. She has never experienced pain like this before. It is relieved only by dilaudid. Her bowel habits have remained stable with BMs occuring once/day. No blood, melena, constipation, or diarrhea. She has experience some nausea and vomitted x 2 ("clear, like water") yesterday. She tolerated her lunch today without any difficulty. She denies f/c. . In the ED, initial vitals were Pain ___ T97.6 ___ BP147/96 RR16 SaO2 100% RA. Labs notable for no leukocytosis. The pt underwent a CT Abdomen/Pelvis which showed normal appearing appendix and a fluid collection on the rectus muscles, ? seroma vs hematoma, which had been seen on MRI ___. Multiple fibriods were seen and apparently unchanged. Pelvix u/s showed fibriods. BHCG was neg. Pt was seen by surgery who felt that there was nothing warranting surgical intervention at this point. She received dilaudid 2mg iv total; zofran 4mg iv, 1L IVNS. Vitals prior to transfer: ___ 115/74 99ra ___. . Currently, the pt continues to be in pain. She notes pain that is improved with dilaudid administration. Review of systems is otherwise negative, with no urinary symptoms, CP, SOB. Past Medical History: S/P C-SECTION ___ Rubella +, HepB sAG neg, Rh neg (Rhogam given ___ S/P MOTOR VEHICLE ACCIDENT ___ LBP, Lspine neg S/P TUBAL LIGATION ___ ABNORMAL PAP SMEAR ___ LGSIL, ASCUS, s/p LEEP with squamous cell CIS in koilocytosis, nl paps ___ CHRONIC LOW BACK PAIN s/p spinal surgery, MRI ___: L5-S1 disc herniation on right, displacing S1 nerve root, borderline canal stenosis at L4-5, minor L3-4 disc bulge, nl EMG, MRI ___: L5-S1 disc herniation on right, displacing S1 nerve root, CONDYLOMA ACUMINATA ___ on cervix GASTROESOPHAGEAL REFLUX HEMORRHOIDS HIV TEST ___ negative ___ MENOMETRORRHAGIA OVARIAN CYSTS ___ L 4.2x2.9x3.9cm, TV US ___ resolved PPD POSITIVE ___ no INH secondary to pregnancy CXR neg UTERINE FIBROIDS VITAMIN D DEFICIENCY 18 in ___ Social History: ___ Family History: ___ Physical Exam: Admission: afebrile 121/76 84 18 96% RA GENERAL - female in mild distress ___ to pain 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 HEART - RRR, no MRG, nl S1-S2 ABDOMEN - quiet BS, + ___, TTP worse in RLQ>RUQ>LQs, no masses or HSM, no peritoneal signs EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Discharge: normotensive, afebrile GENERAL - NAD 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 HEART - RRR, no MRG, nl S1-S2 ABDOMEN - hyperactive bs, + ___, TTP worse in RLQ>RUQ but improved compared to admission, no masses or HSM, no peritoneal signs, GU - right adnexal tenderness, no cervical motion tenderness EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Pertinent Results: Admission: ___ 03:10AM BLOOD WBC-6.5 RBC-4.79 Hgb-8.9* Hct-31.1* MCV-65* MCH-18.5* MCHC-28.5* RDW-19.4* Plt ___ ___ 03:10AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-138 K-4.2 Cl-104 HCO3-25 AnGap-13 ___ 03:10AM BLOOD ALT-23 AST-22 AlkPhos-61 TotBili-0.3 ___ 03:20AM URINE UCG-NEGATIVE ___ 03:20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 03:20AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-2 Discharge: ___ 07:49AM BLOOD WBC-4.4 RBC-4.74 Hgb-8.8* Hct-30.9* MCV-65* MCH-18.6* MCHC-28.5* RDW-20.0* Plt ___ ___ 07:49AM BLOOD Plt ___ ___ 07:49AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-28 AnGap-12 Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. Pertinent Labs and Studies: RUQUS RIGHT UPPER QUADRANT ULTRASOUND: The liver is homogeneous in echogenicity without suspicious focal lesion. The main portal vein is patent with hepatopetal flow. There is a large 1.2 cm stone within the gallbladder neck. However, the gallbladder is nondistended and demonstrates no wall thickening or pericholecystic fluid. The patient was nontender on examination. No intra- or extra-hepatic biliary ductal dilatation is identified. The common bile duct measures 4 mm. Limited views of both kidneys demonstrate no hydronephrosis. The pancreatic head, neck and body appear normal. Evaluation of the tail is limited by overlying bowel gas. CT A/P 1 cm thick mildly rim enhancing fluid collection overlying the rectus muscles (601b:14) containing complex fluid. This could represent a seroma or hematoma. No significant neighboring stranding, but infection cannot be entirely excluded. 2. Normal appendix. 3. Very large fibroid uterus, similar in appearance to the MRI exam from ___. Ovaries appear normal. IMPRESSION: Cholelithiasis without evidence of acute cholecystitis Pelvic US FINDINGS: The uterus is enlarged, measuring 12.3 x 7.7 x 10.8 cm, dominated by a left lateral fibroid measuring up to 8.8 x 5.4 x 9.8 cm. No free fluid is detected. The right ovary is normal. The left ovary was equivocally seen, possibly lying superiorly to the left fibroid as seen on the ___ pelvic MR examination. The right ovary appears normal but vascular waveforms could not be reliably obtained due to positioning difficulty. IMPRESSION: 1. Markedly enlarged bulky fibroid uterus. 2. Normal right ovary. 3. Left ovary equivocally seen. Brief Hospital Course: Ms ___ is a ___ yo female with a hx of fibroids presenting with abdominal pain x 2 days with associated nausea and vomiting. # Abdominal Pain - On admission, CT scan did not identify clear etiology of abdominal pain. The seroma was old and should not cause pain. Therefore, the differential included appendicitis vs ovarian pathology vs colitis vs gall bladder disease vs renal calculi. With pain described as radiating to the groin, renal calculi would be concerning, however, none were identified on CT. Additionally, no evidence of appendicitis or ovarian pathology by CT and US. With cholelithiasis present on CT, along with positive ___, age, obesity, and female sex, gallbladder pathology remained possible. However, liver function tests were normal and ultrasound only revealed cholelithiasis. Bimanual examination demonstrated right adnexal tenderness without cervical motion tenderness. Chlamydia and Ghonorhea PCR were negative. Additionally ovarian torsion was not suggested by ultrasound. It was thought that the pain could represent a ruptured follicle. Infectious colitis was also considered given her nausea and vomiting on presentation. During her stay she was treated with tylenol and IV dilaudid which was converted to oral oxycodone. Her symptoms improved. SHe tolerated a regular diet and was discharged with followup to general surgery for her cholelithiasis, ob/gyn for her right adnexal tenderness and history of uterine bleeding, and her PCP. # Urinalysis - UA demonstrated 1 WBC, moderate Leuk esterase, and few bacteria present. Culture returned as multiple flora present. Patient had no suprapubic pain or dysuria but complained of urinary frequency. She was treated with 3 doses of cipro in the setting of her abdominal pain. THis was then discontinued as it was unlikely to explain her symptoms of abdominal pain. Chronic # GERD - omeprazole was continued while in house # Anemia - likely secondary to uterine bleeding. Iron studies confirmed iron deficiency. Patient will continue iron sulfate supplementation and medroxyprogesterone at home. Transitional # f/u with general surgery for evaluation of cholelithiasis # f/u with ob/gyn for evaluation of uterine bleeding and adnexal tenderness # f/u with PCP ___ on ___: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. MedroxyPROGESTERone Acetate 10 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Fe Sulfate 325 PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. MedroxyPROGESTERone Acetate 10 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H pain 4. Docusate Sodium 100 mg PO BID RX Colace 100 mg 1 capsule(s) by mouth twice daily Disp #60 Tablet Refills:0 5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth q6hrs Disp #40 Tablet Refills:0 6. Senna 2 TAB PO BID:PRN constipation RX senna 8.6 mg 1 Daily by mouth constipation Disp #30 Tablet Refills:0 7. Polyethylene Glycol 17 g PO DAILY RX Miralax 17 gram/dose 1 dose by mouth Daily Disp #1 Bottle Refills:0 8. Ferrous Sulfate 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Abdominal pain Secondary: GERD, Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you during your recent admission to ___ for your abdominal pain. It is thought that your pain may be multifactorial. You have a stone in your gallbladder which may cause pain. In addition, you have some tenderness of your R ovary. We do not believe that this is due to an infection but we are testing that. You will be notified of these results if you need to be treated with antibiotics. Your pain has improved since admission and you are tolerating a regular diet and maintaining your hydration. We will also send you home with some pain medication (oxycodone). Followup Instructions: ___
10094476-DS-6	10,094,476	21,993,712	DS	6	2120-04-27 00:00:00	2120-04-27 17:52:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Forteo / clindamycin / Neosporin / adhesive tape / Diflucan / Bactrim DS / Plaquenil / Augmentin / alendronate sodium / Dilaudid / vancomycin / Keflex / topiramate / Lyrica / Cat gut suture Attending: ___. Chief Complaint: Knee pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx Waldenstrom's macroglobulinemia and bilateral knee replacements cb septic arthritis receiving monthly IVIg therapy pw excruciating R knee pain. The patient has had weakness, fatigue, and bone pain worse below the knees for the last several months, ever since recovering from likely viral URI in ___. with 4 months of R knee pain that extends up the thigh and down the leg brought on by walking. She has had 4 months of chronic R knee pain that extends up the thigh and down the leg while walking. The pain is sharp and stabbing. The night prior to admission at 5pm, she developed sudden onset of this pain with ___ severity while at home. No trauma, fall, or direct blow to knee. She was in excruciating pain and felt unable to move her R leg due to pain. She took Tylenol and aleve to relieve the pain, which have helped moderately with the pain. She also has some tingling in her R foot; however, she has had intermittent paresthesias for months. The pain lasted through the night and the morning, including during her appointment with her hematologist. She has been using crutches to ambulate. Of note, she has had prior episodes of excruciating R knee pain that have resolved with oxycodone and NSAIDs. Her pain has improved to ___ after receiving oxycodone in ED. Patient endorses some chills in the past few months. Denies fevers, nausea, vomiting, shortness of breath, chest pain, palpitations, diarrhea/constipation. In the ED, initial vital signs were notable for: Temp 98.3, HR 72, BP 123/78, O2 sat 96% Ra. Exam notable for: Cardiac: faint decrescendo diastolic murmur at ___ reported aortic regurgitation. MSK: R knee pain on passive ROM. Whole leg painful to palpation. Bl knee caps feel warm to the touch. Studies performed include: R lower extremity ultrasound: no DVT R pelvis/hip XR: stable appearance of bilateral femoral hardware. No evidence of fracture or dislocation. Moderate degenerative change at the hip joints bilaterally. R knee XR: No evidence of hardware complication, fracture, or dislocation. Patient was given: 5mg PO oxycodone immediate release, 1000mg PO Tylenol Review of Systems: ================== Complete ROS obtained and is otherwise negative. Past Medical History: - ___'s macroglobulinemia - Osteoporosis - Hypothyroidism - Peripheral neuropathy - Hypogammaglobulinemia - OA - Lumbar radiculopathy - Hyperplastic colon polyps - Iron deficiency - Migraine - Depression - Eating disorder - GERD - Fibromyalgia - Hemorrhoids - Rosacea PAST SURGICAL HISTORY: - Bilateral breast reduction - ___ - Right ankle torn ligament repair - ___ - Laparoscopic Fundoplication - ___ - Incisional hernia repair - ___ - 2 RT hand trigger finger surgeries and tenosynovectomy of wrist - ___ - LT hand CTR and 2 LT hand trigger finger releases - ___ - ORIF of RT distal radius fracture - ___ - Removal of lipoma in the arm, RT ring trigger finger release, and removal of 2 loose screws in RT wrist - ___ - DeQuervain's release and removal of ganglion - ___ - Bilateral total knee arthroplasties: first in ___, cb infection bilaterally s/p polyethylene exchange in ___. In ___, bilateral knees septic again s/p hardware removal and antibiotic spacer placement. ___ bilateral knee revisions. - s/p Tenolysis of right FCR tendon, revision right carpal tunnel release, right index finger MCP joint release, reconstruction of right index finger flexor digitorum profundus tendon with gracilis allograft ___ - Status post ORIF previous left proximal hip fracture - Cataracts, ___ - Blephoroplasty, ___ Social History: ___ Family History: Mother with metastatic lung cancer. Father died tragically in plane crash. Physical Exam: ADMISSION EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at ___ reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain on distraction with passive ROM knee and hip joints. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and ___ bilaterally. Normal sensation, although complains of intermittent tingling. DISCHARGE EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at ___ reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain with passive ROM knee and hip joints. No anterior/posterior drawer sign. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and ___ bilaterally. Normal sensation, although complains of intermittent tingling. Pertinent Results: ADMISSION LABS: ============= ___ 01:44AM BLOOD WBC-5.7 RBC-3.91 Hgb-12.0 Hct-35.7 MCV-91 MCH-30.7 MCHC-33.6 RDW-13.3 RDWSD-44.3 Plt ___ ___ 01:44AM BLOOD Glucose-101* UreaN-29* Creat-0.8 Na-141 K-4.1 Cl-101 HCO3-27 AnGap-13 ___ 01:45AM BLOOD cTropnT-<0.01 ___ 01:44AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1 ___ 01:44AM BLOOD TSH-9.9* ___ 01:44AM BLOOD T3-80 Free T4-1.1 ___ 01:44AM BLOOD CRP-3.0 DISCHARGE LABS: ============== None REPORTS/STUDIES: =============== ___ RIGHT LOWER EXTREMITY ULTRASOUND There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. ___ HIP/PELVIS XRAY The patient is status post ORIF of a left femoral neck fracture, without evidence of screw migration or loosening in comparison to ___. The positioning of a partially imaged intramedullary femoral stem appears in unchanged position to ___. No evidence of adjacent fracture or loosening. There is moderate joint space narrowing and bony spurring at the hip joints, bilaterally. There is disc space narrowing and osteophytosis in the visualized lumbar spine. No acute fracture or dislocation. Chronic deformities of the right superior and inferior pubic rami are again noted. No worrisome lytic or sclerotic lesion. ___ RIGHT KNEE XRAY The patient is status post total right knee arthroplasty. There is no evidence of hardware migration or periprosthetic fracture. Appearance of the knee joint appears stable from ___. There is mild osteopenia about the knee joint. No worrisome lytic or sclerotic lesions. No significant soft tissue swelling. Brief Hospital Course: ___ with PMHx significant for Waldenstrom's macroglobulinemia receiving monthly IV Ig therapy, osteoporosis c/b several fractures, bilateral TKA complicated by remote history of septic arthritis, lumber disc disease with chronic bilateral knee and lower leg pain who presented with acute worsening of right knee pain. # Acute on Chronic Knee pain Patient has complicated orthopedic and osteoporotic fracture history. History of bilateral TKA complicated by infection bilaterally in ___ and ___, now s/p revisions in ___. She has had chronic bilateral leg pain described as "bone pain" for months, also with intermittent paresthesias of feet. Xray of pelvis/hip obtained in emergency room with stable appearance of femoral hardware but moderate DJD changes at hip joints. Xray of right knee w/o evidence of hardware complication, fracture, or dislocation. No warmth or swelling/effusion. Patient has remained afebrile without leukocytosis, making infection unlikely likely. No evidence to suggest crystal arthropathy. Of note, patient had PET scanning ___ w/o osseous lesions and Bone Scan ___ with DJD in her knees. Notably, in previous episodes of pain exacerbation, she has responded to NSAIDs. Her pain is likely chronic, secondary to DJD, OA, lumbar radiculopathy and history of multiple knee surgeries with hardware. Also has a history of fibromyalgia. No concern for acute musculoskeletal process, with XR showing no fracture or implant loosening. No DVT of right lower extremity. Do not suspect meniscal tear or ligament strain. Patient was given tylenol and NSAIDS with moderate improvement. ___ was consulted who recommended that she was safe to be discharged home and could have outpatient ___. # Fatigue. Reports fatigue since URI last ___. Nonspecific symptoms. Labs on admission including CBC and electrolytes are normal. Differential considered included hypothyrodisim, fibromyalgia, MDD/anxiety, related to her Waldenstrom's macroglobulenemia. TSH noted to be 9.9. Free t4 was 1.1, t3 was 80. Levothyroxine was increased to 75 mcg daily after discussion with PCP. #Hypothyroidism. Was found to have elevated TSH and low-normal FT4 and T3. In coordination with her PCP, was increased to 75 mcg levothyroxine for discharge. She will need follow up labs in 6 weeks. # Waldenstrom's macroglobulinemia: On monthly IV Ig. Has routine Heme/Onc follow up and allergy f/u. #Depression/Anxiety: Patient reported feeling significant anxiety and stress at home due to several issues including poor contact with her children/grandchildren, she lives alone and has had history of trauma (i.e. former abusive husband, father died tragically). Continued home SSRI, SNRI, ativan. SW consult offered to patient but she deferred. TRANSITIONAL ISSUES: ================= [] Will increase her levothyroxine from 50mcg to 75mcg iso TSH elevated to 9.9. She will need outpatient labs in 6 weeks. [] Neuropathy: She will have follow up with her neurologist Dr. ___ on ___. [] For pain: Recommended patient take acetaminophen, naproxen, and warm compresses as needed for symptoms. [] Patient expressed significant isolation as she is estranged from her children and grandchildren. [] Pt was provided script for outpatient ___ ___ sessions) assess how she is responding to ___ and if she needs more sessions with them Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Denosumab (Prolia) 60 mg SC ONCE 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. DULoxetine 60 mg PO DAILY 5. LORazepam 4 mg PO QHS 6. Montelukast 10 mg PO QHS 7. Sertraline 200 mg PO QHS 8. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines 9. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral unknown 10. ___ (cranberry extract) unknown oral unknown 11. docusate calcium unknown oral unknown 12. Lactaid (lactase) 3,000 unit oral DAILY 13. Multivitamins 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 150 mg PO QHS 16. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 17. Artificial Tears ___ DROP BOTH EYES PRN DRY EYE 18. dexlansoprazole 60 mg oral QAM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate 2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 5. Artificial Tears ___ DROP BOTH EYES PRN DRY EYE 6. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral BID 7. ___ (cranberry extract) 1 U oral DAILY unknown dosage 8. Denosumab (Prolia) 60 mg SC ONCE 9. dexlansoprazole 60 mg oral QAM 10. docusate calcium unknown oral DAILY 11. DULoxetine 60 mg PO DAILY 12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 13. Lactaid (lactase) 3,000 unit oral DAILY 14. LORazepam 4 mg PO QHS 15. Montelukast 10 mg PO QHS 16. Multivitamins 1 TAB PO DAILY 17. Polyethylene Glycol 17 g PO DAILY 18. Ranitidine 150 mg PO QHS 19. Sertraline 200 mg PO QHS 20. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Knee Pain Secondary Diagnosis: Hypothyroidism, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with knee pain. You had X-rays of your knee and hips and an ultrasound of your leg which did not show anything concerning to explain your pain. There was no evidence of fracture to your hips or knee and no issues with your hardware. There was no blood clot in the leg. Your thyroid tests showed they thyroid levels were low. What to do next? - We will prescribe you a higher dose levothyroxine of 75mcg. You should take this medicine once a day. Please have follow up thyroid labs taken in 6 weeks. - Please call your primary care doctor's office ___ morning. Your primary care doctor is aware that you should follow up with her in 1 week. - Please take your medicines as prescribed and follow up with your primary care doctor and orthopedic doctor. We wish you the best, Your ___ Care Team Followup Instructions: ___
10094582-DS-11	10,094,582	29,660,954	DS	11	2126-11-25 00:00:00	2126-11-25 13:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: codeine Attending: ___ Chief Complaint: Seizures Major Surgical or Invasive Procedure: None History of Present Illness: ___ (DOB ___ is a ___ year old woman with history of epilepsy and nonepileptic seizures followed at ___, anxiety, depression, PTSD, who presents with prolonged seizure. History was initially limited and obtained via report. She was in a group therapy session today when she had a seizure and fell to the ground. EMS was called and on arrival she was having generalized shaking movements, and so they administered Ativan 2mg IM x2 doses while en route. At ___, she continued to have shaking movements, and she was given additional 2mg of Ativan IV. Movements did not cease, and were associated with tachycardia, but the remainder of her vital signs remained normal including her oxygen saturation. Neurology was consulted and she was also given a load of keppra IV 2000mg. While keppra was infusing, the movements stopped. She awoke and was able to state her name and date of birth slowly, but could not provide additional history. For the remainder of the encounter and examination she had multiple further episodes of shaking movements, lasting up to 30 seconds each time, followed by return back to the awake but slowed state. There was high suspicion for nonepileptic seizures based on her clinical event (as described below in the examination) and past history, as well as lack of responsiveness to Ativan, Upon repeat visit with patient later, she was back to her baseline and able to provide additional history. She had just started a new intensive psychiatric day program yesterday and had the second session today. She states that the session which focused on grief became extremely intense and anxiety provoking for her, and last remembers sitting in the chair facing the other participants. She does not recall any of the events as described above. She states adamantly that she will not be returning to this program again. Her past neurologic history was found via ___ records and reviewed. She is followed by Drs. ___ and ___. Apparently her seizures began in ___ with a cluster of 22 events in 24 hours. She was evaluated at a local hospital, started on tegretol, and admitted to ___ for LTM, which revealed "3 seizure-like events captured notable for right sided and full body shaking with difficulty speaking that did not show any evidence of electrographic correlate" however was maintained on AED. She continued to have events, and was readmitted for LTM again in ___. This time she did have three events which did have an EEG correlate, all arising from sleep, characterized by tonic extension followed by flexion of arms and generalized shaking. EEG showed irregular ___ Hz frontally predominant spike and wave complexes prior to event, then rhythmic theta at ___ Hz starting in F3/F4/Fz, then generalizing in one second. She had, in addition, several events during wakefulness consisting of behavioral arrest, feeling unwell with racing heartbeat and tachycardia to 120-130s, which did not have EEG correlate. She had been maintained on keppra at a dose of 2500mg BID; decision was made in the past year to cross-taper this with lamictal to better improve her mood. She increased lamictal over the summer to 200mg BID, and has since been decreasing her keppra by 500mg BID increments every 4 weeks, now at 1500mg BID. She denies any missed doses. Her last seizure was over a year ago and last a few minutes; she has never had a single event this prolonged. Neurology ROS is negative for headache, visual symptoms, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. Past Medical History: Epilepsy PNES PTSD Depression SI with multiple hospitalizations in past, followed by ___ psychiatrist Dr. ___ Possible borderline personality disorder Social History: ___ Family History: non-contributory Physical Exam: ===ADMISSION EXAM=== Gen: eyes closed, not responsive, intermittent 30 second - 1 min episodes consisting of LUE tonic extension with tremulous movements, RUE tonic flexion and hand fixed in claw posture, BLE tonic internal rotation. Between episodes, she was awake, slow to respond. HEENT: few lacerations in forehead/temporal region, hard C-collar in place Resp: breathing comfortably on room air CV: tachycardic Abd: soft, nontender, nondistended Ext: warm, well perfused Neurologic: - MS: unresponsive with eyes closed during episodes. Between episodes, she is awake without any inter-ictal somnolence. Regards and tracks examiner. Slow to respond but able to state own name and age, unable to state location or date. Follows simple commands slowly (raises her arms) but unable to comply with most of neurology examination. Appears frightened. - CN: PERRL 3->2mm, tracks in all fields of gaze, face appears symmetric. - Sensorimotor: withdraws all extremities to noxious stimuli. - Reflexes: 1+ throughout, toes mute. ===DISCHARGE EXAM=== General: Awake, cooperative, NAD. HEENT: lacerations noted in forehead/temporal region, no scleral icterus noted, MMM, no lesions noted in oropharynx Resp: breathing comfortably on room air CV: regular rate and rhythm, no m/g/r Abd: soft, nontender, nondistended Ext: warm, well perfused Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3->2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: 1+ throughout, symmetric. Plantar response was mute bilaterally. -Coordination: No dysmetria on FNF bilaterally. Pertinent Results: ===ADMISSION LABS=== ___ 01:23PM BLOOD WBC-8.0 RBC-4.22 Hgb-12.1 Hct-37.3 MCV-88 MCH-28.7 MCHC-32.4 RDW-13.1 RDWSD-42.2 Plt ___ ___ 01:23PM BLOOD Neuts-67.7 ___ Monos-6.8 Eos-1.4 Baso-0.5 Im ___ AbsNeut-5.41 AbsLymp-1.84 AbsMono-0.54 AbsEos-0.11 AbsBaso-0.04 ___ 01:23PM BLOOD ___ PTT-30.4 ___ ___ 01:23PM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-136 K-4.3 Cl-97 HCO3-21* AnGap-22* ___ 01:23PM BLOOD ALT-12 AST-14 AlkPhos-92 TotBili-<0.2 ___ 01:23PM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.3 Mg-1.9 ___ 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:22PM BLOOD Lactate-1.5 ___ 03:35PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ===DIAGNOSTIC STUDIES=== ___ CT HEAD 1. No acute intracranial abnormality. Brief Hospital Course: Ms. ___ was admitted to the Neurology service after multiple episodes of shaking movements that started during a psychotherapy session. EEG showed normal background with beta frequency, likely due to the Ativan she received in the field and the ED. Infectious work up was negative. Most likely cause of her spells was thought to be psychogenic, non-epileptic seizures. By the following morning, she was back to her baseline, with mild residual headache. No changes to her medications were made at this time. She has Neurology follow up with Dr. ___ Dr. ___ at ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1500 mg PO BID 2. LamoTRIgine 200 mg PO BID 3. Amitriptyline 25 mg PO QHS 4. Strattera (atomoxetine) 25 mg oral BID 5. Citalopram 20 mg PO DAILY 6. TraZODone 150 mg PO QHS 7. CloNIDine 0.1 mg PO QHS 8. ClonazePAM 1 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Non-epileptic seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted after having multiple shaking episodes. You were admitted to the hospital and received medications to treat seizures. You were monitored on EEG which did not show seizure activity. Your home medications were not changed. You are advised to take all of your medications exactly as directed and do not miss doses. In addition, we advise you to avoid driving or operating heavy machinery for at least 6 months following these events. Please follow up with your Neurologist as scheduled. It was a pleasure taking care of you. Sincerely, ___ Neurology Followup Instructions: ___
10094629-DS-15	10,094,629	28,659,097	DS	15	2196-12-08 00:00:00	2196-12-09 09:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: s/p fall with right facial trauma Major Surgical or Invasive Procedure: Right globe rupture repair History of Present Illness: ___ with a PMH of right eye blindness, CVA, HTN, obesity; who presents s/p a mechanical fall in bathroom, falling onto the right side of her face on the tile. She denies a loss of conciousness, and thinks that she lost her balance while reaching for her walker after completing her urinary void. She denies dizziness, cp, sob, palpitations or HA prior to her fall. Upon review of OMR, she was last admitted ___ with garbled speech and was found to have an acute left brain stem infarct with an occluded left superior cerebellar artery complicated by hypertensive urgency with SBP in the 200s. She was monitored in the ICU closely and was discharged to rehab for aggresive ___ for residual right-sided weakness. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: 1. Breast Cancer: Clinical T2, N0, M0 infiltrating ductal cancer of the left breast, grade III, EIC positive, PR positive, HER-2/neu 3+ by immuno staining and pending FISH - stage II. status post excision without radiation on Arimidex first diagnosed in ___ 2. hypertension 3. glaucoma 4. bunionectomy 5. bilateral cataract surgery 6. left corneal replacement 7. osteoporosis 8. hyperlipidemia 9. right eye blindness following complicated cataract surgery in ___ 10. diarrhea (resolved after starting loperimide) Social History: ___ Family History: Her father died at ___ of uncertain causes, her mother at ___ with heart disease. She has two brothers; one ___, one ___ who both have prostate cancer. She is married. Her husband worked as a ___. She had three children, a son is now ___, daughter ___, her oldest son died at age ___ of AIDS. She has four grandchildren. Physical Exam: VS: 98.4 185/73 86 18 93%RA; pain ___ GEN: No apparent distress HEENT: Right eye with patch in place; Left pupil round and reactive to light, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound; obese EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, ___ motor function globally DERM: right facial echymoses Pertinent Results: ___ 09:30PM WBC-10.7# RBC-3.64* HGB-10.3* HCT-30.3* MCV-83 MCH-28.3 MCHC-34.0 RDW-12.9 ___ 09:30PM NEUTS-90.8* LYMPHS-6.2* MONOS-2.4 EOS-0.3 BASOS-0.2 ___ 09:30PM PLT COUNT-228 ___ 09:30PM ___ PTT-33.8 ___ ___ 05:46PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-MOD ___ 05:46PM URINE RBC-<1 WBC-21* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 05:46PM URINE MUCOUS-RARE CT ORBIT, SELLA & IAC W/O CONTRANST: 1. Acute right orbital floor fracture, with right lobe proptosis, and likely globe disruption with vitreous hemorrhage. Surgical implant has been rotated laterally. 2. Zygoma and right lateral wall fracture with subjacent hematoma resulting in mass effect of the right lateral rectus muscle. Mild stranding at the superior intraconal fat may represent early extension of hemorrhage. 3. Minimally displaced fractures of the anterior, posterior and medial right maxillary sinus walls with blood and air products within the cavity. 4. Extension of fracture to right lateral aspect of the upper maxilla, without direct extension into the body or hard palate. 5. Intact mandible. 6. No temporal bone fracture. Intact pterygoid plates. CT HEAD W/O CONTRAST: 1. Multiple right facial bone fractures and acute right orbit findings; please refer to the facial bone report from earlier today for details. 2. No acute intracranial process. Brief Hospital Course: ___ h/o right eye blindness, CVA, HTN; p/w mechanical fall with right sided facial trauma s/p right globe rupture repair. #. Fall: Likely mechanical given history of stroke and right eye blindness at baseline in the setting UTI and possible vasovagal response following urination. Electrolytes, cardiac enzymes, B12, TSH were normal. The patient did not have any events on telemetry. #. Hypertension: Continued hydrochlorothiazide, losartan metoprolol succinate and terazosin. #. Right globe rupture: In OR, she tollerated her right globe rupture repair well with sBP's in 150-180. She was given a plastic eye shield to wear at bedtime. She was discharged on several eye gtts per ophthalmology recommendations. She was discharged with ophthalmology follow up. #. Right facial fractures: Per plastics, no immediate indication for surgical repair given lack of evidence of extraocular muscle entrapment or impingment of fractures on globe or nerve on imaging. However she may require a delayed surgical repair once edema has resolved in ___ days. She was discharged with a follow up appointment with Dr. ___, Plastic Surgery. She was advised to follow sinus precautions x 1 week (e.g. no using straws, sneeze with mouth open, no sniffing, no smoking, keep head of bed elevated to 45 degrees). #. Urinary tract infection: Patient was initially on unasyn per surgical recommendations. Then she was changed to cipro per ophthalmology recommendations, to continue for one week. Urine culture was consistent with contamination. #. Hyperlipidemia: Continued home simvastatin #. H/O stroke: Aspirin was held during the hospitalization given high risk for bleeding complications. Ophthalmology was contacted re: restarting aspirin, and agreed to restart on discharge. . FEN: Low salt diet . Access: PIV . Prophylaxis: Pneumoboots for VTE prophylaxis. . Precautions: None . Communication: Patient . Dispo: Pending clinical improvement . CODE: DNR/DNI (confirmed on this admission) Medications on Admission: alendronate 70 mg 1 Tablet by mouth once a week in am with 8 oz water anastrozole 1 mg 1 Tablet by mouth once a day ___ hydrochlorothiazide 25 mg 1 Tablet by mouth once a day ___ loperamide 2 mg ___ Capsules by mouth qpm ___ losartan 100 mg 1 Tablet by mouth qpm ___ metoprolol succinate 200 mg E.R. 1 Tablet by mouth at hs ___ oxybutynin chloride 10 mg E.R. 1 Tab by mouth at bedtime ___ simvastatin 40 mg 1 Tablet by mouth qpm ___ terazosin 5 mg 1 Capsule by mouth qpm ___ timolol 0.5 % 1 drop in each eye twice a day (Prescribed by Other Provider) * OTCs * aspirin 325 mg E.C. 1 Tablet by mouth once a day ___ cholecalciferol 1,000 unit 1 Capsule by mouth once a day (OTC) ___ multivit-iron-min-folic acid [Centrum] Dosage uncertain Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID (2 times a day). 2. Pred Forte 1 % Drops, Suspension Sig: One (1) gtt Ophthalmic four times a day: Right eye. Disp:80 mL Refills:2 3. Vigamox 0.5 % Drops Sig: One (1) gtt Ophthalmic QID (4 times a day): Right eye. Disp:120 gtt Refills:2 4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) mg Ophthalmic HS (at bedtime). Disp:60 mg Refills:2 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 6. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO HS (at bedtime). 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 10. oxymetazoline 0.05 % Aerosol, Spray Sig: Two (2) Spray Nasal BID (2 times a day) for 4 days. Disp:1 bottle Refills:0 11. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Globe rupture, right eye Orbital fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after a fall with a facial and orbital fracture. You had surgery by the ophthalmology team to repair and orbital injury. You tolerated this well. You are being started on several new medications to take for your eye. Your home medications are the same. You have a plastic eye shield that you should wear at bedtime. Followup Instructions: ___
10094629-DS-16	10,094,629	20,062,606	DS	16	2199-05-22 00:00:00	2199-05-22 20:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Enalapril Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: This ___ y/o woman h/o HTN & ischemic CVA with residual R sided deficit presents with her son and daughter in law for ___ days of moderately severe, progressively worsening confusion, associated with visual and auditory hallucinations ("spots on my arm") and delusions ("my family is trying to poison me") but no fever or focal somatic complaint, without modifying factors. Patient's husband was her primary care-taker as she is unable to cook, dress, or use the restroom herself after her stroke. He died suddenly from a seizure on ___. Since then her son and daughter in law flew out from ___ to be with her. She had been tearful and grieving as expected but this past ___ began to have paranoia, visual hallucinations. This change in mental status occurred after family members who had been visiting left, and the house was more quiet. Additionally her home has been rearranged as they are cleaning after the Mr. ___ sudden death. Patient has had decreased PO intake, drinking 6 oz of water, a yogurt, and some cereal within the past few days. She is fearful per report that she is being poisoned and requires coaxing to take medications as she is afraid they are poision. Family denies fevers or chills, or any pain. ED Course Initial Vital Signs: T 98.8 BP 178/61 P 80 R 20 O2Sat 100% RA Labs notable for negative UA, Cr 1.8 from baseline of 0.8, wbc 7.1, H/H 11.7/36.0 at baseline. CT head was unremarkable, and clear CXR (my read). The patient received fluids in the ED and was admitted to the floor. On the floor, the patient denies any pain. She does endorse visual hallucinations and see's figures. She also felt that a truck was trying to hit her while she was on her way to the hospital. Review of Systems: (+) per HPI Past Medical History: 1. Breast Cancer: Clinical T2, N0, M0 infiltrating ductal cancer of the left breast, grade III, EIC positive, PR positive, HER-2/neu 3+ by immuno staining and pending FISH - stage II. status post excision without radiation on Arimidex first diagnosed in ___ 2. hypertension 3. glaucoma 4. bunionectomy 5. bilateral cataract surgery 6. left corneal replacement 7. osteoporosis 8. hyperlipidemia 9. right eye blindness following complicated cataract surgery in ___ 10. diarrhea (resolved after starting loperimide) 11. Stroke in ___ with right sided weakness Social History: ___ Family History: Her father died at ___ of uncertain causes, her mother at ___ with heart disease. She has two brothers; one ___, one ___ who both have prostate cancer. Her husband recently died in ___. She had three children, a son is now ___, daughter ___, her oldest son died at age ___ of AIDS. She has four grandchildren. Physical Exam: INITIAL PHYSICAL EXAM =============== Vitals- T 98.8 BP 178/61 P 80 R 20 O2 sat 100% RA General: alert, oriented, endorses visual hallucinations, tearful HEENT: EOMI, NC/AT, R eye with corneal clouding, dry mucous membranes Neck: supple, no LAD CV: RRR, no rubs or gallops Lungs: CTAB w/ decreased breath sounds at bilateral bases Abdomen: soft, NT, ND Ext: trace ___ edema, warm and well perfused Neuro: able to move/wiggle all extremities, good grip strength in LUE, right extremity with decreased movement, L hand contracted Skin: no rash or lesions Discharge Physical Exam =============== Vitals- T 99.1 BP 120-130/40-50 P ___ R 18 O2 sat 95% RA, emotionally stable General: alert, oriented, NAD, denies visual hallucinations HEENT: EOMI, NC/AT, R eye with corneal clouding, dry mucous membranes Neck: supple, no LAD CV: RRR, no rubs or gallops Lungs: CTAB, decreased breath sounds at bases Abdomen: soft, NT, ND Ext: warm and well perfused, no pedal edema Neuro: able to move/wiggle all extremities, right extremities with decreased movement, R hand contracted Skin: no rash or lesions Pertinent Results: INITIAL LAB RESULTS ============= ___ 01:41PM BLOOD WBC-7.1 RBC-4.10* Hgb-11.7* Hct-36.0 MCV-88 MCH-28.5 MCHC-32.5 RDW-12.9 Plt ___ ___ 01:41PM BLOOD Glucose-98 UreaN-39* Creat-1.8* Na-135 K-4.2 Cl-96 HCO3-27 AnGap-16 ___ 01:30PM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8 ___ 05:55AM BLOOD VitB12-845 ___ 05:55AM BLOOD TSH-0.70 ___ 05:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:39PM BLOOD ___ pO2-247* pCO2-34* pH-7.43 calTCO2-23 Base XS-0 Comment-GREEN TOP ___ 01:39PM BLOOD Lactate-1.0 ___ 02:30PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:30PM URINE Hours-RANDOM UreaN-330 Creat-71 Na-48 K-22 Cl-40 Phos-19.2 ___ 08:09PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG IMAGING ====== ___ CT Head IMPRESSION: 1. Chronic changes as described above. No evidence of subdural hematoma or acute infarction. 2. Minimally displaced replaced right lens, unchanged since ___. Clinical correlation is recommended. ___ CXR IMPRESSION: No evidence of acute cardiopulmonary disease. Increased flattening of the left humeral head, although likely a chronic process, possibly avascular necrosis. ___ EEG IMPRESSION: This is an abnormal EEG with a waking background characterized by a low voltage ___ Hz theta/alpha background. This is indicative of mild diffuse cerebral dysfunction, which is nonspecific in regards to etiology. There are no focal abnormalities or epileptiform discharges. If clinically indicated, repeat EEG with sleep recording may provide additional information. DISCHARGE LABS ============ ___ 06:08AM BLOOD Glucose-82 UreaN-30* Creat-1.2* Na-143 K-3.9 Cl-107 HCO3-21* AnGap-19 ___ 10:33AM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:33AM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-3 TransE-9 ___ 10:33AM URINE Mucous-OCC Brief Hospital Course: Ms. ___ is an ___ F with HTN, s/p stroke in ___ with residual right sided weakness, blind in right eye who presents with acute paranoia and AMS in setting of husband's recent unexpected death, with intermittent episodes of non-responsiveness. Patient is now medically cleared for transfer to an inpatient psychiatric facility. ACUTE ISSUES # Paranoia, encephalopathy The patient's paranoia and altered mental status are most likely due to an acute grief reaction from her husband's recent and unexpected death. She is blind in her R eye and s/p stroke in ___ with underlying neuro deficits, and hard of hearing in left ear making her more at risk for AMS/delirium. Non contrast head CT was negative. An infectious etiology was less likely given no leukoctyosis, afebrile, negative UA, and clear CXR. During admission, she was at times combative with nursing staff, and refused her medications and lab draws. She received Haldol BID with improvement in her combativeness and cooperation with medication administration. She was evaluated by the psychiatry team and it was determined that she should be transferred to the geriatric psychiatry department when medically stable for further management of psychosis. # Episodes of non-responsiveness / catatonia The patient had recurrent episodes of non-responsiveness with some withdrawal to deep sternal rub and resistance to eye opening. Vitals, EKG, and ABG were wnl. The patient would then wake up spontaneously and resume her previous mental status. An EEG was performed, and was negative for epileptiform changes. Neurology was consulted, who felt that the episodes were most likely psychiatric in nature and that an MRI brain should be performed when the patient is stable to rule out an uncommon presentation for PRES. PRES was considered highly unlikely due to normal blood pressure and lack of headache, and given the patient's combativeness, MRI was deferred to outpatient. The psychiatry team evaluated the patient and determined that these episodes were most likely due to catatonia and psychosis as a grief reaction from her husband's sudden death. She received IV Ativan during these episodes thereafter. # ___ The patient presented with an elevated Cr to 1.8 from baseline of 0.9. This was most likely pre-renal due to decreased PO intake. Her home HCTZ and Losartan were intially held and she received IVF. Her creatinine was trended and improved significantly to 1.2. Home medications were restarted prior to discharge. # HTN The patient's home anti-hypertensive regimen was held given ___ as above. During this period she received IV hydralazine PRN. With improvement in her ___ and cooperation, her HCTZ and Losartan were restarted. Her BPs were then stable with goal SBP 120-170. We recommend amlodipine 5mg daily if needed for improved BP control. # UTI On the day of discharge, patient was noted to have increased urinary frequency. UA was sent and consistent with UTI. Urine culture was also sent and is pending. The patient was started on 3 day course of Bactrim DS 1 tab BID (last day = evening of ___. CHRONIC ISSUES # s/p ischemic stroke with residual R sided hemiplegia The patient was continued on aspirin # hyperlipidemia The patient was continued on her home statin # Glaucoma The patient was continued on her home timolol TRANSITIONAL ISSUES - outpatient MRI brain w/wo contrast - Goal SBP of 120-170. If needed, add amlodipine 5mg qday. - Continue bactrim DS 1 tab BID through the evening of ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Multivitamins 1 TAB PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 4. Alendronate Sodium 70 mg PO QMON 5. Aspirin 325 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Oxybutynin 10 mg PO HS 10. Simvastatin 10 mg PO QPM 11. Terazosin 5 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Oxybutynin 10 mg PO HS 7. Simvastatin 10 mg PO QPM 8. Terazosin 5 mg PO DAILY 9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 10. Vitamin D 1000 UNIT PO DAILY 11. Haloperidol 0.5 mg PO BID 12. Alendronate Sodium 70 mg PO QMON 13. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days 14. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS 1. Altered Mental Status 2. Acute Kidney Injury 3. Hypertension 4. Urinary tract infection SECONDARY DIAGNOSIS 1. Hyperlipidemia 2. Glaucoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___: It was our pleasure caring for you at ___ ___. You were admitted because you were found to be very confused, and were not eating. You were evaluated by the neurology and psychiatry team. It was determined that your confusion was most likely due to a grief reaction after the very unfortunate passing of your husband. You received medications to help manage your symptoms and were eventually transferred to an inpatient geriatric psychiatry facility. On the last day of your stay, you developed increased urinary frequency and were given antibiotics for a UTI. Thank you for choosing ___. We wish you the very best. Sincerely, Your ___ Team Followup Instructions: ___
10094902-DS-9	10,094,902	22,639,837	DS	9	2136-06-19 00:00:00	2136-06-19 19:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: morphine Attending: ___. Chief Complaint: Right-sided abdominal pain Major Surgical or Invasive Procedure: IV antibiotics History of Present Illness: ___ yo G0 presents with worsesned RLQ pain. Patient reports for past week has had pelvic pain, first on left side, now mainly on right side. She reports she was evaluated in OSH ED one week prior for pain and was told she had a negative workup with a small ovarian cyst and discharged home. Reports since that time pain has persisted, becoming worse on right and last night became severe with episode of emesis so presented to ___ ED. In ED patient had pelvic ultrasound as well as CT scan performed with CT scan concerning for possible bilateral ___, worse on right side. Patient reports not currently sexually active, last active one month prior. Had colposcopy with biopsies performed on ___ for LSIL Pap with negative biopsies. Denies any other GYN procedures. She has a Mirena IUD which has been in place for ___ years. Reports fever at home yesterday to 100.5. No fever on presentation. Episode of emesis as above. No further vomiting. Denies abnormal discharge, constipation, diarrhea, dysuria, abnormal vaginal bleeding. Past Medical History: GYN Hx: - LMP: does not get period with Mirena IUD - Denies history of STI, pelvic infection - Previously sexually active with one partner, not sexually activity for past month - Denies history of abnormal or painful periods PMHx: Denies PSHx: Breast implants, Wisdom teeth extraction Allergies: - Morphine-> itching, hives Social History: ___ Family History: Non-contributory Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, moderate tenderness to palpation over right upper quadrant, voluntary guarding (due to anticipation per patient), no rebound Ext: no TTP Pertinent Results: Admission labs: . ___ 01:45AM BLOOD WBC-12.1* RBC-4.09 Hgb-12.0 Hct-35.7 MCV-87 MCH-29.3 MCHC-33.6 RDW-13.0 RDWSD-41.3 Plt ___ ___ 01:45AM BLOOD Neuts-79.1* Lymphs-9.5* Monos-10.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.53* AbsLymp-1.14* AbsMono-1.28* AbsEos-0.03* AbsBaso-0.03 ___ 01:45AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-136 K-3.7 Cl-100 HCO3-24 AnGap-16 . Relevant labs: . ___ 06:03AM BLOOD WBC-8.7 RBC-3.68* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.0 RDWSD-42.8 Plt ___ ___ 07:35AM BLOOD WBC-7.9 RBC-3.88* Hgb-11.1* Hct-34.6 MCV-89 MCH-28.6 MCHC-32.1 RDW-13.0 RDWSD-42.4 Plt ___ ___ 01:15PM BLOOD ALT-10 AST-15 LD(LDH)-113 AlkPhos-55 Amylase-24 TotBili-0.4 ___ 01:15PM BLOOD Lipase-28 ___ 01:15AM BLOOD Genta-0.4* . Imaging: . ___ CT ABD & PELVIS WITH CO 1. Bilateral tubular hypodensities in the pelvis may suggest dilated fallopian tubes which may indicate salpingitis. Clinical correlation advised. 2. Non visualized appendix however no evidence of acute appendicitis. . ___ PELVIS, NON-OBSTETRIC 1. Right ovarian cyst measuring 2.6 x 2.2 x 2.2 cm. 2. Smaller cystic structure posterior to the cyst on the right, which may represent dilated tube/mild hydrosalpinx vs para-ovarian cyst. No internal echoes or other complicating features. No evidence of torsion. . ___ ABDOMEN US (COMPLETE ST 1. Mild fullness of the right renal collecting system may reflect presence of underlying reflux as bilateral ureteric jets are well demonstrated and no definite cause for obstruction is noted. There is no nephrolithiasis. 2. 8 mm echogenic hepatic lesion in the left lobe is incompletely characterized but likely represents a hemangioma. 3. No evidence of cholelithiasis or cholecystitis. Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service with right-sided abdominal pain and imaging concerning for tubo-ovarian abscess. . She was treated with IV gentamicin and clindamycin initially. Her IUD was removed due to concern for tubo-ovarian abscess. Her leukocytosis resolved and her right lower quadrant pain improved. However she continued to have right upper quadrant pain and IV ampicillin was added on ___ given no subjective improvement. Liver function tests were all within normal limits, and an abdominal ultrasound showed a <1cm stable hepatic hemangioma, no cholelithiasis, no nephrolithiasis or urethral stone, minor dilation of right collecting system possibly due to reflux. She was transitioned to oral antibiotics on ___. Her right upper quadrant pain was reported to be ___ initially, though she was able to ambulate and carry out normal daily activities such as showering, and her pain improved to ___. . Patient was found to have a positive Chlamydia test. She was offered Expedited Partner Treatment but declined. She had one partner in the last three months, and agrees to notify her partner. . By hospital day 6, she was on oral antibiotics, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home to complete a total of 14 days of oral antibiotics, in stable condition with outpatient follow-up scheduled. Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain do not take more than 4000mg total per day RX acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:1 2. Docusate Sodium 100 mg PO BID please take while taking narcotic pain medication RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #50 Capsule Refills:2 3. Ibuprofen 600 mg PO Q6H:PRN pain take with food RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drive while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 5. MetRONIDAZOLE (FLagyl) 500 mg PO BID please take until ___, please do not drink alcohol while taking this medication RX metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 6. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #20 Tablet Refills:0 7. Doxycycline Hyclate 100 mg PO Q12H Please take until ___, take with food but not dairy RX doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Tubo-ovarian 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 the gynecology service for IV antibiotics. Your infection and symptoms have improved and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: Take your medications as prescribed. Please take the doxycycline with food but not dairy and not drink alcohol while taking metronidazole. Take both antibiotic medications until ___. * Please notify your partner of the need to seek treatment for Chlamydia. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10094971-DS-5	10,094,971	20,468,650	DS	5	2122-04-19 00:00:00	2122-04-19 15:03:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ambien Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: Wound vac placement History of Present Illness: ___ year old male with metastatic RCC to brain s/p cyberknife, HTN, HL and COPD who presents with confusion. He has been at rehab for the last 3 months after a hospitalization in ___ for new diagnosis of metastatic RCC to brain. He used up his 100 days of rehab and was discharged home 9 days ago. He lives with his daughter and had an extensive plan for care including home health aides, ___, ___, and many family members. He was doing well for a few days and then began to get progressively confused. He stopped eating and began to get agitated. Noted significant pain in his coccyx at the site of an ulcer. No fevers, no CP, SOB. Urine noted to be dark and had been started on a course of cipro which was due to be completed tomorrow. No BM in 5 days. Of note, he has a sacral ulcer which is being cared for by a wound nurse. Notably, he was admitted ___ to the MICU with fevers and hypotension felt to be due to urosepsis. Urine culture had no growth and he was discharged with a 10 day course of IV cefepime which finished ___. Currently, the patient is confused and thinks he is in the hospital because he fell on his butt. Only complains of butt pain. In the ED, initial vitals were 97.2 125 99/68 22 100% ra. UA showed lg leuks, 85 WBC, 8 RBC. WBC was 14.0, lactate 1.8. CT head showed no new brain mets and stable vasogenic edema. Given IV ceftriaxone. Vitals on transfer 79 108/48 20 98%. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: ONCOLOGIC HISTORY: Renal cell carcinoma with multiple brain metastases, diagnosed from right kidney biopsy on ___ that showed oncolytic renal cell carcinoma, and CyberKnife radiosurgery on ___ to 2200 cGy at 76% isodose line. PAST MEDICAL HISTORY: Hypertension Hypercholesterolemia COPD Alcoholism Depression Anxiety S/p bilateral knee replacements, the left in ___ and the right in ___ Chronic degenerative lumbar spine disease Former 50-pack-year smoking Cervical stenosis History of right-sided sciatica after a fall years ago GERD Social History: ___ Family History: Mom - osteoarthritis, CAD, heart valve disease Aunts - osteoarthritis, Dad - died of alcoholism at age of ___ Sister - osteoarthritis, otherwise healthy Physical Exam: Vitals: 98.2 96/54 95 18 99%RA 161 lbs GEN: Awake and conversant but very confused. Appears thin and fatigued. HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, OP clear but very dry Neck: Supple, no JVD, no thyromegaly. Lymph nodes: No cervical, supraclavicular or axillary LAD. CV: Irregularly irregular with II/VI systolic murmur at apex. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft but a little full feeling, does not appear tender, +BS. and right hip, BACK: Large 3cm sacral ulcer with some drainage, probes 2.5cm in several directions and 3cm towards the rectum, very painful Neuro: CN II-XII appear intact. Difficult to do full neuro exam but has ___ strength in RLE, ___ in LLE, moving both upper extremities. Inattentive on exam and oriented only to self and ___ Thinks president is ___. Pertinent Results: ___ 11:15AM WBC-14.0# RBC-3.29 HGB-7.3* HCT-25.5* MCV-78# MCH-22.3# MCHC-28.7* RDW-18.3* ___ 11:15AM NEUTS-76.9* LYMPHS-17.5* MONOS-5.2 EOS-0.3 BASOS-0.2 ___ 11:15AM PLT COUNT-607* ___ 11:15AM ___ PTT-29.3 ___ ___ 11:11AM LACTATE-1.8 ___ 11:15AM CALCIUM-11.2* PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 11:15AM ALT(SGPT)-17 AST(SGOT)-31 ALK PHOS-99 TOT BILI-0.3 ___ 11:15AM GLUCOSE-132* UREA N-12 CREAT-0.6 SODIUM-134 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-31 ANION GAP-9 . CT head ___: No acute intracranial hemorrhage. No new brain metastases identified. Again seen is vasogenic edema in the left frontal parafalcine region, at the site of the previously known metastatic focus. Near complete left maxillary sinus opacification. Sinus mucosal thickening of the left ethmoid sinus. Partial opacification of the right mastoid air cell. . CXR ___: Bilateral calcified pleural plaques limit assessment of the underlying lung parenchyma, but no new focal consolidation is seen. Chronic mild interstitial abnormality could reflect asbestosis and is unchanged. . CT pelvis ___: 1. Sacral soft tissue without definite CT evidence of osteomyelitis. 2. Although the bladder is collapsed, the wall appears thickened with intraluminal air and mild surrounding stranding, worrisome for possible cystitis. Recommend correlation with exam and labs. . RUE U/S ___: No deep vein thrombosis of the right upper extremity. . CT torso ___: 1. Enlarging right renal mass with new right renal vein tumor thrombus. 2. Enlarging and new pulmonary nodules, most consistent with metastases. 3. New small bilateral pleural effusions. 4. Stable hypodense chest wall lesion, which could be a metastasis. 5. Stable indeterminate left adrenal nodule and hypodense left renal lesions. 6. Stable 10-mm right retroperitoneal lymph node. 7. Sacral decubitus ulcer. No discrete fluid collection. 8. Bladder wall thickening with some air likely due to underdistention and recent instrumentation. The differential includes cystitis. 9. Cholelithiasis without evidence of cholecystitis. . ___ 11:59 am URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. . ___ Blood cx negative . ___ MRI Brain with contrast: IMPRESSION: Moderately motion-limited study without evidence of acute abnormalities or disease progression. . Discharge labs: ___ 06:05AM BLOOD WBC-9.7 RBC-2.87 Hgb-6.5* Hct-22.7* MCV-79* MCH-22.7* MCHC-28.7* RDW-19.1* Plt ___ ___ 06:05AM BLOOD Glucose-109* UreaN-7 Creat-0.3* Na-138 K-3.7 Cl-106 HCO3-25 AnGap-11 ___ 06:05AM BLOOD Albumin-1.6* Calcium-7.5* Phos-2.6* Mg-1.7 ___ 06:45AM BLOOD VitB12-1873* ___ 06:45AM BLOOD TSH-1.9 ___ 06:25AM BLOOD PTH-6* ___ 06:45AM BLOOD Cortsol-26.7* Brief Hospital Course: ___ year old male with metastatic RCC to brain s/p cyberknife, HTN, HL and COPD who presents with confusion. . # Acute encephalopathy: He presented with acute toxic/metabolic encephalopathy felt to be multifactorial. He was profoundly dehydrated, hypercalcemic, with a positive UA and has known brain mets. He was started on vanco/cefepime and given aggressive IV fluids and pamidronate. His mental status mildly improved with these measures. He had a CT head and an MRI with conrast that showed no change in brain mets. He was occasionally agitated and combative which was treated with haldol 0.5-1.0 mg TID prn and scheduled at HS without excessive sedation. . # Hypotension: He was hypotensive to the 80's/___'s shortly after admission. He was given multiple fluid boluses and vanco/cefepime with improvement in his blood pressure. He had recently been on decadron but AM cortisol was elevated and he was not felt to be adrenally insufficient. Home hydralazine, atenolol, and lasix were discontinued. . # Hypercalcemia: He had a corrected calcium of 13 on admission. He was given IV fluids and pamidronate with improvement of his calcium. This was felt to account for some of his mental status changes. PTH was appropriately suppressed. . # Renal cell carcinoma with brain mets s/p cyberknife: He was not on any systemic chemotherapy due to his relatively low burden of disease. He had a restaging CT torso which showed enlargement of his renal mass and multiple new pulmonary metastases. Head CT and MRI showed stable brain mets and edema. CT torso also showed tumor thrombus in the right renal vein but given lack of established benefit of anticoagulation and his brain mets, he was not anticoagulated. After discussion with ___ and ___, his daughters who are his health care proxies, it was decided that the patient should be DNR/DNI and transitioned to hospice care with a palliative focus. . # UTI: Completed course of ciprofloxacin for UTI prior to admission and received 3 days of cefepime here. Urine culture contaminated with mixed flora. repeat urine cx negative. D/C'd cefepime per ID recs. Blood cultures were negative. . # ___ weakness: He has known ___ weakness from brain mets and patient has not walked at all in several weeks. His weakness appeared stable from prior exam. . # Multiple pressure ulcers: He had a stage IV sacral decubitus ulcer and several stage I ulcers (left heel, right hip) on admission. The general surgery team was consulted and placed a wound vac. He was started on MS contin for basal pain control given his significant pain and difficulty asking for pain medication. He was also continued on MSIR and IV morphine as needed. . # Atrial flutter: He was in atrial flutter with 4:1 block on admission. During episodes of hypotension, he would have variable conduction with some RVR with 3:1 block (HRs 120's). He was started on low dose metoprolol (in place of his home atenolol) which he tolerated well and remained rate-controlled. . # Anemia: Hct was 22 on admission and he was given 2 units of PRBCs over the course of his hospitalization. Stools were guaiac negative. Iron studies were consistent with anemia of inflammatory block. . # RUE swelling: Ultrasound was negative for DVT and his edema became more symmetric consistent with anasarca. . # COPD: Continued on home spiriva and albuterol. . # HL: Discontinued home atorvastatin given his goals of care. . # Constipation: He had had no BM in 5 days on admission. This was likely related to hypercalcemia and perhaps narcotics use. He was given an aggressive bowel regimen and his constipation resolved. . # Anxiety: Continued home zoloft. He had been on trazodone TID at night but this discontinued due to confusion and sedation at the time of his admission. . # Malnutrition: He had albumin level of 1.4-1.7 during admission and had very little oral intake. He began eating small amounts as his mental status cleared. He developed anasarca with IV fluid resuscitation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY Hold for HR<55, SBP<100 2. Atorvastatin 40 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 4. Furosemide 40 mg PO DAILY 5. HydrALAzine 25 mg PO BID 6. Lactulose 15 mL PO Q6H:PRN constipation 7. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain 8. Potassium Chloride 10 mEq PO DAILY 9. Sertraline 100 mg PO DAILY 10. Tiotropium Bromide 1 CAP IH DAILY 11. traZODONE 50 mg PO HS 12. Calcarb 600 With Vitamin D NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral BID 13. Ferrous Sulfate 325 mg PO BID 14. Docusate Sodium 100 mg PO BID 15. traZODONE 25 mg PO BID At 1pm and 5pm 16. Senna 2 TAB PO HS 17. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry nose Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain 3. Senna 2 TAB PO HS Hold for loose stools 4. Sertraline 100 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Morphine SR (MS ___ 15 mg PO Q12H 8. Metoprolol Tartrate 25 mg PO BID Hold for HR < 50 or SBP < 100 9. Haloperidol 0.5-1 mg PO TID:PRN agitation 10. Haloperidol 1 mg PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute encephalopathy Hypotension due to dehydration Urinary tract infection Hypercalcemia Metastatic renal cell carcinoma to brain Atrial flutter Sacral decubitus ulcer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with confusion. This was felt to be from several reasons including a bladderinfection, high calcium levels, cancer in your brain, and dehydration. You were given IV antibiotics and IV fluids and medicine to decrease your high calcium. Your confusion improved but your thinking did not entirely return to normal. A CT scan of your body showed that your cancer has grown in your lungs. An MRI of your brain showed that your brain metastases were stable. You had a wound vac placed on your sacral ulcer to promote healing. After discussion with your daughters who are your health care proxies, you were made DNR/DNI and will be transferred to hospice. The focus of your care will be on your symptoms to keep you as comfortable as possilbe. Followup Instructions: ___
10095139-DS-10	10,095,139	25,266,690	DS	10	2157-10-16 00:00:00	2157-10-17 16:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Aspirin Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with chronic pancreatitis ___ gallstones previous h/o Puestow procedure (___) and h/o choledocholithiasis with recent ERCP, sphincterotomy, and multiple stone extraction presents to ___ for abdominal pain. Pain was similar to last time she was admitted (late ___ where they discovered she had choledocholithiasis. Per patient, she has been experiencing 1 day of colicky abd pain with associated nausea and bilious emesis. Poor PO intake. Diarrhea but no flatus. Pain has been getting worse since presentation to ___. Last C-scope ___ years ago and per patient no masses or polyps found. At ___, CT scan performed showing SBO. Patient was then transferred here for further management. NGT placed, approximately ___ilious/contrast material out. Past Medical History: PMhx: chronic pancreatitis, gallstones, fibromylagia, chronic abdominal pain, Hep C PShx: Peustow, TAH, TKR Social History: ___ Family History: Cousin with U.C. Physical Exam: Admission PE: 98.3 65 146/85 18 95% RA A+OX3, appears in pain no scleral icterus RRR CTAB Soft, ND, TTP epigastrium and R periumbilical and RLQ, previous cheveron scar seen no hernias guiac negative, no masses felt Discharge PE: ___ GEN:AAOx3, NAD HEART: RRR S1S2 LUNGS: CTAB AB: mild tenderness left lower quadrant EXT: peripheral pulses intact bilaterally Pertinent Results: ___ 01:45PM BLOOD WBC-5.2 RBC-4.48 Hgb-13.6 Hct-37.3 MCV-83 MCH-30.3 MCHC-36.5* RDW-13.6 Plt ___ ___ 05:09AM BLOOD WBC-5.0 RBC-4.48 Hgb-13.6 Hct-38.2 MCV-85 MCH-30.4 MCHC-35.6* RDW-13.5 Plt ___ ___ 01:45PM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-116* UreaN-3* Creat-0.8 Na-138 K-4.4 Cl-111* HCO3-23 AnGap-8 ___ 06:00AM BLOOD Glucose-130* UreaN-6 Creat-0.7 Na-139 K-3.9 Cl-106 HCO3-23 AnGap-14 ___ 05:09AM BLOOD ALT-11 AST-20 AlkPhos-59 TotBili-0.5 ___ 07:00AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.3 ___ 06:00AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.1 ___: chest x-ray: No evidence of acute cardiopulmonary process. NG tube in appropriate position. ___: abdominal x-ray: On the current exam, the bowel gas pattern is nonspecific. Air is seen in few scattered loops of non-dilated small bowel. Air and stool are seen scattered throughout non-distended loops of colon, including within the rectum. No free air is seen on the decubitus film. Lung bases are not well evaluated on these views.Multiple injection granulomas are again noted. ___: left venous duplex: No evidence of deep vein thrombosis. Brief Hospital Course: The patient was admitted to the Acute Care Surgery Service on ___ with a partial small bowel obstruction. The patient was transferred to the hospital floor for further care. The hospital course was uneventful and the patient was discharged to home. Hospital Course by Systems: Neuro: Pain was well controlled with IV dilaudid. Followed by Chronic Pain Service. After return of bowel function, the patient resumed her home oral opiods. Cardiovascular: Remained hemodynamically stable. Pulmonary: The patient was ambulating independently prior to discharge. GI: NGT inserted HD0, and removed. Kept NPO with IVF until bowel function returned. LFTs monitored, remained in normal range. After return of bowel function, the patient resumed a regular diet. GU: Patient was able to void independently. Electrolytes monitored, remained in normal range. Heme: Received heparin subcutaneously and pneumatic compression boots for DVT prophylaxis. ID: WBC monitored closely, remained in normal range. The white blood cell count on discharge was 5.2. The patient was discharged to home in stable condition on HD # 6, ambulating and voiding independently, and with adequate pain control. An appointment was made with the primary care provider for ___. The patient was also given detailed discharge instructions outlining activity, diet, follow up, and the appropriate medication scripts. Medications on Admission: Nexium 40", valium 10", oxycontin 80''', oxycodone 60 QID, lyrica 100''', PEG, colace, MTV, Creon 10K TID Discharge Medications: 1. Diazepam 10 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. NexIUM Packet (esomeprazole magnesium) 40 mg Oral BID 4. OxycoDONE (Immediate Release) 60 mg PO Q6H:PRN pain 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 6. Pregabalin 100 mg PO TID 7. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the Acute Care Surgery service with abdominal pain, and were found to have a partial small bowel obstruction. You were treated with bowel rest and pain medications, and are now ready to return to home. Please follow the instructions below: -You are being given a prescription for narcotic pain medication. Do not drive or drink alcohol if taking narcotic pain medication. -No strenuous exercise or heavy lifting for at least two weeks. -Resume all of your home medications unless advised otherwise. -If you do not already have an appointment scheduled, call the APS office at ___ to make an appointment in ___ days. -Call the ___ clinic if you have any questions. -Call the ___ clinic or go to the nearest emergency room if you have fevers > ___ F, abdominal pain, or for anything else that is troubling you. Followup Instructions: ___
10095323-DS-12	10,095,323	24,908,097	DS	12	2162-03-22 00:00:00	2162-03-22 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: dizziness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with PMH HTN, chronic hand pain, chronic headaches, prediabetes, who presents from home with dizziness and nausea. Reports of onset of symptoms are variable, with ED reporting last ___, patient reporting 2d PTA, outpatient notes reporting 4d PTA. Patient reported hyperacute onset of dizziness, feeling like the room is spinning around him, at first lasting a few minutes, then up to an hour, with nausea started day PTA, no vomiting, and feeling sweaty, resolving without intervention. Worse with opening his eyes (has been keeping them closed), head turn (esp to the right), position changes. Associated with R side tinnitus, which patient has had intermittently over years. No ear pain, fevers. No falls, LOC. In the ED at 12:30 ___, code stroke was called given patient's severe nystagmus. PE showed: General: unwell appearing ___ male n NAD HEENT: NC, AT. Significant nystagmus with central gaze. Right beating nystagmus, which initially appeared direction changing. Neck: no cervical lymphadenopathy Chest: CTAB CV: RRR, nrml s1/s2, no m/g/r. Abdomen: soft, ___, no HSM Ext: no edema Neuro: AOx3, ___ intact, ataxia appreciated, strength ___ in all extremities, FNF intact, HINTS (performed after CT/CTA) corrective saccade and right beating nystagmus. No dysarthria. No aphasia. Symmetric face. CTA head and neck was done. CT head: No acute intracranial hemorrhage or infarct. CTA head and neck: The major vessels of the neck, circle of ___, and their principal intracranial branches appear without flow limiting stenosis, occlusion, or formation of aneurysms larger than 3 mm. Hypoplastic left venous sinus. Final read pending reformats. Neurology recommendations: ___ man who presented as a code stroke after several episodes of room spinning vertigo over the past 3 days. There are several reassuring findings on exam: Right beating nystagmus with rightward and leftward gaze, corrective saccades to the right, no nystagmus with vertical gaze, and absence of other neurological signs. The nystagmus worsened when fixation was interrupted, another feature of peripheral vertigo. Recommendations -symptomatic treatment of vertigo per ED -treatment of lab abnormalities per ED -return to ED if new symptoms such as weakness, aphasia, etc... -dispo per ED -if symptoms persist for more than 1 week, will need PCP referral to ___ neurologist" Per conversation with ED, symptoms most consistent with vestibular neuritis. Otoscope exam was normal. Patient was not walking independently in ED, had assistance (counter to documented code stroke exam), but was initially feeling better and considered going home, but then had recurrence of symptoms. He received: ___ 17:13 IV LORazepam 1 mg ___ 22:31 PO Meclizine 25 mg ___ 22:31 PO Potassium Chloride 40 mEq ___ 22:33 PO Acetaminophen 650 mg Upon arrival to floor, patient reported the above story. He felt some relief with meclizine and Ativan. Reported almost blacking out when sat up for the CT scanner. Reported occasional R ear tinnitus (ringing, not pulsatile), usually if congested. He denied nasal congestion, sore throat, cough, dyspnea, CP, palpitations, lightheadness, abdominal pain, weakness/numbness/tingling, diarrhea, poor UOP. Reported poor PO intake today but good appetite. Has daily headaches for which he usually takes Excedrin. He has chronic hand pain related to MVC ___ years ago and occasionally takes NSAIDs for this. Past Medical History: Essential hypertension obesity Colon adenoma Social History: ___ Family History: Father Cancer - ___ (70); Heart ___ Mother ___ No Significant Medical History Physical Exam: ADMISSION EXAM VITALS: 97.6 PO 137 / 85 L Lying 57 20 95 RA GENERAL: Alert, uncomfortable EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Neck: no cervical LAD CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is ___ GI: Abdomen soft, ___ to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, central gaze and R beating nystagmus (do not see any on the left), speech fluent, moves all limbs, sensation to light touch grossly intact throughout, strength ___ throughout, ni tact FNF, deferred ambulation PSYCH: pleasant, appropriate affect DISCHARGE EXAM 24 HR Data (last updated ___ @ 727) Temp: 97.8 (Tm 97.8), BP: 124/76 (___), HR: 58 (___), RR: 18 (___), O2 sat: 97% (___), O2 delivery: RA, Wt: 285 lb/129.28 kg GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMMs CV: RRR no m/r/g RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is ___ GI: Abdomen soft, ___ to palpation. EXTR: wwp no edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI with severe horizontal nystagmys with rightward gaze, speech fluent, motor function grossly intact/symmetric, FTN intact bilaterally PSYCH: pleasant, appropriate affect Pertinent Results: Labs ___ 04:10PM BLOOD ___ ___ Plt ___ ___ 07:15AM BLOOD ___ ___ Plt ___ ___ 04:10PM BLOOD ___ ___ ___ 04:10PM BLOOD ___ ___ ___ 07:15AM BLOOD ___ ___ ___ 05:18PM BLOOD ___ ___ 05:18PM BLOOD cTropnT-<0.01 ___ 05:18PM BLOOD ___ ___ 07:15AM BLOOD ___ ___ 05:18PM BLOOD ___ ___ ___ 05:28PM BLOOD ___ ___ CTA head/neck 1. Normal head CT. 2. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. Brief Hospital Course: #Suspected vestibular neuritis ___ is a ___ man with HTN, chronic hand pain, chronic headaches, and prediabetes, who presented from home with dizziness and nausea, likely due to vestibular neuritis. His symptoms began several days before the admission and were rapid in onset, causing severe nausea and gait instability. He was evaluated by neurology and noted to have rightward nystagmus, most severe with rightward eye movements. HINTS exam and all clinical features felt to be consistent with peripheral cause of vertigo and most consistent with vestibular neuritis. He was started on meclizine with slight improvement. Other treatments were held per neurology recommendations given lack of evidence for efficacy. The patient was able to tolerate POs and ambulate and preferred to return home. He was counseled on safety while at home and still symptomatic, as well as red flags that should prompt immediate return to care. He was given a small amount of meclizine in case there are moments when he needs symptom control in the upcoming days, but otherwise he was encouraged to avoid ___ to allow for recovery of his vestibular system. He was provided with a referral to vestibular ___ and should ___ closely with his PCP. Referral to neurology can be considered as an outpatient. # Leukocytosis In absence of other infectious symptoms, signs, possibly stress reaction. Improving prior to discharge # HTN Held amlodipine and HCTZ initially since not eating/drinking well, but restarted at discharge since PO intake improved. # Chronic headaches Reports frequent headaches relieved by Excedrin, not thought to be migraines, unclear cause. Consider outpatient referral to headache clinic. ====================== TRANSITIONAL ISSUES: - close PCP ___ - consider neurology referral if persistent symptoms - return to ED if new neurologic features - vestibular ___ referral given to patient ====================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Diclofenac Sodium ___ 50 mg PO TID:PRN pain 4. Excedrin Extra Strength (___) ___ mg oral DAILY:PRN headache Discharge Medications: 1. Meclizine 25 mg PO DAILY:PRN vertigo Duration: 3 Days RX meclizine 25 mg 1 tablet(s) by mouth daily as needed Disp #3 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. Diclofenac Sodium ___ 50 mg PO TID:PRN pain 4. Excedrin Extra Strength (___) ___ mg oral DAILY:PRN headache 5. Hydrochlorothiazide 25 mg PO DAILY 6.Outpatient Physical Therapy ___ rehabilitation Diagnosis: vestibular neuritis (ICD 10 H81.2) Discharge Disposition: Home Discharge Diagnosis: Suspected vestibular neuritis 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 severe dizziness, which we suspect was due to vestibular neuritis, which is an inflammation of the vestibular system, which is involved in balance. It is often caused by a virus. This condition typically ___, and we expect that your symptoms will gradually improve in the upcoming ___. We have provided a referral for vestibular physical therapy, which can help in the recovery process. We have prescribed several pills of meclizine which you can take if needed for ongoing symptoms. As we discussed, you should exercise additional precautions when you return home to remain safe from falls if your symptoms persist. You should call ___ if you develop new symptoms of blurry or double vision, difficulty with speech, weakness, numbness, difficulty walking, or worsened coordination. If your current symptoms are slow to improve or are not improving over the upcoming days, then you should contact your primary care doctor. Followup Instructions: ___
10095542-DS-3	10,095,542	25,562,395	DS	3	2134-05-28 00:00:00	2134-05-31 18:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / morphine Attending: ___. Chief Complaint: Right Radius Fracture/Dislocation Major Surgical or Invasive Procedure: 1. Washout and debridement open fracture down to and inclusive of bone, right wrist. 2. Operative treatment right distal radius fracture with external fixator and multiple fragments; 3 or more. History of Present Illness: ___ with history of R BKA after arterial clot in ___, hypothyroidism, who sustained a right wrist fracture s/p mechanical fall earlier today, who is transferred from ___ ___ to ___ for further evaluation. Patient reports that earlier today she was standing on a chair, when she lost her balance and fell, landing on her right wrist. Did strike head, but denies LOC. Called ___ and was brought to OSH, where exam was notable for a right wrist deformity with laceration, and x-ray showed distal radius fracture and dislocation. She was immobilized and splinted, and received cefazolin 1gm IV given laceration. She was given dilaudid for pain control, but then developed N/V requiring zofran and ativan administration. Also received Td booster per report. She was transferred to ___ for Orthpedic evaluation. . In the ED, initial VS 97 81 122/64 16 93%RA->99%2L. She had a desat to 83% on RA when attempting to wean O2. Her CXR showed possible COPD but no acute process. Was felt her hypoxia may be secondary to dilaudid administration, or perhaps aspiration given N/V prior to transfer. Given the head strike, she had a CT head which did not show any acute process. She was seen by Ortho, who did not note any distal neuro/motor/vascular deficits. Recommended pain control. She had reduction and splinting at the bedside. Recommended cefazolin Q8H overnight. Plan is for ORIF in AM. Given hypoxia, patient admitted to medicine, with ortho following. VS prior to transfer were 98 78 105/65 14 99%. . Currently, patient reports right wrist pain but is otherwise without complaints. Nausea/vomiting have resolved, and she has never felt short of breath. Denies any HA, dizziness, or chest pain. . She has no known history of CAD, no history of stroke, and no history of CAD. Reports she has been able to go up flight of stairs without chest pain, though recently has been limiting activity secondary to pain in her right BKA stump. Does report occasional dyspnea with stairs, but not always. No orthopnea or PND. . REVIEW OF SYSTEMS: As per HPI. Has post-nasal drip and recent non-productive cough. No fevers, chills, sweats, weight change, headache, dizziness, CP, SOB, abdominal pain, diarrhea, constipation, melena, hematochezia, dysuria. Past Medical History: NHL ___ treated with chemo/XRT Hypothyroidism UTIs s/p hysterectomy s/p appendectomy s/p tonsillectomy s/p back surgery following MVA s/p R BKA after arterial clot Social History: ___ Family History: Brother - prostate cancer. Sisters - breast cancer, brain cancer, melanoma, colon cancer. Father had stroke. . Physical Exam: On admission: VS - Temp 98.4 F, BP 110/70, HR 78, R 18, O2-sat 94% 2L NC GENERAL: pleasant elderly female, lying flat in bed, NAD HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM NECK: supple, no JVD, no LAD LUNGS: CTAB without wheezing, rales or rhonchi, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no r/m/g, nl S1-S2 ABDOMEN: bowel sounds present, soft, NT, ND, no organomegaly, no rebound/guarding EXTREMITIES: s/p R BKA, no tenderness in stump, LLE warm, well-perfused with 2+ pulses, no edema, right wrist in splint, fingers warm and well-perfused SKIN: no rashes or jaundice NEURO: awake, A&Ox3, CNs II-XII grossly intact, able to move all 4 extremities, able to move all digits right hand PSYCH: calm, appropriate . On discharge: Stable VS. R wrist with external fixator in place w/ pins. R fingers swollen. Sensation/pulses intact. Pertinent Results: On admission: ___ 04:10PM BLOOD WBC-10.9 RBC-4.72 Hgb-13.4 Hct-39.8 MCV-85 MCH-28.3 MCHC-33.5 RDW-13.3 Plt ___ ___ 04:10PM BLOOD Neuts-92.3* Lymphs-5.9* Monos-1.5* Eos-0.1 Baso-0.2 ___ 04:10PM BLOOD ___ PTT-31.6 ___ ___ 04:10PM BLOOD Glucose-180* UreaN-9 Creat-0.7 Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 ___ 12:55PM BLOOD Calcium-8.3* Phos-2.6* Mg-2.1 . CXR: IMPRESSION: Slight prominence of the interstitial markings and hyperinflation, possibly due to COPD. No focal lung consolidation. . CT Head: No acute process . Initial wrist Xray: FINDINGS: No true lateral view of the right wrist was obtained, the views are obliqued. Given this, there is a comminuted, impacted intra-articular fracture of the distal radius. The carpal bones are displaced laterally in relation to the radius and ulna, dislocated on the AP view. No true lateral view was obtained for best assessment. There are osteoarthritic changes at the first carpometacarpal joint with joint space narrowing, flattening of the trapezium and sclerosis. No elbow fracture is seen. . Post-op Wrist Xray: There has been fixation of the distal radius fracture via cutaneous pins. There is improved anatomic alignment. There has been subsequent placement of external fixation pins within the second metacarpal shaft and the distal radius. There are severe degenerative changes of the first CMC and triscaphe joints. The total intraservice fluoroscopic time was 79.4 seconds. Please refer to the operative note for additional details. Brief Hospital Course: Hospitalization summary: ___ with history of R BKA after arterial clot in ___ and hypothyroidism who sustained a comminuted, impacted intra-articular fracture of the right distal radius with carpal bone displacement s/p mechanical fall now s/p ORIF in OR on ___. . #. Right Radius Fracture/Dislocation: Patient reported history of mechanical fall. She was standing on a rocking chair trying to retrieve a puzzle box when she fall off the chair and onto her wrist. Originally went to OSH and then transferred to ___ for definitive mgmt. Patient was seen in the ED where Xray showed open, comminuted fracture. She was treated with ancef x at least 3 doses and underwent ORIF on ___ in the OR with external fixator device placed. Ortho followed as consultants and advised on pin care. She was scheduled for follow-up in 1 weeks time per ortho resident and home ___ was arranged for pin care and dressing changes. Narcotics caused significant nausea and pain was controlled with standing tylenol and naproxen. Physical Therapy and Occupational Therapy Consult Services all thought the patient was safe for discharge to home. . #. Hypoxia: Apparent reason for admission to medicine though no hypoxia on the floor. Transient desat in the ED. CXR showed increased interstitial markings - pt has no smoking history but did give h/o L-sided radiation for NHL. Patient reported history of PFTs as outpt and should be monitored for pulmonary symptoms. . #. Hypothyroidism: Continued 25 mcg levothyroxine qday. . #. h/o UTIs: Urinalysis was negative and patient was asymptomatic. . # Hyperglycemia: Patient had high blood sugars while on D5 IVF. She should be screened for diabetes as an outpatient. . Transitional Issues: - diabetes screen - orthopedics follow-up for management of external fixator and fracture # CODE: Full Code # CONTACT: HCP is ___ ___ son ___ ___ is secondary HCP ___ Medications on Admission: levothyroxine 25 mcg per day lots of antibiotics over the past several months for UTIs (nitrofurantoin, bactrim, cipro) occasional allegra lumigan gtt 0.01% Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 7 days: After 7 days, can take only as needed for pain. Disp:60 Tablet(s) Refills:0 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lumigan 0.01 % Drops Sig: One (1) gtt Ophthalmic at bedtime: R eye. 4. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days: After 7 days, can take only as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Open intraarticular right distal radius fracture . Secondary: Hypothyroidism Remote distal below the knee amputation on the right Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the ___ ___. You were admitted after you fell and broke your wrist. You sustained an open right radial fracture, which was repaired in the operating room by the orthopedic surgeons. We have arranged for ___ visiting RN to come help with the cleansing and dressing changes for your wrist. You should not carry any weight or use your R wrist until further advised by your surgeon and his team. . We made the following changes to your medications: We STARTED Tylenol 1g three times per day for pain (would take this round-the-clock for 7 days and then as needed for pain) We STARTED Naproxen 500 mg twice per day for pain (would also take this medication standing for ~ 7 days and then as needed for pain. Take this with food as it may upset your stomach. . Your follow-up appointments are listed below. We wish you a speedy recovery! Followup Instructions: ___
10095681-DS-18	10,095,681	23,257,434	DS	18	2149-06-21 00:00:00	2149-06-21 14:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: iodine strong / Morphine / potassium iodide Attending: ___ Chief Complaint: fell out of chair and hit head Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of dementia, atrial fibrillation on Coumadin, fell out of her chair and struck the left side of her face. She did not lose consciousness. Has a small right frontal Subarachnoid Hemorrhage. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother, brother with atrial fibrillation. Physical Exam: On Admission ============ O: T: 96 HR:88 BP: 154/96 RR:16 Sat:100% RA GCS at the scene: 15 GCS upon Neurosurgery Evaluation: 15 Airway: [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: with Care attendant translating Gen: WD/WN, comfortable, NAD. HEENT: left periorbital ecchymosis and minimal edema Neck: supple, no midline tenderness 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 briskly reactive to light, left 1mm larger than right. Visual fields not tested III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk and normal tone bilaterally. jaw tremor. Strength full power ___ throughout. No pronator drift c/o pain in left arm Sensation: Intact to light touch ============ At Discharge ============ General: VS: Tmax 98.1F, cur 97.5F, HR: 60-71, BP: 130/56, RR ___, SpO2 96-99% RA Bowel Regimen: [x]Yes [ ]No Last BM: PTA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time - says ___ for year, daughter at bedside says that this is her baseline Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 4-3mm Left 4-3mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No - symmetric nasolabial flattening Tongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip LeftDoes not move because of pain IPQuadHamATEHLGast [x]Sensation intact to light touch Pertinent Results: Please see OMR for lab/imaging results. Brief Hospital Course: ___ with history of dementia, afib on Coumadin, s/p fall out of chair, struck the left side of her face, and has small right frontal SAH. #Traumatic Subarachnoid Hemorrhage She presented to the emergency department after falling and hitting her head as she was trying to sit down in a chair. In the ED, a ___ showed a small right frontal traumatic subarachnoid hemorrhage, and on exam she was neuro intact aside from baseline confusion regarding date. She had an area of ecchymosis over her left forehead/medial canthus. She was admitted to ___ for monitoring. Repeat NCHCT was stable. She was evaluated by ___, and was discharged home with existing services. #Left Arm Pain In the ED, she also complained of left arm pain. She was evaluated by ___ for a trauma workup, including XRays of left shoulder and left elbow were performed, which were negative for fracture. #UTI On ED presentation, her UA was positive for UTI, and she was started on ceftriaxone while in the ED. She was continued on Ciprofloxacin 250mg BID. Medications on Admission: ALENDRONATE - alendronate 70 mg tablet. 1 tablet(s) by mouth Once every week AMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth daily FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth once a day LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by mouth daily take 1 extra tablet on ___. Please take on empty stomach, 45min before breakfast without other medications. LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth twice a day METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 (One) tablet(s) by mouth twice a day WARFARIN [COUMADIN] - Coumadin 5 mg tablet. one tablet(s) by mouth AS DIRECTED Medications - ___ CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 400 unit chewable tablet. 2 tablet(s) by mouth daily - (OTC) CRANBERRY - Dosage uncertain - (OTC) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days RX ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO HS 5. Alendronate Sodium 70 mg PO 1X/WEEK (SA) Please continue to take it the day you normally take it. 6. amLODIPine 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Losartan Potassium 25 mg PO BID 10. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage Urinary tract infection Hyponatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Again, please do not take Coumadin (Warfarin) for one month, and do not resume taking it without your neurosurgeon's approval. This will be restarted by your PCP after your neurosurgery follow-up appointment. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10095681-DS-20	10,095,681	27,503,137	DS	20	2149-07-25 00:00:00	2149-07-25 10:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with history of atrial fibrillation who was taken off her anticoagulation in the setting of developing a ___ s/p fall last year who then presented with acute left leg ischemia and underwent left cutdown, femoral/popliteal embolectomy on ___ ___. Her post-operative course was uncomplicated and she was discharged to rehab on ___. She was seen in clinic on ___ ___ noted to be doing well without complaints. She was discharged home from rehab yesterday and is brought into the ER today by her caregiver at her daughter's request. Per the daughter, the patient has been reporting posterior left calf pain with walking since being discharged from the hospital. The pain has been stable. The patient denies current pain at the time of evaluation but is unable to provide any further history. Per her caregiver, she has been otherwise doing well and is ambulating without difficulty. Denies fevers or chills. She has been taking her coumadin daily at rehab but did not take it today. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: Gen: NAD, Alert, responsive and conversant HEENT: no neck masses, no cervical LAD< Pulm: unlabored breathing, normal chest excursion CV: irregularly irregular Abd: soft, non-tender, no masses Ext: feet warm bilaterally, lateral deviation of LLE digits, intact LLE sensation bilateral ___ Pulse exam: R: P/P/P/D L:P/D/D(monophasic)/D (monophasic) Pertinent Results: ___ 07:15AM BLOOD WBC-5.6 RBC-3.34 Hgb-9.9* Hct-31.2* MCV-93 MCH-29.6 MCHC-31.7* RDW-15.4 RDWSD-52.5* Plt ___ ___ 06:55AM BLOOD WBC-6.3 RBC-3.34* Hgb-9.9* Hct-30.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-15.5 RDWSD-52.6* Plt ___ ___ 01:50AM BLOOD WBC-6.6 RBC-3.23* Hgb-9.5* Hct-29.6* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.4 RDWSD-51.8* Plt ___ ___ 09:50AM BLOOD WBC-5.8 RBC-3.30* Hgb-9.6* Hct-30.5* MCV-92 MCH-29.1 MCHC-31.5* RDW-15.5 RDWSD-53.2* Plt ___ ___ 02:10PM BLOOD WBC-7.1 RBC-3.31* Hgb-9.9* Hct-30.9* MCV-93 MCH-29.9 MCHC-32.0 RDW-15.8* RDWSD-54.1* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD ___ ___ 06:55AM BLOOD ___ PTT-30.4 ___ ___ 09:50AM BLOOD ___ PTT-117.7* ___ ___ 05:29PM URINE Blood-SM* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* Brief Hospital Course: ___ hx afib recently underwent femoral/popliteal embolectomy ___ acute limb ischemia, and now presented this admission with subacute left leg pain, subtherapeutic INR. She was managed non-operatively with anticoagulation. She was started on a heparin drip and titrated to a goal of 60-90. She was restarted on Coumadin with INR goal of ___. She was switched from heparin drip to lovenox to bridge her Coumadin. Her discharge INR was 1.4. She will continue daily dosing of warfarin 5mg, with a 90mg lovenox bridge until warfarin is therapeutic. Outpatient Coumadin management for her is being done the ___ clinic here at ___. She was also noted to have urinary frequency and UA was positive. She was started on Bactrim and will complete a 5 day course of cefpodixime on discharge. She was evaluated by physical therapy while admitted. She was deemed her okay to discharge home given she was ambulating at baseline levels, and the level of support (24hour caretaker) she has at home. She was discharged home with ___ services on ___. ___ will administer her lovenox 90mg once daily dosing, and draw INR labs as required. She will follow up with ___ clinic for outpatient warfarin management. These instructions were conveyed to patient and daughter who verbalized understanding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Senna 17.2 mg PO QHS 3. Warfarin 5 mg PO DAILY 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. Losartan Potassium 25 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. amLODIPine 5 mg PO DAILY 10. Enoxaparin Sodium 60 mg SC Q12H Start: Tomorrow - ___, First Dose: First Routine Administration Time 11. Docusate Sodium 100 mg PO BID 12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 2. Enoxaparin Sodium 90 mg SC Q24H Start: Tomorrow - ___, First Dose: First Routine Administration Time Please administer 1st dose within 24 hours of last dose. RX enoxaparin [Lovenox] ___ mg/mL 90 MG sc Q24H Disp #21 Syringe Refills:0 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Losartan Potassium 25 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Senna 17.2 mg PO QHS 13. Warfarin 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - leg pain likely secondary to Left femoral arterial thrombus - urinary tract infection Discharge Condition: Mental Status: coherent most times Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - at baseline level. Discharge Instructions: Dear ___, ___ were admitted for persistent subacute leg pain and urinary tract infection. ___ were treated with anti-coagulation and antibiotics. ___ will need to remain on anticoagulation going forward. Medications: 1. ___ will continue to take warfarin. ___ are being discharged home on 5mg Coumadin daily. Take as recommended. Follow up with your ___ clinic for adjustments to your Coumadin levels as appriopriate 2. Because your Coumadin level (measured with INR) is still not at goal, ___ are being discharged home on lovenox 90mg once daily. This will be administered by visiting nurses that will come to your house. 3. ___ will complete a 5 day course of antibiotics for Urinary tract infection that ___ were found to have. 4. Except told otherwise, please resume other medications ___ were on ACTIVITY: - we encourage ___ to get out of bed, walk and be as active as ___ can tolerate. Followup Instructions: ___
10095681-DS-21	10,095,681	25,225,196	DS	21	2150-03-21 00:00:00	2150-03-21 17:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Supratherapeutic INR Epigastric pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with CHF, afib on warfarin, hypothyroidism, dementia who presents with nausea, decreased PO intake and a supratherapeutic INR. Per patient's daughter, patient was in her usual state of health until this morning when she developed mild nausea that has persisted throughout the day. She denies vomiting. She has not eaten or had any fluids today. She denies diarrhea, last BM was two days ago and had normal appearance. Visting ___ drew an INR and found it to be 7.4 and told patient to present to the ED. Patient denies bleeding although has some bruising on arms, legs, and chest. Denies any recent changes to diet or medications. In the ED: Initial vital signs were notable for: 96.3 76 144/64 18 100% RA Exam notable for: Afebrile, VSS Appears comfortable Irregularly irregular rhythm, normal rate, normal S1 and S2, no m/r/g Breathing comfortably on room air, CTAB soft, non-distended, minimal epigastric tenderness without guarding or rebound No ___ edema Bruises present on arms and legs Labs were notable for: INR 6.2 AST 55, AlkP 138 Na 124 UA: large leuk esterase, positive nitrite, >182 WBCs EKG: atrial fibrillation, QTC 501 Patient was given: - Ceftriaxone - Metoprolol - IVF Consults: None Upon arrival to the floor, attempted to use the interpreter phone, but the patient was speaking over the phone. Spoke with the patient in ___ though the patient is hard of hearing and has baseline dementia making the interview difficult. She endorsed abdominal pain rating the pain a ___. Denies nausea or vomiting at this point. Reports having to urinate more frequently but unclear given she is incontinent at baseline. Spoke with her daughter, ___, who endorses the patient woke up with abdominal pain and generalized weakness. Reports have nausea but no emesis. Did not eat or drink during the day. Given the belly pain, they brought her into the ED. Reports that she has been having daily soft bowel movements but none in the last 2 days. Unclear though given ___ has documented diarrhea per nursing note? REVIEW OF SYSTEMS: ROS as above. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 2258) Temp: 97.3 (Tm 97.3), BP: 158/83, HR: 86, RR: 19, O2 sat: 98%, O2 delivery: Ra, Wt: 139.11 lb/63.1 kg GENERAL: Alert and interactive. In no acute distress. ___ speaking but does not like the interpreter phone. Answers about 60% of questions appropriately HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally anteriorly. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, mild tenderness to palpation worse in the LUQ and epigastrium. No rebound or guarding. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Mild tenderness to palpation in the L calf. SKIN: WWP. No rash. NEUROLOGIC: Alert and oriented person, to hospital (___), and not to time (year ___. CN2-12 intact. Moving all four extremities with purpose. DISCHARGE PHYSICAL EXAM: VS:97.6 PO \|118 / 63\| 67 \|18 \|97 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normoactive bowel sounds, non distended, mild tenderness to palpation in epigastrium. No guarding or masses. BACK: TLSO brace in place. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: Alert and interaction. CN2-12 grossly intact. Moving all four extremities with purpose. Strength ___ with dorsi and plantarflexion of ___. SKIN: Warm, dry. No rashes. Pertinent Results: ADMISSION LABS: ================ ___ 04:20PM BLOOD WBC-8.7 RBC-4.11 Hgb-11.7 Hct-35.1 MCV-85 MCH-28.5 MCHC-33.3 RDW-14.6 RDWSD-45.4 Plt ___ ___ 04:20PM BLOOD Neuts-76.9 Lymphs-14.6* Monos-7.6 Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.70* AbsLymp-1.27 AbsMono-0.66 AbsEos-0.01* AbsBaso-0.02 ___ 04:20PM BLOOD ___ PTT-43.6* ___ ___ 04:20PM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-124* K-6.8* Cl-89* HCO3-22 AnGap-13 ___ 04:20PM BLOOD ALT-15 AST-55* AlkPhos-138* TotBili-1.1 ___ 07:30AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.3 Mg-1.9 ___ 04:34PM BLOOD Lactate-1.2 Na-126* K-5.1 MICROBIOLOGY: ___ 5:51 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S URINE STUDIES: Urine Color Straw YELLOW Urine Appearance Hazy Specific Gravity 1.008 DIPSTICK URINALYSIS Blood SM* Nitrite POS* Protein 100* Glucose NEG Ketone TR* Bilirubin NEG Urobilinogen NEG pH 7.5 Leukocytes LG* MICROSCOPIC URINE EXAMINATION RBC 5* WBC >182* Bacteria MOD* Yeast NONE Epithelial Cells 4 IMAGING: ========== ___ MRI L SPINE IMPRESSION: 1. Acute transverse fracture through the superior L2 vertebral body extending into the left L2 pedicle with surrounding marrow edema. No buckling/discontinuity of the posterior cortex or bony retropulsion into the spinal canal. Ligamentum flavum and posterior longitudinal ligament appear continuous. The anterior longitudinal ligament also appears mostly continuous. 2. No spinal cord signal abnormality. 3. Left psoas intramuscular hematoma and edema. 4. Reactive soft tissue edema surrounding the L2 fracture. 5. Moderate multilevel lumbar spondylosis, notably causing severe right L5-S1 neural foraminal stenosis likely with impingement on the exiting right L5 nerve root. Further details, as above. ___ CT ABD & PELVIS W/O CONTRAST IMPRESSION: 1. Acute comminuted fracture through the L2 vertebral body with extension into the left pedicle. No retropulsion of fracture fragments. 2. New left psoas intramuscular hematoma. 3. No evidence of acute pancreatitis. 4. Cardiomegaly. Small pericardial effusion. 5. Small bilateral pleural effusions. DISCHARGE LABS: ___ 08:03AM BLOOD WBC-9.4 RBC-4.36 Hgb-12.4 Hct-38.0 MCV-87 MCH-28.4 MCHC-32.6 RDW-14.4 RDWSD-45.4 Plt ___ ___ 08:03AM BLOOD Glucose-82 UreaN-19 Creat-0.9 Na-132* K-4.9 Cl-94* HCO3-23 AnGap-15 ___ 07:35AM BLOOD ALT-10 AST-16 LD(LDH)-213 AlkPhos-131* TotBili-0.6 ___ 08:03AM BLOOD Calcium-9.0 Phos-3.6 Brief Hospital Course: Ms. ___ is a ___ year old woman with CHF, afib on warfarin, hypothyroidism, dementia who presented with nausea, epigastric abdominal pain,decreased PO intake and a supratherapeutic INR found to have a urinary tract infection and acute lumbar fracture and psoas hematoma. ACUTE ISSUES: ============= #Acute unstable L1 fracture #Osteoporosis Incidentally found to have an acute L1 vertebral fracture with MRI concerning for unstable fracture given extension into the left pedicle. No history of trauma or fall, possibly ___ osteoporosis. Neurosurgery was consulted and recommended TLSO bracing for all awake hours for 1 month. She will need follow up with neurosurgery in one month for reimaging to determine duration of TLSO bracing. In terms of her osteoporosis, she is currently on a drug holiday from home alenodronate 70mg 1x/week, she has follow up with endocrinology. #Psoas hematoma This was found incidentally on imaging and likely in setting of supratherapeutic INR and given fracture as above may suggest fall or trauma. Her hemoglobin remained stable throughout admission without concern for ongoing bleed. #Abdominal Pain #Constipation #Nausea On admission, family reported constipation with no bowel movement in two days prior to admission. She is s/p appendectomy and cholescystectomy. Lipase on admission was 38. Abdominal pain though potentially from baseline constipation. KUB without evidence of obstruction. Alternatively, thought that she may have some component of gastritis and was empirically started on a PPI and given bowel regimen with eventual alleviation of pain. There was no evidence of GI bleed. Work up overall unremarkable and likely multifactorial and possible with some referred pain from vertebral fracture. #UTI #Nausea U/A in the ED showed large ___, nitrates +, and WBC >182. Has been having UTI almost every ___ months and baseline incontinence. Urine culture grew Klebsiella. She was empirically started on ceftriaxone, whcih was switched to Bactrim to complete 7 day course. #Supratherapeutic INR #Atrial fibrillation She takes warfarin for atrial fibrillation at home. She had no reported bleeding. INR elevation may have been in setting of increased acetaminophen use at home. Eventually down-trended to 1.8 from 2.6 without any reversal. Her CHADSVASC score is 5. The decision was made to continue patient on warfarin given concern for threatened ischemic limb in past although risks of bleeding due to fall were also considered. Patient was started on reduced dose of warfarin with 2.5mg daily. She was continued on metoprolol. #Hypovolemic hyponatremia Chronic over last several months. Consistent with hypovolemic hyponatremia. Improved and stable. 132 at time of discharge. Continued to hold home lasix. CHRONIC ISSUES: =============== #Hypothyroidism s/p thyroidictomy in ___ (papillary thyroid microcarcinoma) - continued home levothyroxine 88mcg daily; extra dose each ___. #Hypertension BP stable this admission. - continued amlodipine 5mg daily - metoprolol as above - held home losartan 25mg BID #HFpEF #CAD Last echo in ___ with severe LAE. Moderate LV hypertrophy. LVEF of 70%. RV hypertrophy. Moderate AR and MR, Severe TR. - Continued home aspirin - held home Lasix 20mg daily given hyponatremia 36 min was spent seeing, examining, and coordinating discharge. TRANSITIONAL ISSUES: ======================= [ ] Patient was resumed on redosed dose of home warfarin 2.5mg daily, INR should be rechecked on ___. Goal INR ___. Ongoing discussion should be had on risks and benefits of continuing anticoagulation. [ ] Patient will need repeat CT L spine in ~1 month from discharge with follow up appoinment with Dr. ___ neurosurgery. The number for the office to schedule the appointment and the CT scan is ___. [ ] A PPI was started this admission for epigastric abdominal pain. Please continue to evaluate ongoing need for this medication and consider discontinuation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Losartan Potassium 25 mg PO BID 7. Senna 17.2 mg PO QHS 8. Metoprolol Succinate XL 50 mg PO BID 9. Warfarin 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN abdominal pain/nausea 2. Bisacodyl ___AILY 3. Pantoprazole 40 mg PO Q12H 4. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 5. Levothyroxine Sodium 176 mcg PO 1X/WEEK (___) 6. ___ MD to order daily dose PO DAILY16 7. Warfarin 2.5 mg PO DAILY16 Duration: 1 Dose 8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 9. amLODIPine 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Losartan Potassium 25 mg PO BID 13. Metoprolol Succinate XL 50 mg PO BID 14. Senna 17.2 mg PO QHS 15. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you speak with your doctor. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Supratherapeutic INR Urinary tract infection Acute lumbar vertebral fracture Psoas hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___: You were admitted to the hospital because you had an elevated INR and you were experiencing abdominal pain. At the hospital, you were found to have a urinary tract infection and you were given antibiotics. You were experiencing abdominal pain so you had a CT scan which showed a fracture in your spine and a small hematoma in your psoas muscle. You were seen by the neurosurgeon who recommended that you wear a brace. Your warfarin was held and your INR improved. You were then restarted on warfarin. When you leave the hospital you will go to rehab. Please follow up with all of your doctors. It was a pleasure caring for you! Sincerely, Your ___ Treatment Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10095682-DS-9	10,095,682	23,420,795	DS	9	2122-03-30 00:00:00	2122-03-31 07:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: simvastatin / atorvastatin Attending: ___. Chief Complaint: Back and left leg pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with a history CAD s/p multiple PCIs (last ___, COPD, GERD, lumbar disc disease, and melanoma presenting with c/o left hip/back pain. Patient reports left hip pain that started 5 weeks ago all of a sudden after doing yardwork. Describes it as mostly pain in his left hip but occasionally has low back pain. Pain is sharp, intermittent to constant, and radiates down to his left ankle. He received steroid injections about 6 weeks ago for spinal stenosis and similar pain, but had very little relief. He has also been taking advil with mild relief. Denies fevers/chills, no numbness/tingling or weakness, does have a 'burning' sensation with this pain. No difficulty with bowel or bladder control. This morning, the pain was worse than ever and not responsive to advil so he presented to ___. In the ___, labs were notable for normal CBC and chemistries (Cr 1.0). He received 10mg diazepam as well as morphine IV. Given his recent epidural steroid injections, the team at ___ wanted to rule-out epidural abscess, so he was transferred to ___ ___ for consideration of CT myelogram. In the ___ ___ initial vitals were: 98.1 60 137/65 18 95%. No new labs were drawn. CT L spine without contrast showed moderate degenerative changes with large distended bladder. After the CT patient urinated large amount with PVR 147cc. Patient was given tylenol, oxcodone 5mg x2. On the floor, patient says left hip pain is currently ___, down from ___, has no other complaints. Past Medical History: GERD (Gastroesophageal Reflux Disease) Hyperlipidemia Back pain Melanoma - left eye ___, also on back COPD (chronic obstructive pulmonary disease) Squamous cell carcinoma of skin Gout Elevated PSA Hypertension Colonic polyp Coronary artery disease: ___: DES to the LAD; ___: DES to LAD; ___: DES to OM2 Coronary stent Erosive esophagitis Chronic cough ___ esophagus Constipation Lower GI bleed S/P coronary artery stent placement Dysphagia Esophageal dilatation Elevated CPK Lumbar disc disease Social History: ___ Family History: Father ___ [Other] [OTHER] Mother ? [Other] [OTHER] Son ___ Physical ___: Admission Physical Exam: Vitals - 97.6 156/83 hr 52 20 96% RA GENERAL: awake, alert, NAD HEENT: EOMI, PERRLA, OMM no lesions NECK: supple CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTABL ABDOMEN: soft, nontender, +BS EXTREMITIES: no cyanosis, clubbing or edema NEURO: CN II-XII intact, strength ___ in UE and ___ b/l MSK: negative straight leg raise and ___ test SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge Physical Exam: Vitals: 98.2 134/80 58 18 97% RA GENERAL: awake, alert, NAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB ABDOMEN: soft, nontender EXTREMITIES: no cyanosis, clubbing or edema NEURO: CN II-XII grossly intact, strength ___ in UE and ___ b/l, lower extremity sensation intact to light touch BACK: no spinal process or paraspinal tenderness SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission Labs: ___ 06:00AM BLOOD WBC-5.3 RBC-4.42* Hgb-13.1* Hct-39.3* MCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 Plt ___ ___ 06:00AM BLOOD Glucose-133* UreaN-11 Creat-0.8 Na-140 K-3.6 Cl-104 HCO___ AnGap-14 Imaging: ___ CT L spine w/o contrast preliminary report: 1. Mild retrolisthesis of T12 on L1 causing mild canal narrowing. 2. Mild to moderate spinal canal narrowing at L3-L4 from posterior osteophyte complex and hypertrophy of the ligamentum flavum. 3. No compression fracture. 4. Moderate multilevel degenerative changes with multilevel mild to moderate uncovertebral hypertrophy and mild canal narrowing as described above. 5. Large distended bladder. Brief Hospital Course: ___ year old male with PMH CAD s/p multiple PCIs (last ___, COPD, GERD, lumbar disc disease, and melanoma who presented with c/o left hip/back pain. His symptoms were consistent with radiculopathy, likely from disc herniation. He was discharged with pain control and PCP and ___ follow-up. Active Issues # Lumbar Radiculopathy Constellation of symptoms were suggestive of lumbar radiculopathy. CT L spine without contrast showed degenerative changes. He had no bowel or bladder incontinence or lower extremity weakness suggestive of cord compression or cauda equina syndrome. He also had no point tenderness, fever/chills, or leukocytosis that would be suggestive of epidural abscess. We were unable to obtain an MRI given his history of ocular melanoma and metal in the eye, and given that he was not showing any symptoms that would be suggestive of a cord compression it was felt that CT myelogram was not necessary at this time. At time of discharge he was able to ambulate independently, and pain was well controlled with oxycodone and standing tylenol with valium for muscle spasm. He will have PCP and ___ follow-up. Chronic Issues # COPD: He was asymptomatic. Continued albuterol:PRN # HTN: BP was well controlled. Continued amlodipine, amiloride # GERD: continued pantoprazole # Gout: continued prophylactic medications # CAD: continued atenolol, statin, aspirin Transitional Issues: 1. Continue to monitor back pain. ___ need physical therapy or additional therapeutics. If pain worsens, consider further imaging. 2. We are working on scheduling a follow-up with the spine center (see above). 3. Discharged with 10 tablets of 5mg diazepam and 20 tablets of 5mg oxycodone. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 2. Febuxostat 40 mg PO DAILY 3. Pantoprazole 20 mg PO Q12H 4. Amiloride HCl 5 mg PO QAM 5. Rosuvastatin Calcium 20 mg PO DAILY 6. Amlodipine 5 mg PO DAILY 7. Atenolol 50 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 9. Magnesium Oxide 250 mg PO DAILY 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amiloride HCl 5 mg PO QAM 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Febuxostat 40 mg PO DAILY 6. Pantoprazole 20 mg PO Q12H 7. Rosuvastatin Calcium 20 mg PO DAILY 8. Acetaminophen 650 mg PO Q8H 9. Diazepam 5 mg PO Q6H:PRN muscle spasm RX diazepam 5 mg 1 tablet by mouth Q6h PRN Disp #10 Tablet Refills:0 10. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:0 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth Q4h PRN Disp #20 Tablet Refills:*0 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 13. Magnesium Oxide 250 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp 15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary: lumbar radiculopathy 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 of severe back and leg pain. Your pain was improved with narcotic medications. A CT scan of your back showed some degenerative changes (which often happen with age) and canal narrowing which is consistent with your prior diagnosis of spinal stenosis. We did not do further imaging because other causes such as infection were unlikely. Your pain improved and you were able to walk without need of assistance. You are safe to be discharged home. You have a follow-up appointment with you primary care doctor on ___ (see below). We are sending you home with oxycodone, a narcotic pain medication, and diazepam. The diazepam is a muscle relaxant to help with spasm. Do not take this when driving and do not mix with alcohol. We wish you the best. Sincerely, Your ___ Team Followup Instructions: ___
10095982-DS-10	10,095,982	25,909,015	DS	10	2130-01-13 00:00:00	2130-01-13 15:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right upper quadrant abdominal pain. Major Surgical or Invasive Procedure: ___ Catheter placement into recurrent abscess collection in the gallbladder fossa History of Present Illness: Mr. ___ is a ___ year old male s/p laparoscopic subtotal cholecystectomy on ___ with post-operative fluid collection s/p ___ drain ___ now presenting with progressive RUQ pain since drain removal. Reports pain began about 2 weeks after drain removed on ___ and has gotten progressively worse for the last 2 weeks. Drain output was purulent but only showed GPCs on gram stain with Cx = mixed growth. After presenting with RUQ pain on ___, a CT scan showed a 3.1 x 7.1 x 6.7 cm fluid collection in the gallbladder fossa and patient was referred to the ED. Reports pain is worse with food. Denies N/V/F/C/diarrhea or difficulty urinating. Past Medical History: Past Medical History: DMII (on insulin + metformin), HTN, HL, chronic back pain, choledocholithiasis + cholecystitis s/p subtotal lap chole ___ Past Surgical History: 3 hernia repairs knee surgery bilaterally subtotal lap chole ___ [back wall left behind to avoid bleeding] Social History: ___ Family History: Mother, passed at age ___, DMII Physical Exam: On admission: VS: 98.7, 90, 109/63, 16, 95% RA Gen - NAD Heart - RRR Lungs - decreased breath sounds right lung base, otherwise clear Abdomen - soft, non-distended, palpable firmness in RUQ with TTP and some guarding, no rebound Extrem - no edema On discharge: VS: T98.3, 70, 131/64, 14, 95% on room air Pertinent Results: ___ 04:42AM BLOOD WBC-10.0 RBC-3.71* Hgb-10.9* Hct-33.5* MCV-90 MCH-29.3 MCHC-32.4 RDW-13.7 Plt ___ ___ 05:44AM BLOOD WBC-11.4* RBC-3.77* Hgb-11.1* Hct-33.4* MCV-89 MCH-29.5 MCHC-33.2 RDW-14.0 Plt ___ ___ 03:45PM BLOOD WBC-15.9# RBC-4.00 Hgb-11.7* Hct-36.0* MCV-90 MCH-29.4 MCHC-32.6 RDW-13.7 Plt ___ ___ 03:45PM BLOOD Neuts-73.3* ___ Monos-6.1 Eos-0.7 Baso-0.3 ___ 05:44AM BLOOD ___ PTT-30.7 ___ ___ 03:49PM BLOOD ___ PTT-29.0 ___ ___ 04:42AM BLOOD Glucose-101* UreaN-33* Creat-1.4* Na-136 K-4.8 Cl-102 HCO3-28 AnGap-11 ___ 05:44AM BLOOD Glucose-122* UreaN-44* Creat-1.9* Na-139 K-5.3* Cl-100 HCO3-26 AnGap-18 ___ 03:45PM BLOOD Glucose-190* UreaN-44* Creat-2.1* Na-136 K-4.9 Cl-95* HCO3-28 AnGap-18 ___ 05:44AM BLOOD ALT-15 AST-14 AlkPhos-104 TotBili-0.3 ___:45PM BLOOD ALT-17 AST-14 AlkPhos-120 TotBili-0.2 ___ 04:42AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.3 ___ 05:44AM BLOOD Calcium-9.2 Phos-5.3# Mg-2.6 ___ 03:45PM BLOOD Albumin-3.6 ___ 03:51PM BLOOD Lactate-2.1 IMAGING: ___ Interventional Radiology: Placement of drainage tube Ultrasound-guided 8 ___ drainage catheter placement into recurrent abscess collection in the gallbladder fossa yielding 100 mL of purulent material without immediate complication. Of note, two gallstones, are noted within this residual collection and will be removed at some point. Brief Hospital Course: Mr. ___ was admitted to the Acute Care Surgery service for further management of his right upper quadrant pain. As previously discussed, his ___ CT of the abdomen and pelvis revealed a fluid collection in the gallbladder fossa. He was admitted to the inpatient ward with plans to have the fluid drained in radiology the next morning. Mr. ___ was kept NPO for that procedure and started on empiric antibiotics. On the morning of ___, Mr. ___ underwent placement of a RUQ drainage tube in radiology. Approximately 100cc of purulent material was sent for culture. A drain was left in place. There were no complications during the procedure. Once transferred back to the inpatient ward, the patient was started on an oral diet. Due to an elevated creatinine on admission of 2.1, the patient was given IV fluids in addition to oral fluids, food. He creatinine slowly decreased to 1.9, then 1.4. His blood glucose levels were checked before meals and at bedtime. With his home dose of glargine, his glucose was well controlled. His metformin was held until he follows up with his PCP, ___ ___, in approximately one week. The patient was also instructed to hold his diclofenac potassium as a result of his elevated creatinine. While on the inpatient ward, Mr. ___ had episodes of hypotension with a systolic blood pressure in the ___. In preparation for discharge, his home dose of Toprol XL (150mg daily) was cut in half. His lisinopril-HCTZ (___) was also held until the patient sees Dr. ___. ___ services were established for the patient so his drain output could be monitored, as well as his vital signs, while on the new medication regimen. The above plan was discussed with Dr. ___ on the afternoon of ___. At the time of discharge, Mr. ___ was afebrile, hemodynamically stable and in no acute distress. He was discharged in the care of his wife. The patient will follow up in the ___ clinic within one week to determine if his drain could be discontinued. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Lisinopril 40 mg PO DAILY 3. Hydrochlorothiazide 50 mg PO DAILY 4. Simvastatin 40 mg PO DAILY 5. Glargine 25 Units Breakfast Glargine 25 Units Dinner 6. diclofenac potassium 50 mg Oral BID 7. Metoprolol Succinate XL 150 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #14 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. Glargine 25 Units Breakfast Glargine 25 Units Bedtime 5. Metoprolol Succinate XL 75 mg PO DAILY RX metoprolol succinate 50 mg ___ tablet extended release 24 hr(s) by mouth once a day Disp #30 Tablet Refills:0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 7. Simvastatin 40 mg PO HS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right upper quadrant (gallbladder fossa) abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with complaints of right upper quadrant pain. CT scanning showed that you had a new fluid collection in the same area. You were taken to radiology the following morning for placement of a drain. You were also started on oral antibiotics, which will continue for a total of one week. You are now being discharged home with the following instructions: General Drain Care: Please record the daily output from your drain and bring those numbers with you to your follow-up ACS appointment. The ___ nurse ___ assist you as needed. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. ***Please note that there are changes to your home medication regimen. Please see the list of medications attached for those changes. You will need to follow up with your PCP at the appointment below for close follow up of your blood pressure and kidney lab values (creatinine). Followup Instructions: ___
10095982-DS-13	10,095,982	25,886,557	DS	13	2130-09-23 00:00:00	2130-09-28 16:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: ___: CT-guided drainage of collection posterior to the right lobe of the liver History of Present Illness: ___ s/p laparoscopic subtotal cholecystectomy for acute on chronic cholecystitis ___ complicated by retained intra-abdominal stones necessitating drainage of abscess and open removal of stones ___ (___) returns with persistent right upper quadrant pain and drainage from his old open cholecystectomy scar. He has not experienced any fevers, chills, nausea, vomiting, constipation or diarrhea. He has experienced roughly a thirty pound weight loss over the last year. Since the ___, he has had a draining sinus from his old incision. He was evaluated by surgery at that time and was noted to have drainage but was otherwise asymptomatic and this was followed. Surgery is now consulted for further workup and management Past Medical History: -DMII (on insulin + metformin) -HTN -HL -chronic back pain / sciatica -bilat eustachean tube dysfxn (followed at ___) -choledocholithiasis + cholecystitis s/p subtotal lap chole ___ Past Surgical History: -3 hernia repairs -knee surgery bilaterally -subtotal lap chole ___ [back wall left behind to avoid bleeding] Social History: ___ Family History: Mother passed at age ___, DMII Physical Exam: Admission Physical Exam ___: Vitals: Temp 97.8 HR 94 BP 145/91 RR 14 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, minimally tender RUQ, no rebound or guarding, normoactive bowel sounds, no palpable masses Incision: lateral pinpoint drainage of purulent fluid Ext: No ___ edema, ___ warm and well perfused Discharge PE: ___: Vitals: 98.2, 70, 134/64, 18, 97% on RA Gen: NAD, comfortable appearing man Lungs: CTAB CV: S1, S2, RRR Abd: soft, nontender, nondistended, ___ guided JP drain in Left flank with scant bilous tinged drainage. Extrm: warm, well perfused, +PP Neuro: A+OX3, MAE to command, PERRL Pertinent Results: ___ 01:30PM PLT COUNT-278 ___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86 MCH-27.4 MCHC-32.0 RDW-15.8* ___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86 MCH-27.4 MCHC-32.0 RDW-15.8* ___ 01:30PM ALBUMIN-3.6 ___ 01:30PM LIPASE-12 ___ 01:30PM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-61 TOT BILI-0.2 ___ 01:30PM estGFR-Using this ___ 01:30PM GLUCOSE-198* UREA N-14 CREAT-0.7 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 ___ 09:30AM BLOOD WBC-6.2 RBC-4.01* Hgb-11.0* Hct-34.5* MCV-86 MCH-27.5 MCHC-32.0 RDW-15.9* Plt ___ ___ 09:30AM BLOOD Plt ___ ___ 09:30AM BLOOD Glucose-269* UreaN-22* Creat-1.0 Na-137 K-5.1 Cl-100 HCO3-26 AnGap-16 ___ 06:10AM BLOOD ALT-9 AST-14 AlkPhos-61 TotBili-0.4 ___ 09:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0 ___: CT ABD/PELVIS: 1. New subdiaphragmatic fluid collection with rim enhancement along the posterior right hepatic lobe measures up to 4.9 cm, compatible with abscess. 2. New moderate right pleural effusion. 3. Small residual fluid collection along the anterolateral right hepatic lobe appears smaller compared to prior studies; however, superinfection cannot be excluded. 4. Hepatic and renal cysts. 5. Splenomegaly. 6. Enlarged prostate. ___: ___ Drainage: Technically successful CT-guided drainage of collection posterior to the right lobe of the liver with 20 cc of purulent fluid withdrawn, a sample of which was sent for analysis. An additional 90 cc of clear yellow right pleural fluid were withdrawn for better access for drainage of right posterior upper abdominal collection. ___: CXR: There is now complete clearing of pre-existing interstitial parenchymal opacities ___ 3:00 pm FLUID,OTHER LIVER ABSCESS. ___ ADDON PER ___ ___ @0819. GRAM STAIN (Final ___: Reported to and read back by ___ @ 1834 ON ___ - ___. 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE ROD(S). MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___: No thin, branching, partially acid fast rods seen. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): ___ 3:00 pm PLEURAL FLUID ADDON FOR ___ PER ___ ___ @0819. GRAM STAIN (Final ___: Reported to and read back by ___ @ 1834 ON ___ - ___. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE ROD(S). MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___: No thin, branching, partially acid fast rods seen. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): Brief Hospital Course: Mr. ___ is a ___ y.o. man with PMH significant for Diabetes, HTN, HLD s/p lap subtotal cholecystectomy in ___ which was complicated by retained stones within the abdomen s/p removal of stones and abscess drainge in ___ who returned with new liver abscess. He presented ___ with increased RUQ abdominal pain and drainage from the incision of his previous cholecystectomy site. CT ABD/PELVIS on admission revealed a new subdiaphragmatic fluid collection with rim enhancement adjacent to the posterior right hepatic lobe measures up to 4.9 cm compatible with abscess and new moderate right pleural effusion. Right upper quadrant ultra sound was negative for retained stone and new subdiaphragmatic fluid collection along the posterior right hepatic lobe consistant with CT scan. On ___, ___ evaluated the patient, placed a drain posterior to the right lobe of the liver, and send culture from the purulent fluid that was aspirated. ___ also aspirated fluid from the new right pleural effusion at this time and sent it for culture. ID was consulted at this time. While inpatient, the patient remained afebrile and hemodynamically stable. His WBC remained in the 6.0-7.0 range. At the time of discharge the patient's drain remained in place with scant, bilous tinged fluid. His gram stain at the time grew out thin branching rods. Given the length of time for this to speciate, the decision was made with ID to send the patient home on empiric coverage for Norcardia and Actinomycosis. He will follow up with ID in 2 weeks. He was tolerating a regular diet without nausea and vomitting. He was ambulating independently. He will follow up with the ___ clinic in 2 weeks and will have ___ services at the time of discharge to assist with drain care. Medications on Admission: Amitriptyline 25 mg PO HS Hydrochlorothiazide 25 mg PO DAILY Metoprolol Tartrate 75 mg PO BID Lisinopril 20 mg PO DAILY MetFORMIN (Glucophage) 500 mg PO BID Glargine 20 Units SC BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amitriptyline 25 mg PO HS 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Metoprolol Tartrate 75 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #25 Capsule Refills:0 7. Penicillin V Potassium 500 mg PO Q6H RX penicillin V potassium 500 mg 1 tablet(s) by mouth every six (6) hours Disp #56 Tablet Refills:0 8. Sulfameth/Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 9. Lisinopril 20 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Glargine 20 Units Breakfast Glargine 20 Units Dinner Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hepatic Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ for a hepatic abscess that was drained by the interventional radiologists. A drain was placed and you will be discharge home with it. Please see your appointments below. Please return to the hospital or call your PCP/NP with the following symptoms: 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. JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10095982-DS-16	10,095,982	23,069,054	DS	16	2131-10-03 00:00:00	2131-10-23 17:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with PMHx DMII, CAD, HTN, HLD, cholecystectomy c/b intra-abdominal abscesses presenting with abdominal pain and persistent subcapsular perihepatic fluid collection despite prior ___ drainage at ___, has been admitted to ___ since ___ for further evaluation. Medicine has been consulted for hypoxia and new oxygen requirement. Mr. ___ was admitted to ___ from ___ for acute abdominal pain. He was found to have liver abscess and right subcapsular fluid collection, requiring ___ drainage. According to OSH transfer note, hospital course was complicated by septic shock requiring pressors, right-sided empyema s/p thoracentesis, VATS, and chest tube placement (now removed), PAF in the setting of sepsis, ___, ___ (proBNP ___), and urinary retention. Pleural fluid culture was negative but pt responded well to ABX. ID was consulted at OSH and recommended 4-weeks of ABX. He was to undergo PICC placement for IV ABX but due to insurance issues, he was discharged on amoxicillin 500mg tid with plan to f/u with PCP, ___, thoracic surgery. However, he represented to ___ from home on ___ complaining of worsening abdominal pain. Pt was admitted to ___ on ___ to ___. ___ was consulted for possible reopositioning or replacement of drain. However, ___ did not recommend any further drainage interventions. Pt was on vancomycin and zosyn from ___ here. Antibiotics were discontinued on ___ due to absence of infectious signs or symptoms. Pt has been on 2L oxygen while on the floor. An attempt was made to wean off oxygen today but pt desatted to 88% on 1L. Pt reports productive, progressive cough. Denies fever, chills. Denies dyspnea, chest pain, abodminal pain. Past Medical History: -DMII (on insulin + metformin) -HTN -HLD -chronic back pain / sciatica -bilat eustachean tube dysfunction (followed at ___) -choledocholithiasis + cholecystitis s/p subtotal lap cholecystectomy ___ Past Surgical History: -hernia repairs x 3 -knee surgery (bilateral) -subtotal lap cholecystectomy ___ (posterior wall left behind to avoid bleeding) Social History: ___ Family History: Mother passed at age ___, DMII Physical Exam: Discharge exam: Vitals: Tm/Tc 98.1, BP 127/63, HR 80-86, ___ RA Ambultaory O2 sat: 93 at rest; 92 when ambulating I/Os: since MN I 180, O 200; 24h I 1140, O 1240 General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated at 8cm, no LAD Lungs:no wheezes appreciated. Bibasilar trace crackles at the lung base R>L, slightly improved form ___ CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GU: no foley Ext: 1+ edema bilateral legs, 2+ pulses, no clubbing, cyanosis or edema. Pertinent Results: ___ 05:43AM BLOOD WBC-6.9 RBC-3.64* Hgb-9.8* Hct-30.5* MCV-84 MCH-27.0 MCHC-32.2 RDW-17.3* Plt ___ ___ 08:16AM BLOOD WBC-7.3# RBC-4.10* Hgb-11.2* Hct-35.1* MCV-86 MCH-27.2 MCHC-31.8 RDW-17.1* Plt ___ ___ 02:51PM BLOOD Neuts-57.1 ___ Monos-10.4 Eos-2.0 Baso-0.4 ___ 05:43AM BLOOD Plt ___ ___ 08:16AM BLOOD Plt ___ ___ 08:16AM BLOOD ___ PTT-31.3 ___ ___ 05:43AM BLOOD Glucose-142* UreaN-20 Creat-1.4* Na-142 K-4.7 Cl-101 HCO3-28 AnGap-18 ___ 08:16AM BLOOD Glucose-165* UreaN-14 Creat-1.3* Na-141 K-4.5 Cl-102 HCO3-28 AnGap-16 ___ 08:16AM BLOOD ALT-16 AST-20 AlkPhos-89 TotBili-0.3 ___ 02:51PM BLOOD ALT-15 AST-14 AlkPhos-71 TotBili-0.2 ___ 02:51PM BLOOD Lipase-15 ___ 05:58AM BLOOD proBNP-4867* ___ 08:40PM BLOOD cTropnT-0.02* ___ 02:51PM BLOOD cTropnT-0.02* ___ 05:43AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.3 ___ 08:16AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.3 ___ 04:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7 ___ 02:51PM BLOOD Albumin-2.7* ___ 08:38PM BLOOD Lactate-2.2* ___ 03:00PM BLOOD Lactate-1.8 ___ 04:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:10PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 04:10PM URINE RBC-2 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1 ___ 04:10PM URINE CastGr-3* CastHy-5* ___ 04:10PM URINE Mucous-RARE ___ 2:55 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:51 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ Echocardiogram Echocardiographic Measurements ResultsMeasurementsNormal Range Left Atrium - Long Axis Dimension:4.7 cm<= 4.0 cm Left Atrium - Four Chamber Length:6.0 cm<= 5.2 cm Right Atrium - Four Chamber Length:5.3 cm<= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm<= 5.6 cm Left Ventricle - Systolic Dimension: 4.5 cm Left Ventricle - Fractional Shortening: 0.15>= 0.29 Left Ventricle - Ejection Fraction: 41%>= 55% Left Ventricle - Lateral Peak E': 0.13 m/s> 0.08 m/s Left Ventricle - Septal Peak E': 0.09 m/s> 0.08 m/s Left Ventricle - Ratio E/E': 7< 13 Aorta - Sinus Level:3.7 cm<= 3.6 cm Aortic Valve - Peak Velocity: 1.7 m/sec<= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave:0.8 m/sec Mitral Valve - A Wave:1.3 m/sec Mitral Valve - E/A ratio:0.62 Mitral Valve - E Wave deceleration time:127 ms140-250 ms ___ LEFT ATRIUM: Mild ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global LV hypokinesis. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral valve supporting structures. No MS. ___ (1+) MR. ___ VALVE: Tricuspid valve not well visualized. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting tachycardia (HR>100bpm). Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (45 - 50 %). There is beat to beat variation of myocardial contractility. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild global left ventricular systolic dysfunction. ___ CXR: UNDERLYING MEDICAL CONDITION: ___ year old man with recent empyema s/p drainage, now w/ persistent 2L O2 requirement REASON FOR THIS EXAMINATION: Pls veal any interval change or etiology of new O2 requirement Final Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with recent empyema s/p drainage, now w/ persistent 2L O2 requirement // Pls veal any interval change or etiology of new O2 requirement TECHNIQUE: PA and lateral radiographs of the chest. COMPARISON: ___. FINDINGS: Moderate right pleural effusion is decreased with right basilar pigtail catheter in place. A small left pleural effusion is unchanged. Mild pulmonary edema superimposed on chronic interstitial changes attributable to emphysema is unchanged. Mild cardiomegaly is unchanged. Extensive spinal degenerative changes are stable. IMPRESSION: Decreased moderate right pleural effusion with chest tube in place. Stable small left pleural effusion. Stable mild pulmonary edema superimposed on emphysema. ___ ECG: ___ ___ ___ Cardiovascular ReportECGStudy Date of ___ 8:30:26 ___ Sinus rhythm. Frequent atrial ectopy and occasional ventricular ectopy. Left ventricular hypertrophy. Left axis deviation. Delayed R wave transition. Compared to the previous tracing of ___ the rate has slowed. There is atrial and ventricular ectopy. Otherwise, no diagnostic interim change. Read ___ ___ Axes RatePRQRSQTQTc (___) ___-___ ___ - CXR: FINDINGS: Portable AP upright chest film ___ at 14:32 is submitted. IMPRESSION: Overall cardiac and mediastinal contours are stably enlarged. There is a small right basilar and lateral pleural effusion. The overall interstitium is somewhat prominent, particularly in the right mid and lower lung, but this does not appear to be significantly changed since ___. Given that the left lung appears grossly clear, this more likely represents an infectious process rather than edema. Clinical correlation, however, is advised. No pneumothorax. ___ - Lower Extremity US: FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. A patent duplicated left popliteal vein is noted. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis within bilateral lower extremities. Brief Hospital Course: Mr. ___ is a ___ with PMHx DMII, CAD, HTN, HLD, cholecystectomy c/b intra-abdominal abscesses presenting with abdominal pain and persistent subcapsular perihepatic fluid collection despite prior ___ drainage at OSH. Pt was admitted to ___ on ___ to ACS. ___ was consulted for possible reopositioning or replacement of drain. However, ___ did not recommend any further drainage interventions. Pt was on vancomycin and zosyn from ___ here. Antibiotics were discontinued on ___ due to absence of infectious signs or symptoms. Pt was on 2L oxygen while on the floor. An attempt was made to wean off oxygen today but pt desatted to 88% on 1L. While in the hospital he developed hypoxia and a new oxygen requirement because of pulmonary edema. Our echocardiogram confirmed the patient has mild congestive heart failure(LVEF of 45-50%) which was probably caused him to retain fluid in his lungs. He was treated with IV and PO lasix and his respiratory status improved. Transitional Issues: 1) ___ and mild hyperkalemia - Cr 1.4->1.5->1.7 despite holding lasix ___. K 5.6. Pt left AMA. Told him to hold lisinopril and lasix until labs rechecked. Gave information on low potassium diet. *Needs repeat electrolytes (including potassium) ___ ___ 2) Drain - Patient has a pigtail catheter in the right upper quadrant at site of prior hepatic abscess placed at ___. With resolution of he symptoms and completion of appropriate antibiotic therapy. He has an appointment with Dr. ___ the drain removed ___. 3) Hypoxia - Patient developed shortness of breath and an oxygen requirement with evidence of pulmonary edema on physical exam and chest Xray. His condition improved with IV and PO lasix. After a creatinine bump to 1.5, patient was taken off PO lasix. On follow up with PCP, the ___ volume status should be evaluated and the decision made whether to put him on standing PO lasix. 4) CHF - ___ echocardiogram while at ___ showed mild global left ventricular hypokinesis (45 - 50%). Patient will follow up with his PCP and have an appointment with the cardiologist Dr. ___. 5) History of pAF - He has reported history of paroxysmal atrial fibrillation in the setting of sepsis (no EKG or telemetry strips are documented in atrial fibrillation). He was monitored on telemetry here, with no atrial fibrillation occuring (over a 24 hour period). His CHADS2VASC score is 4. He has an appointment with the cardiologist Dr. ___ for consideration of an event monitor (and also for his depressed EF as above). 5) Actinomyces ___ infection - Patient is known to have been infected with actinomyces ___. Actinomyces could very well explain the recurrent pleural and abdominal collections. Unfortunately treatment can last up to ___ year. He will follow up with Infectious Disease Doctor ___ MD on ___ to determine necessity and length of continued treatment. 6)DM - While inpatient, Mr. ___ has been on a sliding scale without any long-acting insulin with BGs <200 even though at home he is on 22U BID levomir. We are sending him home on 5U BID levomir. He says he has not been taking Humalog with meals, so that was not continued on discharge. If his sugars are high after two days at home, we have encouraged him to increase his levomir to 7U BID and slowly uptitrate to avoid hypoglycemia. 7) Med rec: ___ recollection of his medications is different than what is listed with pharmacy and PCP. We instructed him to bring his medications to his appointment tomorrow. Needs recheck of creatinine at follow-up appointment (was 1.5 on day of discharge) and re-evaluation of his volume status He was told of risks of leaving and pending issues/abnormal findings. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 20 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Amoxicillin 500 mg PO Q8H 5. Levemir (insulin detemir) 22 U subcutaneous BID 6. HumaLOG (insulin lispro) sliding scale subcutaneous BID:PRN Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H worsening cough 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Lisinopril 20 mg PO DAILY 4. Simvastatin 40 mg PO QPM 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Levemir (insulin detemir) 5 units subcutaneous BID 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Abominal abscesses Pulmonary edema Congestive heart failure Discharge Condition: . Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It has been a pleasure taking care of you at ___ ___. When you came to the hospital, you were complaining of worsening abdominal pain. Our surgeons and radiologists evaluated you determined that you didn't need surgery or any additional drainage tubes for your pain. We put you on strong antibiotics while you were here to treat your pain. While in the hospital you had trouble breathing and needed supplemental oxygen. We gave you medications to make you urinate out the extra fluid collecting in your lungs and your trouble breathing got a lot better. Now that you are breathing much better, we are sending you home and giving you the information to follow up with the surgery clinic to take out you drainage tube and the ___ clinic to to determine how long you should continue taking antibiotics. You will also need to see a Cardiologist (heart doctor). This is very important! Followup Instructions: ___
10095982-DS-8	10,095,982	22,345,836	DS	8	2129-10-15 00:00:00	2129-10-16 05:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Epigastric pain. Major Surgical or Invasive Procedure: ___ ERCP ___ laparoscopic cholecystitis History of Present Illness: ___ with DMII on insulin, high cholesterol, hypertension, and 3 prior hernia repairs who presents to the ___ ED from OSH with 1 day of diffuse epigastric pain. This morning he ate bread and experienced a sudden onset of diffuse epigastric pain that steadily increased to ___ in severity. The pain was colicky, did not radiate, and had no clear aggravating or alleviating triggers. He also experienced nausea with a slight amount of vomitus that was non bloody. Mr. ___ decided to present to ___, and he was transferred to the ___ ED shortly thereafter. Since eating bread this morning, Mr. ___ has not consumed any food and has lost his appetite. His last bowel movement was yesterday, and was normal in color, consistency, and smell and was non-bloody and not painful. Mr. ___ has had pervious unremarkable colonoscopies, and has not experienced any fever, chills, night sweats, or weight loss. Past Medical History: PMH: 1. DMII, on insulin 2. hypertension 3. high cholesterol 4. chronic back pain PSH: 3 hernia repairs knee surgery in both knees Social History: ___ Family History: Mother, passed at age ___, DMII Physical Exam: On admission: Vitals: 100.0 102 126/64 16 95% RA Gen: Pleasant, AO x 3, in no acute distress Car: RRR, nl S1 and S2 Pulm: CTA bilaterally Abd: +BS. Soft, nontender, nondistended, negative ___ sign, tender to palpation over epigastrium. Extr: + distal pulses, no edema On discharge: Pertinent Results: ___ 05:12AM BLOOD WBC-12.4* RBC-4.20* Hgb-13.2* Hct-40.3 MCV-96 MCH-31.5 MCHC-32.9 RDW-13.1 Plt ___ ___ 06:02AM BLOOD WBC-11.9* RBC-3.66* Hgb-12.1* Hct-35.6* MCV-97 MCH-33.0* MCHC-33.9 RDW-13.0 Plt ___ ___ 10:35AM BLOOD WBC-10.5 RBC-3.83* Hgb-12.2* Hct-37.1* MCV-97 MCH-31.8 MCHC-32.8 RDW-12.9 Plt ___ ___ 05:35AM BLOOD WBC-6.0 RBC-3.84* Hgb-12.1* Hct-37.2* MCV-97 MCH-31.5 MCHC-32.5 RDW-13.2 Plt ___ ___ 05:12AM BLOOD Glucose-488* UreaN-23* Creat-1.1 Na-130* K-5.7* Cl-95* HCO3-25 AnGap-16 ___ 10:40AM BLOOD Na-134 K-4.0 Cl-97 ___ 06:02AM BLOOD Glucose-189* UreaN-21* Creat-1.5* Na-135 K-4.0 Cl-99 HCO3-22 AnGap-18 ___ 10:35AM BLOOD Glucose-213* UreaN-20 Creat-1.3* Na-136 K-3.9 Cl-100 HCO3-24 AnGap-16 ___ 05:35AM BLOOD Glucose-198* UreaN-17 Creat-1.2 Na-138 K-4.1 Cl-104 HCO3-24 AnGap-14 ___ 05:12AM BLOOD ALT-625* AST-436* AlkPhos-479* TotBili-5.4* ___ 06:02AM BLOOD ALT-389* AST-133* AlkPhos-427* TotBili-6.6* ___ 10:35AM BLOOD ALT-355* AST-117* AlkPhos-462* TotBili-7.1* ___ 08:10PM BLOOD ALT-357* AST-88* AlkPhos-461* TotBili-6.4* ___ 05:35AM BLOOD ALT-287* AST-73* AlkPhos-466* TotBili-5.2* ___ 05:12AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.9 ___ 06:02AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9 ___ 10:35AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1 ___ 05:35AM BLOOD Calcium-8.7 Phos-2.4* Mg-2.2 IMAGING: ___ Liver/gallbladder U/S 1. Cholelithiasis without evidence of cholecystitis. 2. Intrahepatic bile duct dilation. 3. The CBD measures 13 mm, unchanged from the outside hospital CT. Brief Hospital Course: Mr. ___ presented to ___ ED with epigastric pain. On further evaluation, he was found to have cholelithiasis, impacted stones at the ampulla and a common bile duct of 20mm. His labwork was significant for transaminitis of 436/625 (AST/ALT), alk phos of 479 and a total bilirubin of 5.4. Her was started on Zosyn for empiric coverage, which was later transitioned to Unasyn. He was kept NPO, given IV fluids and narcotic/non-narcotic pain medications were administered. He underwent an ERCP on ___ (HD 2) where a sphincterotomy was performed and a stone was removed. He tolerated the procedure well. He was transferred back to the inpatient ward for further management. On ___, Mr. ___ was taken to the operating suite where he underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He we subsequently taken to the PACU for recovery. While in the PACU, Mr. ___ had one instance of urinary retention for which required that he be catheterized on a single, one-time basis. He was transferred to the inpatient ward thereafter. The patient was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and she remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced to regular (carbohydrate consistent), which he tolerated without abdominal pain, nausea, or vomiting. He required a second instance of urinary retention for which his bladder was drained using a one-time catheter. He subsequently voiding on his own without issue. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. Both oxycodone and hydromorphone seemed to make the patient itch, so the patient was discharged on 50mg of tramadol as needed. His pain level was approximately ___ prior to discharge and the patient was fairly comfortable. Prior to discharge, Mr. ___ was a minimal oxygent where he was saturating well. On room air, his oxygenation was 90-93%. He had no shortness of breath or dyspnea. He was pulling 2 liters on his incentive spirometer. Lungs were clear bilaterally with slightly diminished bases. The patient was encouraged to cough, deep breath, use his incentive spirometer and amublate as much as possible. On the afternoon of ___, Mr. ___ was discharged home with scheduled follow up in ___ clinic. He will be going home with a right-sided JP drain that was placed during his surgery. ___ services were established to assist the patient with drain care/education at home. He will follow-up in the ___ clinic in approximately one week and the decision to discontinue his drain will be determined at that time. Medications on Admission: 1. Levemir 20 units SQ'' 2. Metormin 500mg'' 3. Simvastatin 40mg' 4. Metoprolol succinate 150mg' 5. Amytriptyline 25mg' 6. Lisinopril/HCTZ ___ 7. Oxycodone acetaminophen, ___ PRN 8. Celebrex ___ PRN pain Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Amitriptyline 25 mg PO HS 3. CeleBREX NF (celecoxib) 100 mg Oral BID:PRN pain Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary.AST Approval Required 4. Hydrochlorothiazide 25 mg PO DAILY You may continue to take lisinopril/HCTZ ___ 1 tab twice a day as directed by your physician. 5. Lisinopril 20 mg PO BID You may continue to take lisinopril/HCTZ ___ 1 tab twice a day as directed by your physician. 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Tartrate 75 mg PO BID You may continue to take metoprolol succinatae (ER) 150mg DAILY as you were prior to this admission. 8. Simvastatin 40 mg PO DAILY 9. Glargine 20 Units Breakfast Glargine 20 Units Bedtime 10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 11. Docusate Sodium 100 mg PO BID 12. Senna 1 TAB PO BID You do not need to take if you're having regular or loose bowel movements. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Choledocholithiasis, and acute-on-chronic cholecystitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ on ___ with complaints of epigastric/stomach pain. CT scanning showed that you had an impacted stone. You were admitted to the hospital. You underwent an ERCP where you had a sphinterotomy (hole placed in your duct) and a stone was removed. On ___, you had your gallbladder removed laparoscopically (through small holes in your abdomen). During that procedure, you had a drain placed to avoid any fluid from accumulating in your abdomen. See below for drain care. The drain will be likely be removed when you come back for follow-up in the ___ clinic (see below). You have since recovered well and are now being discharged with the following instructions: 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: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. DRAIN CARE: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10095982-DS-9	10,095,982	21,599,347	DS	9	2129-10-30 00:00:00	2129-10-30 12:40:00	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: ___ CT-guided therapeutic drainage History of Present Illness: Mr. ___ is a ___ y/o gentleman who came into the hospital late ___ with choledocholithiasis and cholecystitis. He underwent ERCP with removal of a CBD stone, followed by lap cholecystectomy on ___ which was quite difficult due to chronic inflammation. The cystic duct was stapled and endolooped, there were multiple dropped stones, and part of the gallbladder wall was left on the liver bed. He went home the next day and was doing relatively well but for the past ___ days has had worsening right sided abdominal pain. He has been taking POs without nausea/vomiting, and denies any fevers/chills. He has been passing gas and having bowel movements with milk of magnesia. He went to ___ where his WBC was 12 and a CT scan of the abd/pelvis demnstrated a subhepatic fluid collection. He is transferred here for further management. Past Medical History: PMH: 1. DMII, on insulin 2. hypertension 3. high cholesterol 4. chronic back pain PSH: 3 hernia repairs knee surgery in both knees Social History: ___ Family History: Mother, passed at age ___, DMII Physical Exam: Physical Exam upon discharge: T: 98.2 P: 82 BP: 140/51 RR: 18 O2sat: 99% on RA General: awake, alert, oriented x 3 HEENT: NCAT, EOMI, anicteric Heart: RRR, NMRG Lungs: CTAB, normal excursion, no respiratory distress Chest: non-tender, no deformities Back: no vertebral tenderness, no CVAT Abdomen: soft, nondistended, mildly but approrpiately tender only near drain site, drain site clean/dry/intact. Well healed incisions without hernia. Pelvis: deferred Extremities: WWP, no CCE, no tenderness Pertinent Results: ___ 10:50PM BLOOD WBC-10.9# RBC-3.58* Hgb-11.3* Hct-33.5* MCV-94 MCH-31.6 MCHC-33.7 RDW-12.4 Plt ___ ___ 10:50PM BLOOD Neuts-74.8* Lymphs-16.5* Monos-6.2 Eos-1.7 Baso-0.9 ___ 10:50PM BLOOD Plt ___ ___ 10:50PM BLOOD ___ PTT-33.0 ___ ___ 10:50PM BLOOD Glucose-171* UreaN-33* Creat-1.5* Na-136 K-5.1 Cl-98 HCO3-26 AnGap-17 ___ 10:50PM BLOOD ALT-20 AST-16 AlkPhos-167* TotBili-0.8 ___ 10:50PM BLOOD Albumin-3.5 ___ 10:55PM BLOOD Lactate-1.1 ___ Imaging GALLBLADDER SCAN IMPRESSION: No evidence of leak during the time of the study. ___ ___ ___ MOD SEDATION, FIR IMPRESSION: CT-guided therapeutic drainage of GB fossa abscess with removal of 60cc pus. 8fr drain in place. No complications. Brief Hospital Course: Mr. ___ was admitted to ___ for management of abdominal collection found when he presented to the ED with abdominal pain. He underwent ___ drainage on ___. He was placed on IV antibiotics while in-house. A HIDA scan revealed no biliary leak. He was transitioned to oral antibiotics and discharged on a 2 week course. He was set up with ___ nursing for drain care. He will plan to follow up in ___ clinic in ___ days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO HS 2. CeleBREX NF (celecoxib) 100 mg Oral BID 3. Hydrochlorothiazide 25 mg PO DAILY 4. Glargine 20 Units Breakfast Glargine 20 Units Dinner 5. Lisinopril 20 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Tartrate 75 mg PO BID Discharge Medications: 1. Amitriptyline 25 mg PO HS 2. Hydrochlorothiazide 25 mg PO DAILY 3. Metoprolol Tartrate 75 mg PO BID 4. CeleBREX NF (celecoxib) 100 mg ORAL BID 5. Lisinopril 20 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #28 Tablet Refills:0 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 9. Glargine 20 Units Breakfast Glargine 20 Units Dinner Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Abdominal collection, treated by ___ drainage 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 ___ for management of your abdominal pain, which was due to a collection of fluid in your abdomen. This has now been drained by a drain. You are doing well, and are now prepared to complete your recovery at home with the following instructions: DIET: Regular ACTIVITY: No restrictions MEDICATIONS: - Please resume all your usual home medications, unless instructed otherwise - Please be sure to complete the prescribed course of AUGMENTIN (an antibiotic), for TWO WEEKS. DRAIN CARE: - The drain must remain in place. - You have been set up with a Visiting Nurse to come to your home and help take care of the drain - Please be sure to empty the bag every day, and measure and record the output daily. - Please keep the bag pinned to your clothes, to avoid accidentally pulling the drain out. - Please call the clinic if you notice any concerning signs such as redness around the drain, increased pain, change in color of the drainage to red or green, or any other signs that may concern you. FOLLOW-UP: -Please call the Acute Care Surgery clinic at ___ to confirm your follow-up appointment in 2 weeks. This is very important. Followup Instructions: ___
10096046-DS-9	10,096,046	25,557,189	DS	9	2131-08-01 00:00:00	2131-08-03 19:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of scleroderma, hypothyroidism, hypertension presenting with weakness, cough. Per patient has felt generally unwell for the last several weeks, ___: rhinorrhea, dry cough, chest congestion. She denies overt fevers, chills, sweats. Started taking Coricidin for her cough with little improvement. Over the last week notes several episodes of diarrhea which have since resolved. In the setting of symptoms notes anorexia, lightheadedness, dizziness. Presented to endocrinologist today for regular follow-up where she was found to be hypotensive: Vital Signs: BP: a) 76/46; b) 80/50. Heart Rate: a) 62; b) 86. Ultimately sent to the ED, where initial VS 98.5 60 92/56 20 98%. EKG: TWI, RBBB unchanged from previous, no acute changes Labs notable for a creatinine 2.0. +UA. Patient received 2L IVF, IV ciprofloxacin and transferred to the floor VS prior to transfer: 52 117/60 15 97% On arrival, patient is feeling somewhat better; still reports dry cough. Denies HA, sore throat, dysphagia, chest pain, shortness of breath, abdominal pain, n/v/d, myalgias. Past Medical History: Atypical chest pain # HTN # RBBB (chronic) # Scleroderma # GERD # Hypothyroidism # Hyperparathyroidism # Osteoporosis # TnA, appy, CCY, partial colectomy for pre-malignant polyp, TAH # Lung nodules; cleared on last CT chest ___ Social History: ___ Family History: Brother died in his sleep at age ___. Brother with AAA. . Physical Exam: ADMISSION: VS: 97 116/65 59 20 100%RA 46.9kg GENERAL: Alert, oriented NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM NECK: supple, no appreciable LAD, no appreciable thyroid nodule LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, ___ SEM MRG, nl S1-S2 ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection BACK: no pain on palp of spine, mild left sided flank pain NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout . DISCHARGE: VS - 97.4/98.4, 131/71, 58, 95RA GENERAL - Sleeping this morning with husband in chair. Awakes easily, Appears comfortable, in NAD. Coughs few times during encounter. HEENT - Moist mucosa, erythema of posterior pharynx without exudate, EOMI, sclerae anicteric NECK - Thin, no JVD, no thyromegaly, LUNGS - No focal wheezing with forced expiration, minimal crackles on right lower base, no other adventitious sounds. Good air movement, resp unlabored, no accessory muscle use. Sits up on her own. HEART - Rate in the ___, regular, ___ systolic ejection murmur at RUSB. ABDOMEN - Scaphoid, NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - No ___ edema b/l, 2+ pulses of DP and radial b/l. NEURO - awake, A&Ox3, CNs II-XII grossly intact, patient able to sit up on her own, gait not evaluated. Pertinent Results: ADMISSION: - WBC 5.7, Hct 41.9, PLT 220, Cr 2.0, INR 1.1 - Uric Acid 9.2, Mg 1.5, Albumin 3.4 - TSH 1.1 . MICRO: - Influenza A/B by DFA: NEG - Urine Cx: NEG - Blood Cx: Pending . IMAGING: CXR: no acute intrathoracic abnormalities . DISCHARGE: - Cr .9, all labs normal Brief Hospital Course: ___ with a history of scleroderma, hypothyroidism, hypertension presenting with hypotension, cough and found to have ___. . # ___: Cr 2.0 on admission, baseline .9, Cr 1.2 on HD 1 after 3L IVF. Likely pre-renal in setting of poor PO intake due to Influenza; no recent medications or peripheral eosinophilia to evoke AIN. Possible ATN given low forward flow in setting of hypotension. Patient was well hydrated with baseline GFR on day of discharge. Urine analysis consistent with pre renal. TRANSITIONAL - Ensure adequate PO Hydration - PCP ___ up . # Hypotension: Found to have BP of ___ in Endocrine office with lightheadedness and dizziness. After admission, pressures back to baseline (110s-120s/60s-70s). As above, secondary to hypovolemia in setting of poor PO intake. Other potential causes include sepsis (does not meet SIRS criteria), Cardiac (nothing to suggest poor cardiac function, EKG unchanged), or adrenal (not consistent with chem10 panel). Also, BP back to baseline after IVF. EF>55% on stress TTE in ___. Orthostatics on day of discharge without drop in BP and < 10 beat rise in HR. TRANSITIONAL - Ensure adequate PO Hydration - PCP ___ up . # Cough/Malaise/Myalgias: For one week prior to arrival and in setting of sick contacts at home (husband, son). ___ DFA checked and was negative, etiology likely another viral pathogen. Physical therapy recommended home ___. . # Asymptomatic Bacteruria with Pyuria: +UA on admission and given Cipro in ED. No symptoms so we did not continue antibiotics. Urine cultures were negative. No history of resistant urinary microbes. . ------ chronic ------ # Scleroderma: Per patient well controlled; stable on penicillamine daily for several yrs. We continued penicillamine 250mg daily . # Hypertension. Hypotensive in the ED that improved with IVF. We held the patient's home amlodipine 5mg daily, Valsartan 320 mg daily, we asked the patient to hold her anti hypertensive medications at home TRANSITIONAL - Discuss with PCP regarding anti HTN meds . # Primary hyperparathyroidism. Corrected calcium on admission 11. Recent ionized calcium in clinic normal. Parathyroid scan showed possible right lower pole parathyroid adenoma. We continued Vit D 1000U daily . # Hypothyroidism: TSH on admission normal We continued levothyroxine 75mcg . # Elevated Uric acid: Uric Acid 9.2. Per patient, though never formally dx with gout; believes she carries the dx. No clincal signs. TRANSITIONAL - PCP follow up on Uric Acid . TRANSITIONAL CODE: FULL PACT Services active - Offered ___ and home ___, patient refused - Social: Social work consultation who reached out to elder services about the patient's continued difficulties with home burning down over a year ago. Elder services knew of patient and would continue to reach out to her. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY Start: In am for 6 days weekly 2. Amlodipine 5 mg PO DAILY 3. Omeprazole 20 mg PO DAILY Start: In am 4. Penicillamine 250 mg PO DAILY 5. Valsartan 320 mg PO DAILY 6. Vitamin D3 NF (cholecalciferol (vitamin D3)) 1,000 unit Oral 3days/week 7. Levothyroxine Sodium 150 mcg PO DAILY for one day weekly 8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN body rash Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY for 6 days weekly 2. Omeprazole 20 mg PO DAILY 3. Penicillamine 250 mg PO DAILY 4. Levothyroxine Sodium 150 mcg PO DAILY for one day weekly 5. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN body rash 6. Vitamin D3 NF (cholecalciferol (vitamin D3)) 1,000 unit Oral 3days/week Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, acute kidney injury Secondary: scleroderma, gerd, hypothyroidism, osteoprosis. 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 low blood pressure. On admission, your labs showed injury to your kidneys. The low blood pressure and the kidney injury were both likely due to poor fluid intake. Both problems improved back to your normal levels with fluid through the vein. Please stop your amlodipine and valsartan until you see your primary care physician. Please drink at least an extra cup of water daily. We offered you a visiting nurse and physical therapy to help with your strength and conditioning, although you were not interested in the services. We also had our social worker see you who contacted the elder services, who you have been in contact with previously about your housing situation. Elder services will continue to reach out to you in the future. Followup Instructions: ___
10096109-DS-8	10,096,109	21,449,873	DS	8	2148-12-07 00:00:00	2148-12-07 10:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: cipro latex apple juice Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with Crohn's disease s/p multiple bowel resections (including entire colon & proctectomy), w/ ileostomy, w/ h/o multiple SBOs, p/w abd pain since yesterday afternoon. No ostomy output or gas since that time. + 1 episode of bilious vomiting this morning. Subjective f/c, unsure of temperature. Ostomy began functioning while in ED; it is putting out green liquid. Pain has improved. She reports her obstructions generally resolve within hours to days. She reports her obstructions used to occur 3x/year, but have been increasing in frequency. This is her ___ episode in ___ weeks. Past Medical History: PMH: Crohn's disease, HTN PSH: multiple small and large bowel resections, colostomy (age ___, ileostomy (age ___, ?proctectomy (___), LUE fracture repair (age ___, splenectomy (age ___ Social History: ___ Family History: Mother w/ HTN. Maternal ___ with DM. Paternal & maternal uncles w/ prostate ca. Paternal uncle w/ lung ca. Paternal aunts w/ breast ca. Cousin w/ pancreatic ca. Physical Exam: On admission: PE: 98.1 90 ___ 99%RA Gen: NAD, nontoxic appearance, NGT in place w/ 400cc bilious output in can ___: RRR Pulm: CTA b/l Abd: soft, ND, mildly tender to palpation just L of midline, no rebound/guarding, hypoactive bowel sounds, ostomy bag w/ liquid output Ext: no c/c/e Brief Hospital Course: The patient was admitted to the surgical service for a bowel obstruction. She had an NGT placed and was made NPO with IVF. She began to have ostomy output of both gas and stool. NGT output was minimal and therefore was removed. She was discharged home tolerating a regular diet, ambulating without assistance. Medications on Admission: 1. Escitalopram Oxalate 30 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY Discharge Medications: 1. Escitalopram Oxalate 30 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the office or return to the emergency room if you experience fever, chills, shortness of breath, chest pain, nausea, vomiting, diarrhea or any concerning symptoms. Followup Instructions: ___
10096391-DS-17	10,096,391	26,251,990	DS	17	2145-12-09 00:00:00	2145-12-13 17:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ropinirole Attending: ___. Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: Percutaneous cholecystostomy History of Present Illness: ___ is a ___ year old woman with a history of hypertension and a recent admission for fatigue and epigastric pain, who was found to have cystic duct obstruction on HIDA and presents for treatment. Of note, her prior hospitalization was complicated by afib with RVR and syncopal events. She was started on Coumadin for anticoagulation but discharged on xarelto which she picked up at the pharmacy today. She underwent HIDA during her stay but left AMA before receiving the results so that she could go to her husband's doctor appointment. This morning, she was told over the phone that she has cystic duct obstruction, and she presents for direct admission for percutaneous drainage. In the ED, initial vitals: T 97.4 P 70 BP 122/46 RR 16 SpO2 100% RA - Exam notable for: mild RUQ tenderness - Labs notable for: INR 3.8, BUN 48, Cr 1.5, WBC 12.0, H/H 10.6/32.9, LFTs normal - Imaging notable for: HIDA scan on ___ suggestive of cystic duct obstruction - Pt given: 1L NS - Vitals prior to transfer: P 63 BP 114/50 She endorses fatigue over the past few days but improved from one week ago. She is unable to walk up a full flight of stairs without taking a break. She denies pain but endorses low appetite. No fevers, chills, shortness of breath, chest pain or palpitations, or additional syncopal events since discharge. 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 numbness or weakness, no focal deficits. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals- T 98.0 P 68 BP 107/60 RR 18 SpO2 99% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated, no LAD Lungs- Lungs clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- +BS, soft, mild RUQ tenderness with deep inspiration, no rebound tenderness or guarding, no organomegaly GU- No foley Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- Motor function grossly normal DISCHARGE EXAM: Vitals: Tc 98.6, Tm 98.8, BP 130-146/72-83, HR 97-100s, 97% 2L, weaned to 92-95% on RA, satted 92-93% on RA with ambulation General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated Lungs- faint bibasilar crackles, no wheezing CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- Perc chole tube in place draining blood tinged fluid. Bandage C/D/I. Tender over RUQ. Otherwise soft, nontender elsewhere, +BS. Ext- Warm, well perfused, 2+ pulses, no edema Pertinent Results: LABS ON ADMISSION: ___ 04:35PM GLUCOSE-116* UREA N-48* CREAT-1.5* SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18 ___ 04:35PM ALT(SGPT)-38 AST(SGOT)-39 ALK PHOS-53 TOT BILI-0.2 ___ 04:35PM LIPASE-58 ___ 04:35PM ALBUMIN-4.1 CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.2 ___ 04:35PM WBC-12.0* RBC-3.52* HGB-10.6* HCT-32.9* MCV-94 MCH-30.1 MCHC-32.2 RDW-13.0 RDWSD-43.9 ___ 04:35PM NEUTS-64.6 ___ MONOS-12.6 EOS-0.6* BASOS-0.4 IM ___ AbsNeut-7.77* AbsLymp-2.59 AbsMono-1.51* AbsEos-0.07 AbsBaso-0.05 ___ 04:35PM PLT COUNT-310 ___ 04:35PM ___ PTT-43.5* ___ ___ 04:35PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:35PM URINE RBC-4* WBC-32* BACTERIA-FEW YEAST-NONE EPI-5 ___ 04:35PM URINE HYALINE-1* ___ 04:35PM URINE MUCOUS-RARE LABS ON DISCHARGE: ___ 05:00AM BLOOD WBC-14.5* RBC-3.43* Hgb-10.3* Hct-31.5* MCV-92 MCH-30.0 MCHC-32.7 RDW-12.9 RDWSD-43.6 Plt ___ ___ 05:00AM BLOOD ___ ___ 05:00AM BLOOD Glucose-99 UreaN-21* Creat-1.2* Na-136 K-3.7 Cl-96 HCO3-23 AnGap-21* ___ 05:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9 IMAGING: U/S guided percutaneous cholecystostomy tube ___: FINDINGS: Gallbladder was identified with multiple stones, and amenable to drain placement. Post-procedure imaging showed no evidence of complication. IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. CXR ___ FINDINGS: Moderate cardiomegaly is stable. Mild to moderate pulmonary edema is new. Right lower lobe opacities are likely atelectasis. There is pleural small right effusion. There is no evident pneumothorax. Catheter projects in the right upper quadrant of the abdomen IMPRESSION: Mild to moderate pulmonary edema Brief Hospital Course: ___ with one week of epigastric pain and fatigue, with recent admission complicated by afib with RVR and syncope, found to have cystic duct obstruction on HIDA, readmitted for percutaneous cholecystostomy. #Cystic duct obstruction: She had mild RUQ pain and only mild pain with ___ test. However, imaging was consistent with cystic duct obstruction. Her INR was reversed with 3U FFP and she underwent percutaneous cholecystostomy on ___ which was uncomplicated. She received Unasyn while in house and was discharged on Augmentin for a 7 day course to end on ___. She will see Cardiology for a preoperative evaluation, then pursue follow-up with General Surgery for future elective cholecystectomy. #Atrial fibrillation: Her anti-arrhythmic medications were continued, but the dose of metoprolol was decreased due to sinus bradycardia. Her Rivaroxaban was held for supratherapeutic INR and she was instructed to restart on ___. She was monitored on telemetry and remained in sinus rhythm throughout, with no syncopal episodes. #Pulmonary edema: After her procedure and receiving IV fluids, she had an oxygen requirement and CXR evidence of pulmonary edema. She improved with diuresis and was discharged on room air. ___: Her Cr on admission was 1.5 from her baseline of 1.0, which resolved with IV fluids. Her home lisinopril was held in this setting. Her discharged Cr was 1.2. TRANSITIONAL ISSUES: -Outpatient f/u with general surgery for elective cholecystectomy -Cardiology appointment on ___. Recommend pre-operative evaluation if further work-up is needed for her arrhythmia and heart failure before cholecystectomy -Fluid from perc chole was sent for culture, results pending -Set up for home ___ to monitor chole drain. Instructions to call Radiology when output falls <10cc for 2 days in a row for consideration of removal. -Augmentin until ___ -Metoprolol decreased to 50 mg XL -should hold xarelto and restart on ___ -will need Chem 7, BUN/Cr, INR on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Rivaroxaban 15 mg PO DINNER 6. Disopyramide Phosphate 150 mg PO Q8H Discharge Medications: 1. Disopyramide Phosphate 150 mg PO Q8H 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Rivaroxaban 15 mg PO DINNER 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #28 Tablet Refills:0 6. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth every eight (8) hours Disp #15 Tablet Refills:0 7. Lisinopril 10 mg PO DAILY 8. 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 With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Obstructed cystic duct Cholecystitis Atrial fibrillation Pulmonary edema SECONDARY DIAGNOSIS: History of vasovagal syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure caring for you at ___ ___. You came to the hospital because the duct from your gallbladder was blocked. You had a procedure where a tube was placed through your skin to drain your gallbladder. You will eventually need a surgery to remove your gall bladder. After the procedure, you had trouble with breathing which was likely due to extra fluid on your lungs. This improved with use of medications. You were also on antibiotics to help with your infection and you should continue those antibiotics until ___. Please below for instructions on caring for this tube. Please follow up with surgery as scheduled below. Prior to this surgery, you will need to see your cardiologist to have pre-operative evaluation. You will need to have labs drawn on ___. Dr. ___ ___ you with a lab slip. Please have them drawn in the ___. You will have your INR drawn at that time. Please hold your xarelto and restart on ___. We wish you the best! -Your ___ Team ___ Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. -You may shower; wash the area gently with warm, soapy water. -Keep the insertion site clean and dry otherwise. -Avoid swimming, baths, hot tubs; do not submerge yourself in water. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at ___ at ___ and page ___. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the ___ call Interventional Radiology at ___ at ___ and page ___. This is the Radiology fellow on call who can assist you. Followup Instructions: ___
10096391-DS-19	10,096,391	27,466,615	DS	19	2147-05-14 00:00:00	2147-05-16 14:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ropinirole Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ reports a cough and URI symptoms for the past week. Over the past two days she has felt excessively weak and tired. She hasn't been drinking or eating much. Two days ago, while walking into her bedroom she felt weak and lightheaded and fell down 'before she could make it to her bed' and last night she felt dizzy and weak while brushing her teeth and had a "bad fall on her right side.' She may have grazed her head but did not lose consciousness. Her right posterior chest is sore and painful. She initially felt ok and thought she could 'tough it out' at home but was convinced by her family that she should come to the hospital. Past Medical History: hypothyroid, HTN, HLD, IBS, subclavian stenosis, atrial fibrillation, ?interstitial lung disease (notes that she has never been on steroids and that her breathing and exercise have improved, she was last told by a specialist that she does not have diminished lung function) Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: VS: T: 97.9 HR: 72 BP: 115/47 RR: 18 O2: 97% RA HEENT: Head normocephalic, no external signs of trauma Pupils 4->2 mm bilaterally, no blood in orifices midface stable trachea midline, equal chest rise, no bruising or tenderness on CHEST: chest wall anteriorly, 8 cm oblique abrasion to right back abdomen: soft, non-distended, non-tender pelvis: stable and non-tender extremities: warm, non-tender, no lacerations or abrasions gross motor and sensory function intact x 4 extremities Discharge Physical Exam: VS: R: 98.5 PO BP: 117/83 L Sitting HR: 79 RR: 18 O2: 97% Ra GEN: normocephalic, atraumatic HEENT: atraumatic, MMM CV: RRR PULM: coarse rhonchi b/l, no respiratory distress CHEST: right chest wall tenderness with palpation, no overlying skin changes ABD: soft, non-distended, non-tender to palpation EXT: warm, well-perfused, no edema b/l Pertinent Results: IMAGING: ___: ECHO: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. ___: CXR (PA&LAT): Emphysema. Mild fluid overload. No pneumonia. Although no acute fracture or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma to the chest wall is clinically warranted, the location of any referrable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. ___: CT Head: 1. No acute intracranial process. 2. There is acute paranasal sinusitis with fluid, and chronic sphenoid sinusitis. ___: CT C-spine: 1. No evidence for a fracture. 2. Mild retrolisthesis of C4 on C5 is almost certainly degenerative, though there are no prior exams to confirm chronicity. 3. Multilevel degenerative disease. 4. Paraseptal emphysema and partially visualized pleural/parenchymal scarring at the included lung apices. Concurrent CT torso is reported separately. ___: CT Torso: 1. Displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. 2. Diffuse centrilobular emphysema, fibrosis, and multiple areas of scarring. New borderline and enlarged mediastinal and hilar lymph nodes, compared to prior examination. In the setting of centrilobular emphysema and lung fibrosis, tissue sampling could be considered. 3. Severe aortic and coronary artery calcifications. ___: CXR (PA & LAT): Improved vascular congestion. Small pleural effusions. Mild basilar opacities, likely atelectasis. LABS: ___ 06:35AM GLUCOSE-157* UREA N-22* CREAT-1.1 SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-22 ANION GAP-14 ___ 06:35AM cTropnT-<0.01 ___ 06:35AM CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.6 ___ 05:25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-SM ___ 05:25AM URINE RBC-25* WBC-54* BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-1 ___ 05:25AM URINE MUCOUS-RARE ___ 12:00AM GLUCOSE-204* UREA N-28* CREAT-1.3* SODIUM-129* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-20* ANION GAP-19 ___ 12:00AM cTropnT-<0.01 ___ 12:00AM WBC-8.2 RBC-4.02 HGB-12.0 HCT-36.3 MCV-90 MCH-29.9 MCHC-33.1 RDW-13.3 RDWSD-44.0 ___ 12:00AM NEUTS-53.0 ___ MONOS-12.3 EOS-0.1* BASOS-0.1 IM ___ AbsNeut-4.33 AbsLymp-2.77 AbsMono-1.01* AbsEos-0.01* AbsBaso-0.01 ___ 12:00AM PLT COUNT-225 ___ 12:00AM ___ PTT-44.7* ___ ___ 11:55PM LACTATE-1.5 Brief Hospital Course: Ms. ___ is a ___ y/o F w/ hx of atrial fibrillation on Coumadin s/p fall. She reported feeling weak and had a cough and URI symptoms for the past week. Imaging revealed displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. She was also diagnosed with a UTI and was started on Augmentin to cover both possible PNA and UTI. The patient was admitted to the Trauma Surgery service for pain control and respiratory monitoring. On the evening of HD1, the patient had a CXR which demonstrated improved vascular congestion, small pleural effusions, and mild basilar opacities, likely atelectasis. On HD2, the patient had a repeat CXR which showed no relevant change when compared to prior CXR. The lateral radiogram showed minimal b/l dorsal pleural effusions, no evidence of PTX. The patient was alert and oriented throughout hospitalization; pain was managed with acetaminophen, ibuprofen and tramadol. She remained stable from a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient tolerated a regular diet and intake and output were closely monitored. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient's home Coumadin was initially held for a super therapeutic INR of 3.6. When rechecked on HD1, INR was 2.2 so Coumadin was restarted. ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: synthroid ___, lisinopril 10', metoprolol 25ER', pravastatin 40', warfarin 2.5' Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H please take with food RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #8 Tablet Refills:0 3. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate please take with food 4. TraMADol 25 mg PO Q6H:PRN Pain - Severe do NOT drink alcohol or drive while taking this medication RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: -Posterior right tenth and eleventh rib fractures -Right pneumothorax Secondary: -Urinary tract infection -Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ after suffering a fall. You were found to have two right rib fractures and a small right pneumothorax (puncture of the lung). You were also subsequently found to have a urinary tract infection and an upper respiratory infection concerning for pneumonia. Your rib fractures will heal on their own and you should continue to practice with your incentive spirometer to help with your breathing. You had repeat chest x-rays which showed resolution of the pneumothorax. You were started on an antibiotic called Augmentin (amoxicillin/clavulanate) to treat both your urinary tract infection and pneumonia. You are now ready to be discharged home to continue your recovery. Please note the following discharge instructions: Rib Fractures: * Your injury caused right-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * 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). General Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___

Subsets and Splits